Senior Registrar Research Articles

Dr John N. Lunn OBE

Dr John N. Lunn During that time, John worked closely with Bill Mapleson on the CO2 electrode and breathing systems used for paediatric anaesthesia. This interest in paediatrics was further developed while working with Professor Pask in Newcastle and led to his MD thesis on minute volume and compliance measurements during general anaesthesia in very small children. After a spell as Senior Registrar in Norwich, John returned to Cardiff in 1967 as a Senior Lecturer. He continued his research on paediatric anaesthesia and developed an interest in anaesthetic record keeping, an interest that would lead to his major involvement in improving safety in the peri-operative period. He authored and co-authored more than 50 papers in peer-reviewed journals, contributed many chapters to standard anaesthetic texts and authored Lecture Notes in Anaesthetics. He became an examiner for the primary fellowship of the Faculty of Anaesthetists and examined in a host of other countries. He was a highly respected and popular lecturer around the world and became friends with many overseas anaesthetists. His contributions have been recognised with the award of many eponymous awards and honorary fellowships. In his home patch of Cardiff, he was a staunch supporter of trainees and many (myself included) owe John enormous gratitude for the time he gave up to tutor those preparing for their fellowship examinations. He equally expected commitment from trainees both in their studies and in their clinical practice. To trainees, he might at times have seemed over-pedantic in how paediatric anaesthesia was conducted but the lessons learnt will have stayed with them all. John joined the editorial team of Anaesthesia in 1973 as an Assistant Editor. He took over from Tom Boulton as Editor-in-Chief in 1982 and developed the journal from its quarterly format into a monthly journal. He was largely responsible for pushing the journal towards the position that it now holds as one of the most highly-respected journals worldwide. Outside the world of anaesthesia, John's name is linked with patient safety. Early work in Cardiff on the epidemiology of perioperative outcome led to his becoming involved in the work that culminated in the publication in 1982 of Mortality Associated with Anaesthesia. Such was the impact of that work and the questions that it raised both in anaesthetic and surgical practice that the first Confidential Enquiry into Perioperative Deaths (CEPOD) was instigated and reported in 1987. This led onto the launch of the NCEPOD reports that have become an integral part of patient safety over the past years. There can be no doubt that John was the driving force behind NCEPOD in its early days, yet many felt that he did not receive the recognition he deserved. Some degree of recognition was provided by his being awarded an OBE in the honours list. In retirement, John and Anne moved into the country and quietly developed a passion for gardening. John Lunn's contributions to our specialty and to patient care may not seem that significant to the modern generation but for those who worked through those times, his impact has been immense. It would be fair to say that not everyone got on with John from the outset; in modern parlance he might be likened to certain yeast extract spread (you either love it or …..), but those who spent time with him learned just how much more there was to him. He was always a champion for the trainees and a stickler for meticulous care. Behind his perhaps sometimes abrupt exterior was a caring family man who I am proud to have called a friend. John has been laid to rest in the Natural Burial Ground at Usk Castle Chase alongside his wife Anne. There was no big church service, just close family and friends – the way John would have wanted it.

Was there ever a golden age for junior doctors?

As junior doctors prepare for a new contract after fighting the government’s attempt to make them work more unsociable hours without extra pay, Caroline White asked seven doctors how the...

Current practice of adolescent preventive services among paediatric residents in Nigeria

Background. There has been a growing recognition of the challenge of Nigerian adolescents’ health issues and the need to address it. Adolescent preventive services (APS) constitute an effective mechanism to reduce adolescent morbidities. Objective. To evaluate the current practice of APS among Nigerian paediatric residents. Methods. For this cross-sectional survey, we designed an anonymous questionnaire based on Guidelines of APS of the American Medical Association to elicit information on residents’ current practice regarding screening adolescents for specific morbidities. Results. A total of 103 residents participated in the study; nearly 60% were from federal teaching hospitals. The majority (78.6%) attended to adolescents at least once a week. In the last month, the adolescent medicine service most commonly provided by respondents was general health guidance (66.7%). Altogether, less than one-fifth of the residents have recently asked at least two specific questions to screen adolescents for eating disorders, violence, safety issues, depression, substance or sexual abuse. Senior registrars were more likely than registrars to screen adolescents for hypertension (75.0% v. 29.1%, p =0.032), depression (50.0% v. 16.5%, p =0.043) and abuse (62.5% v. 22.1%, p =0.023). Also, residents with <5 years in practice were more likely to screen for relationship issues ( p =0.045). Conclusion. The current level of practice of APS is low among paediatric residents in Nigeria. There is a need to restructure their ongoing practice and training to emphasise preventive paediatrics and other issues pertinent to adolescent care.

