Pathway For Management Of Patients Research Articles

Proposal of a clinical care pathway for quality and safe management of headache patients: a consensus study report

BackgroundHeadache is one of the most prevalent and disabling conditions. Its optimal management requires a coordinated and comprehensive response by health systems, but there is still a wide variability that...

An institutional experience: A retrospective analysis of the effect of transitioning from follicular lesion of undetermined significance to atypia of undetermined significance with subclassified atypia on interobserver concordance, rates of neoplasia, and rates of malignancy.

The rate of malignancy (ROM) in thyroid fine needle aspirations (FNA) classified under "atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), including Hürthle cell type (HLUS)" category of The Bethesda system for reporting thyroid cytopathology (TBSRTC) in literature is highly variable. The 2018 TBSRTC was updated to note a preferred categorization of AUS cases into subcategories. This study evaluates the impact of AUS subclassification on rates of neoplasia (RON), rates of malignancy (ROM), and cytopathologist (CP) concordance. 93 thyroid FNAs previously diagnosed as FLUS or HLUS from January 1, 2013 to December 31, 2014 with subsequent surgical resection were identified. Four CPs reclassified these cases using TBSRTC AUS subcategories of follicular cells with architectural and/or cytologic atypia, predominantly Hürthle cells, and atypical lymphocytes. RON and ROM were calculated for each diagnostic subcategory for each CP. The original RON and ROM for FLUS cases were 31.4% and 15.1% and were 77.8% and 22.2% for HLUS cases. 10.8% of cases showed diagnostic concordance amongst the four CPs. The most frequently utilized subcategory was architectural atypia. RON ranges for architectural atypia, cytologic atypia, architectural and cytologic atypia, and predominantly Hürthle cells were 28.1% to 35.7%, 0% to 33.3%, 35.3% to 66.7%, and 57.1% to 87.5%. The range of ROM was 13.9% to 16.7%, 0% to 33%, 0% to 42.9%, and 0% to 25%, respectively. RON for AUS predominantly Hürthle cells subcategory was higher than previously reported, which may indicate use for tailored patient management pathways. AUS subclassification can result in significant interobserver variability. Therefore, institutions may consider consensus/quality control sessions to optimize diagnostic concordance.

Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery.

To examine the results of a quality-improvement study that implemented an enhanced recovery after surgery (ERAS) program for cesarean delivery. A pre-post design was used to assess changes in opioid use, length of stay, and costs among all patients undergoing cesarean delivery before and after implementation of an evidence-based ERAS pathway for the preoperative, intraoperative, and postoperative management of patients beginning December 2018. A total of 3,679 cesarean deliveries (scheduled and emergent) were included from January 1, 2018, through August 31, 2019, of which 2,171 occurred before implementation on December 17, 2018, and 1,508 occurred postimplementation. Eighty-four percent of patients received opioids as inpatients after cesarean delivery during the preimplementation period, as compared with 24% in the postimplementation period (odds ratio [OR] 16.8, 95% CI 14.3-19.9). Among patients who required any opioids, the total morphine milligram equivalents also significantly decreased (median 56.5 vs 15.0, mean relative change 0.32, 95% CI 0.28-0.35). Compared with the preimplementation period, those in the postimplementation period had a shorter postcesarean length of stay (3.2 vs 2.7 days, mean relative change 0.82, 95% CI 0.80-0.83, median 3 days in both periods), lower median direct costs by $349 (mean relative change 0.93, 95% CI 0.91-0.95), and no change in the 30-day readmission rate (1.4% vs 1.7%, OR 0.83, 95% CI 0.49-1.41). An ERAS approach for the cesarean delivery population is associated with improved outcomes including decreases in opioid use, length of stay, and costs.

Optimal utilization of MSK imaging during COVID-19 pandemic

The COVID-19 pandemic has caused multi-dimensional global crisis in the recent times. There is an increasing necessity of understanding and developing a strategy for optimal utilization of healthcare resources in this time of crisis. Radiology department remains the backbone for diagnosis and for appropriate management of orthopaedic ailments. Amidst COVID-19 pandemic, there is a need to change in imaging algorithm, for various clinical conditions taking care of the exposure risk to patients and healthcare workers and to handle the volume of diagnostic and intervention work. Radiology preparedness is to set the workflow protocols and policies applicable to radiology investigations for different clinical conditions, which will help to attain these objectives. Radiologists are in best position to decide the most appropriate imaging investigation and protocol making it vital to have a frequent Orthopaedic surgeon–Radiologist interaction, which is one of the most important steps in patient management pathway.

