Nottingham University Hospitals NHS Trust Research Articles

Post-operative steroids in the management of capsulitis following TMJ arthroscopy

Post-operative steroids in the management of capsulitis following TMJ arthroscopy

‘Caring around the clock’: a new approach to intentional rounding

Intentional rounding is a widely debated topic and, in this article, Nottingham University Hospitals NHS Trust shares its experience and learning from implementing an innovative approach based on the process across 79 wards. The authors look at the need for education and for cultural shift to achieve the best results. The issue of intentional rounding was raised in 2012 by prime minister David Cameron, who responded to a report of failings published by the Parliamentary and Health Service Ombudsman (2011) by announcing that all nurses would be expected to do hourly rounds to improve care. The need for the process has been demonstrated further in the recommendations from the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013).

Removal of foreign bodies from children’s ears: a nurse-led clinic

This article presents an account of the rationale for and the introduction of a change in practice. The successful removal of foreign bodies from children's ears requires appropriate skills and experience. While traditionally a role for junior doctors, removal of foreign bodies from children's ears at the ear, nose and throat outpatient clinic at Birmingham Children's Hospital was associated with a low success rate. Therefore, it was proposed that an experienced advanced nurse practitioner would carry out this task in an attempt to improve patient outcomes. A database of outcomes was maintained and compared with those from a doctor-led clinic at Nottingham University Hospitals NHS Trust. The results highlight the benefits of nurse-led removal of foreign bodies from children's ears.

AB0349 Exhaled nitric oxide is not elevated in rheumatoid arthritis associated interstitial lung disease: A pilot study

BackgroundExhaled NO (eNO) is elevated in airway and parenchymal lung diseases. The levels of eNO in rheumatoid arthritis associated ILD (RA-ILD) has not been studied before.ObjectivesThe main objective of this...

PTH-053 High Definition (HD) Versus Standard Definition (SD) White Light Endoscopy for Detecting Early Neoplasia (EN) in Barrett’S Oesophagus (BO) During Surveillance Endoscopy. is It Time to Change the Standard of Care?

IntroductionHD endoscopy systems provide superior image resolution. However, the utility of this new and more expensive technology in lesion detection has not been evaluated so far.Our aim was to assess...

Double Drape Tectonic Patch With Cyanoacrylate Glue in the Management of Corneal Perforation With Iris Incarceration

*Department of Ophthalmology, University Hospital of Leicester NHS Trust, Infirmary Square, Leicester, United Kingdom †Department of Ophthalmology, Nottingham University Hospital NHS Trust, Nottingham, United Kingdom Financial disclosures/conflicts of interest: None reported.

The profile of risky single occasion drinkers presenting at an Emergency Department

In 2010/2011, there were over 21 million attendances at English Emergency Departments (EDs), of which 35% are estimated to be alcohol-related. Screening in EDs could have considerable impact in identifying alcohol use disorders and directing people to appropriate interventions. We aimed to describe the screening and profile of risky single occasion drinkers (RSOD) in Nottingham University Hospitals (NUH) NHS Trust ED. Routine admissions data and alcohol screening responses for each patient aged 18 years and over were accessed from the ED information system (EDIS) for a period of 12 months. Of the 99,728 presentations at ED, 55,564 (55.72%) were screened and, of these, 8131 (16.81%) screened positive for RSOD. Compared with those who screened negative, they were 2.63 times more likely to present with injuries. However, the majority (N = 5389, 66.28%) said their current presentation was not related to alcohol consumption. Of those who screened RSOD positive only 1.75% accepted a referral for advice; the majority (85.29%) accepted an information leaflet. Improvements to the screening process are suggested, including potentially targeting screening, using an assessment that may in itself have an impact on drinking outcomes, and improving the relevance of leaflets and brief interventions to specific subgroups of patients.

P254 Identifying MMP-12 Substrates as Therapeutic Targets in COPD

BackgroundMatrix metalloprotease (MMP)-12 is a key protease in COPD which cleaves pulmonary extracellular matrix and non-matrix substrates. Variation in MMP-12 activity affects severity of COPD, yet the mechanism of this,...