George Allen Dalton

After his house jobs in Birmingham, George Allen Dalton was posted to Hong Kong and Japan for his national service in the army. He spent his senior registrar time in...

Inter-observer variability and its correlation to experience in measurement of lower limb mechanical axis on long leg radiographs.

Restoration of mechanical axis (MA) is one of the most important aims of treatment of knee arthritis. The measurement of MA is often done on hip knee ankle (HKA) radiographs (LLR), but its measurement is often difficult and variable. We studied to check if inter-observer variability in the measurement of MA is dependent on the experience of the observer. 48 patients (70 knees) underwent measurement of MA on HKA radiographs. The measurement was done by five observers of different experience. All the results were tested for inter-observer variability. The overall intra-class correlation was 0.70. The two full time consultants had good agreeability among them (p<0.456). All the surgeons who had less than five years of experience among them also had good agreeability amongst them (all p values >0.005). All the other groups (except senior consultant and senior registrar) had statistically significant difference amongst them (all p values <0.005). There is an inter-observer variability in the measurement of MA on the HKA radiographs. The agreeability between the observers increases as the experience of the personnel increases. Although long leg radiographs can be used for assessment for HKA, this variability should be kept in mind while using this as a tool for planning management of the arthritic knee.

Jerome Gerald Lewis

Jerome Gerald Lewis (“Jerry”) was evacuated to Cornwall during the second world war. On returning to St Clement Danes School in London he won a scholarship to the London Hospital...

Does waiting after peri-prostatic nerve block reduce pain during transrectal ultrasound-guided prostate biopsy? A randomized controlled trial.

To determine if a short, clinically sufficient and manageable time delay after peri-prostatic nerve block (PNB) reduces pain during transrectal ultrasound (TRUS)-guided prostate biopsy. This was a prospective, randomized controlled trial. All patients who underwent TRUS-guided prostate biopsy between February and June 2014 were randomized into waiting or control groups. All biopsies were performed by senior registrars with the same PNB technique. Patients in the waiting group waited 5 min after PNB prior to biopsies. Those in the control group did not. Patients were then asked to complete a questionnaire regarding pain associated with different parts of the procedure and their degree of anxiety using a 10-cm, validated visual analogue scale. Mann-Whitney U tests were performed on the pain and anxiety scores and analysis of variance was conducted using the Statistical Package for the Social Sciences software. A total of 92 patients were randomized to 39 in the waiting group and 53 in the control group. Mean overall pain scores were 2.85 and 2.66 (P = 0.626) for the waiting and control groups, respectively. The mean pain scores from probe insertion, biopsy, before leaving the department and mean anxiety scores were similar between the two groups and did not reach statistical significance. Analysis of variance showed that irrespective of group and age, increasing anxiety is associated with an increase in overall pain score (P < 0.0005). Waiting 5 min after PNB did not reduce pain in men undergoing TRUS-guided prostate biopsy.

Nasogastric Tube Placement in Newborns Before Discharge.

