Staff Publication

Can hospital early warning score systems be used to predict mortality and readmissions in patients with chronic obstructive pulmonary disease exacerbations requiring hospitalisation? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E.-J.T., *A lvarez E., *Moudgil H., *Naicker T.R., *Srinivasan K.S.

Citation:
American Journal of Respiratory and Critical Care Medicine, 2014, vol./is. 189/

Abstract:
Rationale: Predicting mortality in chronic obstructive pulmonary disease (COPD) can be complex as disease progression does not often follow a smooth downward trajectory. Identifying patients with COPD approaching the end of the ir life is important as it allows clinicians to initiate appropriately time d discussions centred around advance care planning and palliative care. High rates of early readmission to hospital (within 30 days of discharge) for patients with COPD is also of some national concern and to date, effective strategies to reduce this readmission rate have been limited. The use of early warning score (EWS) systems are now widespread in UK hospitals and are used primarily to alert nursing and medical staff to the severity of, or changes in, a patient's condition. This study aimed to understand whether the EWS systems could be used to predict 30 or 90 day mortality, or readmission rates in patients admitted to hospital with a COPD exacerbation. Met hods Data was collected from 73 consecutive patients admitted to hospital over a three month period (May to August, 2013) with an acute exacerbation of COPD. Collected data included early warning scores on admission, discharge and the peak EWS score. Data regarding in-hospital death, death within 30 and 90 days of admission date and readmission within 30 days of discharge was also collected. Results One patient (1.4%) died during their hospital admission. Four patients (5%) had died within 30 days of admission and 11 pa tients (15%) had died within 90 days of admission. 17 patients were re-admitted within 30 days of discharge (23%). There was no significant difference between median admission, peak and discharge early warning scores in those patients who had died within either 30 or 90 days of admission or who were readmitted within 30 days compared to the median values for the rest of th e group (see table). Conclusions According to the findings of this study, measurement of early warning scores cannot be used in clinical practice to p redict readmission rates, 30 or 90 day mortality in patients admitted to hospital with an acute exacerbation of COPD. (Table Presented).

Inadvertent returns to theatre within 30 days (IRT30) of surgery: an educational tool to monitor surgical complications and improve our performance as surgeons (2015)

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Type of publication:
Journal article

Author(s):
*Sukha A., *Li, E. , *Sykes T., *Fox A., *Schofield A., *Houghton A.

Citation:
Clinical Governance, October 2015, vol./is. 20/4(208-214 )

Abstract:
Purpose – When a patient unexpectedly has to go back to the operating theatre, there is often a perceived problem with the primary operation. An IRT30 is defined as any patient returning to the operating theatre within 30 days of the index procedure. IRT30 has been suggested to be a useful quality indicator of surgical standards and surgeon performance. The purpose of this paper is to evaluate t he usefulness of this validated tool, by assessing all IRT30 over a 12-month period. Learning points for individual surgeons, surgical subspecialty units and the clinical governance leads were reviewed. Design/methodology/app roach – Consecutive series of general and vascular surgical patients undergoing elective and emergency procedures between July 2012 and 2013. Prospective data collection of all IRT30s classified as Types 1-5 by a single-rater and in-depth discussion of Types 3-5 cases at the clinical governance meetings. The individual case learning points were recorded and the collective data monitored monthly. Findings – There were 134 IRT30s. In total 84 cases were discussed: Type 3 (n=80), Type 4 (n=4) and Type 5 (n =0). In total 50 cases were not discussed: Type 1 (n=27), Type 2 (n=2 3). Originality/value – It is crucial that surgeons continue to learn throughout their surgical career by reflecting on their own and their colleague's results, complications and surgical performance. Analysing Types 3 and 4 IRT30s within the governance meetings has identified learning points related to both surgical technique and surgical decision making. By embracing these learning points, surgical technique and individual as well as group surgeon performance can be modified and opportunities for training and focused supervision created.

Growth plate injuries and management (2015)

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Type of publication:
Journal article

Author(s):
*Dover C., Kiely N.

