Large DGH Research Articles

Where Should We Manage Diabetic Ketoacidosis (DKA) in Children?

Background: The leading cause of mortality for children with diabetes is DKA, with cerebral oedema the main cause of death. The onset of cerebral oedema is unpredictable; therefore the key to improving survival is early recognition and aggressive management. The British Society for Paediatric Endocrinology and Diabetes (BSPED)guidelines for DKA were updated in 2009; listing the recommended inpatient observations and emphasising “safe nursing” on general paediatric wards, acknowledging that children with DKA are high dependency patients and require 1:1 nursing. Methods: We audited Paediatric DKA admissions in 2009 (n=26, 8 admitted to HDU) comparing the quality of physiological data collection and outcome between those admitted to the general wards (1:4 nursing) and to HDU (1:2 nursing). Results: The HDU patients were more acidotic (pH 6.9 (range 6.8-7.2) vs 7.2 (7.1-7.3)) (p=0.03) and tended to be more likely to be new diagnoses (71% vs 41%). Children with DKA on HDU had better recording of fluid balance, hourly blood sugars, physiological and neurological observations than those nursed on general paediatric wards. Conclusions: Recording of physiological parameters in a HDU setting was more complete than in a general Paediatric setting. The BSPED guidelines recommend one to one nursing for children with DKA on Intravenous insulin, which may not be feasible in all units. Accurate observations and swift intervention are necessary to improve survival from cerebral oedema. Therefore children with DKA should be managed in a regional HDU or a large DGH with at least 1:2 nursing.

OC-089 One-year experience of a hepato-pancreatobiliary cancer service in a large district general hospital: impact on local cancer care delivery

<h3>Introduction</h3> Dedicated hepato-pancreatobiliary (HPB) cancer teams are rare outside tertiary centres. Patients with HPB cancer pose complex clinical problems requiring close liaison between primary, secondary and tertiary care. Reconfiguration of HPB cancer services in the Mersey region has lead to standardisation of care via referral to Regional Specialist Centres (RSC). However, local cancer care delivery remains fragmented and limited by the variable expertise of various clinical teams involved. We report the impact of a new combined consultant and nurse-led service established to improve overall management and facilitate local ownership of care. <h3>Methods</h3> Our local HPB cancer service (HPBCS) was established on 1 June 2008, the first of such service in a large DGH (catchment population: 360 000) in the Mersey region. All patients with suspected HPB cancer were referred to the local HPB Team comprising of two consultants with interest in HPB diseases (one nominated lead clinician) and a nurse specialist. Patients were case managed as per the Mersey and Cheshire Cancer Network Protocol, with discussion at the appropriate RSC MDT meetings (pancreas and hepatobiliary). The local HPBCS team meets weekly to discuss all new referrals, MDT outcomes and urgent management issues. There is also a weekly HPB nurse-led clinic that provides urgent feedback of RSC decisions, rapid access for symptom control and ensures continuity of care. <h3>Results</h3> 279 patients were referred to the HPBCS between 1 June 08 and 1 June 09: 175 for suspected pancreatic cancer (PC), 104 for hepatobiliary cancer (HC). This compares with 51 for suspected PC over a 6-month period pre-HPBCS and 26 for suspected HC a year pre-HPBCS, representing an annual increase of 72% and 300%, respectively. The outcomes of discussion at the RSC for suspected PC were: inoperable PC (59/175), operable PC (24/175), IPMN (45/175), benign lesions (22/175), pancreatitis (15/175) and pseudocysts (10/175), while for HC: hepatocellular carcinoma (34/104), gallbladder cancer (13/104), cholangiocarcinoma (9/104), liver metastases of unknown primary (2/104), benign liver lesions (23/104) and liver lesions of unknown significance (21/104). 23.7% of cases (45 IPMN, 21 liver lesions of unknown significance) were referred back for local surveillance contributing to an ever expanding pool of patients under the local HPB team. Nearly all cases were referred to the RSCs within 2 weeks of referral. <h3>Conclusion</h3> (1) Since commencement of HPBCS, there is a sharp increase of suspected HPB cancers identified and referred on to RSCs, leading to timely and uniform care as per regional network guidelines. (2) All Wirral patients with suspected HPB cancer are now case managed by the HPBCS with local ownership of care.

