bluuebunny/crossref_metadata_2025 huggingface dataset:
145 Best Medical Therapy for Patients with Peripheral Arterial Disease: A Quality Improvement Project in Vascular Surgery, Aberdeen Royal Infirmary
Authors: Hapca S. , Shepherd J. , Messeder S.J.
Published: February 2022

Introduction

Peripheral arterial disease (PAD) is the leading cause of limb amputation and cardiovascular morbidity. The National Institute for Health and Care Excellence (NICE) advocates best medical therapy (BMT) with high-dose statin (atorvastatin 80mg) and antiplatelets (clopidogrel or aspirin) for secondary prevention in patients with PAD. We assessed compliance to BMT prescribing in our vascular department.

Method

Retrospective data were collected for all patients admitted with symptomatic PAD in our vascular department over a 2-week period. Criteria for BMT were as per NICE guidelines with a standard set to 100%. Following cycle 1, a new admission document prompting antiplatelet and statin review was designed and departmental teaching on BMT delivered. Standard compliance was re-audited after 3 months.

Results

Twenty-five patients were admitted with PAD during cycle 1 with 28% of patients (n = 7) on BMT on admission. This increased to 40% (n = 10) on discharge with 100% (n = 25) on an antiplatelet and 28% (n = 7) on high-dose statin. Overall, there were twenty patients in cycle 2 with 25% of patients (n = 5) on BMT on admission. This increased to 80% (n = 16) on discharge with 100% (n = 20) on an antiplatelet and 80% (n = 16) on high-dose statin.

Conclusions

Our data demonstrated poor implementation of BMT for patients with PAD managed in primary care suggesting a need for primary care education. Adaption of our admission proforma to prompt BMT prescribing as well as departmental teaching was associated with drastic improvement of BMT prescription on discharge and standard adherence.
148 Posterior Malleolus Fractures: Classification and Patient Outcomes
Authors: Banks P. , Lineham B.
Published: February 2022

Aim

Posterior malleolus (PM) fractures are a common and significant injury. Historically, only fractures constituting >30% of the joint surface were managed operatively, however more recent research suggests that the type of fracture and injury mechanism carry more importance. This study compared the patient outcome scores with the most common classification systems, percentage tibial plafond involved (PTP) and fixation method.

Method

Patients diagnosed with PM fractures between December-2020 and January-2015 were identified and invited to answer a Foot and Ankle Outcome Survey (FAOS). Responding patients had CT scans reviewed by a consultant radiologist. The fractures were classified using Mason Malloy, Haraguchi, Bartonicek and PTP. Groups were further divided into those managed as recommended by each classification. The classifications were correlated against FAOS using Pearson correlation coefficient or one-way ANOVA test as appropriate.

Results

59 patients responded with a completed FAOS. When classifications were measured against FAOS no statistically significant difference was identified (Bartonicek F = 1.78 p = 0.15, Haraguchi = F = 0.41 p = 0.66, Mason Malloy F = 1.24 p = 0.30, PTP = 0.11 p = 0.41). When only those managed as recommended by the classification system were included there remained no significant difference (Bartonicek F = 1.8 p = 0.18, Haraguchi F = 2.4 p = 0.10, Mason Malloy F = 0.25 p = 0.86, PTP = 0.25 p = 0.06).

Conclusions

Categorisation of PM fractures by any of the three main classification methods or PTP did not correlate with FAOS in this group including in patients managed as suggested by the classification. Whilst recognising the limitations of this retrospective study this may suggest patient outcome from PM fractures is more significantly influenced by other factors than fracture classification.
152 Improving Imaging in Acute Pancreatitis
Authors: Al-Khazaali B.
Published: February 2022

Aim

In the UK it is not a current practice to perform early (< 3 days) CT for detection and staging of severe cases of acute pancreatitis. Findings of pancreatic necrosis, fat stranding and intraperitoneal fluid should be included in the CT scan report as they are important prognostic factors. Furthermore, radiological facilities should be available to permit US examination of the gallbladder <24 hours of the diagnosis. The aim was to meet 95% for all standards.

Method

Retrospective baseline data were obtained for 83 patients presented with acute pancreatitis between January 2020 and February 2021. Several interventions were implemented including educational posters, emails and lectures to general surgeons and radiologists. Re-auditing was conducted between May and August 2021 to measure the effectiveness of these interventions.

Results

Baseline showed low compliance to standards, and 62% of presented patients underwent early CT (< 3 days). Only 78% received US scan within 24 hours of admission. Second cycle showed increased adherence to NICE guidelines with 56% of patients had CT scan in optimal timing. Reports of CT scans showed minimal improvement in terms of including the prognostic factors. US examination of gall bladder improved with 83% of patients diagnosed with acute pancreatitis.

