Is the ladette culture resulting in more women with broken noses?


The word “ladette”, defined by the Oxford Dictionary as “a young woman who behaves in a boisterous, assertive or crude manner and engages in heavy drinking sessions”, and the related culture of alcohol-fuelled anti-social behaviour has been quoted as being on the rise in the UK.

A retrospective study in three district hospitals has shown an 825 per cent increase in females aged 13–20 years attending for nasal fractures from 2002 to 2009.

The study supports the notion that violence amongst young women is increasing with a significant proportion of injuries being caused by non-domestic violence.

A retrospective study was performed in three district UK hospitals (Luton and Dunstable Hospital, The Lister Hospital and the Royal United Bath Hospital), serving a catchment population of approximately 1.5 million.

Operating theatre data for all females who attended hospital for manipulation of a nasal fracture under anaesthesia between January 2002 and December 2009 were retrieved. Case notes of all female patients attending Luton and Dunstable Hospital for assessment of a nasal fracture over a five-year period, from January 2004 to December 2009, were also reviewed, regardless of whether the patients underwent manipulation of their fracture under anaesthesia or not.

From 2002 to 2009, the collected data demonstrated an increase in the number of women presenting with nasal fractures, in all age groups. The greatest increase in incidence was seen in the 13–20 year age group. There were only 4 girls who underwent manipulation under anaesthesia across the 3 sites in 2002, whereas the respective number in 2009 had risen to 33, representing an 825 per cent increase. By comparison, the incidence in males had only risen from 47 to 102 during the same time period, a 217 per cent increase.

Accidental injury was the most common cause of nasal fracture. Falls and occupational accidents seem to play an increasing role in the epidemiology of nasal injuries in women, as they become more exposed to the respective risk factors in a society that considers them stronger and more independent compared with previous decades. Domestic accidental injuries are also frequently reported; a comment on how many of these are truthfully accidental would be purely speculative. Indeed, domestic violence continues to be under-reported by many victims, and was only cited in 2 per cent of the case notes reviewed in the present study. Sport-related injury was also a common cause of nasal trauma in the present study; an overall increase in nasal fractures amongst young women could also be related to an increased participation in sport.

In almost a quarter of cases in the Luton and Dunstable Hospital, nasal injury was the result of non-domestic violence. This type of violence stems from interpersonal conflicts, and its rates have been associated with the consumption of alcohol. Moreover, at least two UK studies from the past decade showed that alcohol consumption was closely associated with a rise in anti-social behaviour, violence and criminality in young girls. In addition, a significant correlation between cheap, readily-available alcohol and violent injury was found in a study involving 58 accident and emergency departments in 10 distinct economic regions of the UK. Therefore, the increased incidence of nasal fractures amongst young women in the present study may, at least in part, be attributed to increasingly violent behaviour amongst young women.

View the full paper “Is there a change in the epidemiology of nasal fractures in females in the UK?” free for a limited time here.


New research study exploring the benefit of probiotic in people with spinal injury

Researchers at the National Spinal Injuries Centre (NSIC) in Stoke Mandeville Hospital, a research partner of the Centre of Gastroenterology and Clinical Nutrition at University College London, have found that a daily commercial probiotic drink (containing Lactobacillus casei Shirota: Yakult Light) significantly reduces incidence of antibiotic-associated diarrhoea in spinal injury patients.

The study, published today in the peer-reviewed British Journal of Nutrition, was funded by the Healthcare Infection Society and by Yakult UK Limited, who also provided the Yakult Light drinks.

Spinal injury patients are very prone to diarrhoea when on antibiotics. Antibiotics can disturb the ecosystem of micro-organisms normally present in the digestive system, allowing bacteria such as Clostridium difficile to overwhelm the gut.


The randomised controlled study involved 164 spinal injury patients prescribed antibiotics*. The patients were in two groups: one group taking a daily Yakult during the antibiotics and for one week afterwards, and the other group not taking any probiotic.

