Staff Publication

Does a preprinted Evacuation of Retained Products of Conception (ERPC) consent form improve information provided to patients who are undergoing an ERPC compared to a generic hospital consent form? (2015)

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Type of publication:
Conference abstract

Author(s):
*Khattak H., *Bakhai K., *Zainab O.M., *Jones C., *Swain K., *Biswas N.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(21)

Abstract:
Introduction The General Medical Council (GMC) highlights in Good Medical Practice that obtaining informed consent is one of the duties of a doctor. The GMC advocate in the consent guidelines that the process of consenting is a partnership between the doctor and patient to come to a mutually agreed decision. There may be important medico-legal implications for doctors who obtain uninformed consent. This audit investigated the documentation of this clinical interaction. In the light of this, an original audit on 'ERPC Consent' was carried out in 2013. The audit highlighted that 'serious risks' were not consistently recorded. We therefore encouraged the use of a preprinted ERPC consent form. A re-audit was carried out in 2014. Methods A total of 30 case notes and consent forms were obtained, which is 71% of total ERPCs performed over a 3-month period in 2013. These were analysed using a pro forma and results presented at a local clinical governance meeting. As a result of this meeting, the preprinted form was re-introduced. A re-audit was performed, using the same pro forma with 25 case notes (51% of all ERPCs) over a 3 month period in 2014. The results were analysed and also presented to clinical governance. Results The original audit found that in 2013 only 20% of the forms used to take consent were the ERPC specific forms. After re-auditing in 2014, the number rose to 80%. This showed significant results for improvement in documentation for serious risks, in particular infertility (from 37% to 80%), significant cervical trauma (from 10% to 52%), damage to blood vessels (from 47% to 84%) and thrombosis (from 80% to 88%). Conclusion In conclusion, the complete audit cycle showed that there is a significant improvement in documentation of serious risk factors associated with surgical management of miscarriage and provision of information leaflets to the patients about ERPC. However, we recognise that small sample size may have limited our results and therefore propose a re-audit of all ERPCs performed in 2014.

Link to full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201504001-00048&LSLINK=80&D=ovft

High-grade vaginal intraepithelial neoplasia (VAIN2/3): comparison of clinical outcomes between treated and untreated patients in an observational cohort study (2015)

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Type of publication:
Conference abstract

Author(s):
*Pandey B., *Papoutsis D., *Guttikonda S., *Ritchie J., *Reed N., *Panikkar J., *Blundell S.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(149)

Abstract:
Introduction We aimed to compare the clinical outcomes between treated and untreated patients with high-grade vaginal intraepithelial neoplasia (VAIN2/3) in our colposcopy unit. Methods The clinical records of all patients diagnosed with VAIN and vaginal cancer over the time period of 1981-2012 were retrieved and reviewed. The primary outcome was to identify the progression of treated versus untreated patients with VAIN2/3 to vaginal cancer and to compare persistent VAIN disease in both subgroups. The secondary outcome was to identify any associations between particular demographic features of treated/ untreated VAIN2/3 patients with their clinical outcome. Results During the time period of this observational cohort study 36 patients of which 11 patients with VAIN1, 19 with VAIN2/3 disease and 6 with vaginal cancer were identified. In those with VAIN2/3 (n = 19) the diagnosis was made in a younger age in the subgroup of treated patients (n = 8) versus the untreated patients (n = 11) (47 +/- 7.1 versus 54.3 +/- 11.5 years old). Nulliparity and smoking status were similar between the two cohorts. The median follow-up for the untreated women was 7 years (range 1-22 years). In the treated VAIN2/3 group, median time from diagnosis to treatment was 4 years (range 0.2-7 years), and median follow-up after treatment was 7 years (range 0.5-18 years). Treatment methods were ablation (n = 4), excision of lesion (n = 2) and vaginectomy (n = 2). There were no cases of treated VAIN2/3 patients (0%) that progressed to vaginal cancer, whereas n = 3 cases of untreated VAIN2/3 patients (21.4%) progressed to vaginal cancer. Following initial VAIN2/3 diagnosis, 8/11 cases of untreated VAIN2/3 (72.7%) had persistent disease as identified in follow-up cytology/colposcopy/vaginal biopsies. In the treated VAIN2/3 patients, 5/5 cases (100%) had persistent disease post-diagnosis but after treatment this decreased to 2/7 cases (28.5%). Conclusion Treated VAIN2/3 patients were of younger age but of similar smoking status and parity in comparison to untreated patients. Three cases of untreated VAIN2/3 progressed to vaginal cancer, whereas there were no such cases of patients receiving treatment for VAIN2/3. The VAIN2/3 patients who received treatment had a higher rate of persistent VAIN disease at followup post-diagnosis (100% versus 72.7%), but after treatment this rate fell down to 28.5%. Further studies are needed to conclude whether treatment of VAIN2/3 disease reduces the rate of VAIN disease persistence and affects the progression to vaginal cancer.

