bluuebunny/crossref_metadata_2025 huggingface dataset:
The Real Self: Who Am I? Who Are We? (Principle 4)
Authors: Boyatzis Richard E
Published: August 2024

Chapter 4 focuses on the second phase of Intentional Change Theory (ICT), the realization of the Real Self. The Real Self may be a constellation of the ways individuals think about themselves, but in ICT, it is the way one is experienced by others. The Faux Self is a false image of oneself often created from self-protective forces. Therefore, collecting observations from others or direct observation is key to determining the Real Self and one’s strengths and weaknesses. Focusing on Real–Ideal Self discrepancies uses a deficiency approach to reduce this gap. Competencies are the behavioral and observable aspect of a person: a capability of a person, not a characteristic of a job, which are a set of behaviors organized around an underlying intent. The use of competency models developed from expert and opinion sources is a deceptive model and a waste of resources. When comparing one’s Real Self to one’s Ideal Self, a picture of relative strengths and weaknesses emerges as a personal balance sheet.
Unintended Souvenirs: Case Report of a Retained Foreign Body During Cosmetic Surgery Tourism
Authors: Shaffrey Ellen C , Larson Jeffrey D
Published: August 2024

Medical tourism has grown exponentially, spurred by incentives such as cost reductions, minimal wait times, and the allure of recuperative vacations. However, this trend carries substantial risks, as illustrated by the case of a 52-year-old female patient who underwent an abdominoplasty as part of a medical tourism package in Miami, FL, which resulted in a retained foreign body. The case highlights the broader issues of continuity of care, patient safety, and the legal and ethical ramifications faced by patients opting for medical tourism surgical procedures domestically and abroad. It also emphasizes the need for updated standards from professional societies and international cooperation to safeguard patient well-being in the expanding medical tourism sector. Lastly, it underscores the need for physicians and surgeons who manage these complications at home to recognize that prompt management and intervention are critical to avoid the escalation of complications and the increased risk of morbidity and mortality.

Level of Evidence: 5 (Therapeutic)
Genetic determinants of obesity in Korean populations: exploring genome-wide associations and polygenic risk scores
Authors: Jo Jinyeon , Ha Nayoung , Ji Yunmi , Do Ahra , Seo Je Hyun , Oh Bumjo , Choi Sungkyoung , Choe Eun Kyung , Lee Woojoo , Son Jang Won , Won Sungho
Published: August 2024

East Asian populations exhibit a genetic predisposition to obesity, yet comprehensive research on these traits is limited. We conducted a genome-wide association study (GWAS) with 93,673 Korean subjects to uncover novel genetic loci linked to obesity, examining metrics such as body mass index, waist circumference, body fat ratio, and abdominal fat ratio. Participants were categorized into non-obese, metabolically healthy obese (MHO), and metabolically unhealthy obese (MUO) groups. Using advanced computational methods, we developed a multifaceted polygenic risk scores (PRS) model to predict obesity. Our GWAS identified significant genetic effects with distinct sizes and directions within the MHO and MUO groups compared with the non-obese group. Gene-based and gene-set analyses, along with cluster analysis, revealed heterogeneous patterns of significant genes on chromosomes 3 (MUO group) and 11 (MHO group). In analyses targeting genetic predisposition differences based on metabolic health, odds ratios of high PRS compared with medium PRS showed significant differences between non-obese and MUO, and non-obese and MHO. Similar patterns were seen for low PRS compared with medium PRS. These findings were supported by the estimated genetic correlation (0.89 from bivariate GREML). Regional analyses highlighted significant local genetic correlations on chromosome 11, while single variant approaches suggested widespread pleiotropic effects, especially on chromosome 11. In conclusion, our study identifies specific genetic loci and risks associated with obesity in the Korean population, emphasizing the heterogeneous genetic factors contributing to MHO and MUO.
709 An Audit of the Impact of the Introduction of Faecal Immunochemical Testing on Colorectal Two Week Wait Referral Practices and Colorectal Cancer Diagnoses
Authors: O’Connor T , Vallance A , Yim P Y , Shetty S , Grimes H , Hanhausen M R , Waite S , Messenger D
Published: August 2024

Aim

Waiting lists on the colorectal 2 week wait (2WW) pathway have grown more than any other tumour group since the pandemic. Faecal Immunochemical Testing (FIT) has a high sensitivity for the detection of colorectal cancer (CRC). A change in the southwest clinical network 2WW referral criteria was made from 2023, with greater emphasis on FIT. This audit examined the impact of this guideline change on referral practices to the colorectal 2WW service and resultant cancer diagnoses.

Method

A single centre retrospective review of electronic medical records and referral documentation for patients referred to a colorectal 2WW service in 2022 (September-December) prior to guidelines changing, and 2023 (January-April) following guidelines changing, was performed. Referral numbers, use of FIT, endoscopy numbers, and pathologies found were examined and compared between cohorts.

Result: Referrals to the 2WW service reduced by more than 50% (837 in 2022 vs. 399 in 2023). A FIT was performed in 374 (44.8%) patients in 2022 and 297 (75.0%) in 2023. There were 560 colonoscopies performed in the first cohort compared to 270 in the 2023 cohort. A CRC was detected in 24 patients in the 2022 cohort compared to 20 patients in the 2023 cohort (p=0.06).

