General Practice Surgeries Research Articles

Challenging consultations

A typical surgery in general practice will usually contain at least one consultation that does not go well, leaving doctor or patient, or both, feeling puzzled, dissatisfied or frustrated. And every GP will be able to name a few individuals whom they find so consistently debilitating as to be labelled ‘heart-sink patients’. You know who they are: the ‘Unrealistic expecters’; the ‘Nothing ever works’ or the ‘While I’m here’ brigade; the people with long lists or short fuses; the somatisers; the sufferers from medically inexplicable symptoms who nevertheless want endless investigations and referrals; those who have already consulted Dr Google. In this article I will try to tease out why it is that we find some patients difficult, and offer some suggestions for what we can do about it, (or at the very least make our consultations with them easier to bear).

UK physician associate primary care placements: staff and student experiences and perceptions.

ObjectivesTo provide an insight into the experiences and perceptions of physician associate students and primary care staff involved in primary care educational placements in the United Kingdom.MethodsA qualitative study was conducted. Data were collected from focus groups and semi-structured interviews with eight first year physician associate students and six primary care staff in two general practice surgeries in East Sussex, United Kingdom. Recruitment was via purposeful sampling. Thematic Analysis was used to identify themes.ResultsThree themes were identified: perceptions of the physician associate role, interprofessional working, and the physician associate course structure and placements. Staff demonstrated a lack of familiarity with the physician associate programme and there was a risk of unrealistic expectations. Overall, staff and students were positive about their experiences. However, students expressed anxiety over a large amount of learning in a short timeframe, the perceptions of others, and the reluctance of staff to train them in phlebotomy skills. In addition, students were unsure about their career aspirations for the future.ConclusionsParticipants were positive about their experiences however students expressed a number of anxieties, with a scope to improve interprofessional education. Practice staff demonstrated an overall lack of knowledge of the curriculum and physician associates in general leading to a risk of unrealistic expectations. Further studies on these themes with a larger sample size across relevant training institutions in the United Kingdom is required to explore this further.

Research on Teaching Practice of General Surgery for International Students

<p>In general surgical practice, foreign students often neglect the ability to learn and operate. The reasons include defects in teaching system, insufficient practical ability, poor language communication, etc., which leads to the failure of foreign students to improve their surgical skills and poor teaching quality. As a result of the reform of teaching system and emphasis on practice, a high-level teaching team has been created, the quality of international students has been improved, and the practice quality has been gradually improved.</p>

Why work harder than you need to? Maintaining your dental instruments for easier, safer dental surgery

One of the biggest obstacles to effective dental surgery in general practice is that of blunt or damaged instrumentation. There are two surgical extraction techniques and an instrument type for each technique. The Elevation technique uses instruments with fatter, less acutely edged blades to rotate the tooth in its socket, tearing the periodontal ligament fibres to loosen the tooth. The luxation technique uses instruments with thin acutely edged blades to cut the periodontal ligament to loosen the tooth. Most surgeons use both luxation and elevation techniques during dental surgery. When a blade is used to cut any material, the sharp edge of the blade bends over slightly, widening and blunting the cutting edge. If a honing tool is used to realign this bent section back to the original shape, the blade can be maintained in a perfectly sharp state. If a blade is sharpened, metal has to be removed from the blade edge. If this sharpening is done by hand, the original cutting angles are difficult to replicate, resulting in blades that are not appropriately shaped for the surgery being performed. A number of manual and mechanised sharpening systems are available, but even mechanised sharpening, if incorrectly used, can change the characteristics of the blade and prevent it from working as designed. Instead, blades should be gently honed after each use to realign their cutting edges. Dental instruments are not immortal and should be replaced when the blade edges are damaged or misshapen. Regular honing and replacement when necessary will keep your dental kit in a perfect state at all times, resulting in easier, faster and safer dental surgery.

