bluuebunny/crossref_metadata_2025 huggingface dataset:
579 The Perfect OP Note - in the World of Surgery - QIP/Clinical Audit
Authors: Nasim O , Durrani A , Eskander B , Charalampos P
Published: November 2022

Aim

To audit by assessing the completeness of the operative note and if it follows the guidelines and the standard recommendations mentioned in the RCS & BMJ articles.

Method

The audit was registered with the clinical audit department prior to data collection and analysis of the results, Inpatient scanned records were analysed for all operative notes, From 1st June 2020 to 15 June 2020 - From 14th Feb 2021 to 21st Feb 2021 & 1st March 2021 to 7th March 2021 - All trauma and orthopaedic patients were included regardless of the type of procedure.

There were no exclusion criteria in place, All operative notes were analysed & scored against 34 operative criteria's according to ‘good surgical practice’ & BMJ article’

Results

These 96 operative notes were analysed against 34 unique criteria which were gathered from a combination of RCS guidance criteria for operative notes and different trusts operative note proforma headings

There was an increase of 40% in typed operative notes that increased the compliance with the 34 unique criteria. Improvement was seen in 11 unique criteria after the 3rd PDSA cycle.

Conclusion

Facilitation of generic templates, and findings of the Audit itself and then the presentation - brought about a positive change - with more detailed operative notes and improved the quality of the documentation.
619 Plastic Surgery Trauma Operating Theatre: The Impact of a Golden Patient Protocol on Theatre Usage Metrics
Authors: Clough R , Towning R , Mohan A
Published: November 2022

Aim

A golden patient protocol was introduced for the dedicated plastic surgery trauma operating list at St Mary's Hospital, London on 05/10/2020. Criteria preferable for golden patient selection included patients with routine anaesthetic requirements, day case surgery, local anaesthetic cases and those requiring the least equipment. The protocol included distribution of a theatre list with a named golden patient the day prior to operating and communication of this to the anaesthetist and theatre co-ordinator. This study sought to determine the effect of this protocol on theatre efficiency and other key metrics.

Method

Operation timings were retrospectively and prospectively collected from the hospital Cerner® Surginet database prior to and following introduction of the golden patient protocol, respectively. Fields included were anaesthetic start time, surgery start time, surgery end time and time patient left operating theatre. Statistical analysis was performed using the unpaired t-test method.

Result

Data was collected for 73 and 152 operating days before and after the introduction of the golden patient protocol, respectively. Following introduction of the golden patient protocol there was significantly greater mean operations performed per day (2.84 vs 3.29, p=0.0130), reduced mean late start time (34 minutes vs 16 minutes, p=0.0002) and reduced mean overrun time (37 minutes vs 9 minutes, p=0.0001). No significant difference was observed in theatre efficiency (64% vs 67%, p=0.18).

Conclusions

Optimising first patient choice and enhancing communication of this with members of the theatre team can result in more procedures being performed and reduced loss of time at the start of an operating list.
679 Trainee Perceptions of Safety in General Surgery Handover – a Quality Improvement Project
Authors: Egbe A , Cruddas L , Greenfield S
Published: November 2022

Aim

Effective patient handover is an important cornerstone of clinical care and patient safety. The aim of this study was to measure trainee perceptions of handover safety, and to improve the safety of handover.

Method

An anonymous questionnaire was sent to all junior doctors in a general surgery department with a two-stage evening handover, as registrars change over at 17.00 and senior house officers at 20.00.

The intervention involved introduction of a new standard of handover, including a set location and printed patient lists.

Following one month of intervention, a second questionnaire was distributed to assess its impact.

Results

There were 15 respondents to the pre-intervention questionnaire and 16 respondents to the post-intervention questionnaire.

Perception of safety at the 17.00 handover increased from 27% to 56% following the intervention, and at 20.00 this increased from 60% to 88%.

The proportion of respondents who felt that new admissions were handed over well at 17.00 increased from 27% to 38%, with an increase from 67% to 81% for the 20.00 handover.

The proportion of respondents who felt that the ward patients were handed over well at 20.00 increased from 40% to 81%.

The generation of a patient handover list at 20.00 increased from 7% to 25%.

Conclusions

Simple interventions appear to be effective at improving trainee perceptions of safety in patient handover in general surgery.

Ensuring the quality of patient handover must be a priority for all clinicians; however, approaches may need to be tailored to the working shift patterns within a department.
695 Improving Consent Forms for Laparoscopic Cholecystectomy; a Visual Consent Form Toolkit
Authors: Jeilani M , Super J , Riad M , Jayasankar B
Published: November 2022

Aim

Laparoscopic cholecystectomy is a common elective operation with significant complication risks. GMC guidance on consent emphasises informed consent, and failure to warn patients of significant complications can lead to medico-legal implications. We aimed to assess the quality of risk documentation for laparoscopic cholecystectomies performed at our trust. In particular, we aimed to assess improvement since previous cycles after circulation of our boutique ‘Visual Consent Form Toolkit’, an easily accessible resource for risks associated with common procedures.

Method

Consent forms for 49 elective laparoscopic cholecystectomies performed at a busy district general hospital between September and November 2021 were retrospectively analysed. Risk documentation was audited against a standard of 15 common complications associated with laparoscopic cholecystectomy.