Conclusions

The introduction of FIT to the 2WW colorectal service has resulted in fewer referrals. This has reduced the requirement for endoscopy with no reduction in diagnosis of colorectal cancer.
975 A Re-Audit on Bowel Preparation for Colonoscopy in a Surgical Unit of a Tertiary Care Hospital, Sri Lanka
Authors: Saranga K G V , Wickramasinghe V C , Madhawa J K G , Piyarathne S A , Prashantha A H A
Published: August 2024

Aim

This re-audit assessed changes in colonoscopy preparation practices at a Sri Lankan tertiary care hospital, aligning with ESGE guidelines. The primary goal was to gauge adherence improvements after introducing a protocol and educational initiatives.

Method

Conducted from May to July 2023, the initial audit identified deficiencies, leading to protocol development based on ESGE guidelines. Educational initiatives for nursing and junior staff were implemented, adjusting split-dose timing, discontinuing enema use, and providing clear instructions. A re-audit from August to October 2023 assessed the impact, analysing records through descriptive statistics.

Results

The re-audit revealed substantial improvements in colonoscopy preparation adherence to ESGE recommendations. The total number of patients undergoing the procedure was 88 in the initial audit and 96 in the re-audit. Adherence to a low fibre diet rose from 22.72% (n=20) to 90.62% (n=87), and compliance with enhanced instructions improved from 14.7% (n=13) to 70.8% (n=69). Routine enema use was eliminated (0% to 100%). Compliance for split-dose preparation increased from 42.04% (n=37) to 81.25% (n=78), and last dose timing within 5 hours improved similarly. Specific instructions to patients and clinic staff significantly improved from 28.4% (n=25) to 97.9% (n=94).

Conclusions

In conclusion, the re-audit emphasizes significant improvements in colonoscopy preparation, highlighting the positive impact of introduced changes. These findings underscore the effectiveness of evidence-based guidelines, education, and continuous audits. Implementing a checklist, staff, and patient education has proven essential for transforming and enhancing bowel preparation quality. These simple yet focused measures are essential in transforming and streamlining the quality of bowel preparation.
1286 A Closed Loop Audit of the Antibiotic Prophylaxis in Elective Laparoscopic Cholecystectomies at a DGH
Authors: Ikram H , Suleman A H , Ahmad G , Singh R
Published: August 2024

Aim

To re-audit the compliance of departmental practice to the antimicrobial guidelines for elective laparoscopic cholecystectomies. A Cochrane review found no evidence to support the use of antibiotic prophylaxis in elective cases.

Method

A retrospective study looking at all the elective laparoscopic cholecystectomies for the period between 1st June 2023 to 30th September 2023 using local Bluespier theatre software. Electronic operation notes were reviewed to identify cases where antibiotics were given. The main indications were bile spillage, conversion to open and cholecystitis amongst others. Total number of cholecystectomies carried out over the period was 92. At present gentamicin and metronidazole as a single dose was the choice.

Results

Antibiotic use during laparoscopic cholecystectomy is between 39% and 63% due to many cases not documenting the use of antibiotics. Adherence to guidelines reduced from 36% (2019) to 3% in 2023. Patients who received correct antibiotics allergic to penicillin was 75% (2019) and 100% in 2023. Continued lack of antibiotic documentation, use and indication in operation notes. Continued overuse of co-amoxiclav 60% (2019) and 87% in 2023.

Conclusions

Antibiotic prophylaxis in elective cholecystectomies was only performed correctly in 3% of cases. This can have a major impact on patient safety and also the financial aspect to the trust. Understanding why surgeons have failed to adopt the local guidelines may benefit in changing practice. We suggested an education session from the microbiology team to help better understand the importance of antibiotic stewardship and using laminated guidelines in theatre to ensure this is followed closely.
225 The Use of Activated Clotting Time and Prothrombin Time to Predict the Heparin Dose in Paediatric Cardiac Patients on Venoarterial Extracorporeal Membrane Oxygenation Circuits
Authors: Karsan R , Chan-A-Sue T
Published: August 2024

Aim

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a salvage intervention used to treat cardiorespiratory failure. Heparin is the main anticoagulation agent used to prevent clots within the lines and thus circuit failure, dosing is traditionally assessed using activated clotting time (ACT). We aimed to investigate the variables influencing circuit anticoagulation to predict therapeutic heparin dosing to reduce surgical re-exploration.

Method

A retrospective analysis of parameters (ACT, heparin, platelet and prothrombin time (PT)) used to identify bleeding at an early interval in paediatrics (N=10) patients on VA-ECMO at a single centre. The mean values of each variable for all samples taken during VA-ECMO for each patient when grouped by re-exploration due to bleeding or not.

Results

None of the patients experienced clots in the VA-ECMO circuit, suggesting an ACT between 146 - 165 was adequate for anticoagulation. There was a statistically significant difference between the mean ACT of each group, with those not requiring re-exploration having a mean 12.44 units higher than the re-exploration group (95% CI [6.17, 18.71] p<0.001) yet no statistically significant difference between platelet level between groups (p=0.098). PT and the off-set heparin dose were shown to have any predictive power of heparin dose using regression equations:

Heparin dose=([Target ACT]-79-(5.2 ×[Prothrombin]))/0.4

Heparin dose=2.5 ×([Target ACT]-79-(5.2 ×[Prothrombin])).