Conclusions

Early CT may underestimate final severity of acute pancreatitis. Low adherence to guidelines was noticed in the first audit cycle which was increased after the interventions. Further interventions and auditing will be needed.
155 Fracture of Pubic Rami During Hip Fracture Fixation - a Rare Case of Traction Table Related Injury
Authors: Gomindes A.R. , Remtulla M. , Mohammed A. , Cooper J. , Nikolaidis A.
Published: February 2022

Background

Traction tables form the mainstay of closed reduction techniques for lower limb fracture and in particular hip fractures. They offer a versatile solution to continuous traction required in a variety of operations such as closed intramedullary femoral fixation and hip fixation. Counter traction on the table is provided by the perineal post, this has been associated with significant complications such as neuropraxia, erectile dysfunction, cutaneous necrosis, and urethral injuries.

Case presentation

We present a case of an elderly and co-morbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intra-operatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table.

Conclusions

Closed reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed fixation should be accounted for when managing this complex and often frail group of patients.
156 A QIP on Improving Approach Towards Suspected Cauda Equina Syndrome Referrals
Authors: Salik M. , Bhagawati D.
Published: February 2022

Aim

To improve the assessment, documentation, and management of suspected Cauda Equina Syndrome (?CES) referrals by supporting and educating new doctors joining T&O

Method

A survey was done to assess the level of training received by Junior Doctors in Assessment, Documentation, and Management of a ?CES Referral. A need for such training was established from the Survey Report. Teaching was organized and an Infographic poster was published to aid new doctors in safe assessment, documentation, and management of? CES cases. A post Survey was done to assess the impact.

Results

There was a significant need for teaching and training regarding the approach towards dealing with a suspected Cauda Equina Syndrome patient. The teaching was very well received. 90% of the participants believed that the QIP and the infographic poster were useful in training, will be a helpful guide for new doctors in assessment, documentation, and management of suspected Cauda Equina Syndrome patients, and will lead to improvement in patient care and documentation.

Conclusions

Suspected Cauda Equina Syndrome bears a huge significance in Emergency Care and Trauma and Orthopaedics. Mismanagement of such a case and unnecessary delays can have a drastic impact on a patient’s life and as such can also lead to significant medico-legal implications from the managing team. Teaching and training regarding approach towards a suspected Cauda Equina Syndrome can lead to significant improvement in the competence and confidence of the Junior Doctors and New Trainees and thus lead to better patient care, better documentation standards, and potentially prevent unnecessary delays.
164 Testicular Torsion: A Race to Beat the Golden Hours
Authors: Rai A. , Singh R. , Mehana O. , Alam A.
Published: February 2022

Introduction

Testicular torsion is a condition requiring immediate attention and the golden time period for its management is 6 hours at which rate of salvageability of the testes is 90 percent (NICE). This decreases considerably with passing time. Imaging has minimal value.

Method

The electronic data of 36 patients from June 2020 to May 2021 were reviewed and analysed. Majority of patients were between the age of 11–20 i.e., 21. We analysed the mode of admission of these patients, the time between the A&E triage and surgical clerking and A&E triage and induction of anaesthesia.

Results

Majority (70 percent) patients were admitted through Emergency A&E. The time between the A&E triage and surgical clerking was less than 30 minutes for 10 patients while 11 patients had no proper documentation of time. The time between the A&E triage and the induction of anaesthesia was less than 6 hours in 23 patients, and more than 6 hours for 7 of them. 14 underwent Scrotal Exploration and Bilateral orchidopexy and 13 orchidectomies. Out of 13 orchidectomies, 6 had crossed the golden time period at the time of induction. Out of 10 patients booked for USS testis, 8 underwent Orchidectomy and 6 had crossed the golden hour (6 Hours).

Conclusions

Early presentation, diagnosis and exploration of testicular torsion improves the salvable rate of testes. 6 patients who underwent USS testis passed the golden timeframe which shows that there is a scope for faster and appropriate management of testicular torsion.
165 Cataract Surgery: What Intraoperative Factors Impact Surgical Outcomes in Low- and Middle- Income Countries (LMICs)
Authors: Sondh R. , Azizi S.
Published: February 2022

Aim

To describe what intraoperative factors affect the outcomes of cataract surgery in LMICs.

Method

The following databases were screened to find relevant articles: EMBASE (1974–2019), MEDLINE (1946–2019), Global health (1973–2019), PubMed, Cochrane library and Cumulative Index to Nursing and Allied Health Literature. Following this, duplicates were removed, and articles underwent screening.

Results

Perioperative checks – It has been recommended for LMICs to implement similar surgical checklists to what is used in the UK, to reduce the chance of surgical complications. Having the right team - The cataract surgery team may vary in different countries. For example, in Ethiopia the staffing model includes ophthalmologists, non-physician cataract surgeons (NPCS), ophthalmic officers, ophthalmic nurses, operating room nurses and integrated eye care workers. It is common in LMICs for NPCS to outnumber ophthalmologists. Adequately skilled professionals – It’s important to consider having vitreoretinal surgical input available should surgical complications arise. This will help to optimise outcomes. Surgical technique – Techniques performed in LMICs include ICCE (intracapsular cataract extraction), ECCE (extracapsular cataract extraction and MSICS (manual small incision surgery) and phacoemulsification. ECCE and MSICS is the most commonly used in LMICS due to comparable outcomes with phacoemulsification and cost effectiveness. Surgical training and skills transfer – Various international training programmes such as the HelpMeSee programme is designed to help train ophthalmologists and NPCS in MSICS via simulation.