Nutritional Outcomes of patients Undergoing Resection for upper gastroIntestinal cancer in AuStralian Hospitals (NOURISH): protocol for a multicentre point prevalence study

IntroductionNutritional intervention and prevention of malnutrition is significantly important for patients with upper gastrointestinal oesophageal, pancreatic and gastric cancer. However, there is limited information regarding nutritional status, and perioperative nutritional...

Detailed Molecular and Immune Marker Profiling of Archival Prostate Cancer Samples Reveals an Inverse Association between TMPRSS2:ERG Fusion Status and Immune Cell Infiltration

Prostate cancer is a significant global health issue, and limitations to current patient management pathways often result in overtreatment or undertreatment. New ways to stratify patients are urgently needed. We conducted a feasibility study of such novel assessments, looking for associations between genomic changes and lymphocyte infiltration. An innovative workflow using an in-house targeted sequencing panel, immune cell profiling using an image analysis pipeline, RNA sequencing, and exome sequencing in select cases was tested. Gene fusions were profiled by RNA sequencing in 27 of 27 cases, and a significantly higher tumor-infiltrating lymphocyte (TIL) count was noted in tumors without a TMPRSS2:ERG fusion compared with those with the fusion (P=0.01). Although this finding was not replicated in a larger validation set (n=436) of The Cancer Genome Atlas images, there was a trend in the same direction. Differential expression analysis of TIL-high and TIL-low tumors revealed the enrichment of both innate and adaptive immune response pathways. Mutations in mismatch repair genes (MLH1 and MSH6 mutations in 1 of 27 cases) were identified. We describe a potential immune escape mechanism in TMPRSS2:ERG fusion-positive tumors. Detailed profiling, as shown herein, can provide novel insights into tumor biology. Likely differences with findings with other cohorts are related to methods used to define region of interest, but this warrants further study in a larger cohort.

Cutaneous Adverse Events of Anti-PD-1 Therapy and BRAF Inhibitors.

The treatment of advanced melanoma has undergone a dramatic transformation over the last decade with the advent of targeted and immunomodulatory therapies. This transition from cytotoxic chemotherapy has yielded improvements in both survival and quality of life; yet despite their therapeutic advantages, these treatments have been associated with a diverse range of cutaneous adverse events (AEs). These range from relatively benign eczematous conditions to more severe inflammatory and bullous disorders, and can include induction of second malignancies. AEs can result in serious morbidity and risk of mortality if not recognised and managed early. As a consequence of their novelty, and rapid uptake, these agents have been subject to intense scrutiny and there is a general understanding that cutaneous AEs should be anticipated in treatment plans. Dermatologists should be integrated into management teams to assist in the development of treatment protocols for anticipated common AEs and to provide expert management of more severe, rare or unusual AEs. Our experience has shown a reduction in treatment interruptions, more rapid recognition of unusual AEs and improved management pathways for patients suffering cutaneous AEs.

Life as a clinical director: an insight

The clinical director (CD) is responsible for delivering high-quality patient-focused clinically effective healthcare services, which support the core principles of patient safety, and also serves as a conduit transmitting the trust's vision and objectives to clinical staff. The CD has to have a strategy to ensure that this is delivered without compromising patient care. He/she has to speak for all staff and ensure that the directorate strategy is aligned with the vision and strategy of the trust. In the opposite direction, the CD acts as a conduit through implementation of the departmental vision and strategy. To achieve these objectives, the CD works in close collaboration with the divisional triumvirate (executive [senior management team], divisional team [mid-level], directorate/departmental team), service manager, specialty leads, and senior nurses in addition to frontline consultant radiologists to ensure planning and delivery of robust clinical services within their areas and the entire trust. The role of the CD inherently requires "out-of-the-box" strategies, innovation, and influential communication skills for continuous service improvement and effective patient management pathways and flow. The CD ensures that appropriate medical workforce is available in the department to deliver high-quality care and maximise clinical efficiencies through effective deployment of available resources.