Conclusions

The application of the formula has the potential to predict heparin dose in paediatric patients on ECMO which could help reduce the postoperative complication of returning to surgery due to rebleeding when extrapolated to a larger data set.
404 A Reflection on a 3-Cycle Audit in the Use of Perioperative ACE-Inhibitors and A2RBs in Cardiac Surgery
Authors: Rao E , Allam M , Karamanou D
Published: August 2024

Aim

ACE inhibitors and Angiotensin-2-receptor blockers are stopped 24 hours preoperatively as continued use can cause hemodynamic instability and complications including kidney dysfunction, atrial fibrillation and increased mortality. To reflect on the results across 3 cycles to see if our recommendations have led to any improvements towards meeting the standard of 100% patients having ACEi and A2RBs being stopped at least 24 hours preoperatively with any clinical exceptions documented.

Method

There were 3 rounds of data collection (corresponding with each cycle) where patient inpatient notes and drug charts were reviewed. Emergencies and those not on ACE/A2RB were excluded. The first round of data was collected from 50 sequential patients admitted from October 2019 to January 2020, second round from 51 patients reviewed in December 2021 and the third round had been collected from 50 sequential patients admitted from January to June 2023.

Results

In cycle 1, 96% ACEi/A2RBs stopped with reasoning not documented for continuations (n=1). Recommendation was a team meeting to remind of protocol. In cycle 2, 76% ACEi/A2RBs stopped with reasoning not documented for 50% of continuations (n=12). Recommendation was a team meeting to remind of protocol, particularly ward and in-house-unit (IHU) staff. In cycle 3, 92% ACEi/A2RBs stopped with reasoning not documented for continuations (n=2).

Conclusions

The results suggest our recommendations have been effective along with the trust’s recent implementation of an online prescribing platform which has made it easier to track medications patients are given, reinforcing the positive impact of technology in reducing medical errors and ultimately improving patient outcomes.
876 To Score or Not to Score - Is Caprini the Best Tool for Post-Operative VTE Risk Stratification in Patients Undergoing Thoracic Surgery?
Authors: Ajdarpasic D , Hawari M
Published: August 2024

Aim

The incidence of venous thromboembolism (VTE) is high post thoracic surgery, particularly following lung resection. However, there is no consensus to effectively identify and prevent post-op VTE. The modified Caprini score is already used by many surgical specialties, but not all UK Thoracic centres utilise this tool as part of pre-operative assessment. Our centre has implemented the Caprini score since April 2019.

Method

This retrospective single-centre study evaluated patients who underwent thoracic surgery in 2020 and had a diagnosis of VTE at any point post-surgery. Patients were included if they underwent thoracic surgery regardless of pathology or procedure, had a documented Caprini score during pre-operative assessment, and, radiologically confirmed diagnosis of VTE irrespective of imaging modality.

Results

Thirteen patients from a total of 664 thoracic surgery admissions in 2020 were diagnosed with post-op VTE within 3 years. No patient developed VTE within 30 days post-surgery. The shortest period from operation date to VTE diagnosis was 86 days and longest was 1057 days. Seven patients were prescribed Enoxaparin post-discharge and six were not. Of these six patients, three were already on pre-operative anticoagulation therapy for pre-existing co-morbidities.

Conclusions

The Caprini is a useful risk stratification tool in patients undergoing thoracic surgery to prevent VTE within 30 days post-surgery. However, more research is required to analyse specific risk factors and procedure performed to quantify the likelihood of post-op VTE in high-risk patients. This scoring system could then be expanded and implemented within the community based on the timescales of VTE diagnosis in our study.
1176 Osteomyelitis as a Rare Complication of Delayed Diagnosis Spontaneous Bladder Perforation Post-Pelvic Radiotherapy: A Case Report
Authors: EL-Gheryani M , Kumar A
Published: August 2024

Spontaneous, delayed bladder perforation is a rare and serious complication of pelvic radiotherapy. Due to its rarity and late presentation, it usually causes further complications which warrant long inpatient stays before a diagnosis is made. Whilst most published cases highlight peritonitis as a common complication, our case has presented differently with pelvic osteomyelitis as another potential complication. Therefore, our objectives are to increase awareness about this presentation and highlight key aspects of quick diagnosis and management to prevent further complications.

A 76-year-old gentleman, with background of Parkinson’s disease and pelvic radiotherapy for prostate cancer 11 years ago, presented with gradual onset suprapubic pain. He was managed initially with antibiotics and long-term urethral catheter for pelvic osteomyelitis secondary to urinary bladder perforation and then discharged. However, he was readmitted two weeks later with worsening osteomyelitis, delirium and sub-therapeutic Parkinson’s disease. Therefore, bilateral nephrostomies were inserted for acute kidney injury (AKI), further antibiotics given via a peripheral central catheter (PICC) and a prolonged recovery ensued.

