bluuebunny/crossref_metadata_2025 huggingface dataset:
Shifting care from hospitals to the community: a review of the evidence on quality and efficiency
Authors: Sibbald Bonnie , McDonald Ruth , Roland Martin
Published: March 2007

Objectives: A key objective in many health-care systems is to shift specialist services from acute hospitals to the community and so bring care closer to home for patients. Our aim was to review published research into the effectiveness of strategies for achieving this objective.

Methods: We conducted a 'scoping' review and qualitative data synthesis of four strategies: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary and acute care; and interventions to alter the referral behaviour of primary care practitioners.

Results: One hundred and nineteen studies were identified and data systematically extracted. The findings suggest that transferring hospital services to primary care, and interventions that change the referral behaviour of primary care practitioners generally reduced outpatient activity but also risked reducing quality. Savings in cost were offset by increases in overall service volume and loss of economies of scale. Relocating specialists to primary care, and joint working between primary and acute care, improved access without jeopardizing quality. However, outpatient activity was rarely reduced and costs were generally increased due to loss of economies of scale.

Conclusions: Our findings suggest that the policy may be effective in improving access to specialist care for patients and reducing demand on acute hospitals. There is a risk, however, that the quality of care may decline and costs may increase.
Open-ended questions in surveys of patients' satisfaction with family doctors
Authors: Marcinowicz Ludmiła , Chlabicz Sławomir , Grębowski Ryszard
Published: March 2007

Objective: To compare replies to open-ended and closed questions about patient satisfaction with family doctors.

Methods: Two centres of primary health care in Białystok in northeast Poland were chosen. A self-administered questionnaire was mailed to 1000 people (500 from each centre) aged 18 years and over, randomly selected from the practices. Possible responses to the one closed question were: very good, good, bad, very bad or difficult to say. Replies to two open-ended questions were categorized as positive, neutral, negative or ambivalent.

Results: The response rate was 57.9%. There were some discrepancies between the closed-question response and the open-ended question replies. Some of those who replied good or very good to the closed question expressed negative views in response to the two open-ended questions (14.0% and 12.4%).

Conclusions: Answers to open-ended questions add value to a patient satisfaction survey by providing information that answers to closed questions may not elicite.
How useful are Cochrane reviews in identifying research needs?
Authors: Clarke Lorcan , Clarke Mike , Clarke Thomas
Published: March 2007

Objectives: To determine the extent to which reports of Cochrane reviews recommend the need for further research and, if so, the extent to which they make suggestions regarding that research.

Methods: We examined all 2535 reviews in Issue 4, 2005 of The Cochrane Library. Each review was categorized on the basis of whether a suggestion was included about specific interventions, participants, or outcome measures that should be included in future research. We also identified the frequency with which reviews conclude that no more research is needed or feasible, noted the need for further systematic reviewing, and refered to a relevant ongoing or planned study. We also report the number of studies listed in the 'Ongoing Studies' section in each review.

Results: Only 3.2% of reviews suggested explicitly that no more research is needed or feasible. In 82.0% of reviews, suggestions were made as to the specific interventions that need evaluating, in 30.2% the appropriate participants were suggested, and in 51.9% outcome measures were suggested. Suggestions for all three domains were made in 16.9% of the reviews. While 11.6% did not include a specific suggestion about any of these domains, 21.2% of reviews mention a relevant ongoing or planned study in one or both of the 'Implications for Research' and the 'Ongoing Studies' sections.

Conclusions: Most Cochrane reviews identify residual uncertainty and are a rich source of suggestions for further health-care research.
Is the metaphor of 'barriers to change' useful in understanding implementation? Evidence from general medical practice
Authors: Checkland Kath , Harrison Stephen , Marshall Martin
Published: March 2007

Objectives: To investigate how general medical practices in the UK react to bureaucratic initiatives, such as National Health Service (NHS) National Service Frameworks (NSFs), and to explore the value of the metaphor of 'barriers to change' for understanding this.

Methods: Interviews, non-participant observation and documentary analysis within case studies of four practices in northern England.

Results: The practices had not actively implemented NSFs. At interview, various 'barriers' that had prevented implementation were listed, including the complexity of the documents and lack of time. Observation suggested that these barriers were constructions used by the participants to make sense of the situation in which they found themselves.

Conclusion: The metaphor of 'removing barriers to change' was of limited use in a context where non-implementation of policy was an emergent property of underlying organizational realities, likely to be modifiable only if these realities were addressed.
A culture of safety or coping? Ritualistic behaviours in the operating theatre
Authors: Waring Justin , Harrison Steve , Mcdonald Ruth
Published: March 2007

Objectives

The creation of a ‘safety culture’ is a health services priority, yet there is little contemporary research examining the tacit, customary practices that relate to clinical risk. This paper investigates how the ritualistic behaviours of surgeons and anaesthetists serve to normalize risks within the operating theatre, thereby inhibiting organizational learning and enabling such risks to recur.