Conclusions

The above factors are important considerations which influence surgical availability and success. LMICs have an increasingly aging population and cataract services will be required to adapt to the increase demand.
168 Innovation Surgical Leadership: Future Directions
Authors: Haque S.
Published: February 2022

Aim

Which theories, concepts and frameworks have been evidenced for surgical innovation in leadership in the United Kingdom, European Union, and the United States of America?

Method

Systematic scoping synthesis of literature will be employed where appropriate theories, concepts and frameworks will be identified. Drawing upon broader literature on leadership innovation in surgery further examples will be utilised within surgery. s and full- text articles will be used and reviewed for relevance to the research question against an inclusion and exclusion criteria.

Results

The theories of innovative leadership in surgery are broad and non-specific. It demands a professionalism, competence, teamwork, and motivation. Upon comparison of the three country/region profiles there are strong similarities but present differences. It is paramount to understand and underpin these theories in order to foster the future of innovation in surgery. Surgery is fast evolving and developments in leadership must evolve with it. Within innovation, leadership skills must be harnessed including experience and observation. It is through an interprofessional team that surgeons must collaborate in order to provide optimum results and to permit the profession to evolve.

Conclusions

Innovation and surgery are symbiotic, and the next generation of surgical leaders must foster an environment where this is possible to cultivate. Programmes across these country profiles must ensure innovative leadership is present through good mentorship, coaching, team empowerment and feedback. Future directions must be put in place in post -graduate surgical training programmes to ensure that patient care is optimised as the primary objective.
171 Developing & Centralising a Nurse-Led Local Anaesthetic (La) Transperineal (Tp) Biopsy Service During Covid: A Success Story
Authors: Winters D. , Mehmi A. , Odedra A. , Buttleman S. , Ancheta J. , Allchorne P. , Rajan P. , Khan S. , Green J.S.A.
Published: February 2022

Introduction

During the first COVID-19 wave, the BAUS Section of Oncology issued guidance to minimise risks of sepsis and general anaesthesia at prostate biopsy. Consequently, and as a result of diminished diagnostics capacity on Trust acute sites, we implemented a centralised network-wide nurse-led LA TP biopsy service on a COVID-secure “green” site and abandoned trans-rectal biopsies. We evaluated the impact of this service improvement on patient waiting times before and after national lockdown in March 2020.

Method

Classic Quality Improvement (QI) methodology was used with continuous data collection and waiting list management by clinical staff with standard admin support. Balancing measurements were collected. Run charts were used to confirm whether a change led to a real and sustainable improvement.

Results

The number of days waiting, from time of request to date of biopsy, is presented in the following run chart. The mean waiting time for those pre lockdown was 145 days (SD 57) whereas post lockdown was 23 days (SD 20). This identified that there was a significant difference between the average waiting time pre and post lockdown (U = 55.5, p = <0.001) There were also reductions in waiting time when subcategorised into planned Active Surveillance cases, target cases and delayed cases.

Conclusions

Centralising the TP biopsy service and converting to a nurse led LA service has led to reductions in waiting lists and was safely expedited and resilient even in the COVID-19 pandemic. Allowing a second advanced TP practitioner to be fully trained, during COVID. The service was highly valued by patients and staff.
172 Septic Arthritis of the Wrist: Audit of Management and Awareness of National Guidelines Amongst Orthopaedic Surgeons in a District General Hospital
Authors: Raza F. , Seewoonarain S. , Willmott H.
Published: February 2022

Aim

Septic arthritis (SA) of the wrist is relatively uncommon and, in contrast to SA of large joints, can safely be managed with serial aspiration to dryness rather than traditional open surgical drainage. This is supported by BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults. We conducted an audit of management of suspected wrist SA patients and surveyed awareness of relevant guidelines amongst orthopaedic surgeons.

Method

Electronic records of patients referred as suspected wrist SA to the orthopaedic department over a six-month period (August 2020 to February 2021) were retrospectively reviewed. Data analysis included demographics, diagnosis, management, and treatment outcome.

In addition, knowledge of wrist SA management amongst orthopaedic medical staff was determined via a multiple-choice questionnaire.

Results

11 patients were identified (5M:6F, age range 62–91).

6/11 patients underwent wrist aspiration though only one patient had a positive gram stain.

No patients underwent serial aspiration as advocated by national guidelines.

2/11 patients underwent formal surgical washout in theatre.

15 orthopaedic doctors were surveyed (8 Junior Doctors, 4 Registrars, 3 Consultants). 2/15 were aware of national guidelines. 11/15 chose joint aspiration as an initial investigation. 2/15 considered repeated joint aspiration to dryness as definitive management.

Conclusions

This audit highlighted low compliance with national guidelines when managing wrist SA, although this did not adversely affect patient outcomes. We demonstrated lack of awareness of relevant guidelines amongst orthopaedic surgeons. We propose relevant teaching and incorporation of national guidelines into Trust policy.
173 Causes of Death in Patients with Pancreatic Adenocarcinoma: A SEER-Based Study
Authors: Harvitkar R.U. , Harishkumar P. , Ramasamy S.
Published: February 2022

Aim

To identify the commonest causes of non-cancer mortality in patients with PAC and compare their mortality risk with the general population.

