Unscheduled Emergency Department Revisits in a Tertiary Care Hospital – A Quality Improvement Study (2020)

Type of publication:
Journal article

Author(s):
Mohammed Nazim Kt, Nithyanand M, *Dodiy Herman, Sourabh M Prakash, Shahana Sherin, *Benita Florence

Citation:
Indian Journal of Clinical Practice, Vol. 30, No. 10, p. 931-933, March 2020

Abstract:
Patients who revisit the emergency department (ED) within 72 hours constitute an integral key performance indicator of quality emergency care. The number of patient footfalls to the ED in a tertiary care hospital in a rural area of a district in India from December 1, 2018 to May 31, 2019 was 7,808 and the average re-attendances recorded during that period was 0.32%. With increase in the number of healthcare setups, rising standards of the healthcare industry and increase in the expectations of the population visiting hospitals, ED re-attendance within 72 hours has been considered as an important key performance indicator of emergency patient care. The early ED revisit rate at this tertiary care hospital for 6 months was found to be only 0.32% (at an average of 4 cases per month). This is less when compared to many other international hospitals where it ranges from 1.5% to 2.5%. Since readmissions cause unnecessary overcrowding in ED, it would be best if each hospital evaluated their rate of readmission and its causes, and then tried to address the problems found. This can be effective in better management of ED, reduction of treatment costs, increasing patient satisfaction and prevention of ED overcrowding.

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Acute appendicitis secondary to endometriosis of the appendix: A case series (2019)

Type of publication:
Conference abstract

Author(s):
Argyriou O.; Wall M.; Johnson M.; Sutton P.A.; *Tamvakeras P.

Citation:
Colorectal Disease; 2019; vol. 21, S2, p. 36-37

Abstract:
Purpose: To review the clinical presentation, laboratory results, imaging and operative findings of patients subsequently found to have histological evidence of endometriosis of the appendix in a District General Hospital (DGH) between 2016-2018. Method(s): Ten histological reports containing the search term “endometriosis of the appendix” were identified. Four were excluded as planned gynaecological resections for known endometriosis. The case notes, laboratory and imaging reports of six patients were reviewed. Result(s): In three patients, a 72-h or less history of right iliac fossa (RIF) pain was present (24-h or less in two), whereas on two occasions there was a 3-week history of intermittent RIF pain. Three patients reported nausea and vomiting and two were pyrexial. No history of diarrhoea was reported. Inflammatory markers (white cell count-WCC, C-reactive protein-CRP) were raised on three occasions. In five patients, available imaging (CT/USS) was suggestive of an inflammatory process in the right iliac fossa, with principle diagnosis being acute appendicitis, and in one the diagnosis was solely clinical. In all six cases, acute appendicitis was found intraoperatively. The Alvarado score ranged from 4-7. Conclusion(s): Endometriosis of the appendix may present to surgical teams as acute appendicitis. Surgeons should be aware that a longer history of intermittent RIF pain and normal inflammatory markers does not exclude appendicitis secondary to endometriosis. An appendicectomy should be performed, as the aetiology does not appear to otherwise affect the natural history of this condition.

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Transanal endoscopic microsurgery for early rectal cancer-can it be done safely with good outcomes at a in a UK district general hospital (2019)

Type of publication:
Conference abstract

Author(s):
*Vidyasankar V.; *Chakrabarthy A.; *McCloud J.; *Clarke R.