The clinical complications of delayed diagnosis of spontaneous bladder perforation in patients with history of pelvic radiotherapy are rare but difficult to manage. In addition, our case is the first one that highlights osteomyelitis as another potential complication and whilst there are different treatment modalities, the decision should be individualised.
1267 A Case of Cardiac Metastasis: Distant Rare Entity of Colorectal Cancer
Authors: Maharjan A , Paul A , Kalaiselvan R
Published: August 2024

Background

Cardiac metastasis arising from colorectal cancer is extremely rare (1.4-2%) and carries a poor prognosis. The literature review suggests only 31 case reports. Incidence might be underestimated as the majority remain clinically asymptomatic. Symptoms if present are consistent with heart failure. There are no established treatment protocols for managing this aggressive condition, necessitating an individualized treatment approach.

Case Report

A 66-year-old female with a past medical history of hypercholesterolemia and smoking was diagnosed with a recto-sigmoid tumour during a bowel cancer screening colonoscopy. The radiological staging was T4a N1b M0. MDT recommended neo-adjuvant radiotherapy ( SCRT). After SCRT restaging, the tumour showed regression in size. She underwent a robotic low anterior resection and de-functioning loop ileostomy, followed by adjuvant chemotherapy with a good response. During the pre-anaesthetic review for reversal of de-functioning loop ileostomy, an echocardiogram and CT PET revealed a mass in the right ventricle wall. This was histologically confirmed as adenocarcinoma on endomyocardial biopsy. MDT advised targeted adjuvant chemotherapy as this mass was inoperable. After 14 cycles of FOLFIRI (Irinotecan+Flurouracil+folinic acid)+Panitumumab, her repeat scans showed a reduction in right ventricular mass. She successfully underwent a reversal of her loop ileostomy with an uneventful recovery.

Conclusions

Colonic carcinoma can spread to the heart, which is aggressively fatal. Standardizing surveillance is crucial to early detection and improved outcomes. Requires further research to better understand this rare disease progression.
138 Intravenous Morphine Negatively Affects the Length of Hospital Stay in Elective Laparoscopic Major Colorectal Surgery
Authors: Moolamannil M C , Georgiades F , Bevan K
Published: August 2024

Aim

To identify if Morphine, a strong opioid with undesirable effects on bowel motility, during post-operative recovery from abdominal surgery , adversely affects the length of hospital stay.

Method

Data was collected retrospectively from patients who underwent elective laparoscopic colorectal surgery over a period of 6 months (July 2022 – December 2022).

Results

64 patients were identified, and 4 patients were excluded due to missing data, with a total of 60 patients included in this study. There was no difference in patient characteristics when right-sided and left-sided colonic resections were compared. 15mg of intravenous (IV) morphine delivered by patient-controlled analgesia (PCA) was identified as the median dose in our cohort. The length of hospital stays in those patients who received less than 15mg of IV morphine (50%) had a mean length of stay in the hospital of 5 days (median 4 days; range: 2-15 days) compared to those receiving more than 15mg with a mean length of stay in hospital of 9 days (median 5.5 days; range: 3-43 days; p<0.001).

Conclusions

Our study reaffirms that increased use of IV morphine has a negative effect on time to opening bowels and a consequent adverse effect on the duration of hospital stay. Hence, alternate analgesia options, strict monitoring, and potential limitation of the total amount of IV morphine prescribed may be beneficial in selected patients undergoing laparoscopic colorectal surgery.
1007 Flipping the Radiology – Teaching ‘Normal Radiological Anatomy’ to UK Medical Students
Authors: Vaghela M , Khera G
Published: August 2024

Aim

Our undergraduate medical education series ‘Normal Radiological Anatomy’ aimed to improve confidence and competence in medical students interpreting plain-film and cross-sectional imaging. This is in contrast to the traditional curriculum, where mostly only pathology and relevant landmarks are identified and discussed.

Method

Four extracurricular, hybrid in-person/virtual, voluntary, lectures covering chest/vascular, abdomen, musculoskeletal, and neuroanatomy were delivered through a UK University Surgical Society and offered to all medical students. After the lectures, the students were surveyed with 7 questions.

Results

A total of 72 students attended at least one lecture. However, only feedback forms from individuals who attended all four lectures and gave feedback on all the lectures were considered. With our inclusion criteria, 48 individuals (67% of total attendees) were considered. Before attending the series, the mean confidence level in interpreting scans was 2.6/5. After attending the series, it was reported to be 4.8/5. The series was praised for its detailed demonstration of normal anatomy in scans; showing students rarely taught/discussed vessels/structures in imaging such as the great cerebral vein of Galen and the adrenal glands.

Conclusions

In contrast to conventional radiological education where students are taught to identify pathology in imaging, it may be more productive to teach students how to recognise normal anatomy on scans, as demonstrated in our series. This approach not only drastically increased student confidence when approaching pathological imaging but potentially helped students identify more pathology on scans as they are more familiar with the appearance of normal anatomy in imaging.
1024 Improving Patient Education and Implementation of Early Mobilisation Following Hip or Knee Replacement Surgery
Authors: Hussain N , Yadati S , Laity A , Murphy Lonergan R
Published: August 2024

Aim

Early mobilisation within the enhanced recovery after surgery (ERAS) pathway has been proven to reduce the risk of postoperative complications following orthopaedic surgery. Currently there is suboptimal compliance with NICE guidance on early mobilisation. This QIP is aimed to improve awareness on the importance of early mobilisation within a 24-hour period post-surgery as well as increase the incidence of mobilisation post intervention.