Diagnostic and Management Pathways for Pulmonary Carcinoid Tumours in the United Kingdom: Results from the National Lung Neuroendocrine Tumour Pathway Project.

There is inconsistency among published guidelines for the optimal diagnostic and management pathways for patients with typical (TC) or atypical (AC) pulmonary carcinoid tumours. We conducted a UK-wide clinician survey to assess current practice for the diagnosis, management, and follow-up of patients with TC/AC and descriptively compared management between European Neuroendocrine Tumor Society (ENETS) accredited centres of excellence (CoE) and nonaccredited centres (non-CoE). Twenty-seven clinicians (10 CoE; 17 non-CoE) participated. Computed tomography of thorax, abdomen, and pelvis was the most commonly reported diagnostic tool (96% of respondents), and bone scans and gallium somatostatin receptor scintigraphy positron emission tomography (SRS PET) were the least commonly reported (30% and 37% of respondents, respectively). Adjuvant therapy is considered for resected TC/AC by <5% of respondents for patients with stage N0 M0 AC or TC, up to 48% of respondents for patients with AC with R1 disease. Somatostatin analogues were the most commonly reported first-line treatment (63% of respondents), and chemotherapy was the most commonly reported second-line therapy and third-line therapy (33% and 41%, respectively) for unresectable and metastatic disease. Reported frequency of initial follow-up after primary surgery ranged from every 2 months to annual, and total follow-up duration ranged from 2 years to indefinite depending on disease type (TC/AC) and stage. For most diagnostic investigations, the highest reported frequency of use was in CoE, most notably gallium SRS PET (70% CoE vs. 18% non-CoE respondents). 93% of respondents (100% CoE; 88% non-CoE) reported having neuroendocrine tumour- (NET-) specialist multidisciplinary team meetings at their centre; 59% (90% CoE; 41% non-CoE) had a NET Clinical Nurse Specialist (CNS) and 48% (80% CoE; 29% non-CoE) had a lung NET patient database. The survey results suggest variability between UK centres in diagnostic pathways and management of patients with TC/AC and suggest that CoE may be able to offer an improved service to patients.

Coronavirus disease 2019 pandemic and its implications on triaging patients with brain tumors for surgery, radiotherapy, and chemotherapy

The coronavirus disease 2019 pandemic has the potential to overwhelm the current health-care system in our country. The oncologists face a tricky question as to whom to prioritize treatment for. Postponing cancer treatments might be associated with some risk of compromised clinical outcomes. The risks need to be considered in light of the magnitude of potential benefits, the impact of delaying standard treatment on outcomes, and competing patient-centric and infrastructure priorities. Treatment decisions during the pandemic have to be triaged and prioritized based on the existing health-care facility and the fluidity of the situation. High-priority and urgent interventions include management of suspected high-grade glioma, primary central nervous system lymphoma, and round cell tumors. Low-priority interventions include management of low-grade glioma, benign tumors, and relapsed-refractory brain tumors. Similar to other cancers, the management of patients with brain tumors also needs to be adapted and prioritized; pragmatic patient treatment pathways need to be formalized without compromising the clinical outcomes and overburdening the health infrastructure. Health-care professionals dedicated to oversee the management of patients with brain tumors may have to triage referrals and modify the management of various brain tumors, as treatment pathways will differ from region to region and country to country based on the ground level situation. This document is an endeavor to provide a basic framework to triage and prioritize brain tumor patient management pathways. As the situation is rapidly evolving, we suggest a basic treatment guideline for these patients, which is simple to adopt.

A Retrospective Real-World Study of the Current Treatment Pathways for Myelofibrosis in the UK (The REALISM UK Study)