Methods

A two-year ethnographic study in the operating department of a large teaching hospital in the north of England, including observations of the organizational and clinical setting and interviews with 80 members of staff.

Results

Three ritualistic types of behaviour are identified and described. Each illustrates the taken-for-granted assumptions associated with clinical risk in the operating theatre and is characterized by a patterned response to risk, the first being to tolerate and endure risk, the second being to accommodate risk through slight modifications to clinical practice and the third being to innovate or implement unorthodox practices to control for risk.

Conclusion

These ritualistic behaviours normalize risk within the operating theatre leading to the possibility that some threats will escape appropriate attention and may lead to patient harm. These culturally scripted behaviours also encourage a short-term reactive response to risk that emphasizes the importance of individual coping rather than the more systemic forms of learning associated with participation in incident reporting. This research extends and elaborates upon the current policy orthodoxy to better understand the cultural context of patient safety.
Retention and future job intentions of graduate primary care mental health workers: A newly developed role in England
Authors: Harkness Elaine , Bower Peter , Gask Linda , Sibbald Bonnie
Published: March 2007

Objectives

Modernization of the English National Health Service (NHS) workforce has led to the introduction of a number of new roles. One such role is the graduate primary care mental health worker (PCMHW). Although generally successful in expanding primary mental health care, several challenges were raised by the initial implementation, including retention and development ofeffective career pathways for these workers. The aim of this study wasto examine retention and future job intentions of graduate PCMHWs at the end of their one-year training.

Methods

Mail surveys of the first cohort of graduate PCMHWs recruited in 2004 were conducted at the beginning and end of their 12-month training.

Results

Satisfaction with training courses was generally low. Over half indicated they were likely to leave their graduate PCMHW post within the next few months. However, most intended to stay within the NHS.

Conclusions

After training, problems were highlighted in relation to the quality of the training programmes and lack of development of an effective career pathway. This has serious consequences for the viability of this intiative.
Should I stay or should I go?’ Deciding whether to go to hospital after a 999 call
Authors: Porter Alison , Snooks Helen , Youren Alison , Gaze Sarah , Whitfield Richard , Rapport Frances , Woollard Malcolm
Published: March 2007

Objective

In most UK ambulance services, crews attending someone who has phoned the emergency services on ‘999’ will take the patient to hospital, unless the patient makes the decision to stay at home (or wherever they happen to be when the ambulance arrives). Safety concerns have been raised about non-conveyance decisions. Weunder took a study of one UK Ambulance Service to examine ambulance crew members’ views on how decision-making about non-conveyance works in practice in relation to non-urgent calls.

Methods

A total of 25 paramedics took part in three focus groups. Focus groups were transcribed and analysed thematically.

Results

The ambulance service's apparently straight forward guidance on decision-making about non-conveyance proved tricky in the messiness of the real world, for two reasons. The first was to do with the notion of the patient's capacity to make decisions and how this was interpreted. The second was to do with the complexity of the decision-making process, in which the patient, the crew and, in many cases, family or carers often take part in negotiation and de facto joint decision-making.

Conclusions

There is a mismatch between policy and practice in relation to non-conveyance decisions. Findings should be built into research and service development in this rapidly changing field of practice in emergency and/or unscheduled care. The commonly accepted perspective on shared decision-making should be extended to include the context of ‘999’ ambulance calls.
Fairness from the Top: Perceived Procedural Justice and Collaborative Problem Solving in New Product Development
Authors: Li Haiyang , Bingham John B. , Umphress Elizabeth E.
Published: March 2007

The literature on new product development has examined several important determinants of collaboration among project members. However, we are not aware of any study that links top management decisions with project members’ collaborative behavior. To address this significant gap, this study examines how perceived procedural justice in top management decisions regarding new products is related to collaborative problem solving among new product development project members. Our results from 109 technology firms—as well as from 91 student-based project groups—suggest that perceived procedural justice in top management decisions is positively related to collaborative problem solving among project members, and that collaborative problem solving mediates the relationship between perceived procedural justice and new product performance. Furthermore, we found that the relationship between perceived procedural justice and collaborative problem solving is positively moderated by environmental uncertainty. Contrary to our expectation, however, our findings show a negative moderating effect of project members’ perceived organizational commitment on the relationship between perceived procedural justice and collaborative problem solving.
When Is a New Thing a Good Thing? Technological Change, Product Form Design, and Perceptions of Value for Product Innovations
Authors: Rindova Violina P. , Petkova Antoaneta P.
Published: March 2007

