East Lancashire Research Articles

Summary of: repair vs replacement of failed restorations in general dental practice: factors influencing treatment choices and outcomes.

To investigate the impact of repair vs replacement of failed restorations on patient related outcome measures, and to explore the clinical factors that influence this decision. Multicentre, prospective practice-based study.Setting Dental practices within Salford, Trafford and East Lancashire in the North West of England. General dental practitioners were asked to participate and to recruit adult patients attending for routine dental treatment.Interventions Repair or replacement of failed restorations. Dental anxiety before treatment using the Corah Dental Anxiety Scale and pain intensity immediately and 24 hours post-operatively using the McGill short form pain questionnaire. Operative outcomes included depth of caries, time taken to complete the procedure, use of local anaesthetic and dental material used. Of the 103 patients diagnosed with a failed restoration, a statistically significantly greater number underwent replacement than repair (p = 0.004). Patients undergoing repairs were significantly less anxious (p = 0.008) and had shorter procedure times (p = 0.044). Repairs were associated with minimal caries depth and less use of local anaesthetic. Failed restorations should be repaired where clinically possible, as they are quick and associated with less patient anxiety. Future research should focus on providing high quality prospective data evaluating the longevity of repaired vs replaced restorations.

A review of 1500 consecutive skin malignancy excisions: the East Lancashire experience

Introduction:The objective of the study was to determine any clinical or patient perceived benefit to using a wide bore nasogastric (NG) tube following a head and neck oncological resection. (Ethical approval received). Fine bore tubes get blocked following use and sometimes require removal and replacing. Wide bore tubes have the advantage of minimal blockage they can be more uncomfortable. Variation exists between head and neck surgeons as to which NG is used. Materials/Methods: Patients assigned randomly to those having a wide bore NG tube or a fine bore tube. There are two treatment groups. Collection of information required the use of three forms. The first form was completed by surgeon/anaesthetist placing NG tube, the second by nursing staff on the ward and the third by patients on removal of the NG tube. Each form has a study reference number to allow the information to be collated. 32 patients were included in the study. 17 had a wide bore tube, 15 had narrow bore. Results/Statistics: Statistical analysis is ongoing, however the trend reveals that wide bore tubes never blocked and never needed to be replaced for this reason. Patients however found them more uncomfortable. Narrow bore tubes frequently blocked with increased time demands on nurses/team to unblock/replace, with increased radiographical exposure. Conclusion/relevance:Given the increased risk of blocking of narrow bore NG tubes it is our view that where tolerated a wide bore NG tube should be used for feeding purposes in the post operative period.

Going the extra mile for patients.

Just 14 months after she changed career to become a healthcare assistant, Dot O'Meara was presented with one of East Lancashire Hospitals NHS Trust's ten unsung hero awards, writes Carol Davis, freelance journalist.

PA.49 Anencephaly: A Review in East Lancashire

IntroductionOne of the 3 major neural tube defects, anencephaly is incompatible with life. Women with affected fetuses are offered termination of the pregnancy. However, about a quarter of the population...

The influence of FDG PET-CT on the detection of extrahepatic disease in patients being considered for resection of colorectal liver metastasis.

The aim of this study was to evaluate the influence of flurodeoxyglucose positron emission tomography computed tomography (FDG PET-CT), as an adjunct to conventional CT staging, in the detection of extrahepatic disease in patients with potentially resectable colorectal liver metastasis. Overall, 133 consecutive patients with colorectal liver metastases staged with CT and PET-CT referred to the East Lancashire regional hepatobiliary multidisciplinary team over a two-year period were included in this study. Abnormal findings on PET-CT were correlated with follow-up imaging and/or histology. All imaging was reviewed by specialist hepatobiliary radiologists for the presence/absence of extrahepatic disease. The influence of the PET-CT findings was categorised for each patient in relation to operability and other significant findings. PET-CT had a major impact on staging of extra hepatic disease in 20% of patients, in comparison with the initial CT. Six per cent of patients were upstaged from operable CT findings to inoperable findings on PET-CT because of the discovery of inoperable occult extrahepatic disease. Five per cent had operable local regional nodal disease detected on PET-CT. A further 3% had premalignant colorectal lesions detected on PET-CT. Six per cent of patients were downstaged from indeterminate or suspected inoperable CT findings to operable findings on PET-CT. The use of PET-CT in this setting may prevent futile operations, guide the resection of local regional nodal disease and downstage a number of patients thought to have extrahepatic disease on conventional imaging. This study has shown similar results to other recent studies and supports the use of PET-CT as a necessary staging modality in patients with potentially resectable colorectal liver metastases.