The aim of this study was to assess the knowledge of medical staff (physicians) at different levels about insertion or placement of nasogastric tube (NGT) in a normal newborn before discharge. It was a survey-based, observational study conducted at King Khalid University Hospital. Atotal of 103 doctors were sent text message; among those 81 (78.6%) responded. Among the respondents, 27, 16, 11 and 27 were neonatologists, general physicians, obstetricians/ ENT/pediatric surgeons, and senior registrars neonatology (SRN), respectively. Majority of physicians, 57 (70.3%) rejected the idea of insertion of NGTin a normal newborn but in 24 (29.6%), answer was to insert NGTin all the newborns before discharge to check the patency of nasal cavities. Regarding the position, region of doctors and their response, majority from Center said &amp;lsquo;No&amp;rsquo;(not in favour of insertion) but from South, 17/18 (94.4%) said &amp;lsquo;Yes&amp;rsquo;(in favour of insertion). Regarding other specialties, majority of them showed rejection of this idea. In conclusion, most of the healthcare professionals, directly involved with neonatal care, rejected the idea of routine insertion of NGTin normal newborn examination before discharge; rather, some non-invasive technique could be opted.

Post thyroidectomy hypocalcaemia - an audit of 100 cases

Purpose of our study is to compare the incidence of hypocalcaemia after total, near total or subtotal thyroidectomy for benign multinodular goitre. One hundred consecutive thyroidectomies performed for euthyroid benign multinodular goitre at West surgical unit, Mayo hospital, Lahore Pakistan, were included in the study. Mean age of patients was 33 (range 14 to 60) years. Preoperative serum calcium level ranged from 7.7 to 10.0 with an average of 8.8mg/dl. 34 patients had total thyroidectomy, 31 had near total thyroidectomy, 28 had subtotal thyroidectomy and 7 had lobectomy &amp; isthmusectomy. Consultants performed 46 thyroidectomies, while senior registrars and residents performed 52 and 2 thyroidectomies respectively. 28 patients developed clinical features of hypocalcaemia.8 out of 31 patients who had near total thyroidectomy developed hypocalcaemia (25.8%). Out of 34 total thyroidectomies, 11 patients had hypocalcaemia (32.3%). In 28 patients who had subtotal thyroidectomy, 7 developed hypocalcaemia (25%) . 2 out of 7 lobectomy &amp; isthmusectomy patients also required treatment for hypocalcaemia (28.5%). Hypocalcaemia developed within 48 hours of surgery in 53% of our patients. Incidence of hypocalcaemia among patients operated by consultants was 23.9 % (11 out of 46), while among patients operated by senior registrars and residents 17 out of 54 developed hypocalcaemia i.e. 31.5%. Average postoperative duration of hospital stay was 5.42 days in hypocalcaemic patients (range 2-17 days) and it was 2.77 days in normocalcaemic patients (range 1-6 days). We conclude that post thyroidectomy hypocalcaemia is a complication with significant morbidity. The incidence of this complication can be reduced by meticulous surgical technique with special emphasis on haemostasis. Identification and preservation of well vascularized parathyroid glands must be attempted in every thyroidectomy.

Difficulties encountered at Cesarean section

Objective: To evaluate common difficulties encountered by the trainee registrars at C/Section. Design: An observational study. Place and Duration of Study: The Department of Gynae and Obstetrics Unit-II SIMS/Services Hospital, Lahore from 16th February to 16th September 2005. Patients and methods: One hundred cases of C/Section both emergency and elective were included. Almost all were done by trainee registrars and supervised by Senior Registrars. Common difficulties faced by trainees at C/Section were noted. Results: Out of 100, 59 were elective and 41 were emergency C/Sections. All were lower uterine segment C/Sections done on term or near term pregnancies. The commonest indication was previous scar (69) while 31 were primary C/Sections. The major problems encountered included difficulty to approach lower uterine segment due to adhesions formation (45), difficulty in delivering the baby from uterus (39) and the problem faced while securing haemostasis (31). One problem not directly related to C/Section noted was pricks to the surgeons in Hepatitis B &amp; C positive patients. Three cases were noted leading to frustration and depression in the involved doctors.