Innovation researchers recognize that the uncertainty with regard to the value-creating potential of product innovations increases with their technological novelty, and have argued that the usefulness and value of novel products are socially constructed. Despite this recognition, researchers have not explored how the outer form in which a technological innovation is embodied influences the processes through which the innovation’s value is constructed and perceived. In this paper we argue that by embodying novel technologies in objects with specific functional, symbolic, and aesthetic properties, innovating firms also endow their products with cues that trigger a variety of cognitive and emotional responses. Drawing on psychological research we articulate how such cognitive and emotional responses underlie initial perceptions of value and theorize how innovating firms can influence them through product form design. Our framework explains how product form contributes to perceptions of value by modulating the actual technological novelty of a product innovation and facilitating how customers cope with it. Our theoretical framework makes an important contribution to innovation research and practice because it articulates how product form can be used strategically to achieve specific cognitive and emotional effects and enhance the initial customer perceptions of the value of an innovation.
Brokerage, Boundary Spanning, and Leadership in Open Innovation Communities
Authors: Fleming Lee , Waguespack David M.
Published: March 2007

What types of human and social capital identify the emergence of leaders of open innovation communities? Consistent with the norms of an engineering culture, we find that future leaders must first make strong technical contributions. Beyond technical contributions, they must then integrate their communities in order to mobilize volunteers and avoid the ever-present danger of forking and balkanization. This is enabled by two correlated but distinct social positions: social brokerage and boundary spanning between technological areas. An inherent lack of trust associated with brokerage positions can be overcome through physical interaction. Boundary spanners do not suffer this handicap and are much more likely than brokers to advance to leadership. The research separates the influence of human and social capital on promotion, and highlights previously unexamined differences between brokerage- and boundary-spanning positions. Longitudinal analyses of careers within the Internet Engineering Task Force community from 1986–2002 support the arguments.
Organizational Character: On the Regeneration of Camp Poplar Grove
Authors: Birnholtz Jeremy P. , Cohen Michael D. , Hoch Susannah V.
Published: March 2007

We analyze organizational regeneration using case materials from a study of a children’s summer camp. Each year members of various types of seasonal organizations, such as summer camps and ski areas, come together to bring these organizations “back to life” after many months of dormancy. Because many staff members are new and other conditions vary, the result of this regeneration process is necessarily different from the previous year’s organization, but it is nonetheless recognizable to repeat clientele as a familiar instance of “the same” organization. We use this rarely examined process of regeneration to explore the question of how we can regard an organization as being the same entity over time. We suggest that this sameness stems from a coherence and similarity of actions at the organizational level that is analogous to the psychological notion of individual character. Just as individual habits cohere in the character of an individual and allow us to recognize and predict future behavior, we argue that organizations are systems of interacting dispositions to act in a particular way. It is the mutually adapted content of this ensemble of action dispositions that constitutes what we present here as organizational character. We argue that such an ensemble of dispositions is coherent, persistent, and necessary for seasonal regeneration. This work contributes to an ongoing discussion of organizational action and similarity over time. Our focus on regenerative processes in a seasonal organization provides a distinct and informative perspective on these issues.
Does the Referral and Selection for NHS-Funded Dental Implant Treatment in the UK Follow National Guidelines?
Authors: Vartoukian Sonia R , Algraffee Hatem
Published: March 2007

INTRODUCTION

The Royal College of Surgeons of England (RCSE) has provided a national guideline document detailing specific selection criteria for National Health Service (NHS) dental implant therapy in the UK. The aim of this study was to investigate whether these guidelines are being observed both in the referral and selection of patients.

PATIENTS AND METHODS

Information was collected prospectively from 8 consecutive implant assessment clinics at Guy's and St Thomas' Hospital Trust over a 6-month period, via a questionnaire concerning the reason for referral for implant treatment, dental/smoking/radiotherapy status, and the consultant decision on whether an application would be made for NHS implant funding.

RESULTS

Of the 103 referred patients who attended the appointment, 83 (80.6%) fell within the established priority groups for NHS implant therapy: in particular, hypodontia and teeth lost through trauma. However, up to a quarter of patients had untreated caries or periodontitis (n = 23, 22.3% and n = 26, 25.2%, respectively), a contra-indication for NHS implant therapy. The proportion of patients with caries was more than double for general dental practitioner-referred (28.3%) than hospital-referred subjects (12.5%) with the difference approaching statistical significance (P = 0.061). Selection for implant funding application was highly dependent on whether or not a patient belonged to a priority group of the national guidelines (P < 0.001).

CONCLUSIONS

Although in most respects there is good adherence to the RCSE national guidelines both in the referral and selection of patients for NHS implant therapy, about a quarter of patients particularly those referred from general dental practitioners rather than hospitals, would be contra-indicated from NHS therapy because of untreated caries or periodontitis.
A Review of K-wire Related Complications in the Emergency Management of Paediatric Upper Extremity Trauma
Authors: Sharma H , Taylor GR , Clarke NMP
Published: March 2007

INTRODUCTION

Kirschner wires (K-wires) are immensely versatile in fracture fixation in the paediatric population. Complications associated with the K-wiring procedure vary from minor to a life-threatening. The aim of this study was to analyse the outcome of fracture fixation using K-wires in all types of upper-extremity fractures in children in order to assess the incidence and type of complication critically.