Results

There was significant improvement across the board. Risks previously documented at 100% remained at this level (infection & bleeding). Those previously well-documented showed further improvement (CBD injury, bile leak, damage to local structures, open conversion & VTE). Of those not previously well-documented (the rest), all except two (diarrhoea & pancreatitis) showed improvement. In particular anaesthetic risks, which was emphasised in our toolkit, saw the largest improvement.

Conclusions

Risk documentation on consent forms has overall considerably improved with the circulation of our ‘Visual Consent Form Toolkit’. More risks now fully or partially meet the expected standard. From those risks not meeting the expected standard despite numerous audit cycles, we understand that surgeons do not feel these risks should be documented in all situations for all patients, and therefore that an expected standard does not necessarily apply for these risks.
710 Developing a Standardised Form to Improve Communications Between General Surgical Juniors and Microbiologists
Authors: Edmonds R , Jamadar T , Coronelli M , Weerasinghe D , Ali N , Magro T
Published: November 2022

Aim

To improve discussions between microbiology and surgical juniors.

Method

As a group we identified that discussions with microbiology were documented in notes, but not easily found when further discussions were required. We also found that some discussions were more difficult if the junior did not have all of the appropriate information to hand. We created a separate form to document microbiology discussions, bring together the essential information that they required for the conversations and enable quick reference for future discussions. We sent out a questionnaire to assess the level of the difficulties, introduced the form and documented any additional information that was asked for during discussions. We then repeated the questionnaire to assess if there were any improvements.

Results

The original version was insufficient, in that it was not distinct from other paper notes so could be difficult to find, and some questions were asked frequently that we did not have answers for. The discussions however were improved, and the recording of reasoning for decisions enabled more consistent recommendations.

Conclusions

By creating the form we helped juniors prepare for more constructive calls to microbiology, were able to answer some of their questions regarding why prior decisions were made and at the end have the most sensible suggestions and plans from microbiology for surgical patients. While we still use paper notes, the concept and format are suitable for transfer to other specialities and electronic records where available.
714 ‘Administration of Tranexamic Acid in Traumatic Brain Injury in a Major London Trauma Centre’
Authors: Oskooee N , Tsang K
Published: November 2022

Aim

Traumatic brain injury contributes to worldwide death and disability more than any other traumatic insult. CRASH-3 demonstrated tranexamic acid is safe in mild to moderate traumatic brain injury and head injury-related death was reduced when given within 3 hours of injury. This project aims to review adherence to the recommendations at a major trauma centre and implement changes with the view of improving outcomes.

Method

Patients presenting at St Mary's Hospital with a traumatic head injury over a 6-month period were identified. Data collection included: timings of injury and tranexamic acid administration, Glasgow Coma Scale at the scene and admission, and bolus vs. bolus and infusion. Results presented at the regional trauma network meeting with summary poster designed for display in the department. A second cycle of data collection was completed over 2 months following the interventions.

Results

There was an increase in the proportion of patients who received tranexamic acid from 29% in cycle 1 to 51% in cycle 2. The proportion of patients receiving both the initial bolus and infusion also increased from 25% in cycle 1 to 45% in cycle 2. The average time from injury to first dose of tranexamic acid was reduced from 2 hours 16 minutes to 1 hour 33 minutes.

Conclusions

The interventions implemented between cycles 1 and 2 led to an overall improvement in the major trauma unit's adherence to the CRASH-3 recommendations. Decisions where tranexamic acid is withheld are down to clinical judgement however it is recommended that the reasoning is also documented.
737 Recording and Evaluating Affect and Coping During COVID19 in Healthcare-Workers and Outcomes (REACCH-Out): Mental Health Implications for Our Junior Doctor Cohort
Authors: Akbar S
Published: November 2022

The announcement of the COVID19 pandemic has had a huge impact on surgical practice in the UK. Many surgical trainees were redeployed to areas within the hospital to provide additional cover during the pandemic. Providing adequate wellbeing and support to trainees is imperative during this time of hardship.

18 plastic surgery junior doctors were redeployed to either intensive care units, emergency departments or medical wards during the period of study. A mixed methods survey was completed by trainees exploring rates of anxiety, depression and coping during the first peak of the pandemic. A “COVID care package” was provided to support surgical junior doctors.

The average anxiety score for trainees exceeded that regarded as ‘normal’ as predicted by the Hospital Anxiety and Depression Scale. SHOs were found to show higher scores of anxieties and depression throughout the course of study as compared to their registrar counterparts. 43.8% of junior doctors reported greater levels of stress since the announcement of the pandemic. 81% of junior doctors preferred to have regular check-ins with work colleagues during difficult times.

Providing a strong support system for trainees is vital to ensure doctors are not overwhelmed at this volatile time in their careers. The use of psychological monitoring tools to guide the implementation of appropriate levels of support for individuals could aid in enhanced junior doctor wellbeing and support. Feedback suggests that surgical trainees agree that contact with their parent team and colleagues has a positive impact on their wellbeing and prefer these regular “check-ins” to occur on a monthly basis.
746 A Novel Method of Remotely Managing Complex HHT Patients via Telephone Clinic to Reduce Severity and Frequency of Nosebleeds
Authors: Mehtani N , Acharya V , Bullock E , Rennie C
Published: November 2022

Introduction

Hereditary haemorrhagic telangiectasia (HHT) is a complex, multisystemic vascular dysplasia affecting approximately 85,000 European Citizens. Patients who have hereditary haemorrhagic telangiectasia can have severe debilitating manifestation of symptoms which can severely affect their quality of life. One of the severe manifestations is epistaxis, this can often lead to being anaemic, needing blood transfusion and hospital admission.