Method

This population-based study analyzed data of PAC patients registered in the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2016. Patients were followed up until 2016.We studied cancer and non-cancer causes of death and investigated their possible association with age, sex, race, tumor stage at presentation, and treatment modality; each according to the time interval from diagnosis during which death events occurred (intervals included < 1 year, 1–5 years, 5–10 years, and > 10 years after diagnosis).We estimated the standardized mortality ratio (SMR) with the 95% confidence interval (CI) for each mortality cause in each time interval. Analysis was conducted using SEER*Stat software version 8.3.9.

Result

A total of 67,694 PAC patients included in the analysis; of these patients, 64,347 (95.06%) died during the follow-up period. Most deaths occurred due to cancers (61,685; 95.86% of deaths), while non-cancer mortality causes represented only 4.14%.The commonest causes of non-cancer mortality were heart diseases (SMR = 2.79;95%CI,2.6–2.98),cerebrovascular diseases (SMR = 3.11;95% CI, 2.71–3.56), and septicemia (SMR = 8.2;95%CI,6.9–9.68).PAC patients had a higher mortality risk than the general population for all studied mortality causes except Alzheimer's disease (SMR = 0.5;95% CI, 0.3–0.78) and homicide and legal intervention (SMR = 2.29; 95%CI, 0.47–6.68).

Conclusions

About 96% of PAC patients' deaths are due to cancers. While the dominant non-cancer causes of death in these patients include heart diseases, cerebrovascular diseases, and septicemia, with a higher risk of mortality for most non-cancer causes than the general population.
181 Can Movement Modelling Software, in a Digital Preclinical Trial, Help Understand the Optimal Sit to Stand Motion Using Commercially Available Peripheral Nerve Stimulators?
Authors: Noakes A.
Published: February 2022

Aim

Ethical approval is difficult to acquire for functional electrical stimulation trials, simulation may bridge the gap between FES concept and clinical trial approval. Using OpenSim modelling tool, this project aims to identify the minimum number of muscles, their strength and order of stimulation, that can produce the safest standing motion, using commercially available peripheral nerve stimulators.

Method

Modelling was executed using version 4.1 of OpenSim, utilising a previously validated, and extensively referred to, OpenSim lower limb model (Gait2354_Simbody) as the base model. Starting excitation values emulated previous literature for optimal sit to stand motion. EMG values were inputted using the excitation function of the forward dynamics tool, used to predict motion given defined neurological excitation values. Muscle groups and excitation values were altered iteratively to achieve the objective. Once the model performed the required function, within normal joint forces, the simulation was stopped.

Results

For optimal movement, the muscles required included, Gluteus Maximus, Rectus Femoris, Sartorius, Soleus, Tibialis Anterior, Vastus Intermedialis. This exceeded the 5-muscle objective, however muscles that shared a nervous supply could utilise a single FES port. Joint reaction forces remained within literature estimates, knee on tibia joint in the vertical plane achieved 2500N bilaterally, this represents a force equating to 3.64 times body weight.

Conclusions

Movement modelling software can become a fundamental tool in acquiring ethical approval for FES studies through simulation of full body motion. OpenSim requires iterative inputted improvements by the user, therefore a software which generates automated efficient movements would be more accurate and faster.
186 Thyroid Monitoring for Patients Born After the Chernobyl Disaster Within the Blast Radius: A Literature Review
Authors: Faraj A. , Tan S.J.T. , Hussain K.
Published: February 2022

Aim

There is a well-documented increase in incidence of thyroid cancer in individuals living within the blast radius at the time of the Chernobyl nuclear disaster. Following a case encountered in our clinical practice of a patient born within the blast radius but after the blast itself, we aimed to evaluate the evidence of increased thyroid cancer within such a cohort.

Method

We reviewed the existing literature for evidence for or against an increase in thyroid cancer in this population group. Identified articles were reviewed and appraised, evaluating the evidence for any possible increase in incidence.

Results

Very few papers looked at risk in such a population, but those identified suggested no increase in risk of thyroid cancer in individuals born within the radius, after the blast.

Conclusions

We conclude there is little evidence supporting routine monitoring for individuals born within the blast radius after the blast, and as such this should be included in the British Thyroid Association guidelines.
187 Pooled Waiting Lists for Primary Hip and Knee Arthroplasty: Are the Outcomes Inferior to a Named Consultant List?
Authors: Thacker J. , Peake C. , Balasubramani P. , Chongbang T.P. , Jayakanathan M. , Unnithan A.
Published: February 2022

Aim

A pooled waiting list model is where patients are treated in turn by the first available surgeon and works to use existing resources more efficiently to better match demand. Aim is to compare quantitative data of patients on the pooled list and named-consultant’ list and to determine the superiority of either list based on favourable outcomes.