PATIENTS AND METHODS

Between September 1999 and September 2001, we retrospectively reviewed a consecutive series of 105 fractures in 103 paediatric trauma cases (below 12 years) treated with K-wires in a university teaching hospital. The case notes and radiographs were reviewed by an independent single assessor. All paediatric, acute, upper-extremity, displaced and unstable fractures were included. All elective procedures using K-wires were excluded.

RESULTS

We observed an overall 32.3% complication rate associated with the K-wiring procedure affecting 34 pins (24 patients). Wound-related complications included over-granulation in 13 cases, pin tract infection in 6 cases and hypersensitive scar in 1 case. Neurapraxia was found in 3 patients and axonotmesis in 1 patient. Wire loosening at the time of removal in 14 cases and retrograde wire migration in 4 cases were observed. There were 2 cases of penetrating tendonitis and 1 case of osteomyelitis. There was a higher complication rate in terms of wire loosening and pin tract infection when the K-wires: (i) were left outside the skin compared with those placed under the skin; (ii) stayed longer in the patients; and (iii) did not traverse both cortices. There were more complications in complex operations performed by senior surgeons (P = 0.056). The duration of K-wire stay, associated co-morbidity and anatomical location were statistically insignificant.

CONCLUSIONS

Complications are part of operative procedures; an important point to consider is what causes them in order to take preventative measures. We recommend that the risks and complications should be explained to parents during the consenting process to allay their anxiety, irrespective of the fact that most complications are minor and of short duration.
Effect of Introduction of Mini C-arm Image Intensifier in Orthopaedic Theatre
Authors: White SP
Published: March 2007

INTRODUCTION

Image intensifier screening is commonly used in orthopaedic theatres. There has been concern regarding the cumulative radiation dose to surgeons and theatre personnel. The mini C-arm intensifier has been reported to scatter less radiation and have a reduced radiation dose to patients and theatre staff.

MATERIALS AND METHODS

A 2-month prospective survey of usage of radiographer-operated large intensifier and surgeon-operated mini C-arm image intensifier in a district general hospital orthopaedic theatre department.

RESULTS

A total of 153 cases required image intensifier screening – 63% used the large intensifier and 37% the mini C-arm intensifier. There were difficulties with equipment with the large intensifier in 16% of cases. There were delays in 11% of cases using the large intensifier. The total radiographer attendance time was 123 h. For the mini C-arm intensifier, there were no equipment difficulties or delays. The minimum radiographer time saved by using this machine was 21.9 hours.

CONCLUSIONS

The mini C-arm intensifier has saved 15% of the radiographer workload with its current pattern of usage in our department. There have been no problems or delays as a result of its usage in theatre. Usage of the large image intensifier resulted in a 16% problem rate and 11% delay rate. Other departments are encouraged to consider acquisition of a mini C-arm intensifier to facilitate theatre throughput, reduce risk to the patient and theatre personnel, and reduce demands on the radiology department.
Publication Outcome for Research Presented at the Vascular Society of Great Britain and Ireland Annual Meetings
Authors: Bhasin N , Scott DJA
Published: March 2007

BACKGROUND

The Vascular Society of Great Britain and Ireland (VSGBI) annual meeting is a major international vascular surgery conference. Studies suggest that the percentage of presentations that result in full-text publications are a measure of the quality of the meeting. We investigated the publication outcome of abstracts presented to the VSGBI in 2001 and 2002.

MATERIALS AND METHODS

We retrospectively identified abstracts from the conference programmes and conducted a detailed electronic Medline and PubMed search to determine publication. We collected data regarding the study design, subject matter, publishing journal, time to publication, institution of origin, impact factors and RAE levels.

RESULTS

There were 63 publications from 106 abstracts (59.4%), with a median impact factor of 3.507. Prospective observational studies accounted for 20.6% of publications, with abdominal aortic aneurysms being the commonest subject matter (34.9%). The median time to publication was 12 months, with the European Journal of Vascular and Endovascular Surgery publishing 33.3% of the articles. Leicester achieved the highest number of publications and the majority of work came from centres with Research Assessment Exercise (RAE) level scores of 4, university centres accounted for 74.6% of publications.

CONCLUSIONS

We conclude that when compared to equivalent meetings in other specialties and geographical regions, the annual meeting of the VSGBI is of the very highest quality.
The Differential Diagnosis of Foot Lumps: 101 Cases Treated Surgically in North Glasgow Over 4 Years
Authors: Macdonald Duncan JM , Holt G , Vass K , Marsh A , Kumar CS
Published: March 2007

INTRODUCTION

There are a wide variety of different lesions which present as lumps of the foot. There have been very few studies which look at the presenting characteristics or the differential diagnosis of such lesions.

PATIENTS AND METHODS

All patients who underwent excision or biopsy of a foot lump over a period of 4 years were studied in order to determine patient demographics, presenting characteristics, diagnoses encountered and to assess the diagnostic accuracy of the surgeon.