Method

We interviewed 17 inpatients following total hip or knee replacement surgery on their understanding of the importance of early mobilisation after surgery and whether they had been encouraged to do so by their ward teams. Following analysis, we created and distributed patient-centred information leaflets and posters around orthopaedic units in Chelsea and Westminster hospital, with information regarding the benefits of mobilisation along with the complications avoided.

Results

We measured patient knowledge on early mobilisation via electronic survey following distribution of posters and leaflets on the ward. We also assessed if patients operated on following our intervention were mobilising within 24 hours. We demonstrated increased patient knowledge on the benefits of early mobilisation and an absolute increase in patients mobilising within 24 hours.

Conclusions

Further cycles would be beneficial to determine true statistical significance of this intervention.
1156 Women in Surgery: Perceptions, Actions and Experiences
Authors: Shankar M
Published: August 2024

Aim

Women represent roughly 58% of medical school cohorts however only 28% eventually pursue higher training in surgery in the United Kingdom. This study aimed to explore the perceptions, experiences, and actions of women towards surgical specialties.

Method

An electronic survey was distributed to surgeons, trainees, and medical students who identified as female across the United Kingdom for a one-time submission per responder. The link was kept active for 72 hours. 237 complete responses were recorded and statistically analysed.

Results

A total of 112 participants (47.2%) felt that pay inequity based on gender was the biggest deterrent to a career in surgery. Orthopaedic/Trauma Surgery was reported as the most sexist surgical specialty with 36.2% of the responders. The most common action preferred to deal with sexism in the workplace was to demand an apology (40.9%). Overall, family and career conflicts, gender bias, and lack of motivating factors (female role models, mentors) were perceived barriers for women to pursue surgical careers.

Conclusions

These findings highlight the challenges perceived by women to pursue surgical careers. Women who feel biased against are less inclined to choose surgical specialties. Changes must be made to be more inclusive. This study may help guide transformative adaptations within surgical departments.
136 Epidemiology and 5-Year Outcome of Operated Cases of Intracranial Meningioma in a Tertiary Care Centre in Nepal in the Last 10 Years
Authors: Shrestha S , Karmacharya D , Shrestha P
Published: August 2024

Aim

To know the epidemiology and 5-year outcome of operated cases of intracranial meningioma in a tertiary care centre in Nepal in the last 10 years.

Method

This is a retrospective study from the time period of 10 years, from 2010 to 2020 in the Neurosurgery department of Upendra Devkota Memorial National Institute of Neurological and Allied Sciences. The inclusion criteria for the study consist of all the patients who underwent an operation with proven histopathological findings of meningioma. The Glasgow Outcome Score was noted for the 5-year outcome.

Results

A total of 239 patients were operated over the span of 10 years. The mean age of presentation was 47 years. The female-to-male ratio was found to be 2.1:1. The most common site of meningioma was found to be convexity meningioma followed by parafalcine meningioma and sphenoid wing meningioma. The most common histopathological finding was a transitional meningioma, WHO Grade I, followed by fibrous and atypical meningioma. Out of 239 cases, 68 patients had not yet reached 5 years post-operative period. Outcome after 5 years postoperative period, 140 patients (81.87%) had good recovery, 4 patients (2.34%) had moderate disability, 2 patients (1.17%) had a severe disability, 1 patient (0.58%) were in a vegetative state and 24 patients (14.04%) had died. Among all the patients who were operated on, mortality was found to be 10.04%.

Conclusions

Intracranial meningiomas are slow-growing extraaxial tumours, usually benign, most commonly located along convexities, parafalcine, parasagittal and sphenoid ridges. Most are cured if completely removed, which is not always possible.
238 Management of Extravasation Injuries Referred to the Plastic Surgery Department in a Regional Centre
Authors: Evans J , Ahmed O
Published: August 2024

Aim

To assess the volume and outcome of extravasation injuries referred to the plastic surgery department in a regional centre, and to devise and implement a protocol to improve outcomes.

Method

A retrospective review was undertaken of extravasation injuries referred to the plastic surgery department between August 2021 and November 2022. Data collected included time of injury and subsequent referral, drug type and volume, seniority of reviewer and subsequent outcomes including whether patients required surgery. A total of 18 patients were included in this study.

Results

None of the patients had documented first aid from their home teams. 5 of the 18 patients (28%) required surgery (debridement + skin grafting+/- BTM).

Conclusions

Delays in referral to plastic surgery and the lack of first aid from the referring teams may result in poorer outcomes from extravasation injuries. A guideline should be accessible for all clinicians to facilitate early referral and appropriate first aid measures.
745 Improving Time to ERCP for Acute Gallstone Cholangitis Admissions at a District General Hospital: A Closed Loop Audit
Authors: Boyce L
Published: August 2024

Background

NICE guidelines recommend prompt endoscopic retrograde cholangiopancreatography (ERCP) within 72 hours for adults with acute gallstone cholangitis, especially in moderate-to-severe cases. We audited our management of obstructive gallstone disease to enhance timely access to ERCP.

Method

We conducted a closed loop audit at a UK district general hospital, assessing time to ERCP for patients with acute gallstone cholangitis. Severity was graded using the 2018 Tokyo Guidelines. Data was collected over a 5-month period (01/05/2023 to 01/10/2023), analysed and presented to the surgical multi-disciplinary team. Additional referral pathways to 3 nearby tertiary care centre for ERCP were established. Post-intervention admissions were re-audited over a second 5-month period (01/01/2023 to 01/06/2023) to assess the effect of the new referral pathways.