Method

This single centre, retrospective study compared outcomes of primary elective hip and knee arthroplasty for osteoarthritis in patients from pooled and ‘named-consultant’ waiting lists over a 1-year period. The study period was before the corona virus pandemic. 371 total knee replacements (TKR) and 373 total hip replacements (THR) were included. Baseline characteristics were compared between patients from pooled and named-consultant lists.

Results

In the pooled TKR group, a significantly higher proportion of patients were older with higher BMI and ASA grade (p = 0.027, p = 0.479, p<0.001 respectively). There was no difference in baseline characteristics in the THR cohort. Waiting time to surgery was less in the pooled TKR group (mean = 4.17months) with no significant difference in mortality, revision and infection rates, length of stay, operative blood loss, DVT/PE rate, proportion requiring pain team referral and the number with unsatisfactory range of motion at follow-up. There was no significant difference in any outcomes between two groups in the THR cohort.

Conclusions

Pooled lists can therefore be an excellent tool in primary THR/TKR to efficiently utilize all available resources (surgeons and theatre time) without compromising on patient outcomes and prompting use in all UK arthroplasty centres.
188 Quality of Documentation of Patient Notes in the Surgical Department
Authors: Da Costa K. , Islam R. , Khanfar A. , Gelber E.
Published: February 2022

Aim

Quality of documentation of patient notes

Method

Guidance for standards was taken from ‘The importance of Clinical Documentation, Ann R Coll Surg Engl(Suppl) 2014; 96:18–20’

Data of 100 patients over 2 weeks. Assessed:

Results

Availability of notes:

15/100 notes were not available on the wards at the time of data collection

Conclusions

Based on above results the significances of:

Results

Unable to provide proof of treatment if any abnormalities were found and medical negligence
190 Metabonomics in Chronic Venous Disease - Local and Systemic Phenotypes
Authors: Adenipekun A. , Bergner R. , Onida S. , Davies A.
Published: February 2022

Aim

Chronic venous disease (CVD) describes a spectrum of clinical presentations associated with a poorly functioning venous system, ranging from asymptomatic venous disease to varicose veins, skin changes and venous leg ulceration. These conditions negatively impact on quality of life.

There is evidence that ‘local’ blood sampled from lower limb veins contains different biomarkers to systemic blood, particularly with respect to inflammatory and prothrombotic mediators; however, the literature pertaining to metabolic phenotyping platforms is limited. The aim of this study was to assess whether the metabolic signatures in systemic serum differed from the signatures in truncal/varicose vein (local blood) in patients with CVD.

Method

64 patients presenting with CVD were recruited to participate in the study following clinical and duplex ultrasound assessment. Blood samples were collected from the antecubital fossa and from the lowermost refluxing vein or varicosity in the leg. Metabolic profiling was performed using Reversed-Phase Ultra Performance Liquid Chromatography (RP-UPLC) lipid profiling analysis. Univariate and multivariate statistical analysis were performed.

Results

Principal component analysis (PCA) of overall spectral data showed no separation amongst metabolites. Orthogonal Projections to Latent Structures Discriminant Analysis (OPLS-DA) revealed preliminary group differences between leg and arm samples, but this was not significant upon CV-ANOVA testing (P = 1)

Conclusions

The analysis via RP-UPLC did not identify significant differences in the metabolic profile of systemic and local serum samples; however, this may be due to the limited sample size, or the platform employed. Future work will include performing the analysis employing complimentary metabolic phenotyping platforms and a larger sample size.
191 Improving and Maintaining the Implementation of Local Guidance on Vitamin D Supplementation for Patients with Hip Fracture
Authors: Garnett A.
Published: February 2022

Introduction

With the number of older persons presenting to hospital with neck of femur (NOF) fractures climbing annually, there is an emphasis on reducing the impact of environmental factors in at risk individuals. The link between vitamin D deficiency and osteoporotic fractures has long been recognised in older populations and is incorporated in Department of Health ‘Best Practice Tariffs’ for hip fracture management.

Recommendations state that all patients admitted to hospital with a NOF fracture should be assessed for bone protection, and Wirral University Teaching Hospital has developed local guidance to aid appropriate prescription of vitamin D for patients with a deficiency. Concerns were raised by local Orthogeriatricians that this guidance was not being consistently implemented and a review of current practice was requested.

Method

A quality improvement project reviewed vitamin D supplementation for all NOF fracture patients over a 3-month period. Subsequently lanyard cards with a summary of local guidance and correct treatment were created and distributed to junior doctors. Compliance with the guidance on measurement and treatment of low vitamin D levels was reviewed after 3 months and a further 12 months.

Results

Initially the guidance was followed correctly in only 48% of patients. With the implementation of lanyard cards this rose to 78% after 3 months and more encouragingly further increased to 83% after a further 12 months.

