Manchester Hospitals Research Articles

Promoting appropriate medical discharges over the weekend – is 7-day working a reality?

Timely discharge of patients is important for patient safety and satisfaction as well as patient flow and health economics. Improving hospital discharges and promotion of a 7-day service are key priorities of NHS England. Discharging medical patients from hospital over the weekend can be challenging due to both intrinsic and extrinsic issues. We aimed to explore these issues, identify key areas for improvement and increase the number or patients appropriately discharged over the weekend at a major acute teaching hospital in Manchester. Routinely collected data was explored to calculate the following information relating to discharges of medical patients over a 12 month period from 1 …

Hidden from history? A brief modern history of the psychiatric “treatment” of lesbian and bisexual women in England

It is well documented that homosexuality was classified as a mental illness in the DSM until 1973, when it was replaced with the diagnosis of “sexual orientation disturbance”. While it is widely known that homosexual men were criminalised and risked a spell in prison or aversion therapy in a psychiatric hospital (Dickenson, 2013), the class dimension is probably less well known. According to the Queer historian, Chris Waters (2017), it was the more privileged middle class men who were offered aversion therapy, as a “softer” option than jail (Alan Turing being the most prominent example). In contrast, the majority of mostly working class men who were discovered engaging in same-sex relations were more likely to end up in prison, without the offer of “treatment” as an alternative. However, there are aspects of this history we know even less about. Because it is well documented, gay men’s experiences of psychiatric treatment for same-sex attraction have become a dominant historical discourse. But what happened to same-sex attracted women in England (1950–70s) who were not subject to direct court referral routes into psychiatric treatment like their male counterparts? Although female homosexuality was not criminalised in England, it was still, like male homosexuality, officially classified as a mental disorder (“sexual deviation”). As part of a cohort of studies around the theme of sexualities and health funded by the Wellcome Trust, we conducted a bottom-up archival study of women’s and lesbian, gay, bisexual, and transgender (LGB&T) archives in England to investigate this question. Documentation proved to be sparse and fragmented, and what little material we found presented us with numerous challenges to interpretation. A small number of psychiatrists and psychologists had various, often competing, theories about homosexuality and published papers promoting examples of experimental or purportedly successful “treatments”, which they often used to test out their theories. However, it is not clear how much these theories actually influenced practice (Oram and Turnbull, 2001).

A comparison of the academic impact of plastic surgery units in the United Kingdom and Ireland using bibliometric analysis

Academic output is just one aspect of a successful career as a plastic surgeon. However, for those with a strong interest in academia, the academic output of a department will likely be a key factor when deciding how to rank jobs. The aim of this study was to quantify and rank the academic output of plastic surgery units across the UK and Ireland. The Institute for Scientific Information (ISI) Web of Science Bibliometric analysis tool was used to collate cumulative (1950–2016), 10 year (2006–2016) and 3 years (2013–2015) research output data for plastic surgery units in the UK and Ireland. Sixty-six plastic surgery units were identified. Departments were ranked for each time period according to the number of papers produced, number of citations (Nc) and h-index (a measure of the impact of scientific output). The top 3 departments for number of papers in the last 10 years were The Royal Free Hospital, London (226) Broomfield Hospital, Chelmsford (218), and Morriston Hospital and Swansea (188). The top 3 for h-number were The Royal Free Hospital (21) Wythenshawe Hospital, Manchester (18) and Morriston Hospital (17). Academic output varies across plastic surgery units in the UK and Ireland. A number of departments have consistently maintained high academic outputs across the years and will be of interest to surgeons hoping to pursue a career in academia.

Antimicrobial prophylaxis

Perioperative antibiotics have been recommended in small animal surgery for decades. With the increasing importance of antibiotic stewardship in managing antimicrobial resistance, Professor John Williams, of Vets Now 24/7 Emergency Hospital in Manchester, guides Companion readers through when and why they should be used, and what dosages are appropriate.

The Use of Porcine Acellular Dermal Matrix in Single-stage, Implant-based Immediate Breast Reconstruction: A 2-center Retrospective Outcome Study.