Introduction Current treatment options for myelofibrosis (MF) are diverse; apart from rare patients who are eligible for allogeneic transplantation, active treatments are focused on controlling MF-related symptoms and are not disease modifying. Patients who are initially asymptomatic and those at low risk for progression are usually observed without active treatment (watch and wait) until the appearance of symptoms or progression. There are limited real-world data on the management of patients with MF in the United Kingdom (UK). The REALISM UK study documented the early management pathways for patients with MF in routine clinical practice. Method REALISM UK was a multi-centre, retrospective, non-interventional study in 15 UK secondary care centres. Eligible patients were those aged ≥18 years at diagnosis of MF, with diagnosis &gt;6 months and ≤5 years prior to data collection and with ≥1 follow-up visit. Data on patient demographics, clinical characteristics, MF management strategies and outcomes were collected from patients' medical records; the observation period was from the date of MF diagnosis until data collection. The primary endpoint was the time from diagnosis to active treatment. Watch and wait strategies included supportive therapies (blood transfusions, erythropoiesis-stimulating agents, and steroids). Results A total of 200 patients were recruited (63% [n=126/200] with primary MF (PMF); 37% [n=74/200] with secondary MF). The median age at MF diagnosis was 69.7 years (interquartile range [IQR] 63.5-75.7) and 71% (n=141/200) had a JAK2 mutation. At diagnosis, 52% (n=104/200) of patients had International Prognostic Scoring System (IPSS) categories of intermediate-2 (Int-2) or high. Common documented features of disease at diagnosis included an enlarged spleen (47%, n=94/200), anaemia (44%, n=88/200), and constitutional symptoms (e.g. night sweats, unexplained fever, or weight loss [30%, n=60/200]). The median (IQR) time to first active treatment was 46 days (range 0-350) in the total population; patients with higher risk disease were prescribed active treatment sooner: IPSS low, 136.5 days (range 0-625; n=26); IPSS Int-1, 90 days (range 0-494; n=70); IPSS Int-2, 0 days (range 0-252; n=65); IPSS high: 0 days (0-216; n=39). The choice of first management strategy by IPSS at diagnosis is shown in Table 1. During the study period, watch and wait was the first management strategy for 54% (n=107/200) of patients, with the median (IQR) time from diagnosis to active treatment in this group being 322 (130-610) days. Constitutional symptoms were recorded in 20% (n=21/107) of patients for whom watch and wait was the first management strategy. Active treatment was started at diagnosis for 47% (n=93/200) of patients, with the most commonly used medications being hydroxycarbamide (22.5% [n=45/200]) and ruxolitinib (17.5% [n=35/200]). The median (IQR) treatment duration during the study observation window was 346 days (range 121-768) for hydroxycarbamide and 375 days (range 172-691) for ruxolitinib. In total, 5.5% (n=11/200) of patients were recorded as having undergone allogenic stem cell transplantation during the observation period. Conclusion Clinicians in the UK apply a broad range of management strategies for the treatment of patients with MF. Many patients were observed without active treatment following diagnosis, despite having symptomatic disease. The most common active treatments as first management strategies were hydroxycarbamide and ruxolitinib. Disclosures Mead: Pfizer: Consultancy; Novartis: Consultancy, Honoraria, Other: Travel/accommodation expenses, Research Funding, Speakers Bureau; Bristol Myers-Squibb: Consultancy. Somervaille:Novartis: Consultancy, Honoraria. Butt:Novartis: Consultancy, Honoraria, Speakers Bureau. Whiteway:Novartis: Consultancy, Honoraria, Speakers Bureau. Kirkpatrick:Novartis: Consultancy, Honoraria. Roughley:Novartis: Consultancy, Honoraria. Ewing:Novartis: Honoraria, Other: Meeting attendance sponsorship ; Bristol Myers-Squibb: Other: Meeting attendance sponsorship . Garg:Novartis: Consultancy, Honoraria. Harrison:Promedior: Honoraria; Shire: Speakers Bureau; Sierra Oncology: Honoraria; Celgene: Honoraria, Speakers Bureau; Roche: Honoraria; Novartis: Honoraria, Research Funding, Speakers Bureau; Incyte: Speakers Bureau; Gilead: Speakers Bureau; CTI: Speakers Bureau; AOP: Honoraria; Janssen: Speakers Bureau. Bains:Novartis: Employment. Chiu:Novartis: Employment. Hickey:OPEN VIE: Employment.

Routine glucose assessment in the emergency department for detecting unrecognised diabetes: a cluster randomised trial.

