Case Note Analysis Research Articles

15 Need for a permanent pacemaker following the fontan procedure does not adversely affect the long term outlook

Objectives The Fontan procedure remains the predominant palliative approach for a single ventricle circulation despite many concerns about long-term elevation of systemic venous pressures on multiple organ systems. Preservation of cardiac function is a prerequisite for health of the Fontan circuit and loss of sinus rhythm with need for implantation of a permanent pacemaker remains a concern. We sought to compare early and late survival, complications and need for further intervention between those patients who require a permanent pacemaker and patients who remain in sinus rhythm following the Fontan procedure. Methods This single centre, retrospective case note analysis study involved all patients who have undergone the Fontan procedure between 1987 and 2015 and have had regular follow up at Leeds General Infirmary. 145 patients were identified of which two were excluded for having a pacemaker prior to surgery. Of the remainder, 21 patients required a pacemaker. The primary outcome was survival and the secondary outcomes were early and late complications, need for further intervention and oxygen saturation in long-term follow up. Results There was no difference in survival at 7 days, 30 days, 1 year or 5 years (30 day survival SR 92.6%, non-SR 90.5%, p=0.66). The pacemaker group were more likely to have cerebral or renal complications in the first year post procedure but there was no difference in long term complications such as protein losing enteropathy or pulmonary hypertension (acute kidney injury SR 0.8%, non-SR 19.1%, p=0.002). Patients in the pacemaker group were more likely to undergo further interventions and these interventions were more likely to involve cardiopulmonary bypass (SR 0.06%, non-SR 0.48%, p Conclusions This study demonstrates the likely cause of loss of sinus rhythm being more complex surgery performed as part of the Fontan procedure. With more active surgical management of these issues in early childhood as well as preference for an extracardiac conduit loss of sinus rhythm is likely to become a less frequent issue. Despite an increase in early complications and the need for further interventions, pacemaker requirement does not affect long term outcome of the Fontan procedure.

Rigour and Rapport: a qualitative study of parents\u2019 and professionals\u2019 experiences of joint agency infant death investigation

BackgroundIn many countries there are now detailed Child Death Review (CDR) processes following unexpected child deaths. CDR can lead to a fuller understanding of the causes for each child’s death but this potentially intrusive process may increase the distress of bereaved families. In England, a joint agency approach (JAA) is used where police, healthcare and social services investigate sudden child deaths together and a key part of this is the joint home visit (JHV) where specialist police and paediatricians visit the home with the parents to view the scene of death. This study aimed to learn of bereaved parents’ experiences of JAA investigation following Sudden Unexpected Death in Infancy (SUDI).MethodsThis was a qualitative study of joint agency investigation of SUDI by specialist police, healthcare and social services including case note analysis, parental questionnaires, and in-depth interviews with parents and professionals. Families were recruited at the conclusion of the JAA. Data were analysed using a Framework Approach.Results21/113 eligible families and 26 professionals participated giving theoretical saturation of data. There was an inherent conflict for professionals trying to both investigate deaths thoroughly as well as support families. Bereaved parents appreciated the JAA especially for the information it provided about the cause of death but were frustrated with long delays waiting to obtain this. Many parents wanted more emotional support to be routinely provided. Most parents found the JHV helpful but a small minority of mothers found this intensely distressing. In comparison to JHVs, when police visited death scenes without paediatricians, information was missed and parents found these visits more upsetting. There were issues with uniformed non-specialist police traumatising parents by starting criminal investigations and preventing parents from accessing their home or collecting vital possessions.ConclusionsOverall most parents feel supported by professionals during the JAA; however there is scope for improvement. Paediatricians should ensure that parents are kept updated with the progress of the investigations. Some parents require more emotional support and professionals should assist them in accessing this.

The Nutrition and Health Claims Regulation Applies to Commercial Communications Addressed to Health Professionals

Case C-19/15 Verband Sozialer Wettbewerb eV v Innova Vital GmbH (ECJ, 14 July 2016)On 14 July 2016, the Court of Justice delivered its judgment on a request for a preliminary ruling concerning the interpretation of Article 1(2) of Regulation (EC) No 1924/2006 on nutrition and health claims made on foods. The Court ruled for the first time that the Regulation applies to nutrition and health claims made in commercial communications exclusively addressed to health professionals. This represents a major breakthrough as – in a climate of uncertainty – the established industry practice was to interpret Article 1(2) in the sense that the Regulation only applied to commercial communications addressed to final consumers. From now on, food business operators will need to take further precautionary steps to ensure that any information they communicate to health professionals either qualifies as non-commercial or complies with the Regulation. The following case note analyses the content of the judgment and its main implications (authors' summary).

