bluuebunny/crossref_metadata_2025 huggingface dataset:
807 A Review of The Applications of Autologous Fascia Lata Grafts in Reconstructive Surgery
Authors: Baldwin A , Lahiri A
Published: May 2021

Background

We sought to review current applications of fascia lata autografts and update the original collection of uses proposed almost a century ago, thereby revealing the full extent of uses available to the contemporary reconstructive surgeon.

Method

A comprehensive literature search of peer-reviewed articles listed within PubMed and Medline was performed.

Results

The properties of autologous fascia lata grafts are presented, a technique for its harvest and the numerous uses of this material in reconstructive surgery. Specifically, its applications in head and neck surgery, surgery of the limbs, abdominal wall reconstruction and penile reconstruction are reviewed.

There is limited data on donor site morbidity, but complications appear to be uncommon. However, it was established that the reported risk of muscle herniation varies greatly in the available literature from 0-36% and appears to be related to the width of tissue harvested.

Conclusions

Autologous fascia lata grafts are a viable and versatile material in the armamentarium of a reconstructive surgeon, that, with careful planning, can be used with minimal donor site morbidity. This is especially true in lower resource settings where a surgeon may not have access to allogenic material and autologous grafts can provide an easily accessible, cheaper, and practical alternative.
830 Why We Should Be Looking for A Diagonal Ear Lobe Crease In ENT. A Meta-Analysis of Diagonal Ear Lobe Crease and Coronary Artery Disease
Authors: Curtis J , Walford S
Published: May 2021

Introduction

An association between a diagonal ear lobe crease (DELC) and cardiovascular disease, was first suggested by Sanders T. Frank in 1973(1). Since then, there have been numerous further studies that have investigated the association of ‘Frank’s Sign’ with carotid disease, cerebral vascular disease, and diabetic retinopathy. This review looks to see if there is a significant association between the presence of a DELC and coronary artery disease (CAD).

Method

Meta-analysis of selected studies, published between 1974 and 2017, using the PRISMA checklist(2).

Results

We included 12 studies in the pooled analysis, which included 2415 cases and 2545 controls. Our study found that patients with DELC, have an increased likelihood of having CAD (OR 4.61). Also, despite some previous studies suggesting that DELC was simply a result of age, all ten of the included studies that looked at this found that the relationship between DELC and CAD was independent of both age and other known cardiovascular risk factors.

Conclusions

We found that DELC is associated with CAD independently of other known cardiovascular risk factors, including age. Patients with DELC appear to have a substantially increased risk of CAD, and this may be higher for patients with bilateral DELC.
863 Peri-Implant Fluid Collection in Breast Reconstruction and Aesthetic Surgery
Authors: Karagiannidis G , Mallidis E
Published: May 2021

Introduction

Peri-implant fluid more than 6 months from surgery is a known complication of breast surgery.Differential diagnosis includes infection, inflammation,implant rupture and haematoma.Other than infection raised no concern until the identification of Breast Implant Associated Anaplastic Large Cell Lymphoma(BIA-ALCL).

Method

Retrospective electronic data collection for women 18 years or older who met the following inclusion criteria:(a)oncoplastic and/or cosmetic reconstructive surgery with placement of implant(b)peri-implant fluid collection after 6-36 months.

Results

In total,17 women with implants with a mean age of 56 years were included in the study.The mean time between reconstructive surgery and the peri-implant fluid collection was 23 months.The median peri-implant fluid collection size was 143 ml.14 of the 17 peri-implant fluid collections were benign.12 of 14 had polyurethane-coated textured implants.4 of the 17 were BIA-ALCL.

Conclusions

The current literature suggests that late peri-implant seromas arise from friction as the implant moves within the cavity and that this friction is increased with textured rather than smooth implants.In our unit 12/14 of the benign collections appeared in reconstructions with polyurethane implants.Furthermore,BIA-ALCL should always be considered in this situation and aspirate should be sent for cytology.Is this change in polyurethane implants a new entity?
870 Early Weight Bearing In > 60 Years - Is It All A Dream?
Authors: Kapoor S , Choudhry B , Ahmed M
Published: May 2021

Background: Early weight bearing (EWB) is increasingly considered acceptable in surgically managed fractures. However, there are two different outlooks for rehabilitation. EWB in a biologically weak bone may lead to implant failure compared to EWB being beneficial for quicker recovery. We aim to review outcomes for EWB in surgically managed fragility fractures.

Method: This was a retrospective analysis; data was collected from departmental records of operative fixation of lower limb injuries in patients above 60 years. We excluded patients who had procedures for proximal femoral fractures and polytrauma. We compared SF-12 scores, complications, and reoperation rates in those that were EWB to those that were at the conventional 6-week mark.

Results: During a 6-month period from November 2019 to April 2020 we performed 60 operations. N = 30 surgeries were performed in EWB group versus 30 surgeries in late weight bearing group (LWB). The average physical and mental SF-12 score in EWB group was 44.82 and 56.36 compared to a SF-12 score of 44.51and 52.18 in LWB.