RESULTS

In total, 101 patients were identified. Average age was 47.3 years (range, 14–79 years); there was a marked female preponderance with 73 females and 28 males. Thirty different histological types were identified; ganglion cysts were the most commonly encountered lesions and there was only one malignant lesion encountered in this study. Only 58 out of the 101 lumps were correctly diagnosed prior to surgery. Certain lesions were more commonly encountered in specific zones of the foot.

CONCLUSIONS

We have shown that there are a wide variety of potential diagnoses which have to be considered when examining a patient with a foot lump. There is a low diagnostic accuracy for foot lumps and, therefore, surgical excision and histological diagnosis should be sought if there is any uncertainty.
An Experimental Comparison of Handover Methods
Authors: Bhabra Gevdeep , Mackeith Samuel , Monteiro Pedro , Pothier David D
Published: March 2007

INTRODUCTION

With the increase in shift pattern work for junior doctors in the NHS, accurate handover of patient clinical information is of great importance. There is no published method that forms the gold standard of handover and there are large variations in practice. This study aims to compare the reliability of three different handover methods.

PATIENTS AND METHODS

We observed the handover of 12 simulated patients over five consecutive handover cycles between SHOs on a one-to-one basis. Three handover styles were used and a numerical scoring system assessed clinical information lost per handover cycle.

RESULTS

After five handover cycles, only 2.5% of patient information was retained using the verbal-only handover method, 85.5% was retained when using the using the verbal with note taking method and 99% was retained when a printed handout containing all patient information was used.

CONCLUSIONS

When patient information is handed over by the verbal only method, very few facts are retained; therefore, this method should be avoided whenever possible. Verbal handover with note taking is shown to be an effective method of handover in our study, although we accept that this is an artificial scenario and may not reflect the reality of a busy hospital. Nearly all information is retained by the printed handout method but this relies on the handout being regularly updated.
Is there Any Justification for the Routine Histological Examination of Straightforward Cholecystectomy Specimens?
Authors: Darmas B , Mahmud S , Abbas A , Baker AL
Published: March 2007

INTRODUCTION

Gall bladder carcinoma is a rare malignancy that carries a very poor prognosis. Laparoscopic cholecystectomy (LC) is established as the gold-standard treatment for symptomatic gall stones. The aim of the study was to assess the incidence of gall bladder carcinoma and the possibility of reducing the routine histological examination of gall bladder specimens.

PATIENTS AND METHODS

Pathology laboratory data of gall bladder specimens over a period of 5 years (June 2000 to July 2005) were analysed retrospectively. The case notes were retrieved in all cases of malignancies.

RESULTS

The total number of specimens was 1452. Four (0.27%) cases of primary gall bladder carcinoma, one case of primary B-cell lymphoma and one secondary carcinoma were detected as well as one case of intra-epithelial neoplasia. Operative notes revealed that there was a high index of suspicion of malignancy in all cases. Of the 4 primary gall bladder carcinomas, 3 were stage T2 and one T4. Pre-operative ultrasound suspected carcinoma in only one case but a thickened gall bladder wall was noted in all cases.

CONCLUSIONS

All cases of gall bladder carcinoma were suspected pre-operatively or intra-operatively. Histological examination did not alter the management or outcome in any of the cases. We suggest that selectively sending specimens for histopathological examination would result in reduced demands on the histopathology department without compromising patient safety.
Universal Precaution Compliance by Orthopaedic Trauma Team Members in a Major Trauma Resuscitation Scenario
Authors: Sundaram RO , Parkinson RW
Published: March 2007

INTRODUCTION

We determined the compliance rates of orthopaedic trauma team members in applying universal precautions in major trauma resuscitation scenarios and the availability of universal precautions in accident and emergency (A&E) departments throughout England.

MATERIALS AND METHODS

A national telephone survey was implemented contacting the first on-call orthopaedic surgeon and A&E departments in hospital trusts accepting major trauma throughout England. A questionnaire was employed to ascertain current practice, experience and availability of universal precautions when managing a major trauma patient.

RESULTS

Overall, 112 first on-call orthopaedic surgeons and 99 A&E departments responded. There was good compliance for using gloves (99%) and aprons (86%). There was poor compliance in using eye protectors (21%), face masks (18%), shoe covers (4%) and head caps (4%). Trainees applied universal precautions according to the level of risk they subjectively perceived. All A&E departments had gloves and aprons but the availability of the other universal precautions was less. Of trainees, 76 reported that all universal precautions were not readily available in the A&E department.

CONCLUSION

Orthopaedic trauma team members are very compliant in using gloves and aprons, but should be more compliant in using eye protectors. It is questionable whether face masks, head caps and shoe covers need to be used in all trauma scenarios. In general, universal precautions should be more available in the A&E departments. There should be better communication between A&E departments and the trauma team regarding the availability of universal precautions.
Prospective Study on the Role of C-Reactive Protein (CRP) in Patients with an Acute Abdomen
Authors: Salem TA , Molloy RG , O'Dwyer PJ
Published: March 2007

INTRODUCTION

C-reactive protein (CRP) is used routinely in many hospitals to evaluate patients with an acute abdomen. We assessed CRP levels in non-specific abdominal pain (NSAP) and surgical conditions requiring operative or non-operative intervention. The aim of this study was to identify a level of CRP that can be useful in differentiating these three groups.