Antibiotic-associated diarrhoea developed in 54.9% of the patients not given probiotic, but in only 17.1% of those taking the Yakult. This was statistically a highly significant reduction.

Only one case of diarrhoea was diagnosed as being caused by Clostridium difficile over the 2 year study period: this was in the group of patients not given probiotic. There were no cases of C. difficile in the patients on Yakult. The study also identified poor appetite (i.e. risk of undernutrition) as a risk factor for developing antibiotic-associated diarrhoea.

Principal investigator, Dr. Samford Wong said: “Research into prevention of diarrhoea associated with antibiotic use and C. difficile is important, and we thought the probiotic approach was a good idea. We were surprised at how strong the study results were. It is important to remember that the probiotic effect is strain and condition specific, we don’t know if this will apply to other strains. We are now preparing a larger placebo-controlled study to confirm these findings, as this could be a significant benefit to our patients.”

Co-author Dr. Ali Jamous, Consultant Spinal Surgeon, commented ‘Quality of life is a large focus of research at the NSIC with patients being encouraged to participate in sports and supported into re-employment. If diarrhoea develops, their rehabilitation will be delayed, affecting not just the patient but also causing a lot of extra cost to the NHS. Given the severe loss of quality of life for these patients, a cost-effective, reliable and simple therapy would appear to be highly desirable. This is why we supported the current study and are keen to confirm these findings with a larger confirmatory trial.’

* The patients in the study had all sustained a spinal cord injury in the previous six months: approximately 80% of them were men; 74% of the patients had become injured through a traumatic injury.

This paper is freely available for one month

This post appears cortesy of NSIC

About the Author

Dr. Samford Wong (Research Dietitian and Research Associate at the NSIC and Centre for Gastroenterology and Clinical Nutrition at University College London) has been awarded the Spinal Cord Prize by the International Spinal Cord Society, and received the Mike Emmerson Young Investigator Award from the Healthcare Infection Society.

TAVI and its role in treatment of aortic stenosis

submitted by Dr Gokulnath Rajendran & Dr Stephen T Webb both at Papworth Hospital NHS Foundation

Aortic stenosis (AS) is the most common type of valvular heart disease in developed countries. It is a progressive disease and the incidence of
severe stenosis increases with age, ~2% at 65 years and 4% at 85 years[1]. Patients may be asymptomatic or present with syncope, angina or exertional breathlessness. Surgical replacement of aortic valve is the standard treatment to improve quality of life in symptomatic severe AS. However patients who are considered too high risk for surgery could benefit from minimally invasive transcatheter aortic valve implantation (TAVI).

TAVI was first performed in 2002. Since then, technology has evolved rapidly and in the last decade, more than 50,000 procedures have been performed worldwide2. The procedure involves balloon valvuloplasty of the stenosed valve followed by deployment of a bioprosthetic valve by transfemoral or transapical route.
In UK, TAVI is currently performed in cardiac catheterisation suites with operating theatre facilities (‘hybrid’ catheter rooms) in specialist cardiothoracic centres by interventional cardiologists. Patients undergo comprehensive investigations including echocardiography, coronary angiography and computed tomographic (CT) angiography. Multi-disciplinary assessment of the patient is essential prior to the procedure.

Although TAVI can be performed under local anaesthesia, the majority of patients receive general anaesthesia. General anaesthesia provides
the patient immobility and facilitates the use of transoesophageal echocardiography. Anaesthetic management can be potentially challenging as these patients often have multiple comorbidities. The procedure involves rapid ventricular transvenous pacing to temporarily reduce cardiac motion. Pacing wires are inserted in case of bradyarrhythmias. Vasopressors are usually administered to treat intraoperative hypotension and maintain coronary perfusion pressure.

As the procedure may lead to potentially catastrophic haemodynamic instability, a cardiopulmonary bypass circuit and clinical perfusion team are kept on stand-by in the hybrid catheter room. Intraaortic balloon counterpulsation may be necessary to support patients with very poor ventricular function.