Link to full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201504001-00343&LSLINK=80&D=ovft

Teenage pregnancy: incidence and outcomes in a rural Shropshire district general hospital trust (2015)

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Type of publication:
Conference abstract

Author(s):
*Moores K.L., Ritchie J., *Calcott G., *Underwood M. , *Oates S.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(319)

Abstract:
Introduction The UK has the highest rate of teenage pregnancy across Western Europe; however, the rate has been reducing and is currently at its lowest since 1969. Perceptions exist of worse outcomes in teenage pregnancies among healthcare professionals and the public alike. The review sought to determine outcomes of teenage pregnancy (2013-2014) and compare rates of teenage pregnancy (2008-2013) at Shrewsbury and Telford Hospitals (SaTH) NHS Trust and compare with local population outcomes. Methods A 12-month retrospective review of teenage pregnancy outcomes and comparison with outcomes of all deliveries at SaTH between April 2013 and March 2014, a total of 4916 deliveries, was conducted. Data sources included the MEDWAY Hospital Database. Recorded pregnancy outcomes were classified into two categories: outcomes in mothers aged 19 years or younger at time of delivery and outcomes in all mothers who delivered at SaTH in the study period. Parameters assessed included mode of delivery; blood loss; perineal trauma; birthweight; Apgar scores. Teenage pregnancy rates over the last 6 years were compared to recorded rates in 1996. Results The rate of teenage pregnancy has continued to reduce; especially in those aged <16 years. Over 90% of teenage mothers had a vaginal delivery and were half as likely to require caesarean delivery (RR 0.49; 95% CI 0.33-0.75). Low rates of instrumental deliveries were seen in each category; no failed instrumental deliveries occurred among teenage mothers. Teenage mothers were not at a statistically significant increased risk of preterm delivery; however, mean term birthweights were lower among teenage mothers; 3302 g compared with 3464 g in the total population; and mean Apgar scores were the same in both groups. No difference was seen in rates of severe perineal trauma; however, more than 60% of teenage mothers had an intact perineum. Furthermore, teenage mothers had significantly lower rates of postpartum haemorrhage (RR 0.66, 95% CI 0.48-0.90). Conclusion Thus, one may suggest a lower risk of harm to teenage parturients and their babies compared with the local population, contrary to current general beliefs.

Link to full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201504001-00718&LSLINK=80&D=ovft

How can health professionals improve the management of postnatal depression: the patients' perspective (2015)

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Type of publication:
Conference abstract

Author(s):
*Jones, C.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology, April 2015, vol./is. 122/(324)

Abstract:
Introduction Having felt 'lost' myself and almost 'let down' with the management of my own postnatal depression (PND), I wondered whether my view was an anomaly or whether there is a general mismanagement of the illness but from a patient's point of view. There is an increased understanding and awareness of the illness in recent years, largely in part to the use of social media and charitable awareness campaigns. Methods I created a simple online survey asking volunteers who have had PND to provide answers to questions surrounding their help seeking behaviour and how they feel the health professionals treated them and how they feel that their health professionals could improve. This survey was shared amongst a private, online postnatal depression forum in which individuals could opt to take part. There was also an opportunity for those taking part to add 'free text'. These results were collated and analysed. Results A total of 53 responses were obtained. 29% of the responses state they became unwell during pregnancy, 10% between birth and hospital discharge, 22% in the first 6 weeks and the remainder throughout the rest of the first year. All ladies experienced more than one symptom, but in their view, the most alarming symptoms were anxiety (15%), anger (13%), no bond with baby (18%) and imagining or planning own death (24%). 9% of all responders did not seek any help, 38% obtained help in first 6 weeks, 22% in first 6 months and the remainder thereafter. 83% of responders went to their own GP as their first contact. When asked about the first point of contact, in relation to ease of appointment, empathy, knowledge and respect, the responses were mixed. The free text highlighted a few common themes of concern, concerns over computer usage in consultations and lack of follow-up arrangements. Conclusion In conclusion, PND management varies between locations. There are positives and negatives within the patient's journey. I believe we can improve this by returning to our instincts, by acknowledging the distress and managing the mother with compassion.

Link to full-text: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&AN=00134415-201504001-00729&LSLINK=80&D=ovft

Diagnostic laparoscopy in acute right iliac fossa (RIF) pain to take the appendix or to leave it in? (2015)

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Type of publication:
Conference abstract

Author(s):
*Sukha A., *Packer H., *Taylor M., *Goodyear S.

Citation:
Surgical Endoscopy and Other Interventional Techniques, April 2015, vol./is. 29/(S309-S310)

Abstract:
Aims Laparoscopy is used to both investigate acute RIF pain and treat the findings of an inflamed appendix. This study investigates the histology of appendixes where the clinical diagnosis was unclear on presentation and the investigative imaging was inconclusive. Methods Retrospective data collection between January – June 2014 of all appendectomies. Data was collected from Theatre logbooks and the Pathology and PACS computer systems, and analysed in Microsoft Excel. Results 50 patients had an undiagnosed cause of RIF pain. 15% (n = 34) had an USS and 7% (n = 16) had a CT. 58% (n = 29) of scans were reported as negative/inconclusive for appendicitis. All 29 patients had a DL and appendicectomy and 45% (n = 13) were histologically reported as appendicitis. There was 3% (n = 1) associated morbidity and 0% mortality. Conclusion The appendix should be removed when faced with a diagnostic uncertainty and no other pathology is found. The advancement of laparoscopic skills and training has led to low morbidity and mortality as supported by this study. We conclude it is safer to remove the appendix than to leave it in. Key statement The presentation of an acute right iliac fossa pain can sometimes be clinically difficult to diagnose. When investigations are normal or inconclusive and symptoms persist the advancement of laparoscopic surgery allows us to perform diagnostic laparoscopy. When there is no obvious pathology found the appendix should still be removed.