A Case Review: In-Flight Births Over a 4-Year Period in the Northern Territory, Australia

ObjectiveThere has been much newspaper and online news coverage of in-flight obstetric births on commercial aircraft over several decades. This case series reviews several cases of in-flight birth and immediate maternal and neonatal outcomes from air medical retrievals in the Northern Territory of Australia over a 3-year period. MethodsThis is a retrospective written case note and electronic medical retrieval record analysis of 4 patients undergoing in-flight, at altitude, obstetric birth. ResultsFour premature births are recorded by CareFlight Operations over a 4-year period from January 2011 to January 2015. All patients involved were preterm; term ranged from 22 weeks to 36 weeks. Tocolysis was implemented on all 4 patients according to local obstetric guidelines. Maternal complications included 1 patient suffering antepartum hemorrhage and 2 patients suffering postpartum hemorrhage. Three neonates born at altitude needed neonatal resuscitation including positive-pressure ventilation. One neonate, 22 weeks’ gestation, died approximately 2 hours after delivery. Maternal follow-up showed no morbidity or mortality at 1 to 6 days after birth. ConclusionIn-flight deliveries are rare events in air medical medicine. This case series includes patients of variable preterm gestation and correlates poor outcomes to prematurity of neonates. Close communication between remote clinics, obstetric centers, and air medical teams plus up-to-date early labor guidelines are essential for safe practice and to limit the risk of in-flight births.

A process evaluation of a home-based occupational therapy intervention for Parkinson’s patients and their caregivers performed alongside a randomized controlled trial

Objective: To evaluate fidelity, treatment enactment and the experiences of an occupational therapy intervention in Parkinson’s disease, to identify factors that affect intervention delivery and benefits. Design: Mixed methods alongside a randomized controlled trial. Subjects: These include 124 home-dwelling Parkinson’s disease patients and their primary caregivers (recipients), and 18 occupational therapists. Intervention: Ten-week home-based intervention according to the Dutch guidelines for occupational therapy in Parkinson’s disease. Main measures: Data were collected on intervention dose, protocol process, content of treatment (fidelity), offered and performed strategies (treatment enactment), and recipients’ experiences. Therapists’ experiences were collected through case note analyses and focus group interviews. Results: Mean intervention dose was 9.3 (SD 2.3) hours. Mean protocol process adherence was high (93%; SD 9%), however the intervention did not (fully) address the goal for 268 of 617 treatment goals. Frequencies of offered and performed strategies appeared similar, apart from ‘using other tools and materials’ which showed a drop from 279 advised to 149 used. The recipients were satisfied overall with the intervention (mean score 8 out of 10). The therapists noted positive or negative influencing factors on both process and benefits: the research context, the socio-political healthcare context, the recipients’ personal and contextual factors, and the therapists’ competence. Conclusion: We found some prerequisite factors in equipment provision and available dose important for treatment delivery. Other elicited factors related to, or affected, the required professional competencies and tools to tailor interventions to the complexity of interacting personal and contextual factors of patients and caregivers.

Screening for arteriovenous malformations in hereditary haemorrhagic telangiectasia.

To determine whether patients with hereditary haemorrhagic telangiectasia were being screened according to international guidelines, and to review recent evidence in order to provide up-to-date guidelines for the initial systemic management of hereditary haemorrhagic telangiectasia. A retrospective case note analysis was conducted, assessing patients in terms of screening for: genetics, cerebral arteriovenous malformations, pulmonary and hepatic arteriovenous malformations, and gastrointestinal telangiectasia. Databases searched included Medline, the Cumulative Index to Nursing and Allied Health Literature, and Embase. Screening investigations were most frequently performed for hepatic arteriovenous malformations and least frequently for genetics. Recent data suggest avoiding routine genetic and cerebral arteriovenous malformation screening because of treatment morbidities; performing high-resolution chest computed tomography for pulmonary arteriovenous malformation screening; using capsule endoscopy (if possible) to reduce complications from upper gastrointestinal endoscopy; and omitting routine liver enzyme testing in favour of Doppler ultrasound. Opportunities for systemic arteriovenous malformation screening are frequently overlooked. This review highlights the need for screening and considers the form in which it should be undertaken.