Conclusions

We found that the SF-12 scores were different despite EWB. There was no evidence of early complications in the EWB group. Therefore, we advocate EWB for group >60 who were known to have osteoporosis.
876 A Sweeping Success – Management of Type 1A Endoleak Using A Chimney Graft Technique
Authors: O'Sullivan M , Wood P , Kavanagh E , Moloney T
Published: May 2021

Endoleak is a recognised complication after Endovascular Abdominal Aortic Aneurysm Repair (EVAR). In the setting of a rapidly expanding aneurysm – time is of the essence. Perfusion of the renal arteries, superior mesenteric artery (SMA) and coeliac artery must be maintained. To facilitate this a customised fenestrated endograft may be used or a chimney endovascular aortic repair (CHEVAR).

A 78-year-old female initially underwent EVAR in 2016 for a ruptured 6.9cm AAA. She made a good recovery at that time. She was enlisted in a surveillance programme. Her most recent duplex showed an aneurysmal sac of 10cm with associated type 1A endoleak. Given these findings waiting for a fenestrated graft posed an unacceptable delay. She underwent a CHEVAR with bilateral axillary and right femoral access. She had chimney stents deployed in the renal arteries and SMA with aortic cuff extension proximally. Her completion angiogram showed good proximal seal with patent stents. She was unexpectedly unstable post-operatively and had a CT scan which revealed a re-ruptured aneurysm. She was treated in ICU and recovered well. Repeat imaging showed good flow in all 4 grafts with no endoleak.

This case demonstrates the challenges of managing endoleak post EVAR and the importance of robust surveillance and appropriate, timely treatment.
924 The Effect of COVID On the Skin Cancer Referral Pathway
Authors: Ali S , Dunne J
Published: May 2021

Introduction

Due to COVID resulting in all elective surgeries being cancelled; it was thought that patients with suspected skin cancer maybe seeing a specialist and having surgery later than. So, to tackle this as lockdown occurred, the Plastic Surgery department at Charing Cross Hospital secured a minor operation room in outpatients, to keep treating suspected skin cancer. But did it work?

Method

Data was collected from an interval of 2 months before the pandemic (December-January) and 2 months post the pandemic (April-May). Each suspected skin cancer patient who was put on the two weeks wait referral during that time had their receipt of referral, first appointment with a specialist and date of surgery (if that was done) recorded.

Results

Before COVID 81% of patients were seen by a specialist in 2 weeks compared to 89% after COVID. Also, 78% of patients had achieved surgery within 62 days before the pandemic, compared to 86% after the pandemic.

Conclusions

In conclusion, the results showed that the implementation of the minor operation room at short notice enabled the department to meet capacity. Thus, it is utilisation going forward can improve how quickly skin cancers are managed.
942 Cost Effectiveness of Percutaneous EVARs Compared to Standard Cut Down
Authors: Zaki S , Hossack M , Makar R
Published: May 2021

Introduction

Percutaneous EVAR (PEVAR) is gaining popularity worldwide. Our aim is to identify whether PEVAR is cost effective compared to open access.

Method

We retrospectively identified patients undergoing EVAR for unruptured AAA over a 4-year period (April 2014- December 2018). Demographic, procedural, and financial data were collected. Exclusion criteria were complex EVARs and EVARs with planned adjunct procedures. Outcome measures were length of stay (LOS), number of Perclose devices used, number of failures, need for adjuncts, theatre time used, and total cost of each.

Results

318 patients (88.4% male) underwent EVAR between January 2015 and October 2018, average age 76.9 years and median maximal aortic diameter 60mm. 61 EVARs were planned for open access, and a sample of the latest 92 consecutive PEVARs were selected to prevent bias. The median LOS following PEVAR was 1 day less (2 vs 3 days). Mean Proglides used were 5. 2.7% of devices failed, and no surgical cut-down was required in this cohort. Mean theatre time used for PEVAR was 179 minutes vs 213 minutes for open access. All considered, PEVARs cost £124 less.

Conclusions

PEVAR is associated with a shorter length of hospital stay and is more cost effective than open access.
947 Mycotic Pseudoaneurysm Of the Common Carotid Artery: A Rare Neck Lump
Authors: Kenyon O , Tanna R , Sharma V , Kullar P
Published: May 2021

Mycotic pseudoaneurysms are rare, potentially fatal arterial wall infections of either fungal or bacterial origin. The estimated incidence is 20 cases/decade. Trauma is the commonest cause and in 25% the cause remains unknown.

A 62-year-old man presented with a three-week history of a non-tender enlarging neck lump associated with hoarseness of voice. He was apyrexial with no stridor nor dysphagia. The lump measured 10x10cm at levels II-III on the left side of the neck with no overlying erythema. After normal oral examination, flexible nasendoscopy revealed a left-sided pharyngeal swelling occluding 25% of the airway. He was commenced on intravenous antibiotics and steroids. A contrast enhanced CT demonstrated a mycotic pseudoaneurysm of the left common carotid artery (CCA) with a linear foreign body exiting the oesophagus. He underwent emergency surgery with the vascular team to excise 3cm of unhealthy CCA with long saphenous vein graft repair. Neck exploration and panendoscopy found no further defects including no foreign body. He made an excellent recovery and is awaiting an injection thyroplasty to manage his complete left vocal cord palsy.

Although rare, vascular injury and subsequent pseudoaneurysm is an important differential and should always be considered in those presenting with neck swelling.
948 Visceral Artery Aneurysms- A Single Centre Experience Over 6 Years
Authors: Zaki S , Ashrafi M , Balakrishnan A
Published: May 2021

Introduction

The incidence of visceral artery aneurysms (VAA) varies from 0.01-0.1%. They are significant with a mortality risk of up to 75% if ruptured. Given there are no national guidelines we decided to conduct this study to assess the management of VAA in our trust and recommend local guidelines.