Body Mass Index and Time to Mobilise Post Primary Total HIP Arthroplasty

s / International Journal of Surgery 8 (2010) 501–578 519 cases referred to an upper GI unit in a large DGH for consideration for bariatric surgery over a three year period. Data was obtained for 71 patients with mean BMI 53.2 kg/m2. According to NICE guidelines 89% patients fulfilled criteria for consideration for bariatric surgery, with 63% fulfilling criteria for consideration as “first-line” management. All suitable patients were referred to the regional NHS commissioning body but only one patient received weight loss surgery. We estimate that if all patients in our series meeting NICE “first-line” criteria underwent surgery there would be net healthcare savings of £1,134,000 in the first ten postoperative years, which if extrapolated for the region rises to savings of £6,048,000 per year. Although the majority of referred patients are suitable very few are offered surgery despite significant cost-savings over the medium to long term. Increased availability of bariatric surgical services in the NHS is needed to improve the health of patients and reduce the financial burden of obesity-related disease. BODY MASS INDEX AND TIME TO MOBILISE POST PRIMARY TOTAL HIP ARTHROPLASTY E.C. Toll , G.C. Bannister . 1 Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Bristol, UK; Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK Introduction: High body mass index (BMI) may prolong a patient's hospital stay following elective joint replacement surgery due to delayed progression of mobility post-operatively. The aim of this study is to examine any relationship between body mass index and progression of mobility following primary total hip arthroplasty. Methods: The time taken to initially get out of bed, start mobilisation, confidently mobilise with sticks, negotiate stairs safely and to be discharged from inpatient physiotherapy was recorded for 110 consecutive patients undergoing primary total hip arthroplasty in one unit. Spearman's rhowas used to identify any relationships between BMI and the time taken to achieve each of these mobility milestones. Results: No significant relationships were found between BMI and the time taken to reach each of the five mobility milestones. Spearman's rho (day got up) 1⁄4 0.138, p 1⁄4 1.59; Spearman's rho (mobilised 1⁄4 0.72, p 1⁄4 0.462; Spearman's rho (mobilised with sticks) 1⁄4 0.101, p 1⁄4 0.301; Spearman's rho (stairs complete) 1⁄4 0.76, p 1⁄4 0.790; Spearman's rho (inpatient physiotherapy complete) 1⁄4 0.58, p 1⁄4 0.578. Conclusions: Increasing BMI appears to cause no delay in post-operative mobilisation following primary total hip arthroplasty. High BMI should therefore not be the sole reason for excluding patients from receiving elective total hip arthroplasty. FRAGILITY FRACTURE PREVENTION AT A PRIMARY CARE LEVEL Jonathan Evans. Royal United Hospital Bath NHS Trust, UK Aim: To audit the risk stratification and subsequent secondary prevention of osteoporosis in women over the age of 65 with a history of fragility fractures. Audit standards guided by the National Osteoporosis Guideline Group and the governmental Direct Enhanced Service agreement. Risk stratification achieved using the FRAX assessment tool for osteoporosis. Method: All female patients aged over 65 with a history of fragility fracture retrospectively analysed using the practice database. Multiple data abstracted relating to fracture risk. Assessment of DEXA guided diagnosis. Risk analysed using the FRAX tool. Current treatment compared to that recommended through guidelines and level of risk. Results: N 1⁄4 51. Age range 65–96. Subdivided into 76yrs. Proportion of 76 receiving bone sparing therapy 1⁄4 31.6%(100%). Poor recording of osteoporosis risk factors. Average 10yr risk of major fracture1⁄4 26.4%, of hip fracture1⁄4 12%. 5 high-risk patients identified, all under treated. Conclusion: Osteoporosis targets are clearly not being reached. Risk stratification is not being undertaken and cost effective secondary prevention is not being utilised effectively. The FRAX tool has validated utility and should be implemented into patient work up following fracture. ADULT HAND LACERATIONSHOW ACCURATE IS OUR DIAGNOSIS? Santosh Venkatachalam, Patrick Gillespie, Fortune Iwuagwu. St Andrew's center for Hand injuries, Broomfield, Chelmsford Hand injuries rank as second most common category in AE Peritoneal Surface

Performance Of Kiwi Omnicup. Does Training Improve Outcome?

The objective of this study was to evaluate the performance of Kiwi OmniCup to achieve vaginal delivery by trained clinicians. A prospective study of all ventouse deliveries by Kiwi OmniCup was undertaken between January and March 2006 at Northwick Park hospital, a large DGH in London. During this 3 month period, 1045 deliveries took place. OmniCup deliveries were attempted in 116 cases (11%). Successful vaginal delivery was achieved in 104 (90%) cases. This outcome was comparable to that reported in other studies of rigid cup vacuum delivery. 31% of successful deliveries had incorrect placement of the cup. Third and fourth degree perineal tears were reported in 10 cases (9.8%).One infant developed subdural haematoma requiring blood transfusion. Shoulder dystocia was encountered in 5 cases of which one developed Erb’s palsy. This study demonstrated that Kiwi OmniCup is an efficient device for assisted vaginal delivery and training in its correct use consistently improves outcome.

Reserve nitrous oxide cylinders on anaesthetic machines. A survey of attitudes and equipment at a large DGH.

The presence of reserve nitrous oxide cylinders on anaesthetic machines is not necessary and potentially hazardous, wasteful and polluting. Although reserve nitrous oxide cylinders are routinely present on the anaesthetic machines in many hospitals in the UK, it is our concern that they are not checked or maintained properly. We examined a sample of cylinders and surveyed the practice amongst the anaesthetic staff in our Department with an anonymous questionnaire. This confirmed that: (1) the equipment is not properly maintained, 68% of cylinders sampled having passed a 3-year expiry date; (2) checks are of little practical use, are not routinely performed by anaesthetists, and only 46% of respondents routinely check the nitrous oxide cylinders. In conclusion, the nitrous oxide cylinders are not properly checked or maintained and may represent a safety hazard.