Complications of TAVI include delirium, seizure, stroke or TIA, myocardial infarction, cardiac arrhythmia, access site arterial injury and cardiac tamponade. Moderate to severe para-valvular regurgitation may occur after TAVI3.

Two-year survival rate is similar following TAVI compared to surgical procedure3 and is superior compared to medical treatment4. The UK National Institute for Health & Clinical Excellence (NICE) concluded that evidence for the efficacy of TAVI is sufficient to recommend the procedure for those unsuitable for surgery, but that there is0 insufficient evidence to support it for those considered suitable for surgery. Technological refinements could result in expansion of this less-invasive procedure to a broader spectrum of patients in the future.

1 Carabello BA, Paulus WJ. Aortic stenosis. Lancet 2009;373:956-66.
2 Vahanian A. Transcatheter aortic valve implantation: our vision of the future. Arch
Cardiovasc Dis. 2012 Mar;105(3):181-6.

The changing world of vascular surgery

Blog Post by Mr Vish Bhattacharya MB BS, FRCS (Glas & Edin), FRCS (Gen Surg) Consultant General and Vascular Surgeon, Queen Elizabeth Hospital, Gateshead, UK.

Vascular surgery has changed dramatically over the last 10 years. The major emphasis has been on prevention of vascular disease and on minimally invasive surgery. There has been much better awareness among the general body of doctors especially GPs about arterial disease and their management. Early detection of peripheral arterial disease and its management is gaining increased importance in order to reduce the number of amputations.

Venous disease management has also changed and less invasive forms of treatment for example foam sclerotherapy, radiofrequency ablation and laser treatment of veins have emerged. Read more of this post

The future of heart and lung transplantation

Blog Post by Clive Lewis, Andrew Klein, Nick Lees and Stephen Webb, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE

The field of transplantation has spawned more new specialties and Nobel prize winners than any other in medicine. Christiaan Barnard’s performed the first heart transplant in 1969 in Cape Town, South Africa. The first lung transplant was performed even earlier, in 1963, by Hardy and colleagues at the University of Mississippi in the USA, although two decades passed before this procedure become a viable option for end stage lung disease. Heart transplant is now the treatment of choice for selected patients with advanced heart failure, with over 85,000 procedures having been performed worldwide during the last 40 years. On average, more than 5000 heart transplants are undertaken every year, in more than 225 centres.

Two important challenges transplantation are the increasing numbers of referrals, and the falling number of suitable donor organs available. This has lead to a major imbalance between supply and demand. Read more of this post

Non-invasive ventilation for acute cardiogenic pulmonary oedema

Blog Post by Mr Tim Case MPhil MA (Cantab) Medical Student, Hughes Hall, University of Cambridge, Cambridge, CB1 2EW, UK, and Dr Stephen T Webb MB BCh BAO FRCA EDIC, Consultant in Anaesthesia & Intensive Care Medicine, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE, UK

Acute cardiogenic pulmonary oedema (ACPO) is a life-threatening consequence of acute heart failure that affects more than 17000 patients in the UK per year[i].  As the left ventricle fails, increased hydrostatic pressure causes fluid to leave the pulmonary capillaries and fill the alveoli.  Clinical features of ACPO include dyspnoea, tachypnoea, wheeze, pulmonary crepitations and hypoxaemia.  Read more of this post

The Ongoing Challenges with the Peri-operative Care of the Morbidly Obese Patient

Blog Post by Jay B. Brodsky, MD and Harry J.M. Lemmens, MD, PhD, and Stanford University School of Medicine, Stanford, CA, 94305

We are all aware that the world is experiencing an obesity epidemic. Given the great numbers of morbidly obese patients currently undergoing surgery and the predicted increases in those numbers for the future, every health care professional must be familiar with the unique management concerns of these potentially complex patients.          

The morbidly obese patient can be especially challenging for their anesthesiologist and surgeon.  There are physiologic changes to almost every organ system, numerous associated medical co-morbidities, altered uptake and distribution of anesthetic agents and other drugs, potentially difficult airways, as well as technical difficulties related to the large size of these patients. Read more of this post

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