Simple repair is sufficient for most injuries to the duodenum - a case series of 23 patients

Background: Duodenal injury is the most important hollow viscus injury in the abdomen. The study analysed the outcome of duodenal injuries at the unit. Patients &amp; Methods: Prospectively collected data on a case series involving 23 patients over 3 years. It involved demographic details, part of duodenum injured, injury severity according to the AAST, injury-operation time lag, mode of repair, and the extent of significant associated injuries. Results: M:F ratio was 4.75:1. Mean age 33yrs. Patients with non-perforating injury were excluded. All were operated by a senior registrar or senior. 7/23 were blunt, 13/23 firearm &amp; 3/23 stab injuries. D2 was involved in 87%. Injury severity was graded according to AAST (American Association for Surgery of Trauma). 17/23 were Grade II/III, 3 Grade IV &amp; 3 Grade V injuries. Four had injury-operation lag of &gt;18hrs. Two injuries were missed. All injuries up to Grade IV had simple repair. Two of them had T-tube duodenostomy. None had pyloric exclusion. Complex repairs wer e required for 3/23 patients. Five patients died, as a result of associated insults. One delayed repair developed duodenal fistula. Intra-abdominal abscess, septicaemia and wound dehiscence were seen in two patients each. Duodenum-related mortality was zero. Adverse prognostic factors towards morbidity were injury severity &gt;GIII and injury-operation lag &gt;18hrs. The mortality was related to associated injuries. Conclusion: Primary repair is sufficient for most non-resectional duodenal injuries.

Anne Louis Margaret Graham

Eldest daughter of Professor and Mrs R J D Graham, Anne Louis Margaret Graham graduated in 1950. Her first appointment was as house surgeon in obstetrics and gynaecology to Professor...

Mechanical vs Biologic Valves: Our Modern Day Conundrum

Mechanical vs Biologic Valves: Our Modern Day Conundrum

Retrospective analysis of breast lumps in a given population: an institutional study

Background:A lump in the breast is a common complaint presenting in the surgical outpatient department of all major hospitals, with anxiety regarding a possible malignancy being extremely common. Early presentation and prompt diagnosis is essential to relieve anxiety of non-neoplastic conditions, and in case of carcinoma, it can save the patient from metastases. This retrospective study aims to audit the clinic pathologic features of patients with breast lump at teaching hospital in northern India.Methods: A total of 138 patients were included for the present study. The data on all patients who presented with history of breast lump to the surgical outpatient department at a teaching hospital, Maharaja Agrasen Medical College, Agroha from 1st January 2013 to 31st December 2015 were retrospectively analyzed. Information on age at presentation, parity, duration of symptom before presentation, previous breast disease, side and quadrant of breast affected, maximum diameter of breast lump, clinical diagnosis made by the senior registrar or unit consultant, type of biopsy done and histology diagnosis for patients who returned with histology report were extracted from the case files. All the results were analyzed by Statistical Package for Social Sciences (SPSS) software. Chi-square test was used to measure the level of significance.Results:in our present study, out of all the patients, 7 were males and rests were females. Out of 131 females, 3 (2.1%) were premenstrual and 35 (25.4%) were postmenopausal. 39 (28.3%) female patients were nulliparous. Lump was painless in 75 (54.3%) patients. Duration from discovery of lump to presentation was &lt; 1 months in 24 (17.4%), 1-3 months 10 (7.2%), 3-6 months 18 (13.0%), 6-12 months 20 (14.5%), &gt; 12 months in 56 (40.6%) and ranges from 2 days to 19 years. The duration was not documented in 10 (7.2%) patients. Left breast was more affected i.e. 65 (47.1%) cases than right sided. Bilateral involvement in around 12 cases (8.7%). Breast lump was presenting complaint in 138 patients in 3 years. The mean age of patients presenting with breast lump was 36.8 years (Range 15-70 years).Conclusions:Breast lump was the most common presenting complaint with most patients not presenting within one month.

Finn Bøe--war, medicine, music.