Method

We retrospectively identified patients who had a detected VAA between April 2014 and April 2020. Medical records and relevant imaging were reviewed in detail. MDT outcomes and subsequent mortalities noted.

Results

We identified 62 VAA in 59 patients (23 male), median age 65 years, and mean diameter 18.1 mm. 95 % were detected on CT, the indication was mostly malignancy. MDT outcomes were to continue surveillance for 43 patients with yearly scans, 5 patients had primary surgical repair, 7 patients had endovascular interventions, 1 patient had primary endovascular intervention that failed and required surgical intervention. 7 patients were discharged from follow up due to age and size (12 mm) or VAA completely thrombosed.

Conclusions

In our unit decisions to intervene were based on size > 20mm, rapid increase in size on surveillance, the presence of portal hypertension or possibly the patients’ young age. There were no mortalities linked to VAA.
974 Paget-Schroetter Syndrome in A Young Fitness Enthusiast with A Negative D-Dimer. Highlighting the Balance Between Clinical Suspicion and Diagnostic Modalities
Authors: Gani A , Lucas G , Ellis C , El-Karim A , Refson J
Published: May 2021

This case illustrates an athletic 22-year-old, who presented to the hospital with a 3-week history of spontaneous right arm ache, discolouration and swelling. His blood tests were normal, with a negative D-dimer (<150ng/ml). He underwent a CT venogram for suspicion of venous obstruction which was unremarkable. However due to a high clinical suspicion, an ultrasound doppler was performed. This identified the presence of axillary-subclavian thrombosis which in conjunction with other clinical and radiological parameters confirmed the diagnosis of Paget-Schroetter Syndrome (PSS). Our patient was commenced on anticoagulation as the venous obstruction was suspected to be sub-acute with clinical suggestion of collateral formation. Unfortunately, his symptoms failed to resolve over a 6-month period, and he underwent an elective right rib resection with right subclavian bypass using the great saphenous vein with good outcome post-operatively.

PSS is a rare manifestation of venous thoracic outlet syndrome (TOS) commonly seen in young, healthy, athletic individuals. Despite the high effectiveness of D-Dimers in ruling out acute thrombotic process and the accuracy of dedicated CT angiography in excluding vascular thrombotic events, both tests proved inconclusive in this particular case. This latter observation highlights the importance of the clinical context, and risk profiling in guiding results interpretation.
983 Patient’s Satisfaction of Virtual Clinics for Post-Cardiothoracic Surgery Follow Up During COVID
Authors: Durand-Hill M , Ikenna Ike D , n Bhardwaj Shah A , Nijhawan Aditi , Smith Alex , Shipolini Alex , Stamenkovic Sasha
Published: May 2021

Introduction

With advances in technology, virtual clinics are becoming increasingly attractive as a tool for outpatient follow up care. During the COVID-19 pandemic, the implementation of virtual outpatient clinics was crucial, for continued service provision despite social distancing guidelines. We aimed to ascertain patient satisfaction with virtual clinics in cardiothoracic surgery.

Method

Forty patients who attended virtual clinics, post cardiothoracic surgery, were invited to provide feedback by means of a questionnaire. Feedback was gathered by junior doctors.

Results

Thirty-four patients (20 had never had a telephone clinic appointment) agreed to provide feedback. Fifty percent of patients had not been seen since their operation. 91.2% (n = 31) of patients felt that the telephone consultation met their expectations/needs. Patient reported advantages of telephone consultations included: less concern regarding exposure to infection, no concern regarding parking, no travel time and less time off work. 79.4% (n = 27) would have preferred a face-to-face appointment. Patient reported disadvantages of telephone consultations were poor reception, felt they weren’t listened to and would have preferred to have been physically examined.

Conclusions

Patients were satisfied with telephone clinics for routine follow up post cardiothoracic surgery. However, the majority would have preferred face to face appointments.
995 Clinical Outcomes Following Incomplete Colonoscopy
Authors: Khan K S , McCulloch C
Published: May 2021

Introduction

Following incomplete colonoscopy (IC) it is reported that there is up to ﬁve-fold increased risk of colorectal cancer. Our aim was to determine the ﬁnal clinical outcome for patients with a prior IC.

Method

A multi-centre retrospective observational study involving three endoscopy units. All consecutive patients having colonoscopy from over 18 months were analysed. Exclusion criteria included IC was due to obstructing cancer, follow up was not performed due to non-attendance at clinic or investigation and incomplete data set. Electronic notes were analysed to determine patient’s ﬁnal clinical outcome. All patients were followed up for minimum of six months.

Results

Of the 8,490 colonoscopies, 733 (8.6%) were IC. 86 (11.7%) were excluded. Of the 647 included, 469 (72.4%) were females and 473 (73.1%) has further colonic investigations. Secondary investigations were: CT colonography 169 (35.7%), repeat colonoscopy 161 (34.0%), barium enema 95 (20.1%) and others 48 (10.1%). The repeat colonoscopy group achieved a complete colonoscopy in 111 (68.9%) patients. For those who had further investigations 15 (3.2%) had colorectal cancer and 12 (2.5%) has polyps ≥1cm.

