Staff Publication

Demonstrating the impact of laboratory medicine on clinical outcomes (2014)

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Type of publication:
Conference abstract

Author(s):
*Hallworth M.

Citation:
Clinical Chemistry and Laboratory Medicine, July 2014, vol./is. 52/(S34), 1434-6621 (July 2014)

Abstract:
Clinical laboratory workers believe that the work they perform in providing laboratory tests is valuable. However, data to validate this has been limited, and evidence of the contribution of laboratory medicine to the overall process of diagnosis and management is not easy to obtain. This session will describe the work of the IFCC Task Force on the Impact of Laboratory Medicine on Clinical Management and Outcomes (TF-ICO). It will examine existing evidence, review the gaps in our understanding and deficiencies in the way laboratory medicine is used, and indicate how these can be remedied. Many articles and presentations seeking to promote the value of laboratory medicine have made use of what has become known as the ”70% claim”. This is presented in various forms, most commonly that ”Laboratory Medicine influences 70% of clinical decisions”, or minor variations around this figure. However, the data on which this estimate was based represents unpublished studies and anecdotal observations, and cannot now be objectively verified. The IFCC TF-ICO was established in 2012 to evaluate the available evidence supporting the impact of laboratory medicine in healthcare, and to develop the study design for new studies to generate evidence of the contribution made by laboratory medicine. This presentation will examine existing evidence, review the gaps in our understanding and deficiencies in the way laboratory medicine is currently used, indicate how these might be remedied and offer a vision of a future state in which laboratory medicine is used effectively to support patient care and enhance patient safety. An approach to measuring value will be proposed in which the net value of a testing process is defined as delivered benefits minus delivered harm (undesirable effects of testing). Value is maximized by increasing the benefits and reducing harm. Much of the evidence relating to the value of laboratory medicine is poorly structured and does not relate to clinical outcomes. A more rigorous approach is required. Laboratory medicine has much to offer, but can cause adverse outcomes if not properly used. Laboratorians need to refocus their attention onto improving outcomes.

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Top 15 research priorities for preterm birth with clinicians and service users' involvement-outcomes from a james lind alliance priority setting partnership (2014)

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Type of publication:
Conference abstract

Author(s):
Uhm S., Alderdice F., Chambers B., Gyte G., Gale C., Duley L., James C.P., David A.L., McNeill J., Turner M.A., Shennan A., *Deshpande S., Crowe S., Chivers Z., Brady I., Oliver S.

Citation:
Archives of Disease in Childhood: Fetal and Neonatal Edition, June 2014, vol./is. 99/(A158), 1359-2998 (June 2014)

Abstract:
Background Preterm birth is the single most important determinant of adverse infant outcomes in terms of survival, quality of life, psychosocial and emotional impact on the family, and health care costs. Research agenda in this area has been determined primarily by researchers, and the processes for priority setting in research have often lacked transparency. Objectives To identify 15 most important priorities for future research for practitioners and service users in the area of preterm birth. Methods A priority setting partnership was established by involving clinicians, adults who were born preterm, and parents and families with experience of preterm birth. Research uncertainties were gathered from surveys of service users and clinicians, and analyses of systematic reviews and clinical guidance, and then prioritised in a transparent process, using a methodology advocated by the James Lind Alliance. Results 593 uncertainties were submitted by 386 respondents and 52 were identified from literature reviews. After merging similar questions, a long list of 104 questions were distributed for voting. The 30 most popular items were then prioritised at a workshop. The top 15 research priorities included prevention of preterm birth, management of neonatal infection, necrotising enterocolitis, pain and lung damage, care package at discharge, feeding strategies, pre-eclampsia, emotional and practical support, attachment and bonding, premature rupture of membranes and best time for cord clamping. Conclusions These top research priorities in preterm birth provide guidance for researchers and funding bodies to ensure that future research addresses questions that are important to both clinicians and service users.

Link to more details or full-text: http://fn.bmj.com/content/99/Suppl_1/A158.1.abstract

 

Is it a time to consider introducing simulation training for 'Child Safeguarding'? (2014)

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Type of publication:
Conference abstract

Author(s):
*Saran S., *Brough R., *Ganesh M., *Vadali Y.

Citation:
Archives of Disease in Childhood, April 2014, vol./is. 99/(A64), 0003-9888 (April 2014)