Method

Patient data was analysed to record number of hospital visits, A&E attendances, and hospital admissions. Multidisciplinary approach to involve various teams including but not limited to specialist nurses and clinicians.

Results

Virtual clinics facilitate management of HHT patients with complex needs. Provision of (nurse led) specialist virtual clinic in the form of telephone consults giving advice regarding maintenance and emergency care in case of a nosebleeds. This facilitates safe pathway for emergent care and avoids hospital visit with every episode. The patients are provided with an emergency pack and a prevention pack. The emergency pack contains nasal packs, tranexamic acid mouthwash 5%, nasopore, kaltostat whereas the prevention pack contains triple therapy. Analysis of patient data suggests reduced number of hospital visits, A&E attendances, and hospital admissions to seek specialist treatment.

Conclusions

Virtual clinics are an upcoming novel method of managing complex patients. They are beneficial for patients allowing them specialist access to medical advice to manage their symptoms at home. Improved patient care pathway allowing easy access of specialist medical advice. Safer management of complex HHT patients reducing frequent hospital visits for reasons like consultations, blood tests, admissions, and blood transfusion.
839 Improving Oxygen Prescribing on Kardex in Ward Level Care
Authors: Maniarasu V , Sandhu HS , Gunasekaran G
Published: November 2022

Aim

The aim of the QIP was to raise awareness about the importance of oxygen prescription amongst healthcare staff and improve the oxygen prescription rate on Kardex by 50% in 3 weeks at both surgical and medical wards.

Background

Oxygen is considered a type of drug and should be prescribed on the Kardex. The administration of inappropriate oxygen concentration can have fatal consequences such as prolonged hypoxaemia or hyperoxia. Therefore, it is good practice to prescribe oxygen on the Kardex.

Method

Data was collected from 25 patients from surgical and medical wards once weekly. 3 plan-do-study-act (PDSA) interventions were undertaken. Source of information were the Kardex, NEWS observation chart, direct observation of oxygen delivery at patient's bedside and ward round documentation. The reason both surgical and medical wards were selected was to showcase just how prevalent the use of oxygen is in the hospital regardless of the underlying diagnosis.

Results

In PDSA 1, only 8% of the patients had oxygen prescribed. First intervention was to educate the doctors and nurses at the wards on the importance of oxygen prescription and the harmful effects of inaccurate target oxygen saturations. Following this, oxygen prescription increased to 45% in PDSA 2. In the second intervention, visual prompts were displayed in the wards. The oxygen prescription rate in PDSA 3 reached 53%.

Conclusions

We achieved our goal of this QI project through 3 PDSA cycles, which is to improve oxygen prescription by 50%. However, there is still room for improvement to sustain this good clinical practice.
863 Improving the Outcomes of Inpatient Admissions and Optimising Referrals to a Regional Burns Unit Through Introduction of a Specialist Nurse-Led Burns Clinic
Authors: Carvill M , Milto K , Robb L , Jordan D , Widdowson D , Bahia H
Published: November 2022

Aim

We aimed to measure the effect of a specialist nurse-led clinic and referral pathway on admission rate, patient length of stay (LOS), and total bed days. We hypothesised that this intervention would contribute to the optimisation of the patient pathway in a regional burn's unit.

Method

Retrospective analysis of inpatient records in a six-month period over three years at a regional burn's unit (June-November 2018,2019,2020). Analysis of demographics, TBSA, admissions, and length of stay before and after clinic introduction. Statistical analysis included one-way ANOVA.

Results

A reduction in admissions was observed in 2020 compared to 2019 and 2018 (7.3% and 6.7%) for a patient group with equivalent median TBSA (2%) and comparable median age (41 vs. 43.5 and 42.5). Median LOS was significantly shortened compared to 2019 (42.9%, F=4.07, p=0.046) and 2018 (42.9%, F=6.59, p=0.011). Minor burns showed reduced admission rates compared to 2019 (8.5%), and reduced median LOS (42.9% and 33.3%), and reduced total bed days (29.4% and 27.1%) compared to 2019 and 2018 respectively. Referrals to the regional burn's unit as a percentage total of regional A&E burns presentations increased in 2020 compared to 2019 and 2018 (16% vs. 14.4% and 12.1%).

Conclusions

The results suggest that the introduction of a specialist clinic has shortened in-patient stay with a significant effect on minor burns, against a backdrop of increased referrals. We suggest that continuity between clinic and inpatient care by a specialist nursing team has helped to optimise the regional burns unit.
931 Timeline in Management of Urinary Retention: Trial Without Catheter (TWOC) Clinic – Single Centre Outcomes of District General Hospital
Authors: Chkir B , Saqib M
Published: November 2022

Aim

Urinary retention is a common urological emergency, but the management is not standardised due to lack of clinical guidelines & various options available to a complex problem. We aim to assess the timeline of patients going into acute urinary retention & their first/second TWOC appointment until clinic appointment and decision for definitive treatment as-well as to reduce waiting time&improve patients’ safety/experience.