Conclusions

Providing an easily accessible summarised version of local guidance improved measurement of vitamin D levels and appropriate treatment for at risk patients.
193 Aspirin Compared with Other Anticoagulants for Use as VTE Prophylaxis in Elective Orthopaedic Hip and Knee Operations: A Narrative Literature Review
Authors: Olukoya O. , Fultang J.
Published: February 2022

Introduction

Total hip and knee arthroplasty are effective methods for treating arthritis but have an associated risk of venous thromboembolism (VTE). To reduce this risk, prophylactic agents including Aspirin, Low Molecular Weight Heparin, Vitamin K antagonists and Direct Oral Anticoagulants are employed for up to 35 days after surgery. This narrative literature review utilised a systematic approach to critically assess the current evidence surrounding the use of Aspirin for VTE prophylaxis as compared to anticoagulants.

Method

An advanced multistage electronic search was performed in May 2021 using the OVID/Medline and Embase online libraries to identify available studies relevant to the subject from 1974. Additional evidence identified during the review process were added. The final papers meeting the inclusion criteria were then assessed using the Critical Appraisal Skills Programme (CASP) tool.

Results

12 studies (60%) (2 Meta-analysis, 3 randomised trials, 7 retrospective studies) favoured Aspirin over anticoagulants for VTE prophylaxis. 15 studies (75%) (2 meta-analysis, 3 randomised trials, 9 retrospective, 1 matched cohort) showed Aspirin had better bleeding profiles and complication rates; statistically significant in 7 (46.7%) (1 randomised trial, 6 retrospective studies). 8 studies (1 randomised trial, 6 retrospective studies, 1 matched cohort) reported statistically significant results for Aspirin - 5 (62.5%) declared Aspirin superior for VTE prophylaxis, while 7 (87.5%) declared Aspirin superior in terms of bleeding complications.

Conclusions

The current evidence indicates that Aspirin is superior to anticoagulants, in their various iterations, for VTE prophylaxis and in terms of their bleeding profiles.
199 The Influence of Pre-Operative Factors on Patient Length of Stay After Total Knee Replacement
Authors: Yadav S. , Jeyaweerasingam S. , Htwe S.M. , Gadde R. , Rossiter D. , Jacob J. , Unnithan A.
Published: February 2022

Aim

This study aims to assess the impact of pre-operative factors on the length of stay in patients following total knee replacement at our institution.

Method

A total of 478 patients following total knee replacement between January 2017-Decemeber 2019 are included in this study. All patients underwent total knee replacement with a medial rotating total knee prosthesis (MRK; Matt Ortho UK).

Data for each patient was collated retrospectively and included the following: Patient demographics (age and sex), American Society of Anaesthesiology (ASA) score, pre-operative range of movement (ROM), Body Mass Index (BMI), and pre-operative haemoglobin. Each factor was then compared with the length of stay for all 478 patients. Statistical significance was sort for each pre-operative factor for both men and women.

Results

Our cohort of patients includes 291 females and 187 males. Patients ranged from 39 to 90 years with an average age of 68. The average BMI of the cohort was 31.3(18.6–56.56) and the average ASA grade was 2.

Preoperative hemoglobin and the Age of the patient at the time of surgery were the only two factors which had a statistically significant impact on the length of hospital stay (p<0.05). BMI, Pre- operative range of motion and ASA scores had no statistically significant effect on the length of hospital stay in our cohort.

Conclusions

Low pre-operative hemoglobin and increasing age have significant effects on length of stay after total knee replacement. The BMI, pre-operative range of movement and ASA scores do not influence the length of hospital stay.
204 Thoracic Outlet Syndrome After Nuss Procedure for Pectus Excavatum: An Unusual Complication of a Common Procedure
Authors: Gopalaswamy M. , Waterhouse B. , Dunning J.
Published: February 2022

Pectus excavatum is a common abnormality of the chest wall with variable severity. The Nuss procedure was introduced in 1987 and has since become a standard modality of treatment for this condition. This operation has a well-established safety record and significant complications are rare. Case report of a 21-year-old male with pectus exavatum operated on in our department. Symptoms discovered during post-operative follow up: - He complained of purple discolouration and swelling of his left hand, which was positional, particularly pronounced with arms hanging by his side, and relieved when he lifted his arm overhead.- This was also accompanied by his left arm feeling colder to the touch when compared to his right arm. Examination findings: - At rest, no objective sensory deficits were elicited.- On arm elevation and external rotation, the swelling and congestion resolved, but the arm turned white, with a positive Adson’s test.- Findings were highly suggestive of Thoracic Outlet syndrome Imaging findings: CT Angiogram: abnormally fused first and second rib on the left. Obvious kink in the artery suggesting presence of a cervical band. Operative findings: - The anterior scalene was abnormally deep and attached to the lateral and anterior surface of rib and tightly fibrous.- uscle was divided at its insertion and was found to encircle the Subclavian artery completely

Conclusions
205 Vascular Outcomes in TIA Patients
Authors: Manson D. , Johnston M. , Kent F.
Published: February 2022

Aim

To identify vascular outcomes in patients presenting with TIA

Method

We completed a closed loop audit at the University Hospital of Wales assessing vascular outcomes in TIA patients. We audited the first 100 patients with significant carotid ultrasound findings from January 1st, 2020, and then the first 75 patients with significant findings in the repeat study from July 1st, 2021. We assessed the time between symptom onset, referral, and consultation, whether that be geriatric or vascular, and the outcome of that consultation. If patients required surgical vascular intervention, we assessed whether this was conducted within the 14-day window outlined by national and international guidelines.