Conclusions

There is significant risk of missing colorectal malignancy and large polyps following IC. Further colonic investigations should be carried out in this cohort of patients.
1023 The Role of Social Media in Disseminating Plastic Surgery Research: The Relationship Between Citations, Altmetrics and Article Characteristics
Authors: Grant M , Scott-Bridge K , Wade R
Published: May 2021

Background

Social media (SoMe) enable the dissemination of content immediately and directly to interested end-users. Alternative metrics (altmetrics) are non-traditional bibliometrics which describe the exposure and impact of an article on freely available platforms such as Twitter and Facebook. Altmetrics within days of publication are associated with ultimate citation counts in various medical disciplines, except plastic surgery which represents the rationale for this study.

Method

Altmetric explorer was used to extract altmetrics and citation rates for articles published during 2018 in Plastic and Reconstructive Surgery (PRS), the Journal of Plastic, Reconstructive and Aesthetic Surgery, the Annals of Plastics Surgery and Plastic Surgery. Multivariable negative binomial regression was used to estimate the relationship between citations and predictors (presented as the incidence rate ratio, IRR with 95% confidence interval, CI).

Results

Overall, 1215 articles were captured. On average, articles published in PRS were cited nearly five times as often as articles published elsewhere (adjusted IRR 4.77 [95% CI 2.36, 9.62]). Overall, SoMe mentions were positively associated with citation rates (adjusted IRR 1.01 [95% CI 1.01, 1.1]); marginal analysis showed that 45 mentions translated to one extra citation.

Conclusions

Dissemination of plastic surgery research through SoMe channels are associated with significant improvements in short term citations rates.
14 Orthopaedic Post-Operative Elective Proforma
Authors: Castelhano R , Kakkar V
Published: May 2021

Introduction

Post-operative daily reviews are essential for a safer post-op recovery and must recognise, early, potential complications and prevent their advance. The fast turnover of Junior Doctors and often T&O being their first surgical rotation, leads to a decrease in knowledge of which aspects are important to assess in a post-op patient. The aim of this project was to create a proforma that helps in assessing elective post-op patients and reduce mistakes.

Method

QI methodology was applied and a proforma was created and made available in every set of notes of elective patients. Awareness was raised about the proforma which was done at the time of the induction of the new doctors which corresponded to separate PDSA cycles.

Results

Following cycle 1, the adhesion was 98%. VTEP, analgesia, Xray reviewed, examinations were documented in 100% of the patients. The PDSA cycle 2 coincided with the new incoming doctors, despite the efforts, there was poor compliance. The notes were reviewed: VTEP, analgesia and examination were not documented, post-op x-rays were reviewed in 60%.

Conclusions

The PDSA cycle 2 showed how the proforma increases patient safety with good documentation and should continue to be used by the Department.
23 Reaudit and Completing the Audit Cycle of Quality of Informed Consent for Surgery on Neck of Femur Fracture in Royal Stoke University Hospital
Authors: Khaleeq T , Hanif U , Maqsood Y , Ahmed K , Patel A
Published: May 2021

Using guidelines highlighted by the British Orthopaedic Association an reaudit was performed within our department to assess the adequacy of informed consent for NOF fractures to complete the audit cycle. 50 patients were included in the Audit and reaudit. Risk was classified as common, less common, rare and ‘other’. The adequacy of informed consent was evaluated by assessing the quality and accuracy of documentation. Infection, bleeding risks, clots and anaesthetic risks were documented in all patients (100%). Areas of improvement were seen in the documentation of neurovascular injuries (98%), pain (90%) and altered wound healing (87%). There was no significant change in the documentation of failure of surgery (83%) and neurovascular injuries (98%). The Poorly documented risk factors from the initial audit were seen to improve which included mortality (70%), prosthetic dislocation (90%) and limb length discrepancy (50%). There has been a significant improvement in the quality of Informed consent in the department and this could be attributed to the installation of ward posters and verbal dissemination of information to junior doctors. Recommendation for interventions would be to present in the next clinical governance meeting and presenting at the new junior doctors’ induction at August.
37 Improving the Management of Post-Operative Hypocalcaemia in Thyroid Surgery
Authors: Collins R , Lafford G , Ferris R , Turner J , Tassone P
Published: May 2021

Introduction

Hypocalcaemia is a frequent, and potentially dangerous, complication of total thyroidectomy [1, 2]. This quality improvement (QI) project was undertaken in a large ENT department in the East of England over a year. The project improved postoperative guideline compliance by optimising the recognition and management of patients at risk of hypocalcaemia. This process focussed on improving parathyroid hormone (PTH) and calcium blood testing, appropriate prescribing and the monitoring and management of hypocalcaemia.

Method

Following a baseline audit the QI process subsequently involved the introduction of a new intraoperative PTH pathway and the amendment of trust guidelines. In addition, there was a focus on improving clinician awareness of guidelines, junior doctor education, communication between operating surgeons and junior doctors and the optimisation of patient handover.

Results

The measurement of PTH at four hours improved from 42.5% to 52.2%. The project saw a significant improvement in the monitoring of hypocalcaemia (from 22.2% to 83.3% for patients with an intermediate risk of hypocalcaemia) and in the prescribing of prophylactic calcium supplements from 7.5% to 43.5%.