To determine whether routine blood glucose assessment of patients admitted to hospital from emergency departments (EDs) results in higher rates of new diagnoses of diabetes and documentation of follow-up plans. Cluster randomised trial in 18 New South Wales public district and tertiary hospitals, 31 May 2011 - 31 December 2012; outcomes follow-up to 31 March 2016. Patients aged 18 years or more admitted to hospital from EDs. Routine blood glucose assessment at control and intervention hospitals; automatic requests for glycated haemoglobin (HbA1c ) assessment and notification of diabetes services about patients at intervention hospitals with blood glucose levels of 14mmol/L or more. New diagnoses of diabetes and documented follow-up plans for patients with admission blood glucose levels of 14mmol/L or more. Blood glucose was measured in 133837 patients admitted to hospital from an ED. The numbers of new diabetes diagnoses with documented follow-up plans for patients with blood glucose levels of 14mmol/L or more were similar in intervention (83/506 patients, 16%) and control hospitals (73/278, 26%; adjusted odds ratio [aOR], 0.83; 95% CI 0.42-1.7; P=0.61), as were new diabetes diagnoses with or without plans (intervention, 157/506, 31%; control, 86/278, 31%; aOR, 1.51; 95% CI, 0.83-2.80; P=0.18). 30-day re-admission (31% v 22%; aOR, 1.34; 95% CI, 0.86-2.09; P=0.21) and post-hospital mortality rates (24% v 22%; aOR, 1.07; 95% CI, 0.74-1.55; P=0.72) were also similar for patients in intervention and control hospitals. Glucose and HbA1c screening of patients admitted to hospital from EDs does not alone increase detection of previously unidentified diabetes. Adequate resourcing and effective management pathways for patients with newly detected hyperglycaemia and diabetes are needed. Australian New Zealand Clinical Trials Registry, ACTRN12611001007921.

Functional outcome and management pathways for adult patients presenting to an Australian health service with distal radius fracture.

Primarily to determine mid-term functional outcome for patients with distal radius fracture (DRF) and to compare this between operative and conservatively managed patients. Secondarily to examine for differences in age, gender and number of instability factors between management groups. Eligible patients (age 18 years or more, closed DRF managed to completion of care within Monash Health), presenting between 1 January and 31 December 2016. Completion of the patient-rated wrist evaluation (PRWE) questionnaire was sought at 6-12 months post-injury. Management was noted (operative or conservative). Age, sex and number of defined instability factors present (dorsal angulation >20°, intra-articular fracture, associated ulna fracture, dorsal comminution, radial shortening >2 mm) are reported and compared between management groups. Of 369 eligible patients, 199 (54%) completed a PRWE. Median age was 60 years (interquartile range [IQR] 45-71), 150 (75%) were women, median number of instability factors present was 2 (IQR 1-4) and 45 (23%) underwent operative management. Difference in PRWE scores between operative and conservatively managed patients was not significant (20 [IQR 7-36] vs 16 [IQR 5-35]). Differences in age and gender between management groups were not significant. Significantly more in the operative group had presence of four or more instability factors (44% [95% confidence interval 30-60] vs 20% [14-27]). The mid-term median PRWE score was 18 (IQR 5-36). This was not significantly different between operative and conservatively managed patients. Operation was more likely when four or more instability factors were present.

Corrigendum to: Guidelines, training and quality assurance: influence on general practitioner MRI referral quality

ABSTRACT INTRODUCTIONMagnetic resonance imaging (MRI) is an accurate diagnostic test used mainly in secondary care. Uncertainty exists regarding the ability of general practitioners (GPs) to use direct access high-tech imaging pathways appropriately when managing musculoskeletal injury. AIMTo evaluate the use of primary care-centric guidelines, training and quality assurance on the appropriateness of GP MRI referrals for patients with selected musculoskeletal injuries. METHODSThis is an 18-month primary care retrospective study. GPs participated in clinical musculoskeletal training, enabling patient referral for MRI on four body sites. Two reviewers categorised referral appropriateness independently, and reviewer inter-rater agreement between categorisations was measured. MRI results and patient management pathways were described. Associations of scan status and patient management were examined using logistic regression. RESULTSIn total, 273 GPs from 72 practices attended training sessions to receive MRI referral accreditation. Of these, 150 (55%) GPs requested 550 MRI scans, with 527 (96%) eligible for analysis, resulting in 86% considered appropriate; 79% consistent with guidelines and 7% clinically useful but for conditions outside of guidelines. Inter-rater agreement was 75%. Cohen's weighted kappa statistic was 0.38 (95% CI: 0.28–0.48). MRI referrals consistent with guidelines were more likely to show pathology requiring specialist intervention (reviewer 1: odds ratio=2.64, 95% CI 1.51–4.62; reviewer 2: odds ratio=4.44, 95% CI 2.47–7.99), compared to scan requests graded not consistent. DISCUSSIONStudy findings indicate GPs use decision support guidance well, and this has resulted in appropriate MRI referrals and higher specialist intervention rates for selected conditions.