First metatarsophalangeal joint arthrodesis versus proximal phalanx hemiarthroplasty for hallux rigidus: feasibility study for a randomised controlled trial

BackgroundOsteoarthritis of the first metatarsophalangeal joint (hallux rigidus) leads to pain and poor function and mobility. Arthrodesis is the gold standard treatment for end-stage disease. Total joint arthroplasties have been attempted, but early loosening has been attributed to dorsally directed shear forces on the metatarsal component. Metallic proximal phalangeal hemiarthroplasty theoretically avoids this. Whilst early results are promising, no comparative trials exist comparing this to arthrodesis.Methods/DesignThe primary objectives are to determine the range of outcome scores between the two treatment arms (to inform a power calculation). Outcome measures will include the MOXFQ, AOFAS-Hallux and EuroQol EQ-5D-5 L. Secondary objectives are to determine the accrual rate, dropout rate and trial acceptability to both patients and surgeons. These data will allow the development of a larger trial with longer follow-up.This is a prospective randomised controlled single-centre study comparing proximal phalanx hemiarthroplasty (AnaToemic, Arthrex Ltd., Sheffield, UK) with arthrodesis (15 patients in each arm). Randomisation will be performed using a 1:1 allocation ratio in blocks of six.Patients meeting the eligibility criteria will be recruited from three foot and ankle consultant surgeon’s clinics (East Lancashire Hospitals NHS Trust). If agreeable, informed consent will be obtained before patients are randomised.The outcome measure scores will be completed pre-operatively and repeated at 6 weeks, 3 months and 12 months. A radiological review will be performed at 6 weeks and 12 months to determine rates of loosening (hemiarthroplasty) and union (arthrodesis). Data on length of stay, return to work, complications and re-operation rates will also be collected.The analysis will compare the change in outcome scores between treatment groups at all follow-up time points. Scores will be compared using a Student t-test, adjusting for scores at baseline.This study will be conducted in accordance with the current revision of the Declaration of Helsinki (1996) and the ICH-GCP Guideline (International Conference on Harmonisation, Good Clinical Practice, E6(R1), 1996). This study has been approved by the sponsor, the Trust Research & Development office. Ethical approval has been received from the National Research Ethics Service (North East: 12/NE/0385 for protocol version 5.3 dated 3 June 2013).Trial registrationCurrent Controlled Trials ISRCTN88273654

The outcome of a cohort of tuberculin-positive predominantly South Asian new entrants aged 16-34 to the UK: Blackburn 1989-2001

Blackburn, Hyndburn and Ribble Valley Local Government areas of England and Wales, the former a high tuberculosis (TB) prevalence district. The incidence of tuberculosis in new entrants aged 16-34 with positive tuberculin skin tests but normal chest X-rays after initial entry is not definitely known, and was previously estimated from cross-sectional national surveys and derived data for the 2006 and 2011 NICE economic appraisals of new entrant TB screening. New entrants aged 16-34 years predominantly from South Asia (India, Pakistan and Bangladesh), with tuberculin tests inappropriately positive for their BCG history were identified for the years 1989-2001 inclusive from a new entrant database. These entrants were compared with the current GP registration database to see if local residence could be confirmed and the local TB notification database to October 2008. Survival analysis was carried out using Kaplan-Meier survival curves and a Cox Regression model. Four hundred and seventy-nine such new entrants with normal initial chest X-rays were identified. Of these 402 (84%) registered with a General Practitioner in East Lancashire for a period of time and could be followed up by this study. The crude incidence density of active TB amongst these individuals with latent disease was 1297 per 100 000 person-years (95% CI; 991-1698 per 100 000 person-years). After 10 and 15 years of follow-up 13.5 and 16.3% of individuals, respectively, had progressed on to active disease. This patient-derived, rather than estimated, data shows a minimum risk of TB disease of 16.3% at 15 years. The 2006 NICE economic appraisal, suggested that treatment for latent TB infection (LTBI) was cost-effective when the incidence of clinical TB over 15 years surpassed 18% in these populations. The 2011 NICE economic appraisal reduced this to 12% active TB over 15 years, and showed that at 16% active TB over 15 years a single interferon gamma release assay was the most cost-effective strategy. Further cohort studies are urgently needed to confirm or revise the assumptions behind the 2011 NICE economic appraisal.