Method

Using retrospectively collected data, all TWOC admissions from June 2019-December 2019 and June 2020-December 2020 were included. Data was extracted from various sections across our e-system. Outpatient letter appointments also checked to complete the timeline.

Results

Total of 93-TWOC admissions in total, 45 of which were in2019 and 48 in2020. 26%(n=24) of patients have passed their TWOC. 74%(n=69) of patients have failed their TWOC necessitating re-catheterisation/consideration for TURP/re-TWOC.

Time from urinary retention/catheterisation to TWOC admission in 2019 had an average of 36.2days, whereas it was 37.9days in 2020.

Time from urinary catheterisation to clinic also showed variation with an average of 83.9days in 2019 and 56.3days in 2020, ultimately resulting in long waiting-period for an operation.

Conclusions

A TWOC-clinic, where patients can be seen once-a-week to reduce clinic waiting time & improve safety by performing DRE & checking PSA in timely-manner, was proposed. It allows effective use of TWOC slots & timely decision of suitable patients for surgery rather than simply-listing patients for unnecessary further TWOC. It also serves as a platform to safety-net patients with possible underlying prostate-cancer by checking PSA & performing DRE early in their journey for early-management.
960 Referral Documentation in Orthopaedic Trauma
Authors: Rehman H , Lim JW , Cullen F
Published: November 2022

Aim

We aimed to measure and improve documentation and decision making for on-call Orthopaedic Trauma referrals.

Method

Documentation for all referrals to the Orthopaedic Trauma Service, at a major urban trauma centre, in Scotland, over a defined period was reviewed. The audit conducted between February 2020 and November 2021. Documentation was scored. Two further audit cycles were performed after the introduction of an electronic “contact note” system.

Results

There was a dramatic improvement between cycle 1 and cycle 3 of available documentation 76% versus 98%. Documentation was available on the day of referral for 60% of cases reviewed by cycle 3 versus 30% for cycle 1; 98% complete documentation was available by day 2 during cycle 3. The system was rated high satisfactory by 90%% of users.

Conclusions

Complete documentation was more widely and more quickly available after the introduction of an electronic note keeping system. The system was user friendly and rated high satisfactory. We believe the system improved patient safety.
1002 Improving the Medical Student Experience of Trauma and Orthopaedic Education – a Quality Improvement Project
Authors: Khanom S , Nebo V , Noton T , Garlick Ni , Maruthainar N
Published: November 2022

Aim

The medical student experience of clinical placements is closely linked with quality of teaching, varied educational opportunities and sense of belonging within the team. Surgical rotations such as Trauma and Orthopaedics (T&O) have a stereotype for being challenging. At a London teaching hospital student satisfaction of T&O placements was low (8% satisfaction) as assessed by feedback. This quality improvement (QI) project aimed to improve the quality of educational experiences and overall student satisfaction in T&O.

Method

Student feedback from end of placement evaluation forms from academic years 2016–19 was reviewed. A QI driver diagram was created based on the themes raised in the feedback. These were 1) formal teaching, 2) structure and organisation, 3) curriculum content and 4) student engagement and belonging. Each theme was subdivided into multiple achievable strategies to improve student experience while on T&O placements. This included allocated clinic and theatre sessions, bedside teaching, named tutors, curriculum map, WhatsApp communication and a dedicated clinical teaching fellow in the department.

Results

As a result of the implemented QI strategies, student satisfaction improved over the subsequent semesters to 100%, 89%, 100% and 75%, with a greater number of students providing feedback.

Conclusions

The project achieved greater student satisfaction of T&O education and improved the student experience of surgical placements. It also validates student feedback as a valuable tool in developing surgical education.
1003 QIP: Improving Provision of Driving Advice Post Abdominal Surgery
Authors: Ahmed F , Dalip A , Agrawal A
Published: November 2022

Aim

The aim of this QIP was to improve provision of driving advice post abdominal surgery. The royal college of surgeons recommends that before resuming driving after surgery, patients should be free from the sedative effects of any painkillers they may be taking, and they should be comfortable in the driving position and be able to safely control their car, including freely performing an emergency stop.

Method

Relevant discharge summaries from the general surgical department at the QEQM hospital in Margate were screened from 15/01/2021 to 14/04/2021 (N=61) to assess how well the department provided driving advice. Documentation was found to be 52%. An email was sent to junior doctors outlining aims of the QIP. A second intervention was required following initial minor improvement, with a poster made and emailed to doctors rotating into the general surgical department.

Results

In the first month post intervention, 15/05/21–14/05/21, a minor improvement was seen, with the documentation rate being 57% (N=56). Subsequent poster intervention to new rotating junior doctors markedly improved documentation, with monthly results from 20/08/21–19/12/21 showing documentation rates of 62% (N=86), 73% (N=103), 76% (N=111) and 86% (N=82).