Evaluation of Natural Tissue Reinforcement of Inguinal canal For Inguinal Hernia Repair (Desarda Inguinal Herniorraphy)

Background: Inguinal hernia repair is one of the cornerstones of a general surgery practice and is one of the most commonly performed procedures. Although there are no exact figures totaling the number of inguinal hernia repairs performed annually, it has been estimated that approximately 800,000 cases were performed annually in 2003, not including recurrent or bilateral hernias. Aim: To report our experience in recording and evaluating the short-term outcome of inguinal hernia repairs with Desarda's technique. Patients and Methods: A total of 20 adult male patients with primary inguinal hernias were randomly allocated intraoperatively to undergo Desarda inguinal herniorraphy. Results: According to our scale evaluating outcome, desarda technique is effective and safe with least post-operative complications regarding inguinal hernia repair. Conclusion: Desarda repair is easy to perform and has shown to take shorter operative time. Also, there is no need of mesh with less suture material requirement. So, this method proves cost effective than the Lichtenstein method. Desarda hernia repair was found to be superior to Lichtenstein repair in terms of post-operative pain and foreign body sensation. It can be recommended for younger patients.

Using the Hybrid Operating Room in Thoracic Surgery: A Paradigm Shift.

We describe the integration of the hybrid operation room cone-beam computed tomography (CT) scan technology into the practice of general thoracic surgery. The combination of the following three techniques: (1) cone-beam CT scan augmented navigational bronchoscopy, (2) cone-beam CT-guided percutaneous biopsy and/or fiducial placement, and (3) fiducial or image-guided video-assisted thoracic surgery resection, into a single-stage, single-provider procedure allows for diagnosis and treatment in one setting. Rapid on-site evaluation of cytological or pathology specimens is key to this "all-in-one" approach. The time from diagnosis to curative treatment can significantly be reduced using the hybrid operation room technology, leading to decreased upstaging, increased survival and facilitating the otherwise difficult intraoperative detection and resection of small and deeper lesions. Not only does this benefit the overall thoracic healthcare of the community but also provides a cost-effective paradigm for the institution.

Prediction of Postoperative Surgical Risk: A Needs Assessment for a Medical Student Curriculum

Medical students' abilities to predict postoperative complications and death are unknown. We hypothesize that medical students will lack confidence in determining surgical risk and will significantly overestimate surgical risk for post-operative morbidities and mortality. Participants were invited to participate in an electronic, anonymous survey to assess their ability to predict surgical risk. The survey presented 7 complex clinical scenarios representative of a diverse general surgery practice. Participants were asked to assess the likelihood of different morbidities and mortality on a 0-100% scale, and predictions were compared to the ACS NSQIP risk calculator. Yale School of Medicine, New Haven, Connecticut; Tertiary medical center PARTICIPANTS: Third year medical students on their surgery clerkship as well as general surgery residents were invited to participate. Most students were not confident about predicting postoperative complications (83.3%) or mortality (70.8%). Most students did not feel that the surgery clerkship adequately prepared them to assess surgical risk (69.6%). When compared to surgical residents for most presented cases (57% of cases), students and residents similarly overestimated postoperative morbidities and mortality. Estimates varied significantly, with wide 95% confidence intervals. Only 17% of NSQIP predicted estimates fell within the 95% confidence intervals. Medical students overestimate morbidity and mortality following surgery in complex patients. Additionally, they lack confidence in their ability to predict surgical complications. A formal curriculum for risk prediction is needed for medical students.

Patient-initiated additional concerns in general surgery visits

ObjectiveTo understand how and when patients initiate additional concerns in general surgery visits. Methods175 video-recorded visits of a general surgery practice in rural Texas were collected, coded, and analyzed using Conversation analysis. ResultsPatients initiated 377 additional concerns, with 2 or more concerns raised in 80 visits, and 1 concern raised in 37 visits. Three methods of initiation were identified: fitted-to-topic (66%), fitted-to-activity (14%), and disjunctive (20%). Sixty percent of patient-initiated concerns occurred i) before the physical examination, compared to 14% after the physical exam, and ii) in pre-operative visits. ConclusionsIn contrast to the research on acute, primary care visits, patients in general surgery visits do not wait to present “door knob concerns.” Instead, patients in general surgery visits are more likely to initiate concerns early in the visit. Patients most frequently find and create opportunities to introduce new concerns by fitting them to the ongoing talk or activity. Practice implicationsPhysicians should spend more time on the physical exam, as this phase creates a unique opportunity for patients to initiate concerns.