Results

Forty-one patients underwent ERCP for acute gallstone cholangitis. Pre-intervention, median time to ERCP overall was 10 days (5–24), 8 days (5–19) for moderate-to-severe cases, and 28 days (9–46) for mild cases. Post-intervention, median time to ERCP overall was 6 days (4–9), 6 days (6–8) for moderate-to-severe cases, and 4 days (4–25) for mild cases. Median length of stay pre- and post-intervention was 8 (6–13) and 7 days (4–10), respectively.

Conclusions

By establishing referral pathways to tertiary care centres, we successfully reduced time to ERCP for local patients with moderate-to-severe cases. This change contributed to shorter waiting times for ERCP in mild cases and decreased overall length of stay. Collaborative efforts between district general hospitals and tertiary centres improve outcomes in the management of acute gallstone cholangitis.
998 Reducing Medical Student Anxiety and Stress by Providing Guidance on Specialty Training and Self-Assessment Portfolios Early on Within Their Medical School Careers
Authors: Patel R D , Lonergan R M , Bartholomew B
Published: August 2024

Aim

With CST applications becoming increasingly competitive and relying on a strong portfolio, third year is the perfect time to teach medical students how to maximise points. It gives them ample time to prepare and structure their projects with a clear goal in mind. However, they are often unaware of where to begin causing avoidable stress and subsequent regret. Our aim is to explore medical students’ knowledge and awareness of specialty training portfolios as well as to provide guidance on specialty training and self-assessment portfolios through a near-peer talk and to evaluate usefulness of this talk for third year students.

Method

We conducted data collection via an anonymous survey, to establish baseline understanding of CST and other specialty training pathways, as well as interest in learning more. We hosted an optional lecture for third year students on specialty training portfolios by a core surgical trainee and gathered post-session feedback on understanding of specialty pathways and applications. We specifically asked how confident students felt they could organise a portfolio.

Results

Post-session, confidence levels increased while stress related to CST application decreased. A predominant theme was the usefulness of this talk early in the undergraduate programme, so students felt they had clear goals, aims and time to develop their portfolios.

Conclusions

Students feel unclear and anxious about specialty training. A clear understanding of specialty recruitment and postgraduate portfolio empowers students to work towards their career goals in a structured and manageable way. Early dissemination of information on CST applications reduces anxiety and improves confidence.
1270 Enhancing Mobility During Mealtimes on an Orthopaedic Ward: A Collaborative Intervention Approach
Authors: Al-Azzawi H , Keehan R , Jervis C , Fern S Archer , Rajab A , Ein S Abu , Akbar S , Smith A
Published: August 2024

Aim

This quality improvement project aimed to enhance patient mobility by engaging nursing staff in identifying barriers and implementing strategies to increase number of patients sitting out of bed during mealtimes, on a trauma and orthopaedics ward.

Method

Data collection occurred over three weeks (Monday to Friday) to assess patient mobility during mealtimes. Subsequently, the collected data was presented to nursing assistant, staff nurses, the ward sister, and the matron. Collaborative discussions led to the implementation of four key interventions: empowering all staff to engage in mobilisation, reprioritising night staff tasks to include getting patients out of bed, establishing a dedicated mobilisation time of 0730-0800, and communication of these interventions daily during the nursing safety brief. Following the intervention, another week of data collection was conducted.

Results

Initially, only 53% of patients were sitting out of bed during mealtimes. Post-intervention, a significant improvement was observed, with 75% of patients sitting out of bed during mealtimes.

Conclusions

The implementation of targeted interventions led to a significant improvement in patient mobility during mealtimes. By incorporating dedicated time for mobilisation and modifying workflow priorities, the healthcare team successfully increased the number of pts sitting out of bed for mealtimes. These interventions highlight the significance of empowering staff to make their own decisions on how best to achieve shared goals. Such interventions, embedded within routine care practices, have the potential to enhance patient mobility and overall well-being in orthopaedic settings.
350 Adding Education Fellows to Surgical PTWR Improves Medical Student Learning
Authors: Clay W , Lau K , Kimyongur S , Skinner H , Ravi K
Published: August 2024

Aim

To assess if there is any improvement in student evaluation of surgical PTWR when a surgical education fellow is facilitating.

Method

Medical students from two medical schools on surgical placement in a district general hospital were encouraged to attend one surgical post-take ward round during their allocated Surgical Assessment Unit week. The students ranged from their first to final clinical placement. Students were then asked to complete a questionnaire, detailing their thoughts and feelings about their learning needs, objectives, and overall understanding of the cases they saw on the round. There was also space for free text. The students were later invited to join another surgical PTWR with one or more surgical education fellows present in a non-clinical capacity to facilitate the students’ learning by discussing the clinical scenarios in depth. The students were then given the opportunity to fill out a second identical questionnaire and the results were compared.

Results

22 students completed the initial questionnaire, and 23 students completed the post-intervention questionnaire. The results showed that 59.1% students agreed or strongly agreed their learning needs were met and addressed initially, rising to 95.6% on the fellow-facilitated round with 4.3% answering neither agree nor disagree. No students selected disagree/strongly disagree to this question.

