Showing papers by "Wishaw General Hospital published in 2017"

The impact of didactic read-aloud action cards on the performance of cannula cricothyroidotomy in a simulated 'can't intubate can't oxygenate' scenario.

Abstract: Significant benefits have been demonstrated with the use of peri-operative checklists We assessed whether a read-aloud didactic action card would improve performance of cannula cricothyroidotomy in a simulated 'can't intubate, can't oxygenate' scenario A 17-step action card was devised by an expert panel Participants in their first 4 years of anaesthetic training were randomly assigned into 'no-card' or 'card' groups Scenarios were video-recorded for analysis Fifty-three participants (27 no-card and 26 card) completed the scenario The number of steps omitted was mean (SD) 67 (20) in the no-card group vs 03 (05); p < 0001 in the card group, but the no-card group was faster to oxygenation by mean (95% CI) 354 (66-642) s The Kappa statistic was 084 (073-095) Our study demonstrated that action cards are beneficial in achieving successful front-of-neck access using a cannula cricothyroidotomy technique Further investigation is required to determine this tool's effectiveness in other front-of-neck access situations, and its role in teaching or clinical management

Saline irrigation for the management of skin extravasation injury in neonates

Abstract: Background Extravasation injury, a complication commonly seen in the neonatal intensive care unit, can result in scarring with cosmetic and functional sequelae. A wide variety of treatments are available, including subcutaneous irrigation with saline (with or without hyaluronidase), liposuction, use of specific antidotes, topical applications, and normal wound care with dry or wet dressings. All such treatments aim to prevent or reduce the severity of complications. Objectives Primary objective To compare the efficacy and safety of saline irrigation or saline irrigation with prior hyaluronidase infiltration versus no intervention or normal wound care for tissue healing in neonates with extravasation injury. Secondary objectives To evaluate by subgroup analysis of controlled trials the influence of type of extravasate, timing of irrigation following extravasation, and postmenstrual age (PMA) of the neonate at the time of injury on outcomes and adverse effects. Specifically, we planned to perform subgroup analysis for the primary outcome, if appropriate, by examining: 1. time to irrigation from identified extravasation injury (< 1 hour or ≥ 1 hour); 2. type of extravasate (parenteral nutrition fluid or other fluids or medications); 3. amount of saline used (< 500 mL or ≥ 500 mL); and 4. PMA at injury (< 37 completed weeks or ≥ 37 completed weeks). Search methods We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1), MEDLINE via PubMed (1966 to 2 February 2017), Embase (1980 to 2 February 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 February 2017). We also searched clinical trial databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We used the Google Scholar search tool for reverse citations of relevant articles. Selection criteria Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing saline irrigation with or without hyaluronidase infiltration versus no intervention or normal wound care for the management of extravasation injury in neonates. Data collection and analysis Three review authors independently reviewed and identified articles for possible inclusion in this review. We used the GRADE approach to assess the quality of evidence. Main results We found no eligible studies. Our search revealed 10 case reports or case series describing successful outcomes with different interventions for this condition. Authors' conclusions To date, no RCTs have examined the effects of saline irrigation with or without prior hyaluronidase infiltration for management of extravasation injury in neonates. Saline irrigation is frequently reported in the literature as an intervention for management of extravasation injury in neonates. Research should focus first on evaluating the efficacy and safety of this intervention through RCTs. It will also be important for investigators to determine effect size by examining the timing of the intervention, the nature of the infusate, and severity of injury at the time of intervention.