Background:There have been many reported benefits of the usage of acellular dermal matrices (ADMs) in breast reconstruction. ADM reduces the need for rectus abdominis muscle and serratus anterior coverage by providing an inferolateral coverage of the implant/tissue expander. ADM can provide patients with a 1-staged reconstruction. This study was designed to look at the complication rates of 2 major hospitals in the United Kingdom.Methods:A large, 2-center retrospective cohort review of patients, who underwent implant-based breast reconstruction using Strattice (LifeCell Corp., Branchburg, N.J.) between March 2009 and November 2017, was performed. One-way analysis of variance was done to compare outcome significance between groups. Independent t test was performed to compare outcomes of 2 cohorts and regression analysis to include confounding factors using SPSS Statistics for Windows (Version 22.0. Armonk, NY: IBM Corp.).Results:A total of 450 and 400 breast reconstructions were carried out in University Hospital of South Manchester (UHSM) and Royal Free London Hospital (RFH), respectively. We recorded a total complication of 37.8% in RFH cohort and 28% in UHSM cohort. The seroma rate was 11.25% and 13.33% in the UHSM and RFH cohort, respectively. Other complications reported were major and minor infections, implant loss, skin necrosis, hematomas, and implant exposure. Multiple linear regression analysis reported that confounding factors affected certain outcomes.Conclusion:Our 2-center complication rates were comparable to other articles. Results were comparable despite being in 2 different breast units in the United Kingdom.

Effect of the implementation of a fast-track on emergency department length of stay and 30-day readmission

Objectives We aimed to evaluate the effect of the implementation of a fast-track on emergency department length of stay (LOS) and 30-day readmissions. Methods Difference-in-differences analysis. We observed the change in mean Length of Stay (LOS) before and after the implementation of a fast-track in Troyes Hospital. The fast-track is a dedicated healthcare pathway for patients with small injuries or other benign health problems for whom an early discharge can be envisioned. Regional trends were taken in account using data from a control hospital, the Manchester Hospital situated in Charleville-Mezieres. Results The fast-track was implemented on January 13, 2016. The Emergency department of Troyes hospital registered 53,768 stays in 2016 and 57,965 in 2017 (+7.8%). During the same period, Charleville-Mezieres (CM) hospital registered 42,325 and 43,951 entries respectively (+3.7%). The mean length of stay decreased by 12.3 minutes in Troyes, whereas an increase of 2.1 minutes was observed in Charleville-Mezieres (Difference-in-differences: 14.4; 95% CI: 20.3–8.6; P Conclusion The implementation of a fast-track was associated with a decrease in mean LOS. Further studies are needed to help appraise the causes of variability in emergency department LOS and their connections to quality indicators.

Are the Royal College of Surgeons guidelines for poor-prognosis first permanent molars in children being followed?

An audit is undertaken at a Manchester hospital to compare current practice with the updated guidelines.

ERAPID electronic patient self-Reporting of Adverse-events: Patient Information and aDvice: a pilot study protocol in pelvic radiotherapy

BackgroundAn estimated 17,000 patients are treated annually in the UK with radical radiotherapy (RT) for pelvic cancer. New treatment approaches in RT have increased survivorship and changed the subjective toxicity profile for patients who experience acute and long-term pelvic-related adverse events (AE). Multi-disciplinary follow-up creates difficulty for monitoring and responding to these events during treatment and beyond. Originally developed for use in systemic oncology therapy eRAPID (electronic patient self-Reporting of Adverse-events: Patient Information and aDvice) is an online system for patients to report AEs from home. eRAPID enables patient data to be integrated into the electronic patient records for use in clinical practice, provides patient management advice for mild and moderate AE and advice to contact the hospital for severe AE. The system has now been developed for pelvic RT patients, and we aim to test the intervention in a pilot study with staff and patients to inform a future randomised controlled trial (RCT).MethodsEligible patients are those attending St James’s University hospital cancer centre and The Christie Hospital Manchester undergoing pelvic radiotherapy+/−chemotherapy/hormonotherapy for prostate, lower gastrointestinal and gynaecological cancers. A prospective 1:1 randomised (intervention or usual care) parallel group design with repeated measures and mixed methods will be employed. We aim to recruit 168 patients following recommendations for sample size estimates for pilot studies. Participants using eRAPID will report AE (at least weekly) from home weekly for 6 weeks and 6 weeks post-treatment (12-week total) then at 18 and 24 weeks. Hospital staff will review eRAPID reports and use information during consultations. Notifications will be sent to the relevant clinical team when severe symptoms are reported. We will measure patient-reported outcomes using validated questionnaires (Functional Assessment in Cancer Therapy Scale-General (FACT-G), European Organisation for Research and Treatment of Cancer Core Quality of Life questionnaire (EORTC-QLQ-C30), process of care impact (hospital records of patient contacts and admissions) and economic variables (EQ5D-5L, patient use of resources)). Staff and patient experiences will be explored via semi-structured interviews.DiscussionThe objectives are to establish feasibility, recruitment, integrity of the system and attrition rates, determine effect sizes and aid selection of the primary outcome measure for a future RCT. We will also refine the intervention by exploring staff and patient views. The overall goal of this complex intervention is to improve the safe delivery of cancer treatments, enhance patient care and standardise documentation of AE within the clinical datasets.Trial registrationClinicalTrials.gov NCT02747264.