Conclusion

This QIP shows a marked improvement in documentation rates of driving advice post abdominal surgery. Interestingly, it also shows how timing of quality improvement advice can impact departmental outcomes. Newly joining junior doctors presented with the same intervention advice in poster format as leaving doctors were aware from their first day on their surgical rotations of best practice with regards to documenting driving advice.
1026 Good Prescribing Laxatives Practice for Trauma Admissions in Orthopaedic Wards at Altnagelvin Hospital
Authors: Sandhu HS , Safari S , Bonsell L
Published: November 2022

Aim

The aim of this QIP is to firstly increase percentage of T&O admissions to Orthopaedic Wards 23+25 prescribed laxatives by 25% by 1st of December over 1 month and to increase awareness among healthcare staff.

Background

Constipation in elderly during inpatient stay is common, 50% of pts>65years will develop this due to multifactorial reasons. Correct laxatives are very important to curb this predicament.

Method

These data were assessed over the following criteria, laxatives prescribed on admission, administered following prescription, monitoring bowel output, suppositories prescribed after admission. Following each week QI cycles, appropriate interventions were made to improve the adherence and data was re-measured again.

Results

From Baseline data, only 45% of patient were prescribed laxatives and only 20% patients received the medication initially. Of this group, only 20% pts had suppositories prescribed following admission. Lastly, 40% of patients had Bowel Opened (BO)>3days ago. First intervention was educating all SHOs to ensure patients received prescription on admission. Following this, mainly laxative prescription increased by 40%, and patient received their laxatives by 2% respectively in PDSA 1.

In PDSA 2, we actively ensured educating nursing staff to encourage laxative prescriptions and to inform doctors for patients with Last BO>3days ago for suppositories prescribing. Following this, laxative prescription increased to 80% while 65% pts received their prescription. Only 15% pts had BO>3days too.

Conclusion

Regular laxatives are superior to PRN & Recommended regime is Senna+Lactulose for patient adherence. Additionally, suppositories should be given as STAT rather than Prn as well.
175 Rare Complications and Management of Port Site Hernias (PSH) Following Robotic-Assisted Radical Prostatectomy (RARP)
Authors: Lau A , Aseem R , Shrestha A
Published: November 2022

Robot-assisted surgery has become increasingly prevalent in surgical practice and is very commonly performed in urological cancers especially of the prostate gland. Robotic surgical techniques are safe and reproducible; however, they have their associated complications. Risk factors such as the nature of cancer, learning curve of the surgery, experience of the surgeon and patient characteristics have been implicated for potential complications. Complications can range from bleeding, infection, bowel injury, ureteric and nerve damage. Port site hernias (PSH) are an infrequent complication with a reported incidence varying from 0.2–4.8%. Although uncommon, they can result in high morbidity due to bowel incarceration and strangulation.

We report two cases of PSH from our large district general hospital, both at the supraumbilical port site after robotic assisted radical prostatectomy (RARP). The first case presented with complete evisceration and strangulation of a segment of small bowel and the second with bowel incarceration and small bowel obstruction. Our cases highlight potentially rare but severe complications of RARP that should be promptly recognised and urgently treated to prevent significant patient morbidity and mortality.
177 Robotic Assisted Versus Conventional Unicompartmental Knee Arthroplasty: A Systematic Review and Meta-Analysis
Authors: Kar I , Qayum K , Nawaz G
Published: November 2022

Aim

To compare the robotic-assisted unicompartmental knee arthroplasty (UKA) with conventional UKA.

Method

We systematically searched on four databases till September 2021. The outcomes were pooled as mean difference (MD) or standardized mean difference (SMD) or risk ratio (RR), and 95% confidence interval. We used RevMan to perform the analysis.

Results

There were 22 included studies. There were no significant differences between the robotic-assisted UKA and the conventional one in satisfaction rate (RR=1.05, 95% CI [0.98, 1.14], p=0.19), complication rate (RR=0.62, 95% CI [0.32, 1.19], p=0.15), and range of motion (MD= -0.23, 95% CI [-5.76, 5.30], p=0.93). However, robotic-assisted UKA showed significant favouring in the outliers of limb alignment (RR= 0.46, 95% CI [0.29, 0.74], p=0.001). On the other hand, the conventional UKA had better surgical time than the robotic assisted one (MD=20.89, 95% CI [11.87, 29.90], p<0.00001).

Conclusions

There were mainly no significant differences between robotic-assisted UKA and the conventional one in several outcomes such as the satisfaction rate, complication rate, and others. However, robotic-assisted UKA significantly favoured outliers of tibial alignment, and outliers of limb alignment, but prolonged surgical time than the conventional group.
59 Associations of Biological Sex with Clinicopathologic Features of Cutaneous Melanoma
Authors: Tay T , Oudit D , Cook M , Green AC
Published: November 2022

Aim

It is commonly known that women have better prognosis than men after diagnosis of primary cutaneous melanoma. However, few studies have investigated whether histopathological prognostic factors are associated with this difference. This study aimed to investigate if there were sex-specific differences in prognostic features of primary melanoma at time of diagnosis in a large clinical series.

Method

This was a records-based observational study of unselected patients treated for melanoma in a major tertiary oncology centre in the United Kingdoms, 2002–2016. Prognostic features (age at diagnosis; thickness of primary melanoma; ulceration and mitotic count) were extracted from histological reports and sex-specific differences tested for significance using X2 test.