Citation:
Colorectal Disease; Sep 2019; vol. 21, S3, p. 54

Abstract:
Aim: Randomised controlled trials have demonstrated advantages of Transanal endoscopic microsurgery (TEMS) for early rectal cancer resections. The aim of our study was to assess the safety and outcome of TEMS for early rectal cancer at a U.K district general hospital. Method(s): Between July 2011 to January 2017, 27 patients, 13 men and 14 women, Mean age 77 years, underwent TEMS. Mean lesion diameter was 49 mm. Patient selection was based on multidisciplinary decision. Follow up included colonoscopy, MRI and CT according to standard protocol. Patients were admitted for overnight observation and discharged the following day. Result(s): Mean operative time was 60 minutes. Average hospital stay was 24 hours. One patient (3.7%) had bleeding, three (11%) developed perforation, which were identified and repaired immediately. Two (7.4%) developed pyrexia, One patient (3.7%) developed minor stricture. One (3.7%) developed a recto-vaginal fistula. R0 resection was achieved in 81% and R1 resection was achieved in 19% of cancer cases. One patient (3.7%) developed local recurrence. No mortality. Conclusion(s): Our study demonstrates that TEMS for early rectal cancer can be safely performed in selected patients at a district general hospital, with outcomes comparable with international data.

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Childbirth-related pelvic floor trauma in women at-risk: A survey of the current obstetric management of short stature primigravid women (2019)

Type of publication:
Conference abstract

Author(s):
*Rachaneni S.; Freeman R.

Citation:
International Urogynecology Journal; September 2019; vol. 30 (no. 1 Supplement)

Abstract:
Objective: To assess the antenatal and intrapartum management of short statured primigravid women in relation to the awareness of the increased risk of long-term pelvic floor morbidity from childbirth, by Obstetricians and Gynaecologists in the UK. Method(s):We carried out a questionnaire survey with 15 questions about the antenatal and intrapartum management of short statured primigravid women with a clinically large fetus, their timing and mode of delivery and discussion with the women about their risk of long-term pelvic floor morbidity following spontaneous and instrumental vaginal deliveries, their choice of instruments and episiotomy. Result(s): The survey was completed by 424 Members and Fellows of Royal College of Obstetricians and Gynaecologists (UK). We created a scenario of a short stature primigravid woman who presented with a clinically large baby around 38 weeks gestation. Sixty five percent of the responders stated that they would scan for estimated fetal weight, 48% would offer induction of labo-r at 40 weeks gestation and 13% would offer an elective caesarean section at 39-40 weeks. Only 59% of the responders said that would discuss the risks of obstructed labo-r, shoulder dystocia, instrumental delivery and Obstetric anal sphincter injury. Seventy percent of the responders said they would not discuss the long term risks of urinary, fecal incontinence and prolapse during antenatal or intrapartum management. For intrapartum management with failure to progress in the second stage of labo-r, 69% would attempt a rotational instrumental delivery, and only 5% would offer an emergency caesarean section. Manual rotation followed by ‘straight’ forceps application (59%) was the most frequent rotational delivery offered followed by Ventouse (40%) and Keillands forceps rotation. Thirty four percent stated that do not routinely perform an episiotomy in this scenario. The choice of instrument was not based on the long-term risk of pelvic floor dysfunction in 73% of the responses. Conclusion(s): The survey reveals a poor level of counselling of primigravid women of short stature who are known to be at higher risk of long-term pelvic floor trauma and consequent incontinence and prolapse.

Role of flavonoids in the management of acutely symptomatic haemorrhoids: A systematic review and meta-analysis of randomized, controlled trials (2019)

Type of publication:
Conference abstract

Author(s):
*Rehman S.; Miles W.; Sains P.; Sajid M.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5, p. 110

Abstract:
Aims: The objective of this article is to assess the role of role of flavonoids in the management of acutely
symptomatic haemorrhoids.
Method(s): The data retrieved from the published randomized, controlled trials (RCT) regarding the role of flavonoids in the management of acutely symptomatic haemorrhoids was analysed using the principles of metaanalysis. The summated outcome of dichotomous variables was expressed in odds ratio (OR).
Result(s): Ten RCTs on 1478 patients comparing the surgical outcomes in patients having clinically and endoscopically diagnosed acute symptomatic haemorrhoids after using flavonoids versus placebo preparation were analysed. In the random effects model analysis using the statistical software Review Manager 5.3, the symptomatic relief (OR, 0.48; 95% CI, 0.16, 1.3928; z = 1.36; P = 0.18), satisfaction on pain relief (OR, 0.30; 95% CI, 0.08, 1.07; z = 1.86; P = 0.06), recurrence (OR, 0.48; 95% CI, 0.14, 1.63; z = 1.17; P = 0.24) and complications rate (OR, 1.31; 95% CI, 0.49, 3.54; z = 0.54; P = 0.59) were statistically similar in both groups. However, symptomatic haemorrhoidal bleeding control rate was higher in flavonoids group (OR, 0.33; 95% CI, 0.13, 0.84; z = 2.33; P = 0.02).
Conclusion(s): Use of flavonoids to treat symptomatic acute haemorrhoids failed to demonstrate better effectiveness over traditional placebo remedies except better bleeding control.