Conclusions

By optimising postoperative care this QI project improved patient safety as well as impacting on the duration, and overall cost, of inpatient stay.
45 Easier Recognition and Better Communication of The Surgical Team Across the Hospital
Authors: Narayan P P
Published: May 2021

Introduction

Recognition & communication of a surgical team is of paramount significance especially in catastrophic scenarios- like a crowded trauma call in ED, and ward rounds as surgical patients are dispersed across the hospital. Hence implementing posters across all key wards and special ID could play a key role.

Method

Aim was to improve the recognition & communication of the surgical team by means of posters of surgical members(Trainees/ Trust Grades/ Associates)including their name, designation & bleep; and color coded ID/Lanyard for the surgical team. An online survey was conducted for the surgical team(N = 25) and separately for the nursing staff(N = 40) across the hospital to understand how well the surgical team is recognised across the hospital and how changes would bring about a difference in communication and recognition of the surgical team.

Results

Surgical team was poorly recognised across the hospital(12.5%), and most of the surgical & nursing staff thought implementing the changes would play a key role.

Conclusions

It is vital to have posters of surgical team (trainees/ trust grades) across all key wards and in Emergency, along with unique ID for efficient recognition of Surgical team in urgent scenarios & to develop an effective communication with the nursing staff across the hospital.
49 A Quality Improvement Project to Assess and Refine the Handover Process at Morning Trauma Meetings
Authors: Sadiq S , Tahir M , Nur I , Elerian S , Malik A
Published: May 2021

Introduction

Poor handover between shifts can result in patient harm. This study was designed to evaluate the impact of implementing a handover protocol on the quality of information exchanged in the trauma handover meetings in a UK hospital.

Method

A prospective single-centre observational study was performed at an NHS Trust. Ten consecutive weekday trauma meetings, involving 43 patients, were observed to identify poor practices in handover. This data was used in conjunction with the Royal College of Surgeons’ recommendations for effective handover (2007) to create and implement a standard operating protocol (SOP). Following its implementation, a further 8 consecutive meetings, involving a further 47 patients, were observed. The data was analysed using t-test for quantitative variables and chi-square or Fisher’s exact tests for categorical variables.

Results

An improvement was demonstrated in multiple aspects of trauma handover including past medical history, injury date, results, diagnosis, consent, mark, and starvation status (all p < 0.001). Subgroup analyses showed that handover of neck-of-femur fracture patients including information on baseline mobility (p = 0.04), Nottingham-Hip-Fracture Score (p = 0.01), next-of-kin discussion (p = 0.075) and resuscitation status (p = 0.001) all improved following the intervention.

Conclusions

These results demonstrate that the implementation of a well-structured handover protocol can improve the transmission of critical information in trauma meetings.
54 Patient Satisfaction During A Pandemic – Virtually Impossible?
Authors: Harrington B , Keenan R , Aboelmagd M , O'Malley K , Galvin D , Hegarty N , Connolly S
Published: May 2021

Introduction

Throughout the COVID-19 pandemic we conducted virtual urology clinics for the first time at our institution. We aimed to assess patient satisfaction with the virtual clinic format.

Method

Patients who underwent virtual consultation were contacted by phone and surveyed about their appointment. Convenience, thoroughness, satisfaction, preference and reason for appointment were assessed via questionnaire

Results

77 randomly selected patients were contacted. 63 males (82%), 14 females (18%). Median age 61 years (range 16–86). 62 (80%) reviews, 12 (16%) new referrals, and 3 (4%) post-operative patients were surveyed. 55 (71%) were booked for repeat appointment, 13 (17%) for further investigations, 6 (8%) discharged, and 3 (4%) listed for surgery.

73 (95%) found it convenient, 3 (4%) were neutral and 1 (1%) found it inconvenient. 74 (96%) felt thoroughly assessed and 76 (99%) of patients had all their concerns addressed. 74 (96%) were satisfied with their review, 2 (3%) were neutral, and 1 (1%) was dissatisfied. Going forward, 50 (65%) would prefer virtual follow-up and 27 (35%) would prefer an in-person review.

Conclusions

Virtual clinic is preferable to the majority of patients in our urology service and is deemed convenient, thorough and satisfactory by them. It should be facilitated going forward in appropriately selected patients.
66 Cycle 1: Time for Peripherally Inserted Central Catheter (PICC) Insertion for Patients with Complex Infections in The Trauma and Orthopaedic Department at The Royal Infirmary of Edinburgh (RIE)
Authors: Balfour J , Powell-Bowns M
Published: May 2021

Introduction

Bone, joint and soft tissue infections often require long term antibiotic therapy alongside operative management. Intravenous (IV) access is essential for antibiotic administration and monitoring. ‘Long-lines’ such as PICC provide reliable long-term IV access. Aim: analyse time to insertion of ‘Long-lines’ and effects on patient outcomes.

Method

Standard audit protocol. Data tool was developed, trialled, and tested. Data was collected retrospectively from departmental database and TRAK (Online patient record system) for patients admitted with suspected bone, joint or soft tissues infection from 01/11/19- 29/2/20.

Results

91 patients admitted with presumed infection. PICC requested in 30 patients. Mean time to PICC request from admission was 8.7 days (1-33). 23 patients received PICC. Mean time to PICC following request was 6.7 days (1-15). Mean time to PICC from admission was 15.9 days (4-39). 10 of 30(33.3%) patients had documented missed antibiotics due to lack of IV access.