Community cohesion in post-16 education: principles and practice

Background: This paper is the product of a two year investigation into the contribution of post-16 education to community cohesion. The investigation took place between 2010 and 2012 and was funded by the University Centre at Blackburn College in England. Fieldwork was undertaken in three East Lancashire colleges and focused on students aged between 16 and 19 years. Purpose: The aims of the paper are to identify the nature of community cohesion initiatives in East Lancashire’s post-16 sector and to establish the extent to which these initiatives are successful in uniting students from different ethnic, cultural and religious backgrounds. The paper discusses student attitudes towards community cohesion and the role of further education colleges in shaping these attitudes. Sample: The data were collected from nine in-depth interviews with college lecturers and managers and from a questionnaire survey of 355 students. The research was conducted in two further education colleges and a Roman Catholic sixth form college. All three colleges were overwhelmingly dual-ethnic, with white and Asian students making up the majority of the college populations. Design and methods: The methods used throughout the investigation were threefold: (1) a review of the literature on the role of further education colleges as agents of community cohesion, (2) nine semi-structured interviews with college lecturers and managers, and (3) a closed-response questionnaire distributed to 355 further education students. Results: (1) While all three colleges referred to community cohesion in their policy documents, there was an absence of explicit community cohesion strategies. (2) Although there was clear evidence of cultural, ethnic and religious diversity in the three colleges, there was significant variation in cohesion initiatives. Most students, however, recognised the importance of cohesion and felt that, at the macro level, their colleges operated in an inclusive and cohesive manner. (3) At the more micro level, divisions between students were pronounced, evidenced by very little cross-cultural mixing either in or outside classrooms. (4) While over 50% of the survey respondents were unable to offer examples of cohesion initiatives in which they had been involved, around 45% stated that they had learnt about issues such as equality, diversity and integration during their time at college and that this had had a positive effect on their attitudes. Conclusions: The findings both support and refute the contention that further education colleges can make a worthy contribution to community cohesion. For the most part, levels of cohesion are contingent on recruitment of students from different backgrounds and on the ability of teachers and lecturers to impart positive messages about integration and social unity. At the same time, the investigation exposes a dissonance between the value that students claim to place on community cohesion and their ability and/or desire to bring this cohesion about. These conclusions have important implications for pedagogy and for the professional development of those employed in the post-16 sector.

Trusts launch recruitment drives in bid to tackle death rate anomalies

Recruitment drives have been launched by at least three hospitals identified as having higher than expected death rates after a government-ordered review criticised them for inadequate staffing. The review by NHS England medical director Sir Bruce Keogh into the care and treatment provided at 14 trusts in England found insufficient numbers of staff at eight of them. Commenting on the review RCN general secretary Peter Carter said: ‘There is an undeniable link between nurse staffing levels and patient mortality and we cannot keep failing to address this issue.’ Shadow health secretary Andy Burnham claimed that 1,117 nursing jobs had been lost at seven of the investigated trusts since May 2010. The review found evidence of an over-reliance on agency staff, and Nursing Standard research has revealed soaring levels of spend on agency nursing staff at two of the trusts. The amount spent on agency staff at Buckinghamshire Healthcare NHS Trust for example increased from £2 million in 2010/11 to £3.8 million in 2012/13, while United Lincolnshire Hospitals NHS Trust spent £977,094 in 2010/11 on agency nurses, which rocketed to £2.3 million in 2012/13. The trust’s board recently approved the recruitment of 80 more nurses. East Lancashire NHS Trust and Burton Hospitals NHS Foundation Trust are among the 14 organisations reviewed that are now boosting their nursing workforce. The former has appointed 40 more nurses and intends to hire a further 30 as well as 30 healthcare assistants. At Burton, another 49 nurses have been employed.

AB0642 Validation of a disease-specific health – related quality of life measure for italian adult patients with systemic lupus erythematosus: Lupusqol-italy

BackgroundAs recommended by the European League Against Rheumatism (EULAR), assessment of SLE patients should include not only the evaluation of disease activity and chronic damage, but also of quality of...

Rapid response teams to scrutinise staffing at high mortality hospitals

Three of England’s top nurses, appointed to investigate hospitals with high death rates, will focus on staffing levels when they begin their site visits this week. Fourteen hospital trusts are being investigated as part of a review, led by medical director of NHS England Sir Bruce Keogh, into higher than expected mortality rates. Rapid response teams, headed by regional nursing directors Liz Redfern, Gill Harries and Ruth May, will go into seven NHS trusts – the Dudley Group, North Cumbria University Hospitals, Medway, Burton Hospitals, Tameside Hospital, East Lancashire Hospitals and United Lincolnshire Hospitals – over the next few weeks. Sir Bruce announced the review in February, on the same day as the Francis report into failings at Stafford Hospital was published. The report linked appalling care to understaffing. The visits to the other seven trusts will be carried out by teams headed by regional medical directors.