Results

Among 1323 melanoma patients of median age 61 years (range 15–99), and roughly equal proportions of males (640, 48%) and females (683,52%), females had significantly earlier age of presentation on average than males (58 vs 64 years) (p<0.001). Comparing Breslow thickness of <2mm vs ≥2mm, significantly more females (414, 67%) than males (282, 55%) had melanomas <2mm (p<0.001). Other key histopathological factors namely presence of ulceration (p=0.073) and mitotic rate (p=0.618) were not significantly different by sex.

Conclusions

We found that female melanoma patients presented at an earlier age and with thinner primary melanomas than males, but mitotic rate (speed of tumour growth) was not significantly different. These data suggest that females’ better prognosis is explained by their tendency to present earlier with suspicious skin lesions than males.
221 Lynch Syndrome - Do We Really Screen for It?
Authors: Rantos I , Leow TH , Sekyi-Djan MN
Published: November 2022

Aim

Firstly, assess the compliance of our Trust with the DG27 NICE Guidelines (2017) recommending universal screening of patients with Colorectal Cancer (CRC) for Lynch Syndrome (LS), using Immunohistochemistry or Microsatellite Instability testing. Secondly, provide a cost estimate for the Trust to implement universal screening for LS.

Method

Retrospective data collection for all CRC resection specimens reported by the Trust's Pathology Lab in 2019, and check of pathology reports, Clinic letters, and lab results through the Trust's electronic system for screening for LS. Cost estimates were calculated using information from the Histopathology Department and similar Audits by other NHS Trusts.

Results

From the 361 colorectal resection specimens examined at the Trust's Pathology lab, 340 were not screened for LS (NICE Guidelines compliance = 5.8%). Of the 21 screened, 12 patients did not have LS, and for 9 screening was not completed. By categorising the patients into groups by age, location of cancer, and presence of synchronous or metachronous cancers, we found that there was no consistent rationale behind screening (i.e., patients with phenotypical characteristics traditionally related to LS were not screened). We estimated that universal LS screening would cost the Trust approximately £25,000 annually.

Conclusions

There is extremely poor compliance with the NICE Guidelines in a Trust with one of the highest numbers of CRC resections annually. Even the Amsterdam Criteria are not used to screen patients for LS. Screening could change the surgical and oncological management of the patients and also suggest different surveillance and prophylaxis for the affected family members.
595 Outcomes of Two-Stage Revision Surgery of Oncology Endoprostheses for Prosthetic Joint Infection
Authors: Adlan A , McCulloch R , Evans S , Parry M , Stevenson J , Jeys L
Published: November 2022

Aim

We aim to report the outcomes of two-stage revision surgery to eradicate periprosthetic joint infection (PJI) of endoprostheses in orthopaedic oncology.

Method

A retrospective review of 44 patients who underwent two-stage revision surgery to eradicate PJI between 1999 and 2018 was conducted at a single tertiary orthopaedic oncology centre. The patients mean age was 36.1 years (12–78). The sites of prostheses were distal femur in 50%, proximal femur in 11.4%, proximal tibia in 36.4% and total femur with proximal tibia replacement in 2%. The mean follow-up period was 6.9 years (range 0.4–19 years).

Results

The overall rate of infection eradication for the patients was 95.2% at 2 years (95% CI 89–100%) and 79% (95% CI 67–93%) at 5 years. Amputation free survival was over 100% at 2 years and 88% at 5 years (95% CI 78–99.8%). There was no difference in the incidence of reinfection recurrence and amputation of patients with silver-coated implants. Coagulase-negative staphylococcus was the most common microorganism, isolated in 21 patients. Infection was successfully eradicated in 54.5%. Polymicrobial infection was recorded in 18%. Multi-drug resistance (MDR) organisms were recorded in 48% of the cohort.

Conclusions

MDR and polymicrobial organisms are common in orthopaedic oncological patients with lower infection clearance rates than the primary arthroplasty group. The increased attempts at limb salvage to treat infection may explain lower infection-free survival compared to previous series at the same centre, which reported higher rates of primary amputation to treat infection as their initial management.
892 Quality of Life After Pancreaticoduodenectomy
Authors: Russell J , Guildford N , Karavias D , Hamady Z
Published: November 2022

Aim

Pancreaticoduodenectomy (PD) can severely impair quality of life (QOL) and alter normal activities. The European Organization for Research and Treatment of Cancer QOL questionnaire (EORTC QLQ-C30) is an integrated system for assessing QOL in cancer patients. The aim was to evaluate the QOL outcomes for patients who undergo PD over a six-month period peri-operatively.

Method

EORTC QLQ-C30 (v.3) and pancreas-specific (PAN26) questionnaires were offered to patients who underwent PD between July 2018 and March 2019. Patients were invited to complete the questionnaire three times (1–2 weeks pre-operatively, 2–6 weeks post discharge, and 6–8 months post-operatively. Patients were excluded if they did not complete >50% of the questions for at least two consecutive questionnaires. Scores were calculated in accordance with the EORTC QLQ-C30 (version 3) core questionnaire manual. Data was analysed using Cohen's effect size and one way analysis of variance (ANOVA).