Conclusions

Large variation in time for patients receiving PICC from admission and from time of request. A significant proportion of patients are missing IV antibiotics due to poor IV access. Improvement in time to ‘longlines’ would reduce incidence of venepuncture in patients requiring IV access in addition to reducing missed IV antibiotics due to lack of access.
75 Treatment Escalation Plan (TEP) Completion Rates in General Surgery
Authors: Shah H , Yazdanian B
Published: May 2021

Background

TEPs ensure every patient has a ceiling of care formally documented, including a DNACPR decision. This pre-empts complications and provides guidance on how to appropriately manage acutely unwell patients. There is no national standard for TEPs. Our aim: to formally document the incidence of TEP completion in general surgery at a local District General Hospital.

Method

A multi-phase, cross-sectional study of 1. Inpatients on three general surgical wards, 2. TEP completion at post-take after a typical on-call cycle.

Results

15.4% of TEPs were completed, of which 75% had a DNARCPR form. For the two post-take ward rounds, 5% and 7.7% of admitted patients had a TEP. Elective surgical/Enhanced recovery patients (ERP) did not have a TEP. Findings were presented locally, and posters placed in the surgical offices. Cycle 2: 19.6% and 10% completion rate for ward and post-take patients, respectively.

Conclusions

TEPs are rarely completed. Minimal improvement in completion rate was noted at cycle 2. TEPs are more commonly completed for patients not for resuscitation. Future aims include editing the surgical clerking proforma and the elective surgery/ERP paperwork to encourage completion, improving patient care. Currently we are arranging similar audits across other NHS trusts to determine if this is a national problem.
81 Getting It Right First Time (GIRFT): Preliminary Results from Incorporation of A Personalised Surgeon Template In Hip Arthroplasty Surgery Documentation
Authors: Sandhu J , Jabr Y , Sidaginamale R , Logishetty R , Cooke N
Published: May 2021

Introduction

Following the publication of GIRFT guidelines for Total hip replacement operative note documentation produced from analysis of medical negligence claims notified to NHS resolutions by NHS trusts, we reviewed our compliance against the 24 criteria. This was a crucial exercise as inadequate documentation had huge medico-legal consequences and adverse outcome on patient safety. We proposed a pragmatic solution of incorporating prepopulated personalised template into ‘Trackcare' system and providing a dedicated desktop installed in surgeon's room for completion of operative notes.

Method

We led a team of 4 doctors to review our compliance against 24 criteria laid out by GIRFT. After retrospectively examining 20 operative records from a spread of consultants in the department. A re-audit following incorporation of personalised surgeon templates was conducted to close the loop.

Results

Our results showed out of 24 criteria; 8 criteria were met with 80-100% compliance while 15 criteria had <60% compliance. The incorporation of personalised surgeon template has raised compliance to > 90-100% in all 24 criteria.

Conclusions

A preliminary review of a single surgeon template has shown that it is simple to use, has excellent compliance, quick to complete the operative notes, advocates patient safety, is user-friendly and is very promising in minimising medico-legal claims for surgeons and the Trust.
83 Closed Loop Audit Examining Documentation of Advanced Trauma and Life Support (ATLS) Secondary Survey in Polytrauma Cases at The Royal Infirmary of Edinburgh (RIE)
Authors: Balfour J , Powell-Bowns M , Leow J , Arthur C
Published: May 2021

Introduction

Secondary survey is a key aspect of the ATLS guidelines in avoiding missed injuries in polytrauma patients. Aim: Evaluate the documentation of secondary survey in polytrauma cases admitted to the RIE A+E department.

Method

Standard audit protocol, retrospective data collection. Polytrauma patients and patients requiring Trauma CT were identified from the local trauma database. Primary outcome was successful completion and documentation of secondary survey. Cycle 1: All patients from 01/01/2015-01/09/2015. Local policy change included an A+E trauma booklet and policy of secondary survey on admission to Intensive Care. Cycle 2 was completed post-intervention for patients presenting between 11/01/2019-29/05/2019.

Results

Cycle 1 (N = 20, N Secondary survey documented=10, mean=50%). Mean time to secondary survey was 8 hours (range 3-49). Cycle 2 (N = 28, N Secondary survey documented=24, mean=87.5%). Mean time to a secondary survey was 4 hours 30 minutes (range=1-21hrs). Significant improvement in documentation (Fisher’s Exact Test, P = 0.017).

Conclusions

Implementation of the secondary survey protocol and trauma booklet significantly improved documentation of secondary survey in the polytrauma patient. Evidence also suggests improved time to secondary survey. However, documentation of secondary survey is not universal indicating further improvement is required in trauma care, as the RIE moves towards becoming a National Major Trauma Centre.
93 Sexually Transmitted Infections Remain Under-Diagnosed and Under-Treated in Young Men Presenting with Acute Scrotal Pain
Authors: Thomas M , Thursby H , Kitchen M , Liu S
Published: May 2021

Introduction

Epididymitis or epididymo-orchitis causing acute scrotal pain in men ≤35 years is a common presentation to primary and secondary care.Most are caused by sexually-transmitted-infections in this age group. Failure to identify or treat STIs in this population may lead to subfertility.We assessed our practice against British Association of Sexual Health and HIV guidelines.