Utility of testing for apraxia and associated features in dementia

IntroductionExisting literature suggests that the presence or absence of apraxia and associated parietal deficits may be clinically relevant in differential diagnosis of dementia syndromes.AimThis study investigated the profile of these...

Predictors of effective de-escalation in acute inpatient psychiatric settings.

To explore the factors that influence the use of de-escalation and its success in halting conflict in acute psychiatric inpatient setting. De-escalation is the use of verbal and nonverbal communication to reduce or eliminate aggression and violence during the escalation phase of a patient's behaviour. Although de-escalation is a first-line intervention in aggression management in acute psychiatric settings, little is known about the use or effectiveness of this technique. A retrospective case note analysis. For each patient (n=522), their involvement in conflict (e.g. aggression) or containment (e.g. coerced medication) during the first two weeks of their admission was recorded. The frequency and order of the conflict and containment events were identified during each shift. The sequences of events occurring in shifts involving de-escalation were analysed. Sequences where de-escalation ended the pattern of conflict or containment were categorised as 'successful', and all others were categorised as 'unsuccessful'. Over half of patients (53%) experienced de-escalation during the first two weeks of admission, with the majority of these (37%) experiencing multiple episodes. De-escalation was successful in approximately 60% of cases. Successful de-escalations were preceded by fewer, and less aggressive, conflict events, compared with unsuccessful de-escalations, which were most frequently followed by administration of pro re nata medication. Patients with a history of violence were more likely to experience de-escalation, and it was more likely to be unsuccessful. De-escalation is frequently effective in halting a sequence of conflict in acute inpatient settings, but patients with a history of violence may be specifically challenging. These findings provide support for de-escalation in practice but suggest that nurses may lack confidence in using the technique when the risk of violence is greater. Providing evidence-based staff training may improve staff confidence in the use of this potentially powerful technique.

The relation between practice that is consistent with NICE guideline 142 recommendations and waiting times within Autism Spectrum Disorder diagnostic services

BackgroundThis study explores the extent to which recommendations from the National Institute of Health and Care Excellence (NICE) 142 guidelines, section 9.2 (relating to identification, assessment and diagnosis) reflected existing routine clinical practice in Autism Spectrum Disorder (ASD) diagnosing services in Scotland; and whether there was a significant relation between routine practice which more closely reflected these recommendations and waiting times. MethodA cross-sectional, retrospective case note analysis of recently diagnosed adults, in eight ASD services across Scotland. ResultsThe study found that the existing practice of the participating services was consistent with 14 (maximum number) of the included recommendations in at least half of cases analysed (range 37–70 cases) and was not related to increased total waiting time for diagnosis. ConclusionThe results, based only on the included recommendations, suggest that the section 9.2 recommendations can be integrated into clinical practice in Scotland with relative ease and that it is unlikely to have a negative impact on waiting times.

Gender ratio in a clinical population sample, age of diagnosis and duration of assessment in children and adults with autism spectrum disorder.

This article reports on gender ratio, age of diagnosis and the duration of assessment procedures in autism spectrum disorder diagnosis in a national study which included all types of clinical services for children and adults. Findings are reported from a retrospective case note analysis undertaken with a representative sample of 150 Scottish children and adults recently diagnosed with autism spectrum disorder. The study reports key findings that the gender ratio in this consecutively referred cohort is lower than anticipated in some age groups and reduces with increasing age. The gender ratio in children, together with the significant difference in the mean age of referral and diagnosis for girls compared to boys, adds evidence of delayed recognition of autism spectrum disorder in younger girls. There was no significant difference in duration of assessment for males and females suggesting that delays in diagnosis of females occur prior to referral for assessment. Implications for practice and research are considered.

Ethically justified treatment limitations in emergency situations.