Results

A total of 21 patients were included. Overall QOL was reduced post-discharge (mean score 70.4 (±23.6) vs. 54.6 (±21.0), d=1.628, p=0.0412), however, there was no difference between QOL scores pre-operatively and after 6 months. There was a significant difference after 6 months for physical (mean score 98.4 (±9.6) vs. 85.2 (±14.6), d=1.068, p=0.0017) and role (mean score 92.1 (±17.2) vs. 63.9 (±28.7), d=1.1919, p=0.0005) function-related questions. Reduced appetite, diet restriction and pain were worse following discharge but improved significantly after six months.

Conclusions

The results from this study suggest that whilst certain symptoms and functional impairment is common following PD, overall QOL returns to pre-operative levels for most patients.
131 Sleeping It Off - Are Hospital Wards Too Noisy to Allow Patient Recovery?
Authors: Reid M
Published: November 2022

Aim

Increased overnight noise levels are known to stimulate the release of multiple stress hormones and negatively impact upon objective and subjective sleep quality. Increasing levels of noise impairs physical and psychological recovery, and has been shown to slow wound healing, increase complication rates, and lengthen hospital admissions. Noise levels are therefore an important component of post-operative care and recovery. The purpose of this study is to document the actual noise levels experienced by patients overnight and analyse the sources of noise.

Method

Firstly, five-minute recordings were made during four separate hours throughout the night on two wards - one paediatric and one adult. Secondly, researchers described and categorised the sources of noise.

Results

The World Health Organisation (WHO) has recommended that average overnight noise levels in hospitals should not exceed 35 dB. The average recorded on the paediatric and elderly ward was 42.27 dB and 43.91 dB, with peak noise levels of 93.65 dB and 97.01 dB respectively. In every five-minute recording, there was at least one sound louder than 67 dB. Researchers identified multiple avoidable and non-avoidable causes.

Conclusions

The average noise level was significantly greater than the WHO recommendations. Every five-minute recording contained peak sounds of significance. Such noise levels have been linked to poor sleep, increased stress hormone release, delayed wound healing, and an increased post-operative recovery time. Many feasible solutions to address the avoidable causes of these sounds are identified. Addressing this issue is important for both medical and surgical units and is likely to improve patient outcomes.
259 Postoperative Music, a Non-Pharmacological Pain Relief: A Randomized Controlled Trial
Authors: Aghakhani N , Ewalds-Kvist BM , El Boghdady M
Published: November 2022

Aim

Postoperative moderate to severe pain disrupts patients’ sleep and affects their quality of life. Non-pharmacologic pain relief such as music therapy were considered beneficial. We therefore evaluated preferred type of music as pain relief in patients with abdominal surgery in a non-UK teaching hospital.

Method

Patients undergoing open abdominal operations were included. Patients with laparoscopic or rectal surgery and/or spinal or epidural anesthesia were excluded. Routine postoperative analgesics were used. Demographic variables were recorded and VAS pain scale (0 – 10 most severe pain) was assessed in first day postoperative. Patients or their relatives gave informed consent.

Results

Sixty patients (Md age 39 years) were included; 30 patients allocated in experimental group who listened to preferred music using headphones (20 min) vs Control group used headphones without music.

Fisher's exact test and independent t-tests were computed. The pain intensity decreased from 6.94 (SD .13) to 6.21 (SD .21) in the control group (n.s,) and in the experimental group from 7.06 (SD .31) to 3.25 (SD .21), (p <.0001, 2-tailed) with no significant difference between the two groups before intervention. Pain intensity in experimental group decreased due to the intervention. There was a significant difference in pain intensity between the experimental and control groups after music therapy (p < .001, 2-tailed)

Conclusions

The patients who listened to preferred music after surgery, experienced less pain compared to their controls. A long-term follow-up with larger sample size may conform the efficacy of post-operative music as a pain-relief in UK settings.
529 Gallstone Disease and the Risk of Cardiovascular Disease – a Mendelian Randomisation Study
Authors: Fairfield C , Drake T , Pius R , Bretherick A , Campbell A , Clark D , Fallowfield J , Hayward C , Henderson N , Iakovliev A , Joshi P , Mills N , Porteous D , Ramachandran P , Semple R , Shaw C , Sudlow C , Timmers P , Wilson J , Wigmore S , Spiliopoulou A , Harrison E
Published: November 2022

Aim

Gallstones present frequently to surgical units and share risk factors with cardiovascular disease (CVD). Little is known about long-term CVD risk or the presence of any causal relationship. The aim of this study is to assess long-term CVD risk in gallstone-carriers and assess causality through Mendelian randomisation (MR).

Method

458,968 UK Biobank (UKB) participants free from baseline CVD were assessed. Cox regression adjusting for gallstones, age, sex, diabetes, smoking, anthropometric data, serum lipids, exercise and diet was conducted to assess CVD risk after 10 years in gallstone-carriers compared to controls. Two-sample MR was conducted with gallstone-susceptibility variants from the UKB and CVD-susceptibility variants from CardiogramPlusC4D in inverse-variance-weighted meta-analysis. Multivariable MR adjusting for lipid-, smoking- and diabetes-susceptibility variants was undertaken.