Method

Men (age ≤35) diagnosed at our centre with epididymitis/epidiymo-orchitis between January2015 and January2020 were included (n = 313, age range 16-35). Data collected included microbiological and radiological reports,antimicrobial treatment prescribed and documentation of appropriate advice and follow-up.Patients with previous STI were excluded.

Results

53 (16.9%) patients had mid-stream urine analysed;one identified bacterial growth (e.coli).15/313 patients were screened for c.trachomatis.228 (72.8%) patients had a scrotal ultrasound;167 (73.2%) reports suggested epididymitis.32 patients underwent immediate scrotal exploration;19 were epididymitis,one required orchidectomy.

Advice to attend GU-Medicine-clinic was documented in 48cases (15.3%).20 patients (6.4%) received optimal antibiotic management; 83 (26.5%) received suitable antibiotics assuming non-gonococcal cause.210 patients received inadequate/inappropriate antibiotics.

Conclusions

Management of patients with acute scrotal pain is sub-optimal;most patients were inadequately investigated and most received inappropriate antibiotics which may lead to subfertility.Better education and written patient information on risks of STIs may improve outcomes in this population.
109 Game Changing Magnetic Experience in Rural and Urban Wirral Peninsula - Our Experience with Magseed Localisation of Impalpable Breast Tumours and Axillary Nodes
Authors: Arif T , Vinayagam R , Lund J M , Poonawala S
Published: May 2021

Introduction

Magseed is a novel localization technology in which a tiny seed is inserted to accurately mark the site of breast tumour. These can be detected intra-operatively by sentimag localization system. It aids localization of impalpable breast lesions improving margin clearance rates.

Method

A prospective study of first fifty Magseed localised breast tumour and axillary node excisions in Clatterbridge General Hospital.

Results

A total of 50 patients had 52 Magseed inserted. n = 14 was symptomatic, n = 35 was screen detected and n = 1 was an incidental finding on surveillance mammogram for a B3 lesion. 30 seeds were inserted on the right and 22 were inserted on the left (two were bilateral). 44 seeds were inserted under ultrasound guidance and the rest were targeted under stereo guidance (n = 8). Deployment of two resulted in malposition requiring wire localization. Mean age of subjects was 59.76 (range 31-81) years. Mean time to surgery after magseed insertion was 8.04 (range 1-27) days. Mean weight of the specimen was 48.57(range 10-264) gm. Mean size of the lesions was 20.32 (range 8-65) mm. Redo surgery for margin clearance was performed bringing the re-excision rate to 15.38% (n = 8).

Conclusions

We conclude that Magseed localization of breast tumours is a safe and reliable technique
115 An Audit on Dexamethasone Prescribing Practice on Surgically Managed Metastatic Spinal Cord Compression Patients in the Manchester Centre for Clinical Neurosciences: Lessons Learned in Closing the Loop
Authors: Laurente R , Mohammed R , Elmalky M
Published: May 2021

Metastatic Spinal Cord Compression is a surgical emergency owing to its propensity to cause significant morbidity and mortality. Dexamethasone is prescribed to reduce oedema and promote vascular membrane stabilization. The is done so until a more definitive management has been performed.

This is a retrospective study evaluating the steroid-prescribing practice for MSCC patients in 2018 at a tertiary spinal unit in Greater Manchester. Thirty-three patients who underwent stabilisation were evaluated in terms of both steroid prescribing and weaning practices. Standards used against for both were the NICE guidelines and the Edinburgh/Christie’s guidelines.

Of the 33 patients evaluated, only 1 patient received the correct loading dose of 16mg, whilst 27 went straight to being given 8mg BD. 5 did not receive dexamethasone at all. In terms of discontinuation/weaning, 26 were weaned accordingly and 2 were not weaned to continue as adjuvant treatment.

Dexamethasone prescribing practises has since improved over the past two years. 93% of the patients have been correctly weaned as compared to 38% in the past. In terms of prescription, much needs to be done as almost all the patients evaluated did not get the correct loading dose despite receiving the appropriate maintenance.
116 Patient Long Stay in the Manchester Centre for Clinical Neurosciences Complex Spines Department: Numbers, Reasons, and Recommendations
Authors: Laurente R , Yates J , Siddique I
Published: May 2021

Patient long-stay is one of the main causes of inefficient resource management in the National Health Service. Similarly, delays in treatment and access to social care contributes to the trust’s economic burden but also causes a significant delay in care for society's most vulnerable.

A single-centre evaluation of patient long stay was performed in a tertiary spinal unit in Greater Manchester. The top 50 patients who stayed the longest in an acute spinal bed between 2018 and 2019 were selected for analysis. Demographics, indication for transfer from another trust, overall length of stay, and the main reasons for such were evaluated.

Of the 50 assessed, there was an average length of stay of 46.9 days and the majority were comprised of patients with metastatic spinal cord compression. 74% had delays to surgery due to poor medical optimisation pre-transfer.

41% remained as an inpatient longer than necessary due to non-medical concerns. The main reasons included awaiting placement in a rehabilitation facility, social care issues and delays in repatriation back to their referring trust for ongoing care.

Delays in treatment and length of stay were found to be increased in patients who were poorly optimised pre-operatively and who required complex social and medical care post-operatively.
123 Use of The Induction Mobile Application in A Busy General Surgery Department
Authors: Momin S M B , Ismail S
Published: May 2021

Introduction

Contacting other hospital professionals, or accessing local guidelines is a common task for surgeons, which is usually facilitated by inefficient switchboard and intranet systems. Induction is a mobile application which includes crowd-sourced hospital directories and local guidelines, which could theoretically expedite these tasks. To assess this, we undertook a QIP within the General Surgery department using a bespoke Induction group.