PATIENTS AND METHODS

All patients older than 25 years and admitted with acute abdominal pain other than those requiring emergency surgery were included. CRP within 24 h was assessed in all patients. Various cut-off values (< 6, > 6–50, > 50–100, > 100–150 and > 150 mg/l) were used to identify a useful diagnostic level of CRP in the 3 groups.

RESULTS

A total of 211 patients were prospectively evaluated – 129 women and 82 men with a mean age of 62.4 years (range, 27–92 years). CRP was performed in 196 within 24 h of admission. Sixty had NSAP while 136 had a surgical condition, of whom 69 had an operation/intervention while the rest were treated non-operatively. The median and interquartile (IQ) range for the three groups were: NSAP, 16 mg/l and 7.75–85.75 mg/l; surgical non-operative group, 75 mg/l and 30.5–150 mg/l; and surgical-operative, 111 mg/l and 42–212 mg/l, respectively. These results were statistically significant (P = 0.001). NSAP was diagnosed in 61% of patients at levels < 6 mg/l compared to 39% of patients in the surgical groups. At levels > 150 mg/l, NSAP was diagnosed in 15% of patients compared to only 54% and 31% for the operative and non-operative groups, respectively.

CONCLUSIONS

Despite statistically significant differences between the three groups, no useful level of CRP could be identified to differentiate between patients with NSAP and those requiring operative or non-operative management.
Does Rectus Sheath Infusion of Bupivacaine Reduce Postoperative Opioid Requirement?
Authors: Padmanabhan J , Rohatgi A , Niaz A , Chojnowska E , Baig K , Woods WGA
Published: March 2007

INTRODUCTION

The aim of this work was to assess the effect of intermittent bupivacaine infusion into rectus sheath space on postoperative opioid requirement, postoperative pain score and peak expiratory flow rate.

PATIENTS AND METHODS

A prospective, randomised study involving patients undergoing midline laparotomy. Patients were randomised to receive either intermittent infusion of bupivacaine 0.25% or normal saline via catheters placed in the rectus sheath for 48 h after operation. All patients received intravenous morphine infusion on demand with a patient-controlled analgesic device (PCAD).

RESULTS

Forty ASA I–III patients were studied. Nineteen were randomised to receive bupivacaine and 21 patients received normal saline. Patient characteristics and surgical variables were comparable in the two groups. The mean wound lengths were similar. There was no statistically significant difference in postoperative opioid requirement, postoperative pain score and peak expiratory flow rate between the two groups.

CONCLUSIONS

Intermittent bupivacaine infusion into the rectus sheath space after midline laparotomy does not reduce postoperative opioid requirement nor does it affect postoperative pain score or peak expiratory flow rate.
The Risk of Cross-Infection when Marking Surgical Patients Prior to Surgery – Review of Two Types of Marking Pens
Authors: Ballal MSG , Shah N , Ballal M , O'Donoghue M , Pegg DJ
Published: March 2007

INTRODUCTION

Two types of marker pens were compared to find whether they produced different risks of infection transmission over different time intervals.

PATIENTS AND METHODS

Twenty-four patients were marked according to the type of surgery: each had a set of new dry whiteboard marker (DWM) and a permanent marker (PM) pen. Once used, their tips were used to inoculate blood agar plates at different time intervals.

RESULTS

At 0 min, 96% of the DWM pens and 29% of the PM pens were positive of growth. At 3 and 10 min, all of the DWM pens remained positive. The rate dropped to 16.67% in 3 min down to none at 10 min for the PM pens.

CONCLUSIONS

DWM pens carry a significant risk of transmitting infection between patients. It is recommended that they are not used in marking. PM pens should not be used between patients in less than a 10-min interval.
Can Haematological Indices Predict Positive Findings at Endoscopy in Anaemic Patients?
Authors: Schizas AMP , Reid R , George ML
Published: March 2007

INTRODUCTION

Patients with anaemia are commonly referred for bidirectional endoscopy. The aim of this study was to determine if any haematological parameters could predict positive findings at endoscopy.

PATIENTS AND METHODS

A total of 209 patients had bidirectional endoscopies performed for anaemia between September 2002 and March 2004. The endoscopy reports, histology and full blood count results (haemoglobin [Hb], red blood cells [RBCs], packed cell volume [PCV], mean cell volume [MCV] and mean cell haemoglobin [MCH]) were then reviewed. Statistical analysis was performed using non-parametric tests.