Citation:
Orthopaedics and Trauma, August 20 15, vol./is. 29/4(261-267)

Abstract:
The growth plate, or physis, is the name given to the area of cartilaginous tis sue found between the epiphysis and metaphysis of skeletally immature bone. The developing growth plate is weaker than surrounding ossified bone and, therefore, at risk of injury before its closure. Previous studies have shown that fractures account for 10-25% of all paediatric injuries, with growth plate injuries accounting for 15-30% of all paediatric bony injury. The upper limb is most likely to be affected, with the distal radius found to be the most common site of fractures in children. The Salter-Harris classification describes growth plate injuries based upon location and likelihood of growth arrest. In addition to growth arrest, injury to the growth plate often stimulates bone repair, which can lead to limb length discrepancy, bone b ridge formation between the metaphysis and epiphysis, and angulation of the bone. The treatment of growth plate fractures ranges from conservative management to operative fixation and bone grafting. Outcome is varied and dependent upon site and grade of the fracture as well as the age of the patient. Regardless of Salter-Harris classification, an important component of management is counselling the parents about the potential risk of future growth arrest and associated sequelae.

Hormone therapy for breast cancer in men (2015)

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Type of publication:
Journal article

Author(s):
Khan M.H., *Allerton R., *Pettit L.

Citation:
Clinical Breast Cancer, 2015, vol./is. 15/4(245-250)

Abstract:
Breast cancer in men is rare, but its incidence is increasing, in keeping with the aging population. The majority of breast cancers in men are estrogen receptor positive. There is a paucity of clinical trials to inform practice, and much has been extrapolated from breast cancer in women. Hormone therapy represents the mainstay of adjuvant and palliative therapy but may have contraindications or poor tolerability. We review the evidence for choice of hormone therapy in both the adjuvant and palliative setting in breast cancer in men.

The Learning Curve in Endoscopic Dacryocystorhinostomy: Outcomes in Surgery Performed by Trainee Oculoplastic Surgeons (2015)

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Type of publication:
Journal article

Author(s):
Malhotra R., Norris J.H., Sagili S., *Al-Abbadi Z., Avisar I.

Citation:
Orbit, November 2015, vol./is. 34/6(314-319)

Abstract:
To report outcomes of endoscopic DCR (En-DCR) performed by oculoplastic trainees and describe factors to improve success rates for trainees. Methods: Retrospective, single-centre audit of En-DCR procedures performed by three consecutive trainee oculoplastic surgeons, over a 3-year period. Trainees also completed a reflective-learning questionnaire highlighting challenging and technically difficult aspects of En-DCR surgery, with relevant tips. Results: Thirty-eight consecutive independently-performed en-DCR procedures on 38 patients (mean age 58.6 +/- 21.4 years) were studied. Mean time spent in the operating-theatre was 95.7 +/- 27.3 minutes. Success rate for each year was 15/17(88%), 8/8(100%) and 7/13(54%), respectively, at mean follow-up 12.5 +/- 12 months. The lowest success rate year coincided with use of silicone stents in 31% cases compared to 94% and 100% i n the previous 2 years. In cases that failed, video-analysis highlighted in adequate superior bony rhinostomy (2 cases), incomplete retroplacement of posterior-nasal mucosal-flaps (3 cases), significant bleeding (1 case). Those who underwent revision surgery (n = 6), were found to have soft-tissue ostium and sac closure requiring flap revision. Two-cases required further bone removal supero-posterior to the lacrimal sac. Trainees-tips that helped improve their surgery related to patient positioning, instrument handling , bone removal and posture. Conclusion: Good surgical outcomes are achievable training in en-DCR surgery. Adequate operating time needs to be planned. Failure was primarily due to closure of the soft-tissue ostium, either secondary to inadequate osteotomy and sac-marsupialisation or postoperative scarring. Intra-operative mucosal trauma is higher amongst trainees and adjuvant silicone stenting during the training period may be of value where mucosal adhesions are anticipated.

A rare case of vulval myxoid chondrosarcoma (2015)

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Type of publication:
Conference abstract

Author(s):
*Abdelsalam H., *Malcolm A.

Citation:
Journal of Pathology, September 2015, vol./is. 237/(S46)

Abstract:
Introduction: Primary Extraskeletal Myxoid Chondrosaroma (EMC) of the vulva is a rare mesenchymal neoplasm. The myxoid tumour differential diagnosis on a core biopsy can be quite challenging. To date, few cases have been reported in the literature. Case Report: A 42-year old woman noticed a swelling on the right side of the labia, thought to be a Bartholin's cyst i n 2011. She was managed conservatively. She had drainage and marsupialization under general anaesthesia. This resulted in extreme bruising of the vulva. This was managed with antibiotics and non-steroidal anti-inflammatory medication, and it resolved after 3 weeks. Six months later, the patient presented again with a persistent vulval mass. A biopsy was obtained under general anaesthesia, and it showed a myxoid tumour with differential diagnosis of low grade chondroid tumour. An MRI was performed to assess the extent of the disease. The tumour was excised. At surgery, a 7 x 5 cm lobulated, extremely vascular vulval tumour was found. The tumour was inseparable from the inferior pubic ramus of the pelvic bone. A complete macroscopic resection was obtained. Histology confirmed low grade myxoid chondrosarcoma. Conculsion: Vulval lesions with unusual characteristics or insidious evolution in the labia majora or Bartholin's glands area should be carefully and pr omptly investigated. Differential diagnosis of myxoid tumours in the vulva should include myxoid chondrosarcoma amongst other diagnoses.