Invasive pulmonary aspergillosis is associated with adverse clinical outcomes in critically ill patients receiving veno-venous extracorporeal membrane oxygenation

To identify the incidence, risk factors and impact on long-term survival of invasive pulmonary aspergillosis (IPA) and Aspergillus colonisation in patients receiving vv-extracorporeal membrane oxygenation (ECMO). A retrospective evaluation was performed of patients receiving vv-ECMO at a tertiary hospital in Manchester (UK) between January 2012 and December 2016. Data collected included epidemiological data, microbiological cultures, radiographic findings and outcomes. Cases were classified as proven IPA, putative IPA or Aspergillus colonisation according to a validated clinical algorithm. One hundred thirty-four patients were supported with vv-ECMO, median age of 45.5 years (range 16.4–73.4). Ten (7%) patients had putative IPA and nine (7%) had Aspergillus colonisation. Half of the patients with putative IPA lacked classical host risk factors for IPA. The median number of days on ECMO prior to Aspergillus isolation was 5 days. Immunosuppression and influenza A infection were significantly associated with developing IPA in a logistic regression model. Cox regression model demonstrates a three times greater hazard of death associated with IPA. Overall 6-month mortality rate was 38%. Patients with putative IPA and colonised patients had a 6-month mortality rate of 80 and 11%, respectively. Immunosuppression and influenza A infection are independent risk factors for IPA. IPA, but not Aspergillus colonisation, is associated with high long-term mortality in patients supported with vv-ECMO.

Neville Martin Bailey

Neville Martin Bailey served as house surgeon at Withington Hospital and then as house obstetrician at Saint Mary’s Hospital Manchester. National service was still obligatory, so he joined the Royal...

Elsa Mary Bradshaw

After qualifying Elsa Mary Bradshaw went to the Christie Hospital in Manchester as assistant resident surgical officer. In 1964 she moved with her husband to Leicester Royal Infirmary and became...

Philip Edward Jones

Philip Edward Jones (“Phil”) was appointed as a consultant general physician and gastroenterologist to Wythenshawe Hospital in south Manchester in 1982. The son of a singlehanded general practitioner, he had...

Management of Proliferative Endometrium on Biopsy in Post-Menopausal Women

Post-menopausal bleeding (PMB) is usually caused by several endometrial conditions (hyperplasia and carcinoma) for which there are evidence-based treatments. However, there is little literature and no evidence-based treatments for a finding of proliferative endometrium without atypia on Pipelle endometrial biopsy in women presenting with PMB. Our aim is to explore management and treatment options for this subset of women. This is a retrospective, observational case series review of women presenting with PMB to a gynaecology rapid access clinic at a District General Hospital in Manchester, UK over a period of three weeks. Four women who were found to have a proliferative or secretory endometrium on endometrial Pipelle biopsy were chosen. Their history, examination findings, investigations, treatment and follow-up findings were then analysed. This case series has identified the management dilemma posed by patients with proliferative endometrium with no atypia on endometrial sampling. The four patients were followed-up with a repeat Pipelle endometrial biopsy six weeks after presentation to the specialist gynaecology unit. They were subsequently counselled or treated with oral progesterone therapy for six to eight weeks. The management options included the Mirena intrauterine system (IUS), oral progesterone therapy and discharging the patient back to primary care. There is no consensus on the importance of oral progesterone or the duration of follow up necessary to monitor for the development of endometrial hyperplasia or cancer in this subset of patients. Further research is needed to develop evidence-based, management guidelines for proliferative endometrium in women with PMB.