RESULTS

Overall, 197 patients had successful bidirectional endoscopies with 12 requiring completion barium enema. In 48 (23%) of these patients, a cause of anaemia was found with 15 (7.2%) carcinomas detected (2 upper GI and 13 lower GI). There was a significant difference in haemoglobin (9.2 g/dl versus 10.1 g/dl; P = 0.0044), RBCs (3.56 × 1012/l versus 3.83 × 1012/l; P = 0.0325) and PCV (0.279 l/l versus 0.31 l/l; P = 0.0112) between patients with positive findings at endoscopy and those with a normal investigation. Cancer patients had significantly lower haemoglobin (8.65 g/dl versus 10.1 g/dl; P = 0.0103), RBCs (3.45 × 1012/l versus 3.83 × 1012/l; P = 0.0179) and PCV (0.27 l/l versus 0.31 l/l; P = 0.0298) compared with patients with normal endoscopies. There was no significant difference in the other haematological parameters between those found to have positive findings and those that had normal endoscopies.

CONCLUSIONS

Based on this study, the yield of bidirectional endoscopy is low, with haemoglobin and PCV being the most useful haematological indices of significant pathology. Ferritin and MCV did not predict the likelihood of finding a gastrointestinal cause for the anaemia.
Risk Factors for Chronic Pain After Inguinal Hernia Repair
Authors: Dennis R , O'Riordan D
Published: March 2007

INTRODUCTION

Chronic postoperative pain after inguinal hernia repair has an incidence of 0.7–36.7%. This study aimed to look for any relationship between patients presenting with severe pain at initial presentation or a past history of chronic pain conditions and the development of severe chronic pain following inguinal hernia repair.

PATIENTS AND METHODS

This was a retrospective study in which 24 patients referred to a chronic pain clinic following inguinal hernia repair were compared with 24 age- and sex-matched controls. Hospital notes were reviewed for the severity of presenting pain and a past history of chronic pain.

RESULTS

Average age was 55.4 years. In the chronic postoperative pain group, 14 (58%) presented with severe pain versus 3 (13%) in the pain-free group. Twelve (50%) of the chronic postoperative pain group had a past history of chronic pain conditions versus none of the pain-free group. Both of these factors showed a significant (P < 0.005) association with severe chronic pain postoperatively.

CONCLUSIONS

Patients with severe pain at presentation or with a past history of chronic pain conditions are at increased risk of severe chronic pain after inguinal hernia repair. A prospective study is needed to quantify any increased risk, although this would need to be of significant size.
Surgical Approach to Insulinomas: Are Pre-Operative Localisation Tests Necessary?
Authors: Ravi K , Britton BJ
Published: March 2007

INTRODUCTION

Insulinoma is a rare, but curable, endocrine tumour. The ability to localise the tumour accurately before or during surgery is an important factor in the management of these elusive lesions, which has been extensively debated. We have reviewed our experience of these lesions to establish the role of localisation tests.

PATIENTS AND METHODS

The medical records of 20 consecutive patients who had surgery for sporadic insulinomas since 1985 at this institution were retrospectively reviewed. All the patients had a definite biochemical diagnosis of endogenous hyperinsulinism. Results of pre-operative and intra-operative localisation tests were compared with the final outcome.

RESULTS

Of the 20 patients with sporadic insulinomas reviewed, 17 patients (85%) had multiple pre-operative localising investigations. Overall accuracy of pre-operative localisation tests was 33%. Non-invasive pre-operative localisation tests (ultrasonography, CT, MRI) had a combined localisation rate of 25% with MRI having the highest sensitivity of 71%. Invasive tests (angiography, transhepatic portal venous sampling [THPVS], endoscopic ultrasound) detected 48% of lesions with THPVS being most sensitive (67%). THPVS was particularly helpful in localising lesions before re-operation. Intra-operative inspection and palpation localised the lesions correctly in 91% and intra-operative ultrasound in 93% of cases. All 5 occult tumours (indeterminate anatomical site before operation) were palpable at surgery and four of these were also correctly identified by intra-operative ultrasound. Site and size of tumour correlated poorly with pre-operative localisation. Operative procedure did not influence outcome with three patients needing re-operation. One patient died (5% mortality) and 9 patients (45%) had complications. Normoglycaemia has been obtained in all but one patient.

CONCLUSIONS

Insulinomas can be readily localised by systematic operative exploration. Non-invasive pre-operative investigations (ultrasonography/MRI) may help identify the location of tumour to determine the appropriate surgical procedure. Invasive pre-operative localisation tests like angiography and THPVS may be a valuable adjunct for re-operations. This also helps reduce the costs.
Total Hip Arthroplasty Does not Aid Weight Loss
Authors: Middleton FR , Boardman DR
Published: March 2007

INTRODUCTION

Increased body mass index (BMI) is associated with the development of osteoarthritis of the hip. Many overweight patients with an arthritic hip cite restricted mobility and pain as impeding factors in their attempts to lose weight. There is an assumption that weight loss will occur after their surgery due to increased mobility.

PATIENTS AND METHODS

The records of 180 patients who had undergone total hip arthroplasty (THA) were reviewed to identify BMI prior to, and 2 years after, surgery.