Conclusions

The surgical post take ward round is already a generally useful learning tool for medical students on their surgical placements, but the addition of an education fellow in a non-clinical capacity can improve students’ experience, learning and understanding of common post-take surgical pathologies.
421 Surgical Bedside Teaching at St Helier Hospital – a Quality Improvement Project
Authors: Norris C , Al-Jasim A , Lewis T
Published: August 2024

Aim

To assess the impact of bedside sessions on medical students’ confidence in clinical assessment. It aims to assess strengths and weaknesses and guide further interventions.

Method

It employed a mixed-methods approach using both quantitative and qualitative measures in anonymised surveys. The intervention that was introduced was a ‘learning objective ticket’, whereby learning objectives were distributed and discussed prior to the session.

Results

There were 22 responses in the first cycle of the evaluation. Quantitative data revealed that the mean confidence in history taking was 3.55(+/- 0.59) before the session, and 4.32(+/-0.56) after the session (P<0.001).There was also a significantly significant difference in mean confidence levels in examination skills (p<0.001) with confidence going from 3.14(+/-0.56), to 4.45(+/-0.51). Qualitative data highlighted areas of improvement such as clearer learning objectives, greater alignment with assessments and better adherence to time constraints.

There were 18 responses to the survey in the second cycle of this evaluation. Quantitative results showed that 88% of students ‘strongly agreed’ that the learning objectives were clear, 88% of students ’strongly agreed’ learning objectives were relevant, and 72.2% ‘strongly agreed’ that they had met their learning objectives. 12 out of 18 responders (66.7%) ‘strongly agreed’ that the timings of the session were adhered to.

Conclusions

Overall bedside teaching sessions are a valuable tool in undergraduate surgical education. Their impact can be further advanced by linking with learning objective as per constructivist alignment theory. Applying closer alignment with formal assessment could further improve these sessions.
708 Innovating Low-Cost Automated Progress Tracking System (APS) for Laparoscopic Cholecystectomy Simulation (LaChSi) Models in the Lower Middle-Income Countries (LMICs) and Its Application for the Global HPB Surgery in Resource-Limited Settings
Authors: Karki B B , Sharma S , Thapa B , Neupane P , Phuyal S , Shrestha S , Katuwal S , Satyal S , Loubani M
Published: August 2024

Aim

Global HPB surgery aims to provide safe, timely, accessible surgical care and to address the healthcare disparities emphasising equity & sustainability in care delivery for the Hepato-Pancreatico-Biliary (HPB) disease on a global scale, which can be achieved through comprehensive simulation-based surgical training in resource-limited settings. The aim is to develop a low-cost Laparoscopic Cholecystectomy Simulation (LaChSi) model and automated Progress Tracking System (APS) and to ensure a realistic and accurate representation of the laparoscopic cholecystectomy (LC) procedure.

Method

A silicon model replica of the biliary tree fabricated with wires traversing the biliary tree. These wires are connected to a printed circuit board (PCB) at the model's base, linked to a microcontroller and a computer which will track the skills progress of the trainee. Any erroneous manipulation or damage to the bile duct triggers identification, resulting in a negative score for the surgeon and highlights on the computer screen. This facilitates the evaluation of trainee surgeon skills while concurrently enhancing their surgical skills.

Results

The successful adaptation and validation of the APS for laparoscopic appendicectomy models have demonstrated its effectiveness and the suitability of its application for LC. The development of these low-cost LaChSi models will aid in enriching the global HPB workforce, in resource-limited settings.

Conclusions

There is an unmet need for the development of a Low-Cost simulation model in LMICs and these models can provide a safe and standardised method for HPB simulation training before operating on real patients addressing the core value of Global HPB surgery.
896 Near-Peer Teaching (NPT) to Enhance Surgical Education in the Medical Curriculum: A Review of the Current Literature and Recommendations for the Future
Authors: Lee K B C , Rojanathagoon T , Suvarna R , Choi Y S , Chang F
Published: August 2024

Aim

There is increasing evidence of insufficient surgical education in the medical curriculum and a growing sentiment amongst medical students of poor confidence in the operating room (OR). Near-Peer Teaching (NPT) has emerged as a common pedagogical solution utilising cognitive congruence to counter this, whereby senior medical students and recent graduates are recruited as near-peer tutors. We aim to review the successes and areas for improvement in the current literature.

Method

A comprehensive literature search was performed on EMBASE, PubMed and MedLine.

Results

Pre-post questionnaire comparison from a NPT-led surgical skills course reported significantly increased self-perceived confidence in performing some of 8 surgical domains. Providing basic surgical skills in conjunction with 'Flipped Classroom' yielded significantly higher confidence in performing all sutures and knot-ties assessed. Another workshop had medical students achieve double the number of sutures and improved suturing technique post-session. Increased confidence in surgical skills and OR were additionally achieved through a NPT-led OR simulating environment. NPT-led surgical and clinical anatomy courses equipped students with higher confidence and comfort assisting in the OR. Commonly, the informal, perceived 'low-risk' kinaesthetic environment is described to ease feelings of anxiety and be conducive to surgical education. NPT furthermore reported benefits for instructors pertaining to self-efficacy, teaching skills, surgical confidence, and knowledge consolidation.