Results

Risk of CVD was higher in gallstone-carriers than controls (2,579/32,528 [7.1%] versus 23,249/426,082 [5.5%]; adjusted-hazard-ratio 1.48, 95%CI 1.42–1.54). MR demonstrated the opposite, with protective impact of genetic liability to gallstones on CVD (odds-ratio 0.94, 0.89–0.997). Leave-one-out analysis of each variant revealed strongly protective impact of D19H ABCG8 mutation which lowers serum lipids via biliary efflux. Multivariable MR revealed no significant association (odds-ratio 1.02, 0.93–1.11). Univariable MR after excluding all lipid-lowering variants revealed no association.

Conclusions

Gallstone-carriers experience elevated CVD risk partly explained by shared risk factors. MR demonstrated a negative relationship between genetic liability to gallstones and CVD. This was explained by lipid-lowering gallstone-susceptibility variants. Genetic liability to gallstones reduces CVD risk through lowering serum lipids. Gallstones remain a sentinel presentation of CVD risk due to shared environmental but not genetic exposures.
364 Systematic Review of Simulation-Based Training Tools in Plastic Surgery
Authors: Rehman S , Jasionowska S , Aydin A , Dasgupta P , Salibi A , Cavale N
Published: November 2022

Aim

The recent shift from traditional surgical teaching to the incorporation of simulation training in plastic surgery has resulted in the development of a variety of simulation models and tools. We aim to identify all currently available simulators and tools for plastic surgery, assess their validity and establish their effectiveness.

Method

MEDLINE and Embase were searched for articles which validate simulation models in plastic surgery. Each study was screened in accordance with the Messick validity framework, and a rating was given for each section. In order to determine the effectiveness of each study, the McGaghie model of translational outcomes was used.

Results

On screening 2104 articles, 71 were identified to discuss validity and effectiveness. Only one study was found to achieve a high score in all validity parameters and no studies achieved an effectiveness level >2.

Conclusions

With the increasing amount of simulation training tools, there must be more validity studies conducted using updated validity frameworks. In addition, there should be an increased emphasis of the relationship between these simulators and patient outcomes/surgical technique in the operating theatre in order to determine translational outcomes. More training tools evaluating both technical and nontechnical surgical skills are recommended.
635 Validation of Virtual Reality Training for Femoral Nail Procedures in Orthopaedic Surgery: A Systematic Review
Authors: Sharma M , Khanal P , Patel N , Patel A
Published: November 2022

Aim

To evaluate the effectiveness and shortcomings of virtual reality (VR) simulators to teach and assess femoral nail procedures.

Method

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) algorithm was used to screen and select studies from four databases: Embase (via Ovid), PubMed, Web of Science and Scopus. In total, fifty titles were identified. Of these, four studies met the eligibility criteria and underwent narrative analyses.

Results

The studies consisted of 86 participants and measured 17 outcomes associated with procedural learning. Three studies showed that VR simulation trained cognitive and psychomotor skills relevant to the real procedure (construct validity) and one study showed that these skills were transferrable to another simulation model (transfer validity). In addition, two studies employed questionnaires to investigate the visual realism (face validity) and technical accuracy (content validity) of the VR simulators, receiving positive feedback for both components. The main limitation pervading all simulators was the minimality of haptic feedback when interacting with the virtual instruments and environment.

Conclusions

This systematic review demonstrates that VR simulators may be a viable tool for trainees to safely learn and practise femoral nail procedures outside the theatre. However, there remains scope for design and technological enhancements to further improve their effectiveness. To facilitate this continued development, we are presently conducting a large-scale validation study for the DePuy Synthes (Johnson and Johnson) Trochanteric Femoral Nail Advanced VR system, comprising participants from two London, UK, Hospital Trusts.
772 Perspectives on Simulation as an Assessment Tool in Surgical Training: A Qualitative Study of Key Stakeholders
Authors: Toale C , Morris M , O Kavanagh D
Published: November 2022

Aim

The perspectives of the wider surgical community toward simulation-based assessment (SBA) in training is a gap in the literature. This study aims to generate a conceptual framework regarding the acceptable use of SBA in surgical training, through the perceptions and experiences of a broad range of stakeholders.

Method

A sequential transformative qualitative methods approach employing constructivist grounded theory was used. Ten semi-structured interviews were conducted representatives from identified key stakeholder groups; executive management, risk management, a practicing surgeon, an anaesthesiologist, a theatre-nursing representative, a representative from simulation, a patient, a medical student, a junior surgical trainee and a senior surgical trainee. interview transcripts underwent content analysis using NVIVO software (NVIVO 12, QSR International).

Results

Four themes emerged: the ‘need’ for SBA, the concept of a ‘minimum standard’, the ‘optimum design’ of an SBA framework, and ‘fairness’. SBA is a potential solution to challenges in the current training environment. It emerged that it should not replace trainer judgement but could ensure that trainees meet a minimum operative competency standard. SBA should be used to identify underperforming trainees early in training, to provide remediation. The application of SBA in high stakes settings such as trainee selection, autonomy granting, and end-of training certification has perceived benefits over current assessment methods.

Conclusions

This study generates a conceptual framework regarding the acceptable use of simulation as an assessment tool in surgical training, including perspectives from a broad range of stakeholders. Findings can inform the development of simulation-based assessment curricula in surgical training.