Medical emergency teams (METs) implement do not attempt cardiopulmonary resuscitation (DNACPR) orders and other limitations of medical treatment (LOMTs) in hospitals regularly. However, METs operate in emergency situations with limited or no patient information at the scene. We aimed to study the medical ethics of LOMTs implemented in in-hospital emergency situations. This was a prospective observational study with retrospect case-note analysis conducted in a single Finnish university hospital over 16 months. Data were collected according to the Utstein-style scientific statement. There were 774 reviews on 640 patients without preceding LOMT. During the reviews MET assigned LOMTs (including 55 DNACPR orders) for a group of 59 patients who were older (median 77 vs. 68 years; P<0.001) and had higher cumulative comorbidity (median Charlson comorbidity index 2 vs. 1; P=0.001) compared with patients without LOMTs (no-LOMT). Most reviews (71%) leading to new LOMTs occurred during on-call time. In the majority of LOMT cases at least two physicians (86%) and the patient/relatives (76%) were involved in the decision-making. All but one (98%) of the LOMT reviews were documented in the electronic patient records and included clearly described rationale for the LOMT. The median durations of the MET reviews (31 vs. 31 min, P=0.9) were comparable in the two groups. Age alone was never recorded as a reason for LOMT. LOMTs were implemented in a decent and ethically justified manner in emergency situations following the code of conduct recommended by guidelines, even though MET operated under highly suboptimal circumstances for end-of-life care planning.

The economic impact of surgically treated peri-prosthetic hip fractures on a university teaching hospital in Wales 7.5-year study

The number of total hip replacements taking place across the UK continues to grow. In an ageing population, with people placing greater demands on their prostheses, the number of peri-prosthetic fractures is increasing. We studied the economic impact this has on a large teaching hospital.All patients with peri-prosthetic femoral fracture in a 7.5year period were identified. Radiographic and case note analysis was performed. Costings from the finance departments were obtained.90 cases were identified, 58 female and 32 male, with a mean age of 76 (range: 38–91). 89 of the cases were managed surgically, 66% undergoing revision and 33% receiving open reduction and internal fixation. According to the Vancouver Classification, 3% were Type A, 79% Type B and 18% Type C. The mean length of stay was 43days. The mean cost of management was £31,370 (range: £6885–£112,327). Patients with type C fractures had the highest mean length of stay at 53 days and mean cost of £33,417.Including rehabilitation costs, our study illustrated a mean cost of £31,370, roughly four times the current basic NHS tariff of £8552. Although implant costs are greater, treatment with revision where appropriate allows earlier weight bearing, reduced length of stay and lower overall cost.

Comment on “Verkkokauppa.com”

A Finnish limited liability company had carried out its business activities partly through an Estonian limited liability company and evaded, as a result, the payment of private copying levies charged in Finland. Taking into consideration the relations of ownership and control between the two companies, the central ground and purpose for organising business activities in this form was to be regarded as the evasion of a statutory obligation. The Supreme Court of Finland found the practice of the Finnish company reprehensible to such a degree that it was justified to pierce the corporate veil and set aside the separateness of the Estonian company provided in limited liability company legislation, holding the former liable for compensation concerning the unpaid private copying levies vis-a-vis the plaintiff. This case note analyses the criteria set out by the Supreme Court for setting aside the guiding principle of separate assets and liabilities under limited liability company law if the form of a limited liability company has been abused.

Malrotation: Age-Related Differences in Reoperation Rate.

Intestinal malrotation classically presents in the neonatal period with bilious vomiting. However, population studies suggest that up to two-thirds of these patients are diagnosed later in childhood or in adulthood. Increased morbidity in the adult population has been reported. Local experience suggested that surgery was technically more difficult in older children and led to the hypothesis that it would be associated with increased morbidity. A retrospective case note analysis was performed on all children presenting with intestinal malrotation to a tertiary referral center between January 2002 and November 2014. Case notes and operation records were reviewed and those who underwent laparotomy for confirmed malrotation were included. Children were grouped as infants (< 1 year) and older (> 1 year). The primary outcome was total emergency reoperation rate. Secondary outcomes were requirement for a bypass at reoperation and mortality. A total of 131 children with malrotation were identified (104 infants, 27 older children; 78 males; age range, 0-16 years). Overall, 13 patients had emergency reoperation following initial Ladd procedure (6 infants and 7 older children). Risk for reoperation was significantly higher in older children (p = 0.005) and additionally a bypass procedure was more often required in older children than infants (4 children, 2 infants, p = 0.016). Adhesiolysis was required on four occasions and redo Ladd procedure in two; these were evenly distributed between both groups. One child was found to have distal bowel obstruction at reoperation. There were three deaths (2.3%), all in the infant group. One was directly associated with malrotation with extensive bowel necrosis. The other two died of unrelated sepsis several months later. Malrotation surgery in older children is associated with a significantly higher emergency reoperation rate. The primary duodenal bypass procedure should always be considered with longstanding chronic intermittent obstruction associated with malrotation if the simple Ladd procedure is deemed inadequate.