Anterior approach white-line advancement: a hybrid technique for ptosis correction (2015)

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Type of publication:
Journal article

Author(s):
*Sagili S.

Citation:
Ophthalmic Plastic and Reconstructive Surgery , 2015, vol./is. 31/6(478-481)

Abstract:
Purpose: To describe the technique of anterior approach white-line advancement for correction of ptosis. Methods: Retrospective review of consecutive cases that underwent anterior approach white-line advancement for correction of aponeurotic ptosis. In this technique, the posterior surface of the levator aponeurosis (white line) is accessed through a skin crease incision (anterior approach) and advanced toward the tarsal plate. Surgery was considered successful if the following 3 criteria were simultaneously met: postoperative upper margin reflex distance of >2 and <4.5 mm, inter-eyelid height asymmetry of <1 mm, and satisfactory eyelid contour. Written informed consent was obtained from all the patients and the study was HIPPA compliant. Results: Twenty patients (29 eyelids) were included in this study. Mean postoperative follow up was 1.25 months (1 to 6 months). Mean preoperative margin reflex distance was 0.38 mm (.1 to 2 mm) and the mean postoperative margin reflex distance was 3.16 mm (2 to 4 mm). Eighteen patients (90% ) fulfilled the criteria set for success. The patients rated the outcome of surgery as follows: 80% completely satisfied and 20% significantly improved. Conclusion: Anterior approach white-line advancement is a hybrid technique that incorporates the principles of both anterior and posterior approach ptosis correction techniques. The posterior surface of levator aponeurosis (white line) is exposed and advanced toward the superior border of tarsal plate with minimal disruption of eyelid anatomy including the orbital septum and preaponeurotic fat pad. Hence, this technique can achieve superior cosmetic results similar to a posterior approach procedure, without the need for a conjunctival incision.

Breast reconstruction changes: coping mechanisms in breast cancer survivors (2015)

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Type of publication:
Oral presentation

Author(s):
*Blossom Lake, *Heidi Fuller, *Sarah Rastall, *Tamoor Usman

Citation:
San Antonio Breast Cancer Symposium, December 2015

Abstract:
Background: Breast cancer is the commonest malignancy in women. Survivorship care for breast cancer patients needs to be individualised. A key component is recognition that coping mechanisms can be changed by treatment. The aims of this study were to see how women who have had immediate breast reconstruction and mastectomy, compared to those who have mastectomy alone cope and if there were significant differences in coping styles.

Methods: A cohort study using a standardised questionnaire the Brief Cope Scale. Inclusion criteria: all women who had had immediate breast reconstruction and mastectomy in Shropshire from 2003 to 2014 for node negative ductal carcinoma in situ or invasive breast cancer. Each index patient was matched for year of diagnosis, adjuvant therapy and age to one woman who had mastectomy alone.

Results: Questionnaires were sent to 234 patients, with a 58% response rate. Significantly more patients from the reconstruction cohort coped by active coping (T value 1.66, P value 0.04). Significantly less patients coped by active venting in the reconstruction cohort (T value 1.71, P value 0.04).

Conclusion: Breast reconstruction changes coping styles of breast cancer patients, understanding this allows clinicians to individualise survivorship care.

Axillary overtreatment for minimal axillary disease in breast cancer, a 5 year audit of ipsilateral arm lymphoedema ; the real cost to patient and health service (2015)

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Type of publication:
Poster presentation

Author(s):
*Blossom Lake, Jayne Gittins, *Tamoor Usman

Citation:
European Journal of Surgical Oncology Nov 2015 41(11):p s267

Abstract:
NICE guidelines state that axillary node clearance (ANC) is the treatment of choice for the positive axilla, with up to 30% morbidity of lymphoedema. In contrast ASCO guidelines state that patients with 1 / 2 sentinel lymph node positive who have breast conserving surgery with breast radiotherapy should not have ANC. The recent ABS Consensus highlighted the need to minimise overtreatment of minimally involved malignant axilla. The aim of this audit was assess the cost of overtreatment in terms of lymphoedema.