Guidelines, training and quality assurance: influence on general practitioner MRI referral quality

INTRODUCTION Magnetic resonance imaging (MRI) is an accurate diagnostic test used mainly in secondary care. Uncertainty exists regarding the ability of general practitioners (GPs) to use direct access high-tech imaging pathways appropriately when managing musculoskeletal injury. AIM To evaluate the use of primary care-centric guidelines, training and quality assurance on the appropriateness of GP MRI referrals for patients with selected musculoskeletal injuries. METHODS This is an 18-month primary care retrospective study. GPs participated in clinical musculoskeletal training, enabling patient referral for MRI on four body sites. Two reviewers categorised referral appropriateness independently, and reviewer inter-rater agreement between categorisations was measured. MRI results and patient management pathways were described. Associations of scan status and patient management were examined using logistic regression. RESULTS In total, 273 GPs from 72 practices attended training sessions to receive MRI referral accreditation. Of these, 150 (55%) GPs requested 550 MRI scans, with 527 (96%) eligible for analysis, resulting in 86% considered appropriate; 79% consistent with guidelines and 7% clinically useful but for conditions outside of guidelines. Inter-rater agreement was 75%. Cohen's weighted kappa statistic was 0.38 (95% CI: 0.28-0.48). MRI referrals consistent with guidelines were more likely to show pathology requiring specialist intervention (reviewer 1: odds ratio=2.64, 95% CI 1.51-4.62; reviewer 2: odds ratio=4.44, 95% CI 2.47-7.99), compared to scan requests graded not consistent. DISCUSSION Study findings indicate GPs use decision support guidance well, and this has resulted in appropriate MRI referrals and higher specialist intervention rates for selected conditions.

The Current Practice of Lynch Syndrome Diagnosis and Management in Italy: A Qualitative Assessment

Background: Lynch syndrome (LS) is the most frequent form of hereditary colorectal cancer (CRC; up to 3–5% of the total CRC burden) and predisposes to the development of other cancers. Multidisciplinary diagnostic strategies are relevant both to the index cases and to their at-risk relatives, but their implementation is still limited. Our study aimed to explore LS testing practices in Italy. Methods: In order to ascertain the current practice of LS diagnosis and management, we conducted a qualitative assessment by sending a questionnaire to health care professionals at 4 Italian hospitals selected as “models” representing different hospital settings. Based on the surveys, we reconstructed the management pathways for CRC patients in terms of diagnostic strategies and health professionals involved. Results: Seven of the 8 invited professionals filled in the questionnaire. Noncompliance with the latest guidelines was reported, as no tumor “screening” was performed on CRC cases. The lack of a structured multidisciplinary team who manages CRC patients from risk assessment to diagnosis and follow-up was reported. The availability of professionals and laboratory technologies differ widely between hospitals. As for cascade testing of at-risk relatives, a systematic and active approach was absent in all the considered hospitals. Conclusions: Our study shows that no structured and standardized pathways for the diagnosis and management of LS patients are currently in place in Italy. We envisage that by extending our research to further experiences and countries, an increasing awareness of the topic can be translated into a health gain for hereditary CRC patients and their at-risk relatives.

Re-organisation of the management of patients affected with chronic pathologies in Lombardy Region: critical points associated with the management of HIV positive patients.

SummaryThe Regional Council of Lombardy Region published in 2017 two resolutions related to a re-organisation of the management pathway of patients affected with chronic pathologies, to meet the changing needs of the users. The objective of this document is to provide recommendations to the Regional Health Service of Lombardy Region to manage the implementation of the resolutions considering peculiar aspects related to the management of HIV positive patients.These resolutions are a concrete answer to the changing needs of health care users within the regional context. The design of the new approach is coherent with the objectives stated, allowing a tighter integration between hospital services, primary care services and social services, however it should be adapted to each of the 62 chronic pathologies considered. In the case of HIV, not considering antiretroviral treatments within the tariff might limit the cost management capability of the case manager. The full implementation of the resolutions with the inclusion of social services will allow a complete management of chronic patients with positive consequences on their quality of life.