Abstract:
Background Child protection medical examination is an essential competency for any trainee to progress through CCT. Often trainees are apprehensive when asked to perform Child Protection medicals. Inadequate training may lead to poor quality assessments resulting in potential risk to the child, family and possible litigations. Aim To elucidate the learning opportunities which Paediatric trainees get in an average sized district general hospital in England. Methods We have audited notes of children who were referred for the ”Child Protection Medical Examination” to our hospital between 01/05/2012 to 30/09/2013. Results There were 24 ”Child Protection Medical Assessments” performed during 16 months. Both boys and girls were equal in number (12 each). 3 (12%) children were under the age of 12 months, 11 (46%) were between 1 and 5 years and 10 (42%) were older than 5 years. 20 (84%) of these assessments were performed during the weekday and 4 (16%) were done during the weekends. 9 (38%) of the assessments were performed by the ’Community Paediatric Registrars’ who are on call to perform this task in the weekdays during the normal working hours. Equal number 9 (38%) of assessments was performed by the ’Ward Registrars’. On call general paediatric consultants did remaining 6 (24%) assessments. Conclusion Child safeguarding attracts media attention often due to medical inadequacies. We are aware about various serious case reviews in the past and a common recommendation in all of them was to ensure proper training of the front line staff. 24 child protection examinations in 16 months imply an average of 1.5 per month. Just to add to our worry is that on call registrars for child safeguarding have only performed 9 assessments in 16 months, i.e. approximately one assessment every other month. We are seriously concerned about lack of exposure which trainees are getting in this very important component of Paediatric training. We strongly feel to consider other training modalities including introducing simulation technique for ”Child Safeguarding” in the Paediatric curriculum.

Link to more details or full-text: http://adc.bmj.com/content/99/Suppl_1/A64.1

 

Does compliance with the 2 week wait colorectal cancer referral system lead to a higher cancer detection rate? (2014)

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Type of publication:
Conference abstract

Author(s):
*Kaur P., *Cheetham M. , *McCloud J.

Citation:
Colorectal Disease, July 2014, vol./is. 16/(73), 1462-8910 (July 2014)

Abstract:
Background: Current guidelines suggest that patients with a suspected colorectal cancer are seen within 2 weeks of the referral made by general practitioners. Recent data has shown an increase in referrals with a decrease in cancer yield, with up to 25% of all referrals made not meeting referral guidelines. This study aims to determine if there is a higher cancer detection rate in referrals compliant with the referral criteria. Method: A retrospective study of patients referred to a 2-week wait colorectal clinic over a 3-month period was performed. Referral proformas and initial clinic letters were assessed to determine compliancy with the 2 week wait criteria and number of cancers diagnosed. Results: 287 patients were seen in the 3 month period. 38% of referrals were not compliant with the referral criteria. The main reasons for noncompliance were age of the patient (28%) and duration of symptoms (21%). 15 (5.2%) patients were diagnosed with cancer. Compliant referrals had higher cancer detection rate, 13/180 patients (7.2%) when compared with non-compliant referrals, 2/107 patients (1.9%). Conclusion: Compliance with the referral criteria is associated with a higher cancer detection rate. Better education for general practitioners may help to reduce the number of non-compliant referrals reducing work load on strained colorectal units.

 

Laparoscopic ileocaecal resection for Crohn's disease: Initial experience in Shrewsbury (2014)

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Type of publication:
Conference abstract

Author(s):
*Vidyasankar V., *Cheetham M. , *McCloud J

Citation:
Colorectal Disease, July 2014, vol./is. 16/(189), 1462-8910 (July 2014)

Abstract:
Aim: Randomised controlled trials have demonstrated short-term advantages to laparoscopic surgery for ileocaecal Crohn’s disease. Following the introduction of laparoscopic colorectal surgery, we extended our repertoire to include laparoscopic Crohn’s resections. The aim of our study was to assess the safety and outcome following the introduction of laparoscopic resection for ileocaecal Crohn’s. Method: Between January 2008 and November 2012, 30 patients (12 men and 18 women, Median age 30 years), underwent laparoscopic ileocaecal resection for Crohn’s disease. 27 patients had stricturing disease, 2 patients presented with a mass and 1 presented with perforation. Patients were given an intraoperative spinal anaesthetic followed by PCA for 48 hours. All patients were commenced on an enhanced recovery programme. Results: Mean operative time was 90 min. Mean hospital stay was 3 days (range 3-7 days). Two patients (6%) required conversion to open surgery because of a fixed mass (n = 1) and dense adhesions (n = 1). One patient (3%) required reoperation due to haemorrhage. One patient (3%) had prolonged hospital stay due to ileus. One patient (3%) had an anastomotic leak. There were no deaths in this series. Conclusion: Our study demonstrates that laparoscopic resection of ileocaecal Crohn’s disease can be safely performed at a district general hospital with a short length of stay and minimal morbidity.

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Does traction on the cervix under anaesthesia tell us when to perform a concomitant hysterectomy? A 2-year follow-up of a prospective cohort study (2014)

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Type of publication:
Journal article

Author(s):
Madhu C., *Foon R., Agur W., Smith P.