Method

A private Induction group was created with the features mentioned above. We audited Induction against local trust processes (Switchboard and Intranet Trust Guidelines). We estimated cost saving using the 2019 junior doctor pay-scales. We also surveyed our department to evaluate their experiences using the application with a Likert scale.

Results

The timesaving from using Induction compared to current methods was on average 9.93 hours/week accumulated by 16 staff members, giving an estimated cost saving of £10,636.54/year. In a qualitative analysis, respondents rated Induction 4.8/5 for speed and 3.4/5 for completeness of directory, compared to 1.5/5 and 4.5/5 respectively for switchboard. Regarding accessing clinical guidelines, respondents rated the app as ‘easier’ and ‘quicker’ than the intranet.

Conclusions

We have demonstrated significant time and cost-savings using Induction compared to standard practices. Our QIP provides a replicable model to increase efficiency in surgery departments.
129 Recording of the Glasgow Scores in patients admitted to The Great Western Hospital (GWH) with Pancreatitis
Authors: Warner J , Halls M
Published: May 2021

Introduction

Pancreatitis represents a significant pathology in terms of morbidity and mortality and therefore it is important to be able to differentiate between mild and severe episodes. The objective nature of the Glasgow score and ability to predict severity make it a useful guide, however its use within GWH varies greatly.

Method

Both cycles of data collection occurred over one-month periods. Data was collected retrospectively of prospectively recorded data. Intervention implemented following the first audit cycle was a standardised proforma and the biochemistry lab instigated automated analysis of lactate dehydrogenase and calcium. Following this an identical audit was performed. In addition, the presence of CXR on admission and USS within 24hrs of admission was recorded.

Results

During the first audit cycle 44% of patients had a Glasgow score documented on admission, which improved to 63% after the second audit. There was a 17% improvement in USS scanning within 24 hours and a 50% increase in CXR being performed on admission following the second audit.

Conclusions

The changes implemented during the study have increased both the quantity and quality of the data recorded in patients admitted to GWH with pancreatitis. This should function to improve differentiation of those with mild episodes from those with severe.
139 Efficacy of Implementation of a Junior Doctors' Teaching Program on The Secondary Prevention of Peripheral Arterial Disease in Vascular Patients
Authors: Daketsey E , Elkawafi M , Khallaf A , Makar R
Published: May 2021

Introduction

According to NICE Guidelines, the Best medical therapy (BMT) for secondary prevention of peripheral arterial disease includes antiplatelet and statin therapy unless contraindicated. Junior Doctors are usually allocated the job of prescribing patients’ medications. Due to discrepancies in their exposure to vascular surgery in earlier training, we implemented an introductory teaching session for them regarding this BMT and audited the efficacy of this intervention.

Method

A retrospective review of admission and discharge medications of all vascular ward patients from August 12th to 30th September 2019 was done, and the data was analysed via Excel.

Results

Out of 127 patients (median age 70), 67% and 64% had antiplatelet and statin medications respectively,while on admission. 1 in each patient cohort was found discharged without either medication.

The GP of the patient discharged without antiplatelets was contacted to ensure this was rectified. The other patient had refused statin therapy and thus a discharge note to their GP was conducted to reflect this.

Conclusions

A teaching session as part of a vascular departmental induction emphasising the evidence base for antiplatelet and statin therapy can contribute to improving prescription practices of junior doctors starting in the department.
152 Evaluating the Incidence and Predictors of Readmission in Patients Awaiting Cholecystectomy for Previously Diagnosed Acute Gallstone Disease
Authors: Noureldin K , Razzaq H , Whelan K L , Najdawi A , Wong L , Dick G , Halai A
Published: May 2021

Introduction

The prevalence of gallstones up to 15%.20-40% will develop symptomatic gallstones and occupy most of the surgical waiting list. The timing of a cholecystectomy remains controversial.

Method

Retrospective data analysis over 2 years, including: diagnosis, commodities, ASA class, investigations, readmissions numbers and causes, time to surgery, operative details, and rate of conversion to open procedures. Chi-square test was used for analysis.

Results

532 cholecystectomies were performed.44% of the patients had commodities. Presentations were; Acute cholecystitis (41.7%), biliary colic (23.1%), acute pancreatitis (15.9), obstructive jaundice (9.2%). USS was performed in 97.3%, CT scan in 17.8% and MRCP in 45.8%. 14% had ERCP. Re admission rate was 56.4%, between 1-6 times, secondary to; cholecystitis (12.5%), biliary colic (26.7), gallstone pancreatitis (8.2%), obstructive jaundice (8.0%), other complications (0.5-1.5%). Emergency cholecystectomy was performed in 14.9% with conversion rate 1.4%.major complication rate was 2.7. The median time on waiting list was 12 (0-123) weeks. This prolonged to 25 (0-400) weeks, when calculated at time of diagnosis. Complicated gallstones disease (p-value 0.0001) was predictors of recurrent symptoms and readmissions.

Conclusions

Management plan is due to optimize the timing of cholecystectomy to decrease the negative impact on readmission and complication rates plus the hospitals’ bed capacity and costs.