Results

We found that for a multitude of reasons, including delayed patient presentation and arduous referral processes, that patients with significant findings were not receiving vascular input within the 14-day window, let alone receive an operation. We suggested that a centralised vascular referral pathway and a consultant of the week would facilitate a more efficient TIA-vascular process, allowing for carotid endarerectomies to be performed within the internationally advised timeframe. The closed loop revealed that although patient presentation and referral times were obviously unaffected, that vascular consultations were occurring far more rapidly, as aided by the newly incorporated consultant of the week.

Conclusions

That a centralised departmental coordinator, and a consultant of the week delegated towards facilitating TIA referrals for potental carotid endarterecomy, was beneficial in terms of meeting standardised timeframes, but that more could be done to improve the service.
207 An Assessment of Outcome in Patients with Anaemia (Iron Deficient and Non-Iron Deficient) Who Have Colon Cancer - Effect of Treatment with Oral/ IV Iron
Authors: Sukumar A. , Khan K. , Khalid W. , Singh-Ranger D.
Published: February 2022

Aim

Treatment of iron deficiency anaemia in patients undergoing colon cancer resection improves outcome defined by length of stay, recurrence, and requirement for blood transfusions.

Method

Retrospective analysis of patients with anaemia and colonic cancer between January 2018 - August 2019. Anaemia categorised as – Iron Deficiency Anaemia and non- Iron Deficiency anaemia. IDA was defined as hypochromic microcytic anaemia. Patient demographics, tumour location, pre- and post-operative haemoglobin, length of stay, recurrence and requirement for blood transfusions were collected plus treatment for anaemia. Comparisons made between IDA and non-IDA groups in relation to treatment for anaemia with iron (oral/IV). Non-parametric statistical tests used (median, 2-way ANOVA, Kruskal-Wallis) with significance at P <0.05.

Results

150 patients with colonic cancer identified: 77 in IDA group, 46 treated (42 oral, 4 iv iron). 11 in non- IDA group, 8 treated (oral iron).

IDA oral and IV treatment versus non-IDA:

Median age 74, 80 and 78 years (P = 0.814),

Pre- and post op Hb IDA vs non-IDA: 107, 97; 109, 101 (P 0.007 significant),

Requirement for blood transfusion (units) 0.77, 0.50;0.90 (P 0.596)

Length of Stay (days) 6, 5; 7 (P 0.113),

Tumour location: mean of right colon and transverse colon 24.33, 3.667 (P >0.1), and

Recurrence P >0.1.

Conclusions

In our series, iron treatment does not influence recurrence, length of stay, requirement for blood transfusions. Tumour location is not significantly different between IDA and non-IDA group. Patients treated with oral iron therapy are seen to have a larger drop in haemoglobin post operatively than the other groups.
208 Blunt Splenic Trauma, Retrospective Study 2008–2013, the Canberra Hospital
Authors: Khan Hotak M. , Fitzgerald A.
Published: February 2022

Aim

To evaluate the management of Blunt Splenic Trauma (BST) management in multi-injured trauma patients at The Canberra Hospital (TCH). Non operative management (NOM) for hemodynamically stable patients & operative management (OM) for unstable patients. The aim was how to further reduce failed NOM.

Method

Retrospective data collected from of all multi trauma patients with BST from June 2008 - June 2013 at TCH. Data review included patients’ admission notes, CT results, management technique, and clinical outcome.

Results

A total of 161 patients included in the study. All paediatric patients treated with NOM with success rate of 100%. Seventy-three per cent of adults managed NOM with success rate of 97.8%. Twenty-six per cent managed operatively. ICU admissions were 54.4 % and splenic angioembolisation 2.9%. Mortality was 3.7 % with multiple injury patients zero with isolated splenic injury

Conclusions

As per our study NOM is the standard of care for all hemodynamically stable patients with success rate of 97.8% acceptable rate as per evidence more than 96%. All hemodynamically unstable patients with diffuse peritonitis require urgent laparotomy. The query to answer that AE should be considered for all patients with (AAST) grade 4–5 who are hemodynamically stable as adjunct to NOM to reduce rate of fail NOM. Further randomised controlled studies are needed.
210 An Audit to Evaluate Abdominal XR Requests in Surgical Patients
Authors: Bryce A. , Al-Azzawi M. , Watt D.
Published: February 2022

Abdominal x-rays (AXR) are a useful tool in investigating a number of pathologies. However, they expose the patient to up to 7 times more radiation than a standard chest x-ray1. AXR’s that are requested without appropriate indication are not an efficient use of resources. Our aim was to evaluate if requests for AXR’s being made are in line with Royal College of Radiologists (RCR) iRefer guidelines2 and try improving their adherence.

Three data cycles of AXR requests made by surgical staff at Crosshouse hospital were gathered – between January & February, April, and July. Clinical history of the patients and indications in the request for the AXR were compared with guideline recommendations.