Is the negativity rate of laparoscopic appendicectomies on the increase? (2015)

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Type of publication:
Conference abstract

Author(s):
*Sukha A., *Packer H., *Taylor M., *Goodyear S.

Citation:
Surgical Endoscopy and Other Interventional Techniques, April 2015, vol./is. 29/(S313)

Abstract:
Aims: This study investigates the histological appearance of appendixes from laparoscopic and open appendicectomies. We propose that the negativity rate of laparoscopic appendicectomies is when compared to an open appendicectomy due to the advancements in laparoscopic equipment and surgeon skills. Methods Retrospective data collection of all appendicectomies between January – June 2014. Data was collected from Theatre logbooks and the Pathology and PACS computer systems, and analysed in Microsoft Excel. Results 226 appendectomies were performed on the emergency-operating list. 174 (77%) had a laparoscopic appendicectomy and 52(23%) had an open procedure. The negative appendix rate on histology was significantly higher in the laparoscopic group (28.2%, n = 49) versus the open group (11.5%, n = 6) p = 0.05. There was a 2% (n = 5) associated morbidity and 0% mortality. Conclusion Laparoscopic surgery is considered to be a minimally invasive surgical procedure with low associated risks. The appendix is removed when inflamed and often in right iliac fossa pain when no other pathology is found. Our study shows that laparoscopy may be overused resulting in higher than expected negativity rates. Key statement Laparoscopic surgery is fast becoming the preferred operative procedure for the suspected appendicitis diagnostic tool in the unclear presentation of right iliac fossa pain. The minimally invasive procedure is considered to be a safe procedure perhaps resulting in its overuse. We investigate the negativity rate in laparoscopic verses open appendicectomy.

Complications of airway management and how to avoid them (2014)

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Type of publication:
Journal article

Author(s):
*Chandra P., Frerk C.

Citation:
Trends in Anaesthesia and Critical Care, December 2014, vol./is. 4/6(195-199)

Abstract:
Major complications of airway management are rare, but complications causing minor patient harm are common. Our aim should be to manage our patients airways without causing any injury. Complications arise from technique failure, direct and indirect trauma and as a consequence of cardiovascular instability associated with our airway management techniques. Avoiding complications depends on planning (choosing the lowest risk procedure & having a well thought through strategy), providing optimal conditions, using the best available equipment and using the optimum technique for all practical procedures. This review provides an overview of the technical and non-technical aspects of airway management to help minimise the incidence of complications.

Link to more details or full-text:

Effect of hyperventilation on rate corrected QT interval of children (2013)

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Type of publication:
Journal article

Author(s):
*A Kannivelu, V Kudumula, V Bhole

Citation:
Archives of Disease in Childhood. 2013 Feb;98(2):103-6

Abstract:
BACKGROUND: Hyperventilation is known to cause ST segment changes and QT variability in adults, but this has not been systematically studied in children.
AIM: To investigate the effect of hyperventilation on rate corrected QT interval (QTc) in children.
METHODS AND RESULTS: 25 children (male=10) with a median age of 14 (range 8.3-17.6) years were asked to hyperventilate for 1 min before exercise testing using the modified Bruce protocol. Mean QTc at rest, after hyperventilation, at peak exercise and at 1 min of recovery was 425(±31), 460(±30), 446(±38) and 420(±32) ms, respectively. Mean increase (95% CI) in QTc after hyperventilation was 35(19 to 51) ms (p<0.001), while there was minimal difference between QT interval at rest and after hyperventilation (mean QT 352(±41) vs 357(±44) ms). In six children, there were abnormalities in T wave morphology following hyperventilation. The QTc increment following hyperventilation was more pronounced in children with resting QTc <440 ms (n=14, mean increment (95% CI): 55 (33 to 78) ms) compared to children with QTc ≥440 ms (n=11, mean increment (95% CI): 9 (-4 to 22) ms) (p=0.001). QTc prolongation following hyperventilation was seen in children with both low and intermediate probability of long QT syndrome (LQTS). Peak exercise and early recovery did not cause a statistically significant change in QTc in either of these groups.
CONCLUSIONS: Hyperventilation produces repolarisation abnormalities, including prolongation of QTc and T wave abnormalities in children with low probability of LQTS. The likely mechanism is delayed adaptation of QT interval with increased heart rate. Thus, a hyperventilation episode can be misdiagnosed as LQTS, especially in an emergency department.

Link to more details or full-text: http://adc.bmj.com/content/early/2012/12/13/archdischild-2012-302663.full.pdf