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Is it Necessary to do Colonoscopy after Appendicectomy in Patients Over the Age of 50 Years? (2019)

Type of publication:
Conference abstract

Author(s):
*Chakrabarty A.; *Vardhrajan V.; *Cheetham M

Citation:
British Journal of Surgery; Sep 2019; vol. 106 S5; p. 70

Abstract:
Aim: In the United Kingdom 1 in 13 people are affected by appendicitis. The commonest age group is between
10 to 20 years. Appendicitis is relatively uncommon in adults over 50 years. There is a belief that appendicitis
may be precipitated or mimicked by colorectal cancer and hence some surgeons recommend that patients over the age of 50 should undergo a post-operative colonoscopy.
Method(s): We identified patients over the age of 50 years who had appendicectomies in our hospital between
2013 and 2017 usingHES data. Detailed data was collected for all the patients from radiology and endoscopy
data bases. We calculated the cost of post-operative colonoscopy to the health system using PBR tariff.
Result(s): 396 patients aged over 50 underwent emergency appendicectomy during the study period. Of these
284 (72%) had had pre-operative C T scans. 88 (22%) out of the 396 patients underwent a colonoscopy within 3 months of their appendicectomy. Of these 88 patients, 62 had pre-operative CT scans. No cancers were found on post-operative colonoscopy. The cost of performing post-operative colonoscopy in this cohort was 35, 464.
Conclusion(s): In an era of liberal preoperative CT scanning for patients over 50 with right iliac fossa pain, it is
not necessary to perform a colonoscopy after appendicectomy. We recommend that for patients who have a
preoperative CT scan, a post-operative colonoscopy is only needed if there are specific imaging abnormalities.

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Better safe than total; experience of laparoscopic subtotal cholecystectomy in a specialist Upper GI and Bariatric surgery unit and literature review (2019)

Type of publication:
Conference abstract

Author(s):
*Rehman S.; *Abayomi S.; *Jahangir B.; *Maciejewski M.; *Qassem M.; *Kirby G.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5; p. 117

Abstract:
Aims: NICE/AUGIS guidelines suggest performing cholecystectomies while ‘hot’ (within a week). There is a
significant risk of biliary injury and/or open procedure in severely inflamed gallbladders and subtotal
cholecystectomies have been suggested to prevent these. The objective of this article is to present short and
medium term outcomes of laparoscopic subtotal cholecystectomy (LSC) in a specialist upper GI and bariatric
unit.
Method(s): This study included all consecutive patients who underwent LSC between August 2014 and August
2018. Clinical notes were retrospectively analysed. Assessed parameters included demographics, urgency of
operation, method of stump closure, length of inpatient stay, biliary injury, post-op incidence of intervention or
re-operation and post-op complications.
Result(s): 20 patients underwent LSC comprising around 0.7% of all the gallbladder operations performed in
our unit during this period. Median age was 67.1 years. 15 (75%) of these operations were carried out as
elective. Stump was closed by absorbable sutures in 18 (90%) of these patients while endoloop was used in one. Median length of stay was 6.2 days. None of the patients had biliary injury on later follow up and 7 (35%)
patients required ERCP. Post-op complications included chronic abdominal pain, wound infection and bile leak
in 2 (10%), 1 (5%) and 1 (5%) patient respectively.
Conclusion(s): Laparoscopic subtotal cholecystectomy proved to have an acceptable profile of safety and
outcomes in our unit and data is comparable with already published literature. Increased incidence of LSC in
elective patients may highlight the significance of establishing a hot gallbladder service.