Radiofrequency ablation for osteoid osteoma – Recurrence rates and predictive factors

Abstract: Background and purpose Osteoid osteoma is an infrequent but debilitating benign bone lesion which can be successfully managed by percutaneous radiofrequency ablation (RFA). There are few studies investigating the efficacy and follow-up of this treatment. An arbitrary upper limit of 15 mm has been used to differentiate between osteoid osteoma and osteoblastoma with surgery used for lesions above this limit. We aimed to analyse the cases identified from our prospectively maintained database over a ten year period since adoption of this technique in our unit. The primary objectives were to investigate factors which influenced recurrence and the time period at which patients are at risk of this. Basic procedures Consecutive patients with confirmed osteoid osteoma were included. Patient demographics, complications, and recurrence were recorded and multiple regression analysis was performed to investigate causation. Main findings Within a minimum follow up of 21 months (mean 72), a recurrence rate of 16.3% was noted, higher than the published literature. Cox regression analysis to predict chance of recurrence revealed a relationship between larger lucent diameter and recurrence (p = 0.049, CI 95%, hazard ratio 1.33). Conclusions The traditional cut off between osteoid osteoma and osteoblastoma appears less rigidly defined than previously thought and probably represents a progressive scale with larger lesions responding less well to RFA. This study indicates that each millimetre increase represents a ×1.33 chance of recurrence. Clinicians should counsel patients accordingly with lesions approaching the larger limits of this diagnosis.

Long-term outcome of thyrotoxicosis in childhood and adolescence in the west of Scotland: the case for long-term antithyroid treatment and the importance of initial counselling.

Abstract: Background Thyrotoxicosis is both rarer and more severe in children than in adults, rendering management difficult and often unsatisfactory. Objective To ascertain outcome in a geographically defined area of Scotland between 1989 and 2014. Method Retrospective case note review with follow-up questionnaire to family doctors for patients with Graves’ disease and Hashimoto’s thyroiditis. Results Sixty-six patients (58 females:8 males) comprising 53 with Graves’ disease and 13 with Hashimoto’s thyroiditis were diagnosed at median 10.4 (2.9–15.8) years and followed up for 11.8 (2.6–30.2) years. Antithyroid drug (ATD) therapy was stopped electively in 35 patients after 4.5 (1.5–8.6) years, resulting in remission in 10/13 Hashimoto’s thyroiditis and 10/22 Graves’ disease. Side effects occurred in 12 patients receiving carbimazole, six of whom changed to propylthiouracil; no adverse events occurred in the latter patients. Second-line therapy was given to 37 patients (34 with Graves’ disease), comprising radioiodine (22) at 15.6 (9.3–24.4) years for relapse (6), poor control/adherence (14) or electively (2); and surgery (16) at 12 (6.4–21.3) years for relapse (4), poor control/adherence (5) and electively (7). Adherence problems with thyroxine replacement were reported in 10/33 patients in adulthood. C onclusions Hashimoto’s thyroiditis should be distinguished from Graves’ disease at diagnosis since the prognosis for remission is better. Remission rates for Graves’ disease are low (10/53 patients), time to remission variable and adherence with both ATD and thyroxine replacement often problematic. We recommend (a) the giving of long-term ATD rather than a fixed course of treatment in GD and (b) meticulous and realistic counselling of families from the time of diagnosis onwards.

Dubin–Johnson syndrome and intrahepatic cholestasis of pregnancy in a Sri Lankan family: a case report

Abstract: Dubin–Johnson syndrome and intrahepatic cholestasis of pregnancy are rare chronic liver disorders. Dubin–Johnson syndrome may manifest as conjugated hyperbilirubinemia, darkly pigmented liver, presence of abnormal pigment in the parenchyma of hepatocytes and abnormal distribution of the coproporphyrin isomers I and III in the urine. Intrahepatic cholestatic jaundice of pregnancy presents as pruritus, abnormal liver biochemistry and increased serum bile acids. A Sri Lankan girl presented with recurrent episodes of jaundice. She had conjugated hyperbilirubinaemia with diffuse, coarse brown pigments in the hepatocytes. Urine coproporphyrin examination suggested Dubin–Johnson syndrome. Genetic studies confirmed missense homozygous variant p.Trp709Arg in the ATP-binding cassette sub-family C member 2 gene ABCC2 that encodes the Multidrug resistance-associated protein 2 that causes Dubin–Johnson syndrome. The gene study of the mother revealed the same missense variant in ABCC2/MRP2 but with a heterozygous status, and in addition a homozygous missense variant p.Val444Ala in the ATP-binding cassette, sub-family B member 11 gene ABCB11 that encodes the bile salt export pump. Dubin–Johnson syndrome should be considered when the common causes for conjugated hyperbilirubinaemia have been excluded, and patient has an increased percentage of direct bilirubin relative to total bilirubin concentration. Its early diagnosis prevents repeated hospital admissions and investigations. Knowledge of a well known homozygous variant in ABCB11 gene could help in the management of pregnancy.