Conclusions

NPT enhances surgical career interests and improves outcomes of surgical education for both tutors and tutees, when delivered in addition to surgical teachings in the curriculum. The design of NPT and training of tutors however, ought to be supervised by a senior surgical staff.
1062 Out of Theatre Training (OTT) for Vascular Surgery
Authors: Elkawafi M , Alnatsheh W , Alshiek A , Greaves N
Published: August 2024

Introduction

We recognise the challenges faced by Pre-registrar Doctors in acquiring vascular technical skills in theatre . anastomosis and patching are performed with clamped arteries and margins for errors are slim . To bridge the gap between patient safety and training, we introduced Out of Theatre Training ( OTT) in our units. we provide one-to-one training with stress-free and patient-safe environment with consistent feedback and continuous practice . This was started as a pilot in the vascular department, and we aim to provide it to the whole hospital surgical cohort.

Aim

Improve training for pre-registrar Doctors in vascular techniques and evaluate the efficacy of OTT in our unit.

Method

Each trainee was trained using with at least one session on both patch and anastomosis . following this we provide each trainee with personal suturing equipment, grafts, and patches to use in their own time to practice. They send pictures of their work for feedback. OTT was evaluated using pre and post survey to collect both subjective and objective data

Results

7 pre-registrar doctors involved in the pilot, 3 CST,4 F2. trainees evaluated this as an excellent training opportunity. Each participant performed at least 2 anastomosis/patches with 1 on their own. Each trainee acquired at least 2 DOPS in their portfolio. Trainees found themselves more confident in performing the procedure in theatre following this . Further granular data was collected.

Conclusions

We would like to coin (OTT) as a leading method in training in a patient safe, stress-free, trainee focused environment. We encourage other specialities to follow this method.
463 Single-use Products and Plastics Contribute Significantly to Surgical Waste and the Carbon Footprint of Tonsillectomies in the United Kingdom
Authors: Moses O , Cahill G , Miraftab-Salo O , Bhutta M F , Stanford-Moore G B
Published: August 2024

Aim

Tonsillectomy is the fifth highest volume surgical procedure in England. The aims of this study were to characterise the cost, waste, and carbon footprint of equipment used in tonsillectomies at our Trust.

Method

A series of tonsillectomies were observed at three sites in our Trust. Details of the equipment were prospectively collected. This included: item and packaging materials; the quantity and reusability of items opened, used, and wasted; and the weight of recyclable, non-recyclable, and clinical waste produced per tonsillectomy. Reusable instrument trays were excluded from cost analysis. Overall carbon footprint was reported in carbon dioxide equivalents (CO2e) and calculated with published estimates of carbon emissions from individual items’ cradle-to-gate production, sterilisation, and waste streams.

Results

20 tonsillectomies were included for analysis. The mean cost of tonsillectomy equipment was 137.75 GBP. 378 items were recorded in total – 70.5% were single-use, of which 91.6% were either composed of, or packaged in, plastic. The mean carbon footprint of the equipment was 6.78kg CO2e per tonsillectomy. 3.93kg CO2e came from single-use items, with 0.11kg CO2e from unused equipment. The incineration of clinical waste (mean weight 0.74kg) caused an additional 0.79kg CO2e of emissions per tonsillectomy.

Conclusions

Single-use equipment represented a significant carbon hotspot in tonsillectomies performed at our Trust. Reusable alternatives exist for many single-use items, and we suggest these be included in autoclavable sets to maximise reusability and minimise both cost and waste in operating rooms. These adjustments may lower emissions from their use and incineration, thus improving sustainability in surgery.
265 Intracranial Haemorrhage Following Spinal Surgery: A Systematic Review of a Rare but Serious Complication
Authors: Kakroo B , Magan P
Published: August 2024

Aim

The aim of this systematic review is to comprehensively gather and analyse all available literature on intracerebral haemorrhages (ICH) following spinal surgery. We aim to elucidate pre/intraoperative variables such as surgery type, patient-specific risk factors and dural opening and also highlight postoperative variables such as symptoms, intervention, and eventual outcome. We have incorporated 134 studies for this analysis making it the most comprehensive review of this topic thus far.

Method

The search engines used for this systematic review were ScienceDirect, PubMed, Google Scholar, Wiley, SpringerLink and SAGE journals, identifying all cases of intracranial haemorrhage following spinal surgery known of, up until the end of 2022. Keywords that were searched included: “intracranial bleed”, “intracerebral haemorrhage”, “spinal surgery complications”, “bleed post spinal surgery”, “spinal surgery complication”, “incidental durotomy “ and “spinal surgery bleed”.

Results

This section will be presented in the form of tables and graphs. This review comprised of 134 cases, of which 52 (39.7%) were male and 79 (60.3%) were female. We report lumbosacral surgery to be the most common level associated with ICH constituting 63.1% of all cases. 50 patients (41.3%) developed symptoms within 24hrs of the index spinal operation. Focal neurological deficit is the most commonly reported presentation which can encompass a breadth of clinical signs.

Conclusions

We report all known cases of ICH following spinal surgery, which remains a rare occurrence and analyse patient risk factors. We conclude that focal neurological signs in any patient with possible CSF leakage through durotomy should prompt a low threshold to request brain imaging.