RESULTS

BMI significantly increased postoperatively, both in patients with a pre-operative BMI in the recommended range (P < 0.001) and in those whose pre-operative BMI was indicative of obesity (P = 0.01).

CONCLUSIONS

Irrespective of pre-operative BMI, reduction in body mass index did not occur following hip replacement surgery.
Detection of Orthopaedic Implants by Airport Metal Detectors
Authors: Abbassian Ali , Datla Balarama , Brooks RA
Published: March 2007

INTRODUCTION

We performed a questionnaire study to establish the frequency and consequences of the detection of orthopaedic implants by airport security and to help us advise patients correctly. All published literature on this subject is based on experimental studies and no ‘real-life’ data are available.

PATIENTS AND METHODS

A total of 200 patients with a variety of implants were identified. All patients were sent a postal questionnaire enquiring about their experience with airport security since their surgery.

RESULTS

Of the cohort, 154 (77%) patients responded. About half of the implants (47%) were detected, but the majority of patients (72%) were not significantly inconvenienced. When detected, only 9% of patients were asked for documentary evidence of their implant. We also found that patients with a total knee replacement (TKR) had a greater chance of detection as compared to those with a total hip replacement (THR; 71% versus 31%; P = 0.03).

CONCLUSIONS

All patients, and in particular those with a TKR, can be re-assured that, although they have a fair chance of detection by airport security, a major disruption to their journey is unlikely. We advise that documentation to prove the presence of an orthopaedic implant should be offered to those who are concerned about the potential for inconvenience, but such documentation is not required routinely.
Are Routine Postoperative X-rays Needed Following Surgery for Hallux Valgus? An Evaluation of their Use After Scarf Osteotomy
Authors: Murphy Richard J , Blundell Christopher M
Published: March 2007

INTRODUCTION

Postoperative X-rays, following a scarf osteotomy, are generally carried out as routine. The aim of this study was to assess the value of performing such investigations.

PATIENTS AND METHODS

Retrospective data were collected regarding all scarf osteotomies performed by three consultant orthopaedic surgeons at a large teaching hospital. A review of routine postoperative X-rays was carried out.

RESULTS

A total of 274 scarf osteotomies were included in the study. Of these, 95% were followed by at least one routine postoperative X-ray. In total, 412 X-rays were performed of which 11% were not commented upon by a radiologist or a surgeon. Of the X-rays with comments from both specialists, only one case was reported as abnormal by both radiologist and surgeon, with no change in management made as a result of these reports. In two cases, changes to standard management were made on the basis of the routine postoperative X-rays and only one of these was implemented solely on the basis of the routine postoperative images.

CONCLUSIONS

The value of postoperative X-rays following a scarf osteotomy is questionable. We propose, on the basis of this study, that, unless clinically indicated, the routine use of postoperative X-rays following a scarf osteotomy should be abandoned.
A New Clinical Test in Diagnosing Quadriceps Tendon Rupture
Authors: Jolles BM , Garofalo R , Gillain L , Schizas C
Published: March 2007

INTRODUCTION

Extensor mechanism ruptures might be easily overlooked and misdiagnosed, and delayed diagnosis of quadriceps tendon rupture is frequent. However, the literature recommends early surgical repair within 72 h.

PATIENTS AND METHODS

This paper describes a new simple clinical diagnostic test that directly evaluates the integrity of the distal 5 cm of the quadriceps tendon itself. It consists of inserting a needle in the tendon, proximal to the suspected rupture and mobilising the knee joint.

RESULTS

The suspected ruptured quadriceps tendons with a positive ‘needle’ diagnostic test were confirmed intra-operatively.

CONCLUSIONS

This minimally invasive and easily available technique should be considered in the diagnostic work-up and treatment planning of patients with suspected tears of the quadriceps tendon.
Perceptions of Orthopaedic Surgeons Regarding Hepatitis C Viral Transmission: A Questionnaire Survey
Authors: Wallis GC , Kim WY , Chaudhary BR , Henderson JJ
Published: March 2007

INTRODUCTION

Occupationally acquired hepatitis C viral infection is an important issue in surgery since there are no known vaccines or effective prophylaxis.

MATERIALS AND METHODS

An anonymous questionnaire survey was performed to determine the attitudes and perception of risks of occupational acquired hepatitis C viral transmission in orthopaedic surgeons.

RESULTS

A total of 763 questionnaires were posted to orthopaedic surgeons with various subspecialty interests and 261 surgeons responded (34.2%). Of respondents, 117 (47%) had sustained sharps injuries in the previous 12 months. Only 82 surgeons (33%) always reported such injuries, although 208 (84%) expressed concerns of occupationally acquired hepatitis C viral transmission. Orthopaedic surgeons were mostly unaware of the true prevalence of hepatitis C in high-risk groups, such as intravenous drug abusers.

CONCLUSIONS

Greater awareness of all aspects of hepatitis C infection and its risks to the practice of surgery is required. Further debate is necessary on the role of routine testing of surgeons and patients.