Survival after non-resection of colorectal cancer: the argument for including non-operatives in consultant outcome reporting in the UK.

Although the mainstay of colorectal cancer treatment remains operative, a significant proportion of patients end up without surgery. This is because they are either deemed to have no oncological benefit from the resection (too much disease) or to be unfit for major surgery (too frail). The aim of this study was to assess the proportion and survival of these two groups among the totality of practice in a tertiary unit and to discuss the implications on the conceptual understanding of outcome measures. Data was collected over two study periods with the total duration of four years. Patient demographics, comorbidities, cancer staging and management pathways were all recorded. The primary endpoint was all-cause mortality. The total of 909 patients were examined. In the 29% who did not undergo resectional surgery, 6.5% had too little disease, 13.8% had too much disease, while 8.7% were deemed too frail. The highest two-year mortality was observed in the too much (83.2%) and too frail (75.9%) groups, whereas in patients with too little cancer the rate was 5.1%, and in those undergoing a resection it was 19.2% (P<0.001). The study has expectedly shown poor survival in the too much and too frail groups. We believe that understanding the prognosis in these subgroups is vital, as it informs complex decisions on whether to operate. Moreover, an overall reporting taking into account the proportion of these groups in an multidisciplinary team practice (the non-surgical index) is proposed to render individual surgeon's mortality results meaningful as a comparative measure.

The diagnostic yield of computed tomography in the management of acute flank pain and the emergency intervention rate for a proven acute ureteric stone.

The diagnostic and management pathways for patients presenting with acute flank pain are complex. Although computed tomography (CT) of the kidneys, ureters and bladder (KUB) is the gold standard investigation for urolithiasis, the multitude of differential diagnoses must also be considered in the context of long-term risk from ionising radiation. This study investigated the integrated role and diagnostic yield of non-contrast CT in cases of acute flank pain. A retrospective cohort study was undertaken of 1,442 consecutive patients investigated with CT KUB between March 2013 and February 2015. The primary outcome was diagnostic yield of CT with secondary outcomes being predictors of need for urological intervention. A cause for acute flank pain was identified in 717 patients (50%), there was an incidental finding in 389 patients (27%) and normal imaging was reported in 336 patients (23%). A diagnosis was more commonly made in male than in female patients (70% vs 40%) and with increasing age (46% in patients aged <30 years, 56% in those aged 30-49 years and 63% in those aged ≥50 years). The overall rate for an ipsilateral urinary tract stone was 41%. Factors strongly associated with emergency intervention included stone size >10mm (odds ratio [OR]: 11.7, 95% confidence interval [CI]: 3.3-42.7), stones located at the pelviureteric junction (OR: 7.8, 95% CI: 2.6-22.9), C-reactive protein >50mg/l and ≤100mg/l (OR: 15.2, 95% CI: 5.1-45.3), and estimated glomerular filtration rate ≤30ml/min (OR: 5.8, 95% CI: 1.5-21.8). This contemporary study identifies age and sex as independent variables affecting the diagnostic yield of CT KUB in cases of acute flank pain, and highlights factors associated with a need for emergency intervention in proven ureteric stones.

Local Anaesthetic (Medical) Thoracoscopy Services in the UK

Background: Local anaesthetic thoracoscopy (LAT) is an important procedure in the management pathway of patients with pleural effusions, particularly those with suspected malignancy. The last survey evaluating the use and development of LAT services in the UK was conducted over a decade ago. Objectives: We performed a survey of LAT practices in the UK to explore procedural preferences and variations in practice. Methods: The online survey was cascaded via regional pleural specialists to sites performing LAT. One response per site was accepted. Results: Thirty-seven responses were received from England, Scotland and Wales. Most centres have regular access to a dedicated list and a designated area to perform LAT. 97% of the centres have at least 2 trained thoracoscopists. Some variation in practice is seen with patient preparation pre-procedure and medication use. Other procedures, such as insertion of indwelling pleural catheters and adhesiolysis, are not uncommon to be undertaken at the time of LAT. Conclusions: Overall, the results are comparable, excepting some minor variations in patient preparation pre-procedure. We hope that this survey functions as an information resource for centres developing a LAT service or for those considering expansion.