A Single-Centre Series of 40 Patients with Bone-Marrow Biopsy-Defined Large Granular Lymphocyte Leukemia; High Rates of Sustained Response to Oral Methotrexate

AbstractAbstract 3937Large granular lymphocyte (LGL) leukaemia is a rare lymphoproliferation originating in activated cytotoxic CD8+ T cells or occasionally NK cells. Published series incorporating 40 or more patients are few in number with some differences in diagnostic definitions, making comparisons between studies challenging. Investigators have chiefly relied on peripheral blood for diagnosis; typically defined as a persistent excess (>0.5×109/l) of LGLs, associated with monoclonal T-cell receptor (TCR) gene rearrangements by PCR. However, benign monoclonal CD8+T-cell expansions, phenotypically indistinguishable from T-LGL, are well recognised in both healthy elderly individuals and those with autoimmune disease. To-date, reported response rates to oral Methotrexate (MTX) have been in the order of 40–60%, with MTX-failure reportedly occurring in two-thirds of patients after 1 year of follow-up.We studied 40 patients diagnosed with LGL leukemia at Nottingham University Hospitals NHS Trust, UK, between 1990 and 2011. All patients had a persistent (>6 months) large granular lymphocytosis and, importantly, 97.5% (39/40) patients had undergone a bone marrow (BM) biopsy. In all cases an interstitial infiltrate of cytotoxic T cells and/or NK cells, typically demonstrating characteristic linear arrays, established the diagnosis. A majority of patients had correlative peripheral blood PCR studies confirming clonal TCR gene rearrangements in 80%. Although 5 patients had a polyclonal TCR gene, for all such patients the BM findings (>20% LGLs in some cases) together with clinical context (neutropenia, lymphocytosis and 2 cases of pure red cell aplasia (PRCA)) established the diagnosis of LGL leukemia.The median age at diagnosis was 66 years (21–90 years), with an equal sex distribution. The median total lymphocyte count at clinical presentation was 2.7×109/l (0.7–9.4 x109/l) and a lymphocyte count of ≥2×109/l was seen in 27 patients (68%). Thirty patients (75%) were neutropenic at diagnosis (median neutrophil count 0.9 x109/l (range 0.0–6.5 x109/l). In 13 cases neutropenia was accompanied by anemia, thrombocytopenia or both. Rheumatoid factor was positive in 11 of 27 assessable cases (41%), whilst 11 of 40 (28%) had associated autoimmune clinical disorders, including Rheumatoid arthritis (n=6).With a median follow-up for living patients of 3.2 years (range 1.0–15.1 years), 15 patients (38%) have never required treatment. One further patient was already established on MTX at LGL diagnosis. Treatment was not required in any patients who presented with an isolated, asymptomatic lymphocytosis (n=8, 20%).The median time from diagnosis to treatment was 2.1 months; all treatment-requiring patients needed therapy within 6 months of presentation. Treatment was indicated in 24 patients: neutropenia and recurrent infections (n=8); severe neutropenia (n=6); cytopenias associated with other symptoms (mouth ulcers, skin lesions, organomegaly) (n=8); and PRCA (n=2).MTX (10mg/m2, weekly) was employed as first-line therapy (n=9) and after failure of Prednisolone (0.5–1mg/kg) monotherapy (n=7). Amongst 16 MTX-treated patients, 14 (87.5%) achieved a haematological PR (n=6) or CR (n=8) after a median of 2.5 months (1–9 months). (Improvements in quality of response) Continuing responses (haem-PR to CR) were seen up to 2yrs after starting MTX (of MTX). Notably, for the 14 MTX-responders the median duration of response was 6.5 years (0.3–16), censoring for death and drug-cessation due to patient choice. Neither of the 2 patients with PRCA responded to MTX, but Ciclosporin and Fludarabine were effective salvage therapies for MTX-failures.This is one of the largest single-centre series of LGL leukemia reported to-date. The strengths of our study include robust diagnostic evidence of LGL leukemia including BM biopsy and a long follow-up duration. By contrast to the published data, we describe high rates of response to MTX in both steroid-exposed and naive patients. Time to response exceeded 4 months in some cases and responses were sustained for >5 years in a majority of patients. The role of MTX in LGL leukemia warrants further study. Disclosures:No relevant conflicts of interest to declare.

Speech therapy and rehabilitation

Nottinghamshire Healthcare NHS Trust (County Health Partnerships) and Nottingham University Hospitals NHS Trust, Nottingham, UK Correspondence to H. F. Robinson, MSc, FRCSLT, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH, UK. E-mail: [email protected]