Feasibility and acceptability of the use of patient-reported outcome measures in the delivery of nurse-led, supportive care to women with cervical cancer

Abstract: PURPOSE/AIMS: Patient-reported outcome measures (PROMs) can be effectively used to uncover the unmet needs of women with cervical cancer for supportive care. Our aim was to explore the feasibility and acceptability of PROM-driven, nurse-led consultations to enhance delivery of supportive care to women with cervical cancer during active anticancer treatment. DESIGN: A 2-phased, mixed-method prospective study was conducted. Main research variables included feasibility and acceptability parameters of the trialed intervention. METHODS: Preconsultation PROM data were collected during 3 consecutive monthly consultations and used by the gynecology cancers nurse specialist (CNS) to deliver personalized supportive care. The problem checklist and Cervical Cancer Concerns Questionnaire were used to aid data collection. FINDINGS: Because of considerable recruitment challenges, a recruitment rate of 27% (3/11 patients) was achieved. Two patients completed all 3 study assessments. Seven in-clinic patient assessments were performed over 6 months. The study participants praised the opportunity for dedicated time for patients to raise concerns and for the CNS to provide sensitive and personalized support. CONCLUSION: Women with cervical cancer perceive important benefits from participating in PROM-driven, time-protected sessions with their CNS. Our findings provide tentative evidence to support the feasibility and acceptability of this intervention model and warrant future confirmation.

Mentoring: what matters most?

Abstract: Our belief that mentoring provides a powerful means of peer support is supported by the literature, where it has been described as critical to career development. 1 ‘Mentoring’ can be considered a specifi c, longitudinal, relationship between defi ned individuals. 2 This resonates with experiences in our roles as speciality trainee doctors in paediatrics (KC) and renal medicine (SO), and in our educational roles as ‘clinical teaching fellows’ (CTFs).

Level of agreement between three-dimensional volumetric ultrasound and real-time conventional ultrasound in the assessment of synovitis, tenosynovitis and erosions in rheumatoid arthritis patients

Abstract: The aim of the study was to assess agreement between three-dimensional volumetric ultrasound (3D US) performed by inexperienced staff and real-time conventional ultrasound (2D US) performed by experienced rheumatologists in detecting and scoring rheumatoid arthritis (RA) lesions. Thirty-one RA patients underwent examination of seven joints by 2D and 3D US for synovitis and tenosynovitis in B and PD modes and erosions in B mode. A global score for synovitis and global counts for synovitis, tenosynovitis and erosions were also calculated for every patient. Agreement between 2D and 3D US was analysed for counts and scores at the patient level with the intraclass correlation coefficient (ICC) and for counts at the joint level with Cohen's kappa coefficient. B-mode synovitis was detected at a median of five joints in each patient, frequently in wrists and hand joints but less frequently in foot joints. PD-mode synovitis, tenosynovitis and erosions were detected less frequently. All ICCs for agreement between 2D and 3D US findings were significant. All kappa coefficients were significant for B- and PD-mode synovitis and for erosions (except PIP3), while those for tenosynovitis were only significant for MCP2 (B and PD modes) and PIP2 (B mode). Although the 3D US volumes were acquired by inexperienced operators, agreement between 2D and 3D US was acceptable in detecting and scoring synovitis. A higher level of agreement was attained for patient-level global scores and counts than for individual joints.