In January 1944 the Norwegian Resistance Movement placed a radio transmitter in the attic of the Department of Obstetrics and Gynaecology, the National Hospital (Rikshospitalet), Oslo. Knut Haugland (1917-2009) used this to send messages to the Norwegian government-in-exile in London. The transmitter was discovered by the Gestapo, and German troops surrounded the building on 1 April 1944. Haugland survived a dramatic escape. While the transmitter was in operation, Haugland lived with senior registrar Finn Bøe (1906-70) and his family in a hospital apartment. Bøe risked his own life and that of his family to assist during a dramatic phase of the resistance struggle. Bøe had completed a focused and purposeful clinical and academic training when he was appointed senior registrar at the Department of Obstetrics and Gynaecology, the National Hospital, in 1943. He was professionally ambitious. His thesis from 1938 was disqualified, but four years later he submitted a new, experimental thesis which he successfully defended in 1945. In 1955, Bøe became the first senior consultant at the Department of Obstetrics and Gynaecology at Aker hospital. Under his leadership, it became the largest in the Oslo area, and one of the most active in Norway with regard to science. Several of Bøe's own academic works on placental morphology and blood circulation have become classics. Outside of medicine, his great interest was music, and not only as a piano player. He also wrote a book about his fellow townsman Edvard Grieg.

Knowledge, attitude, and practice among primary health-care physicians toward smoking cessation in Makkah, Saudi Arabia

Background: Tobacco smoking is one of the main preventable reasons for death on the planet and is a noteworthy general well-being issue in both developed and developing nations. The primary health-care (PHC) doctors speak to an imperative resource in the battle against smoking. Objective: To detect the prevalence of smoking, smoking-cessation knowledge, and attitude among physicians in PHC centers in Makkah and evaluate the smoking-cessation counseling practices of these physicians. Materials and Methods: A cross-sectional study was conducted at 80 PHC centers in Makkah over a period of 2 months. Data were collected by a validated self-administered questionnaire “Global Health Professional Survey” that was adopted from the WHO. Result: The study included 262 PHC physicians. The prevalence of daily current smoking was (18.7%), while male and female prevalences were 26.7% and 1.2%, respectively. Only (7.3%) were occasional smokers. Majority of ever-smoked physicians reported thinking of quitting smoking. Incorrect knowledge was reported among 25.6% of physicians. Logistic regression revealed that physicians of experience ranged between 2 and 10 years were less likely to express incorrect smoking-related knowledge compared with those with an experience of 1 year or less. Current smokers have approximately four-fold risk for incorrect smoking-related knowledge compared with nonsmokers [adjusted odds ratio (AOR) = 4.04; 95% CI: 2.21–7.36]. Negative attitude was reported among 26.2% of physicians. Logistic regression revealed that physicians aged between 36 and 45 years showed a significant negative attitude toward smoking compared with those in the age group 25–35 years (AOR = 5.83; 95% CI: 2.88–11.79). Bad practice regarding smoking cessation was reported among 52.7% of the physicians. Logistic regression revealed that physicians with longer experience of working in PHC centers were significantly less likely to show bad practice regarding smoking cessation compared with those with an experience of 1 year or less. When compared with residents, senior registrars were less likely to exhibit bad practice regarding smoking cessation (AOR = 0.19; 95% CI: 0.05–0.69). Conclusion: The prevalence of smoking among PHC physicians in Makkah was relatively high. Current smokers either occasionally or daily are more likely to show incorrect smoking-related knowledge compared with nonsmokers. Most of PHC physicians showed positive attitudes toward smoking cessation activities, with no significant difference between current smokers and nonsmokers. Almost a 25% of primary health-care physicians did not receive sufficient training in smoking cessation activities.

Ronald John Leslie Davidson

Ronald John Leslie Davidson (“Ron”) did his house posts in the professorial units of Dundee Royal Infirmary. After two years’ national service in the military hospital in Penang, Malaya, he...

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.

Robert Marshall Adam

Robert (“Rob”) Marshall Adam’s medical career was delayed by the second world war. He was commissioned into the Royal Navy at the end of the war and completed his medical...

Sylvia Madeleine Watkins

Sylvia Madeleine Watkins had a reputation as an exceptionally kind and caring physician, qualities much valued by her patients. In her retirement, she committed her energies to postgraduate development in...