Skin deep advice

Billy Hefferon served eight years in the army before changing career to nursing in 1992. Since qualifying, he has held a range of clinical and research oncology posts and became skin cancer nurse specialist at East Lancashire Hospitals NHS Trust in 2009. Recently, he was highly commended in the NHS Innovation Challenge Prize for developing a skin cancer training module for hair and beauty therapy students. He spoke to Ruth Williams

PL.04 Reducing Caesarean Section Rates Through Choice and Collaboration

East Lancashire Maternity services underwent a major service reconfiguration in November 2010, moving from two Consultant led units to one consultant unit and 3 midwifery led birth centres. This service...

‘Crossing the Road’: The value of inclusive pedagogical practice for South Asian women in Burnley, East Lancashire

Abstract In 2007, the University of Central Lancashire developed a Foundation Degree in Community Leadership. This course was initially conceived to meet a demand within the female South Asian community of Burnley for a higher education programme that would build their capacity to be more effective community activists, and moreover, a requirement for a course that would be able to meet family, cultural and social needs. The purpose of this paper is to explore the value of widening participation to higher education for South Asian women from Burnley in terms of social capital, community cohesion and contribution to the local knowledge economy. The authors used an action research methodology as part of a reflective research process influenced by the work of Paulo Freire (Freire, 1996). This paper argues that widening participation to higher education for women from minority backgrounds is a valuable tool in addressing cultural and social segregation. Moreover, it demonstrates an added value that by broadening the knowledge economy of the Pakistani diaspora in Burnley there is a resulting resonance within the heritage domicile of Gujrat, Pakistan.

Workload of consultant radiologists in a large DGH and how it compares to international benchmarks

To measure radiologist workloads in a UK radiology department using relative value units (RVUs), and compared these data to current international standards from Australia and Ireland. Data on reporting throughput was gathered for 13.5 whole-time equivalent (WTE) consultants at the DGHs of East Lancashire Hospitals Trust (ELHT) between April 2010 to March 2011. RVUs were assigned to the reported imaging studies to create a crude RVU/WTE score. This was compared to benchmarks from Australia and results from a similar study in Ireland. Time spent on teaching, multidisciplinary teams, and administration was factored in to create a net RVU/WTE score, more accurately assessing workload. Radiologists in ELHT reported 110,315 imaging studies, producing a total of 649,617 RVUs. Crude reporting workloads were 48,119.78 RVUs/WTE, and net workloads were 83,674.00 RVUs/WTE (with consultants spending 42.49% of their time on non-reporting commitments). These crude and net workloads are far above the Australian maximum reporting benchmark of 45,000 RVUs. The workload is much higher than international benchmarks, indicating high-quality service and excellent value for money, but also highlights understaffing. Foreign RVU systems do not accurately reflect current UK practices and a UK-specific RVU system should be developed to assess staffing and analyse performance.

Developing a service user evaluation for a multidisciplinary Community Learning Disability Service

This article describes the development of a service user evaluation project for an NHS Adult Community Learning Disability Service in East Lancashire. This project focuses on service user experience and satisfaction with the quality of the service they have received.

Outpatient consent practice for varicose vein surgery

Correspondence: Azzam Al-Amin East Lancashire Healthcare Trust, Department of Vascular Surgery, Royal Blackburn Hospital, Haslingden Road, Blackburn, United Kingdom BB2 3HH Email azzam187@doctors.org.uk Background: The aims of this study were to assess the accuracy and completeness of current consent practice in an outpatient clinic for open and minimally invasive varicose vein surgery, and to ascertain the type of complications suffered by patients and their correlation with consent practice. Methods: This was a retrospective analysis of outpatient consent practice from January to December 2010. All patients undergoing varicose vein surgery by open or endovenous laser therapy under a single consultant were identified. Case notes were examined by looking at clinic letters and consent forms, which were assessed against current standards. Results: Over 12 months, 103 consecutive patients were analyzed, and comprised 69 undergoing open surgery and 34 undergoing endovenous laser therapy. In total, 91% of patients were consented by a consultant, 6% by a senior house officer, and 3% by a registrar. For open surgery, all patients were consented for bruising, infection, numbness, nerve damage, and deep vein thrombosis. Only 43% were consented for pain; 2.76% were suffering pain and 6% were consented for thrombophlebitis without suffering. All patients who underwent endovenous laser therapy were consented for pain, numbness, skin discoloration, thrombophlebitis, nerve damage, and deep vein thrombosis. Only 8.8% were consented for infection and 2.9% suffered. No patients were consented for skin burns. Conclusion: Different strategies should be considered to improve the consent process and avoid the withholding of apparently trivial but crucial information during consenting.