Inhaled Mannitol (Bronchitol) for Cystic Fibrosis

Sarah J. Nolan *, Judith Thornton , Clare S. Murray , Tiffany Dwyer 4 Department of Biostatistics, The University of Liverpool, Liverpool, UK Centre for Clinical Practice, National Institute for Health and Care Excellence, Manchester, UK Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, University of Manchester and University Hospital of South Manchester, Manchester, UK 4 Sydney Medical School, University of Sydney, Sydney, Australia

Alcohol dependence and physical comorbidity: Increased prevalence but reduced relevance of individual comorbidities for hospital-based mortality during a 12.5-year observation period in general hospital admissions in urban North-West England

PurposeAlcohol dependence (AD) is associated with an increase in physical comorbidities. The effects of these diseases on general hospital-based mortality are unclear. Consequently, we conducted a mortality study in which we investigated if the burden of physical comorbidities and their relevance on general hospital-based mortality differs between individuals with and without AD during a 12.5-year observation period in general hospital admissions. MethodsDuring 1 January 2000 and 30 June 2012, 23,371 individuals with AD were admitted at least once to seven General Manchester Hospitals. Their physical comorbidities with a prevalence≥1% were compared to those of 233,710 randomly selected hospital controls, group-matched for age and gender (regardless of primary admission diagnosis or specialized treatments). Physical comorbidities that increased the risk of hospital-based mortality (but not outside of the hospital) during the observation period were identified using multiple logistic regression analyses. ResultsHospital-based mortality rates were 20.4% in the AD sample and 8.3% in the control sample. Individuals with AD compared to controls had a higher burden of physical comorbidities, i.e. alcoholic liver and pancreatic diseases, diseases of the conducting airways, neurological and circulatory diseases, diseases of the upper gastrointestinal tract, renal diseases, cellulitis, iron deficiency anemia, fracture neck of femur, and peripheral vascular disease. In contrast, coronary heart related diseases, risk factors of cardiovascular disease, diverticular disease and cataracts were less frequent in individuals with AD than in controls. Thirty-two individual physical comorbidities contributed to the prediction of hospital-based mortality in univariate analyses in the AD sample; alcoholic liver disease (33.7%), hypertension (16.9%), chronic obstructive pulmonary disease (14.1%), and pneumonia (13.3%) were the most frequent diagnoses in deceased individuals with AD. Multiple forward logistic regression analysis, accounting for possible associations of diseases, identified twenty-three physical comorbidities contributing to hospital-based mortality in individuals with AD. However, all these comorbidities had an equal or even lower impact on hospital-based mortality than in the comparison sample. ConclusionThe excess of in-hospital deaths in general hospitals in individuals with AD is due to an increase of multiple physical comorbidities, even though individual diseases have an equal or even reduced impact on general hospital-based mortality in individuals with AD compared to controls.

When Do Psychiatrists Request Clozapine Serum Levels Assays? Audit of the Practice of Psychiatrists in 3 Hospitals in Manchester, UK

Introduction Monitoring serum clozapine levels can be of great value in determining patient’s concordance with treatment and detecting abnormal levels associated with increased serious side effects. Aims To compare the current practice in ordering clozapine serum level assays with the local guidelines and to establish trends in requesting the test across the 3 hospitals. Methods We reviewed the electronic notes of 105 patients who had 181 results over a period of 6 months to gather demographics, indications for clozapine assays and management after results. Results In 44% (n=80) of cases there was no clear documentation of the reason for requesting the test. 70% (n=71) of the documented indications were in line with the local guidelines. The most common reason for testing clozapine levels was monitoring compliance (n=25, 24.8%), followed by side effects suggesting high serum levels (n=19, 18.8%). the third was smoking cessation (n=16, 15.8%). 30% of the documented indications were classed as 'other', where the indication was not stated in the guidelines. 43% of cases had abnormal levels ( 1.0mg/l), 26% had borderline levels (0.61-0.99mg/l) and 31% had levels within the recommended range (0.35-0.60mg/l). A high degree of inconsistency was observed in the management of clozapine levels especially levels between 0.61-0.99mg/l and levels above1.0mg/l. Conclusions Monitoring compliance, side effects and smoking cessation were the most common reasons for requesting serum clozapine level assays. The observed inconsistency in managing borderline and abnormal results demonstrates the need for expert consensus guidelines on managing clozapine serum levels.