Single Best Answer MCQs in Anaesthesia

TFM Publishing Ltd: London, 2011 ISBN 978-1-903378-83-0, 200 pp Price £30 (€45) This is the second publication in series aimed at individuals sitting postgraduate examinations in anaesthesia. The first volume addressed the clinical components of anaesthetic practice, whereas this book seeks to test a candidate's knowledge of the basic sciences relating to anaesthesia. As with the previous volume, the introduction does not state which examinations are targeted, however the format is keeping with that of the Primary Fellowship of the Royal College of Anaesthetists (FRCA) (UK) examination, where Single Best Answer MCQs (SBAs) were introduced in September 2011. This is in contrast to the European Diploma in Anaesthesiology and Intensive Care where traditional true/false MCQs are employed to test a candidate's knowledge. The book is organised into six papers of 30 SBA questions, with five possible responses to each question. Of these five options, one is the best, and therefore the correct answer. The questions cover all areas of basic science of the FRCA curriculum: pharmacology, physiology, physics, clinical measurement and equipment, and are largely written as clinical vignettes where the question covers the basic science surrounding the scenario or problem posed. Following each paper, there are answers with detailed explanations to questions and references for further reading. As with the previous volume questions are written in a clear, concise manner, with each paper containing questions from the broad range of topics listed above. Answers are clear with brief, but accurate, explanations of the subject addressed using bullet points, formulae and graphs appropriately to present information to the reader. References provided are from popular textbooks, recent publications of scientific journals and internet addresses, and include recently published guidelines. Where the book fails is the lack of a section on exam technique as candidates may not have encountered such a paper before. Nor does it include an index, which would be useful to allow quick reference to questions relating to specific topics and their answers. On the whole, as a book presenting clinical science SBAs it excels, particularly as no other book addressing this format of exam exists. The authors have yet again kept abreast of recent developments in the structure of anaesthetic exams in the UK and any candidate planning on sitting such an exam would be well advised to utilise this well presented publication. Will Whiteley Specialty Registrar in Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK E-mail: [email protected]

Specific guidelines for the treatment of diabetic foot infections 2011

VA Puget Sound Health Care System, University of Washington, Seattle, WA, USA VU University Medical Centre, Amsterdam, The Netherlands Nuffield Orthopaedic Centre, Oxford, UK Gustave Dron Hospital, Tourcoing, France IWGDF, Heemstede, The Netherlands University of Manitoba, Winnipeg, MB, Canada University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA University Medical Centre, Ljubljana, Slovenia Nottingham University Hospitals NHS Trust, Nottingham, UK

Incorporation of expert variability into breast cancer treatment recommendation in designing clinical protocol guided fuzzy rule system models

It has been often demonstrated that clinicians exhibit both inter-expert and intra-expert variability when making difficult decisions. In contrast, the vast majority of computerized models that aim to provide automated support for such decisions do not explicitly recognize or replicate this variability. Furthermore, the perfect consistency of computerized models is often presented as a de facto benefit. In this paper, we describe a novel approach to incorporate variability within a fuzzy inference system using non-stationary fuzzy sets in order to replicate human variability. We apply our approach to a decision problem concerning the recommendation of post-operative breast cancer treatment; specifically, whether or not to administer chemotherapy based on assessment of five clinical variables: NPI (the Nottingham Prognostic Index), estrogen receptor status, vascular invasion, age and lymph node status. In doing so, we explore whether such explicit modeling of variability provides any performance advantage over a more conventional fuzzy approach, when tested on a set of 1310 unselected cases collected over a fourteen year period at the Nottingham University Hospitals NHS Trust, UK. The experimental results show that the standard fuzzy inference system (that does not model variability) achieves overall agreement to clinical practice around 84.6% (95% CI: 84.1–84.9%), while the non-stationary fuzzy model can significantly increase performance to around 88.1% (95% CI: 88.0–88.2%), p<0.001. We conclude that non-stationary fuzzy models provide a valuable new approach that may be applied to clinical decision support systems in any application domain.

A self‐adaptive case‐based reasoning system for dose planning in prostate cancer radiotherapy

Prostate cancer is the most common cancer in the male population. Radiotherapy is often used in the treatment for prostate cancer. In radiotherapy treatment, the oncologist makes a trade-off between the risk and benefit of the radiation, i.e., the task is to deliver a high dose to the prostate cancer cells and minimize side effects of the treatment. The aim of our research is to develop a software system that will assist the oncologist in planning new treatments. A nonlinear case-based reasoning system is developed to capture the expertise and experience of oncologists in treating previous patients. Importance (weights) of different clinical parameters in the dose planning is determined by the oncologist based on their past experience, and is highly subjective. The weights are usually fixed in the system. In this research, the weights are updated automatically each time after generating a treatment plan for a new patient using a group based simulated annealing approach. The developed approach is analyzed on the real data set collected from the Nottingham University Hospitals NHS Trust, City Hospital Campus, UK. Extensive experiments show that the dose plan suggested by the proposed method is coherent with the dose plan prescribed by an experienced oncologist or even better. The developed case-based reasoning system enables the use of knowledge and experience gained by the oncologist in treating new patients. This system may play a vital role to assist the oncologist in making a better decision in less computational time; it utilizes the success rate of the previously treated patients and it can also be used in teaching and training processes.