In total 52 requests for AXR’s were made during January-February, of which 32 (62%) were made appropriately and 20 (38%) did not match guidelines, as the patient’s presenting complaint and clinical history did not match one of the recommended indications to perform AXR. After circulation of educational posters, 70% of requests were made in line with guidelines in April. Followed by 77% in July after a departmental presentation on the use of AXR.

AXR’s requested during these time periods were not all made in line with guidelines. The most commonly noted error was the AXR being requested to rule out obstruction when the clinical history wasn't suspicious of obstruction. This QI project has demonstrated sustainable change and increased the adherence of AXR requests with RCR guidelines within the department.
211 A Snapshot Audit of Time to Intervention for Gallstone Pancreatitis During the First Wave of COVID-19
Authors: O'Halloran R. , Coulson R. , Magee C.
Published: February 2022

Aim

We evaluated time to definitive treatment of Gallstone Pancreatitis (GSP) against the BSG guidelines during the first wave of COVID-19, comparing it to data of the same time period the previous year. Did the first wave of Covid-19 impact on time to intervention for patients diagnosed with GSP?

Method

Data were obtained retrospectively for 40 patients identified via the hospital coding department that presented with GSP between March 2019 - June 2019 and March 2020 – June 2020. Patient demographics, length of stay, time to intervention and re-admission awaiting intervention were recorded.

Results

Twenty-three patients were admitted during the non-COVID period. 30% (n = 7) of the non-COVID cohort had definitive management of GSP during index admission or within 2 weeks.

Seventeen patients were admitted during the first wave of Covid-19. 64.7% (n = 11) of the COVID-19 cohort had definitive management of GSP during the index admission or within 2 weeks.

Conclusions

Prior to COVID-19, we were not meeting guidelines for definitive management on index admission / within 2 weeks. During the first wave of COVID-19, more patients received definitive management of GSP during index admission / within 2 weeks than during the non-COVID period. A higher percentage of patients received surgical management within 2 weeks than in the non-COVID cohort. Those that did not receive management within 2 weeks, waited longer for intervention and had higher rates of re-admission than the non-COVID cohort. Despite anticipated future waves of COVID-19, prioritisation of urgent OP services is essential for those diagnosed with GSP to help reduce re-admission rates whilst awaiting intervention.
212 Surgical Operation Note Audit
Authors: Ibzea S. , Kakroo B.
Published: February 2022

Introduction

Medical record keeping is a fundamental part of the GMC’s Good Medical Practice [1,2]. Surgeons must ensure accurate, comprehensive, and legible records are maintained [3]. An operation note is essential to ensure continuity of care between operating team and other colleagues and provides a medicolegal record of a patient’s care [4]. Handover errors have been implicated in as many as 80% of sentinel events [5], highlighting the importance of ensuring accurate record keeping.

Method

We aimed to assess compliance of surgical operation notes against the Royal College of Surgeons guidance and identified areas for improvement. 48 operation notes were reviewed at a district general hospital in the west midlands over two weeks. Operation notes on standard intranet proforma and custom operation notes were compared to determine better compliance.

Results

We identified areas of most compliance vs areas of least compliance. Most and least compliant outcomes are listed below:

Conclusions

Good compliance was noted. Using the proforma on the intranet resulted in higher compliance than custom notes (84% vs 53% respectively). Adding a complications section to standard proforma can increase compliance. This audit was performed during COVID-19 restrictions therefore investigated emergency operation notes only which limited the audit.
214 The Role of Water-Soluble Contrast Enemas in Assessing Anastomoses Prior to Ileostomy Reversal, and Their Influence on Patient Outcomes
Authors: Giucca A. , Biggs S. , Roach H.
Published: February 2022

Aim

Water-soluble contrast enemas (WSCE) are routinely performed to check anastomotic integrity and patency in patients who have undergone a low anterior resection and loop ileostomy formation, in preparation for subsequent ileostomy reversal. However, no specific guideline exists in this regard. Our aim was to evaluate whether WSCE influence management and patient outcomes.

Method

WSCE examinations performed between January 2019 to March 2021 were retrieved. Radiology reports, discharge summaries, and clinic letters were retrospectively collected from prospectively maintained data to determine outcomes.

Results

Over the 24-month period, we identified 63 patients who underwent a WSCE following an anterior resection. Seven had positive radiological leaks (11%), and six of these seven underwent further investigations, then either proceeded to a successful reversal (3) or are awaiting surgery (3).

Additionally, WSCE identified 10 strictures (16%). Again, due to these findings, they underwent additional investigations before proceeding to interventions (ileostomy reversal, endoscopic dilatation, or resection of stenosed anastomosis).

In total 30 patients (48%) underwent an ileostomy reversal. Only one (2%) was not successful due to a small bowel leak, not related to the low anastomosis.

Conclusions

This study demonstrates a positive WSCE result impacts subsequent investigations or interventions required. A positive result (leak or stricture) was never a contra-indication for reversal, and none of the positive results had significant postoperative complications. The only unsuccessful reversal was not related to the low anastomosis and had a normal WSCE. The exact investigations required, and their timeframe remains unclear, and we question whether radiological or endoluminal examinations should be routinely performed.