Anxiety disorders and physical comorbidity: increased prevalence but reduced relevance of specific risk factors for hospital-based mortality during a 12.5-year observation period in general hospital admissions.

Anxiety disorders (AD) are associated with an increase in physical comorbidities, but the effects of these diseases on hospital-based mortality are unclear. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital-based mortality differed between individuals with and without AD during a 12.5-year observation period in general hospital admissions. During 1 January 2000 and 30 June 2012, 11,481 AD individuals were admitted to seven General Manchester Hospitals. All comorbidities with a prevalence ≥ 1 % were compared with those of 114,810 randomly selected and group-matched hospital controls of the same age and gender, regardless of priority of diagnoses or specialized treatments. Comorbidities that increased the risk of hospital-based mortality (but not mortality outside of the hospital) were identified using multivariate logistic regression analyses. AD individuals compared to controls had a substantial excess comorbidity, but a reduced hospital-based mortality rate. Twenty-two physical comorbidities were increased in AD individuals compared with controls, which included cardiovascular diseases and their risk factors. The most frequent physical comorbidities in AD individuals were hypertension, asthma, cataract, and ischaemic heart disease. Risk factors for hospital-based mortality in AD individuals were lung cancer, alcoholic liver disease, respiratory failure, heart failure, pneumonia, bronchitis, non-specific dementia, breast cancer, COPD, gallbladder calculus, atrial fibrillation, and angina. The impact of atrial fibrillation, angina, and gallbladder calculus on hospital-based mortality was higher in AD individuals than in controls. In contrast, other mortality risk factors had an equal or lower impact on hospital-based mortality in sample comparisons. Therefore AD individuals have a higher burden of physical comorbidity that is associated with a reduced risk of general hospital-based mortality. Atrial fibrillation, angina, and gallbladder calculus are major risk factors for general hospital-based mortality in AD individuals.

The use of TDM in pregnant HIV-positive women: a retrospective cross-sectional review of five years practice in two large hospitals in Manchester.

IntroductionDespite plasma levels of certain HIV drugs decreasing in the third trimester of pregnancy there is no definitive evidence that therapeutic drug monitoring (TDM) improves HIV control and prevents mother-to-child transmission (MTCT). Indeed “one-off” TDM measurements are thought to poorly correlate with overall drug exposure [1]. We aim to describe baseline demographic and clinical characteristics of pregnant women with HIV, and to compare their HIV control, management during pregnancy and neonatal outcomes with respect to whether TDM was performed.Materials and MethodsRetrospective cross-sectional case note analysis was performed on pregnant women with HIV who attended North Manchester General Hospital and Manchester Royal Infirmary from 1st January 2008 to 28th May 2013.ResultsA total of 171 pregnancies were included; 39% (n=66) had TDM. The majority of patients were of African origin (85%) and age range was 16–42 years (median 32 years). TDM was found to be associated with a history of poor adherence to therapy (TDM 23%, vs no TDM 10%, p=0.017), although baseline viral load (VL) and CD4 counts were comparable between TDM and non-TDM groups (p=0.4756 and 0.9492, respectively). TDM was also associated with protease inhibitors (PI) (TDM 94% vs no TDM 77%, p= 0.004). Within the PI group, TDM was more strongly associated with atazanavir use than other PI's (55%, p=0.023). TDM was not associated with any other demographic variable or with either of the two hospital sites (p=0.427). TDM was associated with medication alterations during pregnancy (TDM 67% vs no TDM 13%, p=0.052), but was not associated with any difference in outcomes with similar proportions of newly detectable VL during pregnancy (TDM 12% vs no TDM 7%, p=0.220) and VL detectable at birth (TDM 14% vs no TDM 9%, p= 0.293). There were no instances of MTCT.ConclusionsTDM was associated with PI use and a history of poor adherence at baseline. TDM was not associated with improved HIV control during pregnancy and there was no MTCT. TDM was not shown to have any additional benefit in pregnancy and its routine use is not recommended to improve HIV control or reduce MTCT.