Screening for Atrial Fibrillation Using Economical and Accurate Technology (From the SAFETY Study)

The prevalence of atrial fibrillation (AF) is estimated at more than 3% in the adult population and there has been increased interest in screening for AF. In the SAFETY trial we chose to evaluate if inexpensive, wearable, consumer electrocardiography (ECG) sensing devices (Polar-H7 [PH7] and Firstbeat Bodyguard 2 [BG2]), could be used to detect AF accurately. We undertook a case-control study of 418 participants aged >65 (82 with AF and/or flutter at the study visit and 336 without) attending 3 general practice surgeries in Hampshire, UK for a single screening visit. The PH7 and BG2 devices were tested alongside 2 established AF detection devices (AliveCor and WatchBP) in random order and the diagnosis of AF was confirmed by 12-Lead ECG interpreted by a panel of cardiologists. The sensitivity (95% confidence interval [CI] range), specificity (95% CI range), and overall accuracy (95% CI range) of the 4 devices were: AliveCor: 87.8% (78.7% to 94.0%), 98.8% (97.0% to 99.7%), 96.7% (94.4% to 98.2%); WatchBP: 96.3% (89.7% to 99.2%), 93.5% (90.3% to 95.9%), 94.0% (91.3% to 96.1%): PH7: 96.3% (89.7% to 99.2%), 98.2% (96.2% to 99.3%), 97.9% (96.0% to 99.0%). BG2: 96.3% (89.7% to 99.2%), 98.5% (96.6% to 99.5%), 98.1% (96.3% to 99.2%). The PH7 and BG2 devices were highly reliable (the devices acquired sufficient data and obtained a diagnostic result in all but 1 participant on the first attempt). In conclusion, inexpensive, consumer heart rate monitoring devices (PH7 and BG2) can be used to detect AF accurately with sensitivity and specificity >95%. The consumer devices performed as well or better than WatchBP and AliveCor and have the capability to store or transmit ECG data which could be used to confirm AF.

Impact of a specialist mental health pharmacy team on medicines optimisation in primary care for patients on a severe mental illness register: a pilot study

ObjectiveMedication arrangements for patients with severe mental illness (SMI), including schizophrenia and bipolar disorder, can be complex. Some have shared care between primary and secondary services while others have little...

Forward Surgical Team Experience (FSTE) Is Associated With Increased Confidence With Combat Surgeon Trauma Skills.

Little is known regarding the confidence of military surgeons prior to combat zone deployment. Military surgeons are frequently deployed without peers experienced in combat surgery. We hypothesized that forward surgical team experience (FSTE) increases surgeon confidence with critical skill sets. We conducted a national survey of military affiliated personnel. We used a novel survey instrument that was piloted and validated by experienced military surgeons to collect demographics, education, practice patterns, and confidence parameters for trauma and surgical critical care skills. Skills were defined as crucial operative techniques for hemorrhage control and resuscitation. Surveyors were blinded to participants, and surveys were returned electronically via REDCap database. Data were analyzed with SPSS using appropriate models. Significance was considered p < 0.05. Of 174 distributed surveys, 86 were completed. Nine individuals failed to characterize their FSTE, thus leaving a sample size of 77. At the time of first deployment, 78.4% were alone or with less experienced surgeons and 53.2% had less than 2 yr of post-residency practice. The respondents' confidence in damage control techniques and seven other trauma skills increased relative to FSTE. After adjusting for years of practice, number of trauma resuscitations performed per month and pre-deployment training, there remained a significant positive association between FSTE and confidence in damage control, thoracic surgery, extremity/junctional hemorrhage control, trauma systems administration, adult critical care and airway management. Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Prognostic and Epidemiologic, Level IV.

Importance of accessibility and opening hours to overall patient experience of general practice: analysis of repeated cross-sectional data from a national patient survey.

