Early MRI in occult scaphoid fractures is marginally cost saving compared with conventional management and may reduce potentially large societal costs of unnecessary immobilisation. It enables early detection and appropriate treatment of scaphoid and other injuries.

INTRODUCTION The objectives of this work were to assess the clinical knowledge of clinicians in the accident and emergency (A&E) departments in England & Wales and evaluate the current trend for the acute management of radiologically normal, but clinically suspected, fractures of the scaphoid.SUBJECTS AND METHODS We conducted a telephone survey on 146 A&E senior house officers (SHOs) in 50 different hospitals. This survey assessed the clinicians' experience, their clinical and radiological diagnostic methods, and their initial treatment of suspected scaphoid fractures. RESULTS The majority (55.8%) of SHOs performed only one clinical test to diagnose suspected scaphoid fractures. Overall, 41% were unable to cite the number of the radiographic views taken and only 10% of departments have direct access to further radiological investigation. There is wide variation in the early treatment of this injury, with the scaphoid cast used most commonly (46%). The majority of SHOs (89%) were unable to describe the features of immobilisation. The mean follow-up period was 10 days, and 53% of cases were followed-up by the senior staff in A&E. Of SHOs, 54% were not aware of any local guidelines for the management of suspected scaphoid fractures in their departments, and 92% were not aware of the existence of the 1992 British Association for Accident and Emergency Medicine (BAEM) guidelines. CONCLUSIONS The clinical knowledge and the management of suspected scaphoid fractures in A&E are unsatisfactory. We, therefore, suggest that the dissemination of up-to-date guidelines could help to educate clinicians to provide better care to the patients.

The report, in addressing the unacceptable high mortality of acute liver admissions to hospital reinforces the necessity for an integrated clinical services. The masterplan described is based on regional, geographically sited liver centres, each linked to four to six surrounding district general hospital (DGHs) -a pattern of care similar to that successfully introduced for stroke services. The plan includes establishment of a Lead and Deputy Lead Clinician in each acute hospital, preferably a hepatologist or gastroenterologist with liver interest who will have prime responsibility for organising care of acute liver admissions on a 24/7 basis. Essential for the plan is greater access to Intensive Care Unit/High Dependency Unit (ITU/HDU) facilities in line with Covid-19 experience and associated reconfiguration of emergency care. The report strongly recommends full implementation of the Alcohol Care Teams (ACT) programme in hospitals and improved working links with the acute medical services. The Commission also endorses recommendations from paediatric liver services to improve overall survival figures by earlier diagnosis of biliary atresia based on stool charting and by better care of impaired cognitive ability and developmental mental health problems.

BackgroundWernicke’s encephalopathy (WE) is an acute neuropsychiatric condition caused by depleted intracellular thiamine, most commonly arising in chronic alcohol misusers, who may present to emergency departments (EDs) for a variety of reasons. Guidelines recommend a minimum 5-day course of intravenous (IV) thiamine in at-risk patients unless WE can be excluded.ObjectiveTo estimate the cost impact on the UK public sector (NHS and social services) of a 5-day course of IV thiamine, vs a 2- and 10-day course, in harmful or dependent drinkers presenting to EDs.MethodsA Markov chain model compared expected prognosis of patients under alternative admission strategies over 35 years. Model inputs were derived from a prospective cohort study, expert opinion via structured elicitation and NHS costing databases. Costs (2012/2013 price year) were discounted at 3.5 %.ResultsIncreasing treatment from 2 to 5 days increased acute care costs but reduced the probability of disease progression and thus reduced the expected net costs by GBP87,000 per patient (95 % confidence interval GBP19,300 to GBP172,300) over 35 years.ConclusionsIncreasing length of stay to optimize IV thiamine replacement will place additional strain on acute care but has potential UK public sector cost savings. Social services and the NHS should explore collaborations to realise both the health benefits to patients and savings to the public purse.Electronic supplementary materialThe online version of this article (doi:10.1007/s40258-015-0214-1) contains supplementary material, which is available to authorized users.

(fig 1, A and B).He received inpatient anticoagulation and the symptoms resolved within 24 hours. He remained asymptomatic two months later.Case 2 A 27 year old woman had been on an alcoholic binge. The following morning she awoke with a frontal headache and some discomfort in her neck. These symptoms resolved with simple analgesia. The same evening as she was leaning back in her chair extending her neck she suddenly developed paraesthesiae in the left arm and leg. As she got up to walk she limped on her left leg. After two hours she developed a left facial droop and slurred speech. She then attended the A&E department, by which time her symptoms had resolved and a thorough examination was entirely normal.A diagnosis of migraine was made in the A&E department and she was referred to the neurology outpatient clinic. Once again no signs were detected on clinical examination but an MRI scan of the brain and neck showed a dissection of the right internal carotid artery. There were also two areas of infarction in the right cerebral hemisphere. She was admitted, anticoagulated, and subsequently remained well. DiscussionCarotid artery dissection is well described after trauma to the neck and in some cases may occur even after relatively minor injury.' With modern diagnostic techniques it has been recognised more often and is now known to be a common cause of stroke in the young. Our patients could not recall an injury and thus it was presumed that the dissection was spontaneous.