Fatigue after stroke: frequency and effect on daily life

Purpose: An audit was conducted to assess the frequency of fatigue after stroke, to determine the impact on daily life, and whether it was discussed with clinicians. Method: Patients were recruited from Nottingham University Hospitals NHS Trust stroke service. Patients were interviewed about their fatigue, and the Fatigue Severity Subscale (FSS-FAI), Brief Assessment Schedule for Depression Cards (BASDEC), Barthel Index and Nottingham Extended Activities of Daily Living (EADL) Scale were administered. Results: 64 patients were recruited, with a mean age 73.5 years (SD 14.0, range 37–94 years), 37 (58%) as in-patients and 27 (42%) as outpatients. There were 41 (64%) who reported significant levels of fatigue and 31 (48%) with significant fatigue on the Fatigue Severity Scale. Demographic and clinical variables were not significantly related to fatigue (p > 0.05), apart from gender, with women reporting significantly more fatigue than men (p = 0.006). There was a moderate correlation between the BASDEC and FSS (rs = 0.41, p = 0.002). Of the 41 participants who reported fatigue, 33 (81%) had not discussed this with their clinician. Conclusions: Fatigue was a common problem after stroke. There was a lack of awareness in both patients and clinicians and little advice being given to patients with fatigue.Implications for RehabilitationFatigue was reported to be a common problem in a group of patients recruited through a stroke service.Despite this, few patients had discussed fatigue with clinical team members, suggesting it is under-recognised.Rehabilitation staff need to be aware that patients may suffer from significant levels of fatigue which could affect their progress.

Innovation in tissue viability documentation for acute services

This paper discusses the developmental process, outcome and delivery of an innovative approach to standardising tissue viability documentation across two sites within Nottingham University Hospitals NHS Trust, following the results of benchmarking pressure ulcer preventive care strategies and recommendations from pressure ulcer root cause analysis. It reflects upon the process, highlighting the lessons learnt.

The ‘jimma exchange’ and audit of obstetric outcomes at jimma university hospital, ethiopia

BackgroundAs part of the ‘Jimma Exchange Scheme’, staff from Nottingham University Hospitals NHS Trust travelled to Jimma, Ethiopia to observe working practices in the Obstetrics department of the University Hospital...

Reply: Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography

Sir: We thank Drs. Chevray and Hatef for their thoughtful comments regarding our recently published article, “Relationship between Venous Congestion and Intraflap Venous Anatomy in DIEP Flaps Using Contrast-Enhanced Magnetic Resonance Angiography.”1 Our algorithm for deep inferior epigastric artery perforator (DIEP) flap harvest is similar to that of many large series. Our preference is for single-perforator DIEP flap harvest where there is an obvious dominant perforator whose adequate perfusion of the flap can be demonstrated intraoperatively; where this is not available, multiple perforators within the same intramuscular septum are included to allow sufficient arterial inflow and venous outflow for safe flap harvest. Where inclusion of multiple perforators is necessary but they lie in different intramuscular septae, we have a low threshold for harvesting a muscle-sparing transverse rectus abdominis musculocutaneous flap to avoid damage to the perforators during dissection, to maintain linking vessels between the perforators within the muscle, and for speed of harvest. This algorithm ensures that the flap is adequately perfused while minimizing donor-site morbidity by preserving muscle continuity and the motor nerves to the rectus, and we agree with the authors that inclusion of multiple perforators may be necessary where the anatomy is unfavorable. Our findings have suggested that where a single dominant perforator is not present, inclusion of multiple perforators may increase the chance of including a perforator that adequately drains the flap through a direct venous connection to the superficial inferior epigastric vein. We read the recently published article by Baumann et al. with great interest and hypothesize that this factor may partially explain the decreased rate of fat necrosis seen in multiperforator DIEP flaps in their study,2 although further research will be necessary to determine this. Mark V. Schaverien, M.R.C.S. Stephen J. McCulley, F.C.S.(S.A.)Plast., F.R.C.S.(Plast.) Department of Plastic Surgery Nottingham University Hospitals NHS Trust Nottingham, United Kingdom DISCLOSURE The authors have no financial interests with respect to the content of this communication or the article being discussed.

Staff and patient involvement in benchmarking to improve care

This article outlines work undertaken to relaunch Essence of Care benchmarking at Nottingham University Hospitals NHS Trust (NUH), a 1,665-bed teaching hospital based on two sites. The eight high impact actions for nurses and midwives (NHS Institute 2009) have been aligned with Essence of Care to develop comprehensive tools for quality improvement at local level. This has resulted in increased patient feedback and enhanced staff ownership and involvement in quality-improvement processes and raising standards of care. As a national pilot site for the Productive Ward programme (NHS Institute 2007), NUH has developed links between the two initiatives, reviewing ward processes, increasing direct patient feedback and providing a wealth of data relating to quality of care and patient-safety issues.

The effectiveness of virtual reality interventions in improving balance in adults with impaired balance compared to standard or no treatment: A systematic review

The effectiveness of virtual reality interventions in improving balance in adults with impaired balance compared to standard or no treatment: A systematic review