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Haemorrhoidal artery ligation and/or suture mucopexy for haemorrhoidal disease with or without the use of Doppler ultrasonography: a meta-analysis of randomized, controlled trials (2019)

Type of publication:
Conference abstract

Author(s):
*Rehman S.; Miles W.; Sains P.; Sajid M.; Baig M.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5; p. 27-28

Abstract:
Aims: The objective of this article is to compare the surgical outcomes following haemorrhoidal artery ligation
and/or suture mucopexy for haemorrhoidal disease with or without the use of Doppler ultrasonography.
Method(s): The data retrieved from the published randomized, controlled trials (RCT) comparing the surgical
outcomes following haemorrhoidal artery ligation and/or suture mucopexy for haemorrhoidal disease with or
without the use of Doppler ultrasonography (DUS) was analysed using the principles of meta-analysis. The
summated outcome of dichotomous variables was expressed in risk ratio (RR) and continuous data was
presented in standardised mean difference (SMD).
Result(s): Four RCTs on 270 patients comparing the surgical outcomes following haemorrhoidal artery ligation
and/or suture mucopexy for haemorrhoidal disease with or without the use of Doppler ultrasonography were
analysed using the statistical software Review Manager 5.3. In the random effects model analysis no-DUS
group had shorter procedure time (SMD, 3.69; 95% CI, 2.73, 4.64; z = 7.56; P = 0.00001), better symptomatic
relief rate (RR, 1.95; 95% CI, 1.07, 3.56; z = 2.19; P = 0.03) and lower risk of short or long term haemorrhoidal
bleed (RR, 2.27; 95% CI, 1.25, 4.11; z = 2.70; P = 0.0007). The recurrence rate (RR, 1.87; 95% CI, 0.66, 5.30; z =
1.18; P = 0.24), post-operative pain score and complication rate were similar in both groups.
Conclusion(s): The use of DUS in haemorrhoidal artery ligation and/or suture mucopexy for haemorrhoidal
disease is not mandatory and better clinical outcomes may be achieved without its use.

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Optimising patients with long-term spinal cord injury for nephrectomy: A review of pre-, peri- and post-operative factors to safeguard outcomes (2020)

Type of publication:
Journal article

Author(s):
*Donati-Bourne J.; *Mohamed W.G.E.; *Pillai P.; *O’Dair J.; Kasmani Z.; Bhatt R.I.

Citation:
Journal of Clinical Urology; 2020 [epub ahead of print]

Abstract:
Objectives: To review the potential challenges a urologist may encounter when embarking on simple/partial/radical nephrectomy in patients with long-term spinal cord injury and propose strategies to pre-empt and manage these.
Material(s) and Method(s): Comprehensive literature review via PubMed, MEDLINE and Google Scholar
searching for relevant scientific articles published to date in English. Recommendations for strategies to safeguard surgical outcomes discussed with a panel of experienced upper-tract urologists.
Result(s): Pre-operative considerations: – urethral assessment via flexible cystoscopy due to higher incidence of urethral pathology in spinal cord injury; – assessing for chronic constipation and distended bowel; and – considering glomerular filtration rate assessment by radio-isotope techniques, such as 51chromium-EDTA Perioperative considerations: – adequate theatre staffing for safe patient transfer; and – planned choice of incision, due to higher incidence of previous abdominal surgery, stoma bags and/or foreign body devices. Post-operative considerations: – ensuring attending medical staff are trained to recognise autonomic dysreflexia; – early remobilisation with physiotherapists experienced in treating spinal cord injury; and – attentive antibiotic stewardship due to higher risk of hospital-acquired or urinary infections
Conclusion(s): Patients with long-term spinal cord injury pose significant potential challenges in the pre-, periand post-operative stages of nephrectomy. Familiarisation and optimisation of such factors is recommended to safeguard outcomes.
Level of Evidence: Not applicable for this multicentre audit.