Growth in children with choledochal malformations: effect of the Roux loop.

Excision and biliary reconstruction using a Roux loop is the current standard for choledochal malformation (CM). This is un-physiological, delivering bile beyond the duodenum and excluding a significant length of the jejunum from intestinal absorption. We investigated whether this had an effect on post-operative growth. Retrospective case-note analysis of children surgically treated for CM. Growth variables were converted to standard deviation scores (SDS) and compared against population norms. P < 0.05 was significant. From 1994 to 2014, 135 children (<16 years) were identified. Median age at surgery was 3.3 (IQR 1.5-7) years. Morphology included: type 1 Cystic (n = 54, 40%), type 1 Fusiform (n = 58, 43%) and type 4 (intra and extra-hepatic) (n = 22, 16%). There was pre-operative growth failure [median weight SDS = -0.4 (-1.2 - 0.4), P = 0.0004] with a similar trend for height [SDS = -0.38 (-1.2 - 0.5), P = 0.08)]. This correlated with presentation bilirubin (r s = -0.24, P = 0.004), GGT (r s = -0.27, P = 0.002) and AST (r s = -0.27, P = 0.002) but not morphology (P = 0.82) or presentation (P = 0.4). Median follow-up was 1.9 (0.6-4.7) years, during which time both height (P = 0.73) and weight (P = 0.45) reverted to normal. This is the first report of growth in children with CM following a Roux-loop reconstruction and showed pre-operative growth failure probably attributed to a period of biliary obstruction but catch-up growth when corrected.

Paediatric tracheostomy—An 11 year experience at a Scottish paediatric tertiary referral centre

AimsThe aim of this paper was to review the indications, complications and outcomes for tracheostomy at a Scottish paediatric tertiary referral hospital. MethodsAll patients undergoing tracheostomy between January 2001 and September 2012 were identified. A retrospective case note analysis was performed. Results111 tracheostomies were done in the study period. The mean number per year was 11 (3–12). Full data was available for 95 patients. There were 56 (59%) males and 39 (41%) females. Age at time of tracheostomy ranged from one day to 15 years, the mean age of tracheostomy insertion was 69 weeks. The majority of patients, 75 (79%), were under one year old when they had their tracheostomy. The most common indication was long-term ventilation (20%), followed by craniofacial abnormality causing airway obstruction (18%), followed by subglottic stenosis (14%). 37% of patients were decannulated. ConclusionsThis series reflects current trends in the indications for paediatric tracheostomy, with chronic lung disease of prematurity being the most common indication.

Parkinson's disease without nigral degeneration: a pathological correlate of scans without evidence of dopaminergic deficit (SWEDD)?

ObjectiveTo describe 5 cases of Parkinson's disease lacking any detectable histopathology.BackgroundThe diagnosis of Parkinson's disease is supported histologically by the findings of α-synuclein immunopositive Lewy bodies and neurites and severe...

Are specialist nurse‐led check flexible cystoscopy services as effective as doctor‐led sessions?

ABSTRACTThe demands on service provision have led to an increasing number of check flexible cystoscopies being performed by urology nurse specialists as opposed to doctors. We aimed to compare the performance of urology nurse specialists, in a nurse‐led service, with doctor‐led sessions. Retrospective case note analysis was performed on patients who required further treatment following their check flexible cystoscopies. Data was collected in two separate 3‐month time periods: first (1 October 2012–31 December 2012) all cases that were performed by doctors, second (1 March 2013–31 September 2013) all cases that were performed by nurse specialists. Details recorded included the findings at check flexible cystoscopy, treatment and initial and subsequent histology results. A total of 137 episodes were included in the study (71 – nurse, 66 – doctor). Correct reporting at initial check cystoscopy with subsequent confirmation of TCC, CIS or dysplasia occurred in 99 of 137 (72.3%) of episodes (55 – nurse, 44 – doctor). Over reporting at initial check flexible cystoscopy with findings later showing any variant of inflammation/cystitis, reactive changes, atypia or no lesion occurred in 38 of 137 (27.7%) episodes (16 – nurse, 22 – doctor). The nurse‐led service correctly reported 55 of 71 (77.5%) episodes and over‐reported 16 of 71 (22.5%). The doctors correctly reported 44 of 66 (66.7%) episodes and over reported 22 of 66 (33.3%). This study provides evidence that nurse led check flexible cystoscopy sessions are comparable in quality to doctor‐led sessions and supports the use of these services. This has clear implications on the delivery of a cost effective service to meet current financial demands.