Summary of: Evaluation of the basic erosive wear examination (BEWE) for use in general dental practice

The basic erosive wear examination (BEWE) is a relatively new index proposed for the screening and recording of tooth wear in adults. The aim of this study was to test the validity and reliability of the BEWE. Cross sectional study of a sample of 164 adult patients. General dental practice in East Lancashire, UK in 2010.Subjects Patients attending for routine examination or treatment. By screening patients with the BEWE and comparing the results to the established tooth wear index (TWI) the sensitivity and specificity of the BEWE was established. The BEWE predicted moderate to severe wear (BEWE grade 3) with a sensitivity of 48.6% and a specificity of 96.1%, and predicted severe wear with a sensitivity of 90.9% and a specificity of 91.5% (also BEWE score 3). Inter- and intra-examiner reliability for the BEWE were both moderate (κ(w) = 0.43 and 0.57 respectively). BEWE scores show a similar distribution to TWI scores and the examination is an effective screening test for severe tooth wear. The moderate levels of examiner reliability suggests the BEWE scores should be interpreted with some caution.

Evaluation of the basic erosive wear examination (BEWE) for use in general dental practice

The basic erosive wear examination (BEWE) is a relatively new index proposed for the screening and recording of tooth wear in adults. The aim of this study was to test the validity and reliability of the BEWE. Cross sectional study of a sample of 164 adult patients. General dental practice in East Lancashire, UK in 2010. Patients attending for routine examination or treatment. By screening patients with the BEWE and comparing the results to the established tooth wear index (TWI) the sensitivity and specificity of the BEWE was established.Results The BEWE predicted moderate to severe wear (BEWE grade 3) with a sensitivity of 48.6% and a specificity of 96.1%, and predicted severe wear with a sensitivity of 90.9% and a specificity of 91.5% (also BEWE score 3). Inter- and intra-examiner reliability for the BEWE were both moderate (κ(w) = 0.43 and 0.57 respectively). BEWE scores show a similar distribution to TWI scores and the examination is an effective screening test for severe tooth wear. The moderate levels of examiner reliability suggests the BEWE scores should be interpreted with some caution.

Implementing a statin switching programme in primary care: patients' views and experiences.

• Switching of patients' prescribed medicines within a therapeutic class is a common strategy to reduce prescribing costs, and in England a standard methodology has been promoted for switching processes. • Previous work to date suggests many patients are sceptical of generic products and switching may reduce compliance. • Patients' views on switching in general and the processes used have not been widely sought. • Patients may be less accepting of therapeutic switching programmes than is currently assumed. • Patients lacked understanding of the reason for the switch, despite standard letters and information leaflets being used, and few sought consultations. • Greater explanation of switching, possibly with involvement of community pharmacists, could lead to improved patient understanding and acceptance. INTRODUCTION Estimates suggest £200 million could be saved on prescribing costs in England by implementing medication switches. Few studies have evaluated patients' views or understanding of therapeutic switches. To obtain patient and pharmacist perspectives on switching from atorvastatin to simvastatin within an English Primary Care Trust (PCT). All patients undergoing this switch, in seven self-selected East Lancashire practices, were sent postal questionnaires covering demographics, experiences and views regarding switching, with no reminder. Practice pharmacists implementing switches in these practices were interviewed about processes and their views on these. Pharmacists' switching process involved a standard letter offering a telephone consultation or appointment, plus an information leaflet. They considered most patients accepted switches, with few requesting consultations. Four hundred and ninety-four patients were identified and a response rate of 48.6% (240) obtained. The majority of respondents were happy with the switch (53.7%) and how they were informed (60.1%), with these findings being positively correlated. However over half (52.9%) did not understand the reason for the switch, particularly those with lower educational qualifications. Patients unhappy about switching perceived they had experienced side effects, or only learned of the switch on collecting a prescription or did not recall the consultation offer. Respondents indicated a preference for future switches to involve a face-to-face consultation (59.8%), with two-thirds (65.2%) agreeing that community pharmacists should explain medication switches. The standard process used, in line with nationally-designed templates, resulted in many patients being unhappy with or lacking understanding of switching statins, suggesting that improvements may be needed.