Assessment of knee alignment with varus and valgus force through the range of flexion with non-invasive navigation

Abstract: In image-free total knee arthroplasty (TKA) navigation, infra-red markers are attached to bony landmarks to provide kinematic data intra-operatively, with the aim of improving the precision of implant placement. In non-invasive navigation, infra-red markers are attached to the skin surface, with recent evidence suggesting that this can give repeatable measurements of lower limb mechanical alignment. The aim of our study was to evaluate the use of a non-invasive navigation system in the assessment of mechanical alignment with applied coronal force through the range of flexion. A previously validated non-invasive system (Physiopilot™) was tested on 23 volunteers with healthy knees. Two users performed two registrations of the software workflow on each participant's right and left knees. A force was manually applied to the end-point of varus and valgus knee laxity and the measured change in mechanical alignment was recorded. Force was applied with the knee positioned in increments of flexion from 0 to 90°. In keeping with previous studies, satisfactory values of coefficient of repeatability (CR) of 1.55 and 1.33 were found for intra-observer repeatability in measurement of supine mechanical femoro-tibial angle (MFTA) in extension, with a good inter-observer correlation of intraclass correlation coefficient (ICC) .72. However, when flexion was introduced, intra-observer and inter-observer reliability fell out with acceptable limits. Therefore, the trial did not support use of the Physiopilot™ system as a measure of MFTA when flexion is introduced. It was felt that learning-curve, soft tissue artefacts and lack of force standardisation equipment may have accounted for significant levels of error, with further studies required to address these issues.

Correction to: Dubin-Johnson syndrome and intrahepatic cholestasis of pregnancy in a Sri Lankan family: a case report.

Abstract: Following publication of the original article [1], the authors requested the following corrections:

Collaborative approach to reducing cardiac arrests in an acute medical unit.

Abstract: Cardiac arrests are often preceded by a period of physiological deterioration. Preventing potentially avoidable cardiac arrests therefore depends on reliable recognition of, and response to, those deteriorations. Our hospital’s acute medical unit had one of the highest rates of cardiac arrest in our organisation at baseline. The aim was to reduce our unit’s cardiac arrest rate by over 50%. Pareto chart analysis identified unreliable processes in the recognition and response to deteriorating patients. Process mapping exercises were performed, then the model for improvement and rapid cycle tests of change were used to develop standardised processes for clinical observations, recognising deteriorating patients and responding to hypoxia. Multidisciplinary learning from what went well, incorporating resilience engineering principles, helped to identify good practice and then test ways of making good practice happen more reliably. Learning from success also addressed some of the psychological barriers to change by encouraging pride in work and a positive focus within our unit. The cardiac arrest rate reduced from 4.3/1000 (October 2014 to February 2016) to 1.1/1000 (March 2016 to end of 2016), associated with improved reliability of the following process measures: reliability of clinical observations, documentation of target oxygen saturations, identification of hypoxia and completion of structured response to hypoxia. This study is an example of a multidisciplinary team engaging in quality improvement, identifying their own local problems and testing their solutions scientifically. Learning from what went well had a positive impact on the project, and the team plans to spread the successful interventions across the organisation.

How to write a systematic review: Tips and tricks for surgeons in training

Abstract: Systematic reviews provide high-quality critical appraisal and evidence-based summaries on a topic. They represent a key resource for time-pressured clinicians as they strive to deliver better pati...

Klebsiella Pneumoniae CAUSING SPONDYLODISCITIS: AN UNUSUAL CAUSE OF BACK PAIN IN AN ELDERLY PATIENT

Abstract: Spondylodiscitis is a manifestation of a blood borne infection in the elderly. The diagnosis can be really challenging, especially in those patients with significant co-morbidities. Although Staphylococcus aureus has been incriminated as the most common causative microorganism, other rare pathogens have been described in literature. We present a rather unusual case of an octogenarian who presented with back pain and no obvious foci of infection anywhere else. Blood culture revealed Klebsiella Pneumoniae as the causative microorganism. This patient showed dramatic improvement on intravenous antibiotics and was asymptomatic on follow up with complete resolution of his back pain.