The relationship between waiting times and ‘adherence’ to the Scottish Intercollegiate Guidelines Network 98 guideline in autism spectrum disorder diagnostic services in Scotland

The aim of this study was to explore the extent to which the Scottish Intercollegiate Guidelines Network 98 guidelines on the assessment and diagnosis of autism spectrum disorder were adhered to in child autism spectrum disorder diagnostic services in Scotland and whether there was a significant relationship between routine practice which more closely reflected these recommendations (increased adherence) and increased waiting times. Retrospective, cross-sectional case note analysis was applied to data from 80 case notes. Adherence ranged from a possible 0 (no adherence) to 19 (full adherence). Overall, 17/22 of the recommendations were adhered to in over 50 of the 80 cases and in 70 or more cases for 11/22 of the recommendations, with a mean adherence score of 16 (standard deviation = 1.9). No significant correlation was found between adherence and total wait time for untransformed (r = 0.15, p = 0.32) or transformed data (r = 0.12, p = 0.20). The results indicated that the assessment and diagnostic practices were consistent with the relevant Scottish Intercollegiate Guidelines Network 98 guideline recommendations. Increased adherence to the 19 included recommendations was not significantly related to increased total waiting times, indicating that the Scottish Intercollegiate Guidelines Network 98 recommendations have generally been integrated into practice, without a resultant increase in patient waits.

PWE-084 Itu escalation and renal replacement therapy in decompensated liver disease – utility or futility

Introduction Liver-related mortality continues to increase in the UK with alcohol remaining the leading cause. A recent NCEPOD report highlighted deficiencies in the acute care received by patients with decompensated ALD, including early management and access to specialist review and ITU care. In our instituition, a large DGH, we have a dedicated HDU/ITU and 2 hepatologists. We sought to assess outcomes and predictors of survival of patients admitted to ITU with decompensated CLD and utility of mechanical ventilation (MV) and renal replacement therapy (RRT.) Method We interrogated a prospective ITU-admissions database and identified 64 patients with decompensated CLD of any aetiology admitted bewteen 2008 and 2013. We conducted a case note analysis collecting data on demographics, aetiology of CLD, cause for decompensation, Child–s and MELD scores, interventions received and 30-day and 1-year mortality. We compared outcome to previous study between 2003–07. Results Of 64 patients, 42 (66%) were male. 55 (86%) had ALD. Mean age was 47.7 for ALD and 50.8 for non-ALD. The most common precipitant was UGI bleed (27%), sepsis (20%) and alcoholic hepatitis (17%). AKI was present in 32 (50%; 55% ALD vs 22% non-ALD; p 28 patients (44%) were ventilated and 10 (16%) received RRT (all ALD patients.) The 30-day mortality was 58% for ALD and 66% for non-ALD with 1-year mortalities of 71% and 77%. Overall, survival to hosptial discharge was 20/64 (31%). The best predictor of survival was escalation to ITU within 48 h 17/24 (71%) vs 7/40 (17.5%) (p-value 60 did not survive. Prognosis was better if previously under hepatology service. Receiving either MV or RRT were not predictive of a worse prognosis. As expected, higher MELD score also predicted poorer outcome. Overall survival of ALD patients of 40% over this study period is favourable compared the previous study period (29%). There was an increase in the number of admissions from 35 to 55 patients over the same period. Conclusion Outcomes for patients with decompensated CLD including ALD are improving and ITU escalation should be offered early to all appropriate patients. Ventilation or RRT should be considered as not always predictive of poor outcome. The best chance for survival was in patients escalated within 48 h and those who had been been under the care of hepatology prior to presentation. Disclosure of interest None Declared.