Citation:
International Urogynecology Journal and Pelvic Floor Dysfunction, September 2014, vol./is. 25/9(1213-1217), 0937-3462;1433-3023 (September 2014)

Abstract:
Introduction and hypothesis: Variations exist in urogynaecological practice to decide on hysterectomy in managing prolapse. This study evaluates the outcomes of uterine preservation during anterior colporrhaphy with apparent uterine descent with cervical traction under anaesthesia. We hypothesize that cervical traction should not be used to assess uterine prolapse. Methods: Thirty-five women opting for surgery for symptomatic anterior prolapse (> stage 2) with no uterine prolapse (point C at -3 or above) were recruited. ”Validated cervical traction” was applied under anaesthesia. Only an anterior repair was performed. Incontinence Modular Questionnaire Vaginal Symptoms (ICIQ-VS) questionnaires were used for follow-up. Wilcoxon test was used for statistical analysis. Results: Stage 2 uterine prolapse (POPQ) was demonstrated in all women with traction under anaesthesia. Follow-up was possible in 29 women, 5 did not respond and 1 needed a hysterectomy at 6 months (2.86 %, 95 % CI 0.07-14.91 %). The mean follow-up time was 23 months (range: 13-34 months). There was a significant reduction in the ICIQ-VS scores from 22.7 (pre-operative) to 7.97 at 23 months (p

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Use of a massive haemorrhage protocol in a UK district general hospital is associated with a reduction in mortality (2014)

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Type of publication:
Conference abstract

Author(s):
Lambert L.,Taylor B.,Alistair W.

Citation:
Intensive Care Medicine, September 2014, vol./is. 40/1 SUPPL. 1(S208), 0342-4642 (September 2014) (also published in Anaesthesia, June 2014, vol./is. 69/(118), 0003-2409 (June 2014))

Abstract:
INTRODUCTION. Massive haemorrhage is associated with significant morbidity and mortality. In the context of major trauma managed in a large centre, the use of a massive haemorrhage protocol emphasizing early haemostatic resuscitation reduces mortality (1). However, it is not clear if these models are effective in non-trauma patients (2). There is some concern that these protocols may increase the wastage of blood products which might be a concern in smaller hospitals. (3) OBJECTIVES. To audit the activation of and compliance with a massive haemorrhage protocol in a UK district general hospital. To assess if compliance with the protocol resulted in a difference in mortality, morbidity, length of ICU stay, or use of blood products. METHODS. Retrospective audit over 12 months analyzing the case notes of all patients who had suffered a massive haemorrhage against a massive haemorrhage protocol which emphasizes early haemostatic resuscitation. RESULTS. The protocol was activated in 9 patients, but unfortunately notes were unavailable for one as he was undergoing outpatient treatment. A further 9 patients were identified as having had a massive transfusion, without activation of the protocol, from blood bank data as having been issued emergency uncrossmatched group O blood, or having had more than 10 units of any blood products in a 24 h period. Where a massive haemorrhage protocol was used, 1/8 patients (12.5 %) died. Where a major transfusion was conducted without activation of the protocol, 7/9 patients died (77.8 %). This finding was statistically significant (p = 0.0152) using a 2-tailed fishers exact test. Fewer units of red cells (p = 0.0011) and FFP (p = 0.0034) were used in patients managed according to the protocol, but there was no difference in the use of platelets or cryoprecipitate. Two patients in the group where the protocol had not been activated were given cryoprecipitate despite normal fibrinogen levels, and a further two in this group were not given cryoprecipitate despite fibrinogen levels under 1 g/l CONCLUSIONS. Use of a massive haemorrhage protocol which focuses on rapid haemorrhage control, haemostatic resuscitation and early use of blood is associated with a lower mortality than management of major bleeds without the protocol. This appears to apply in predominantly non-trauma patients in a non-specialist centre. This was a retrospective audit, and the group in whom the protocol was not activated had a higher expected mortality, therefore the results warrant further research.

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Multilevel bypass grafting: Is it worth it? (2014)

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Type of publication:
Journal article

Author(s):
Sharples A., Kay M., Sykes T., Fox A., Houghton A.

Citation:
Annals of Vascular Surgery, October 2014, vol./is. 28/7(1697-1702), 0890-5096;1615-5947 (01 Oct 2014)

Abstract:
Background Traditionally, multilevel arterial disease has been treated with an inflow procedure only but simultaneous multilevel bypass graft procedures have been attempted. However, these procedures are potentially high risk. We report our single-center experience of performing multilevel bypass grafts over the last 15 years.Methods We retrospectively identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital.Results There were 32 multilevel procedures performed. Indication for surgery was acute ischemia in 10 (31.3%), critical ischemia without tissue loss in 10 (31.3%), with tissue loss in 10 (31.3%), and claudication in 2 (6.3%). In 23 (71.9%) cases inflow was restored using a direct iliofemoral or aortofemoral reconstruction. In the remaining 9 (28.1%), an extra-anatomic bypass was constructed. Two (6.3%) patients died within 30 days of surgery. Twenty-nine (90.6%) patients survived to discharge. Twenty-eight patients (87.5%) were alive 1 year after surgery. Limb salvage was 96.9%, 85.7%, and 75.9% at 30 days, 1 year, and 5 years, respectively. Twelve (37.5%) patients required a total of 19 further ipsilateral vascular procedures.Conclusions Our results demonstrate that multilevel bypass procedures can be performed with good long-term outcomes and acceptable mortality, in what is typically a high-risk group with extensive comorbidities. In patients with severe critical limb ischaemia and tissue loss, who have a combination of aortoiliac and infrainguinal disease, there are significant benefits to a primary multilevel grafting procedure.

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