21 * UNDERSTANDING ADVANCE CARE PLANNING

Background: Advance care planning is increasingly recognised as an important aspect of patient care. However there are barriers to its implementation by health care professionals, including apprehension at discussing end of life issues. We also suspect there may be a lack of understanding amongst professionals about advance care planning and developed a survey to further investigate this. Sampling methods: We surveyed staff at a large teaching hospital in South Manchester, using paper based and an online version questionnaire. The sample included a variety of professionals; doctors, nurses, therapists and dieticians. We collected 92 responses over a 2 week period. Results: The majority of respondents were consultants from a variety of specialities. Less than 9% of respondents were able to correctly define advance care planning. A majority felt that planning should be discussed as an inpatient and outpatient and 68% felt that this would improve patient care. 30% of respondents had reservations about advance care planning, including managing a change in the patient's condition and wishes. Furthermore, a majority of respondents would like more training and guidance. Conclusion: Health care professionals at a large teaching hospital in South Manchester recognise the importance of advance care planning. However, barriers to its implementation include a correct understanding of the legal framework and decision making approach. Most staff agreed that planning would improve patient care but had concerns over the practicalities of implementation and the correct setting for this to be done. These results echo literature which suggests that more guidance is needed for professionals and better communication channels between primary and secondary care.

Outcomes of Elderly Patients (≥70 Yo) with Advanced Non-Small Cell Lung Cancer (Nsclc): a Multi-Institutional Analysis

ABSTRACT Aim: Themajority of advanced NSCLC patients (pts) are ≥70 years old. International guidelines recommend use of single agent chemotherapy or, for fit patients with good organ function, platinum-based doublets. This patient group is under-represented in clinical trials and undertreated in clinical practice. Methods: We retrospectively analysed all consecutive pts with advanced NSCLC and ≥70 yo treated at The Christie, Manchester, UK and San Luigi Hospital, Turin, Italy between January 2007 and December 2012. Data retrieved: demographics, performance status (PS), type of treatment, lines of treatment, response rate (RR) and date of progression/death. Primary outcome: percentage (%) of pts receiving systemic anticancer treatment (SACT). Secondary outcomes: % receiving palliative RT or best supportive care (BSC) only, % of pts stopping treatment due to toxicity, RR from first-line systemic ant-cancer therapy (SACT) and median overall survival (OS) calculated with Kaplan-Meier curves. Results: 623 pts were identified. Median age was 75 (range 70-93), 63.4% were male. PS was 0, 1, 2, 3, 4 and unknown in 20.9%, 26.3%, 30%, 20.7%, 1.9% and 0.2% of pts, respectively. Histology: Adenocarcinoma/Squamous/Bronchialveolar carcinoma/NOS: 34.7%/34.2%/26.5%/0.8%/3.8%. 3% of all pts (11% of tested non-squamous) were EGFR mutant. Treatment given: SACT (37%), palliative RT (45%) and BSC (18%). First-line SACT: single agent gemcitabine, vinorelbine, carboplatin, etoposide, pemetrexed and docetaxel (17.8%), platinum based-doublet 76.5%; (carboplatin-based 69.1%, cisplatin-based 7.4%) and gefitinib/erlotinib (EGFR-TKI) (5.7%). Treatment was stopped due to toxicity in 7.9% of pts (all had chemotherapy). Response rate to first-line: PR 9.8%, SD 20%. Second-line and third-line treatment were given to 9.8% and 3% of patients, respectively. Median OS was 10.4, 6.7, 17.8, 4.7 and 2.3 months for doublet chemotherapy, single agent chemotherapy, EGFR-TKI, palliative radiotherapy and BSC, respectively. Conclusions: In our series, 37% of pts received SACT with good tolerability. OS was in keeping with reported series unselected with regards to age; highlighting that fit elderly pts can tolerate and benefit from SACT. Disclosure: All authors have declared no conflicts of interest.