The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients' overall experiences of general practice. To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours. Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011-2012 until 2013-2014. These covered 8289 general practice surgeries in England. Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression. In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices. Patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Policymakers in England should not assume that recent policies to improve access will result in large improvements in patients' overall experience of general practice.

Identifying Patterns in Signs and Symptoms Preceding the Clinical Diagnosis of Alzheimer's Disease: Retrospective Medical Record Review Study and a Nested Case-control Design.

Evidence suggests that individuals with Alzheimer's disease (AD) are often diagnosed in the later stages of their disease with a poor prognosis. This study is aimed to identify patterns in signs and symptoms preceding the clinical diagnosis of AD to suggest a predictive model for earlier diagnosis of the disease in the primary care. A retrospective medical record review; nested case control design. Participants included one hundred and nine patients from three general practice (GP) surgeries in Milton Keynes and Luton Clinical Commissioning Groups (CCG) (37 cases with AD and 72 controls without AD). A retrospective analysis using the logistic regression of the presence of signs and symptoms before the diagnosis of AD was attained. Identification of the timing and sequence of appearance of these presentations as first reported before the clinical diagnosis was measured. Episodic memory with an odds ratio of 1.85 was the most frequent presentation, documented in 1.38% of the controls and 75.6% in cases. Auditory disturbance with an odds ratio of 3.03, which has not previously been noted except in the form of auditory hallucination, could have a diagnostic value. Auditory disturbance, which occurred mostly in the Caucasian females, could discriminate individuals with AD from those without the disease. The symptom, which presented up to 14.5 (mean time) years prior to clinical diagnosis, was identified in Caucasians and mixed race individuals only. The study demonstrates that auditory disturbance could allow an earlier diagnosis of AD in Caucasian females. Episodic memory was confirmed as being frequently noted in AD patients prior to a clinical diagnosis as per previous publications. This study supports the development of a scoring system for the earlier diagnosis of AD. The data used was free from the confounding effects of misinformation, as this was written at the point of collection, thereby benefitting from the use of GP data that is diversified, reliable and valid. Limited sample size that will not allow for generalization of less frequent observations due to their low prevalence in case notes. Randomisation was not achieved; however, the best available nonrandomisation which is consecutive sampling was used. Patterns identified were in LOAD, the baseline could vary with other geographical areas.

Operative technique in robotic left colonic resection.

Minimally invasive techniques have changed the clinical practice in general surgery and provided an improvement of outcomes. Laparoscopic and open surgery have similar oncological outcomes in the colorectal field. Those findings have been proven by prospective randomized multicenter trials and systematic reviews. However, some colorectal operations are still being performed by the open approach. This is partially related to the technical hurdles of the laparoscopic approach (particularly for more complex cases). Robotic surgery can be beneficial in overcoming the laparoscopic hurdles and limitations. Indeed, given the improved dexterity, the 3D stereotactic magnified view (with the camera controlled directly by the surgeon), the tremor filtering technology and the 7 degrees of liberty of the surgical instruments can guarantee a more accurate surgical dissection and tissue manipulation. Herein, after a large robotic experience in this field connected to a robotic program started by Giulianotti et al. in October 2000, we present our approach to robotic left colonic resection with routine splenic flexure mobilization. This approach may be helpful to get more reproducible results, it may be a technical guide and also an additional training tool for surgical residents.

Homeless mortality data from East London.

BackgroundThe rate of homeless mortality is known to be significantly below the national average, with mortality rates varying geographically. This study aims to look at the rates and causes of homeless mortality within East London.QuestionTo characterise homeless mortality of patients registered in two specialist homeless practices, between 2001 and 2016 in the London boroughs of Tower Hamlets and Hackney, by age at death and cause of death.Study DesignA retrospective study of general practice electronic patient records.MethodsElectronic patient records across two general practice surgeries specialising in care for the homeless in East London were examined and their mortality data extracted.ResultsTwo hundred and three deaths recorded in the two general practice surgeries were examined. The average age at death was 47 years, with the highest numbers of deaths being attributed to substance misuse, liver disease and cardiac-related deaths. Those dying of cardiac-related causes died at an average of 51, those dying of liver-related causes died at an average age of 49 years and those dying from substance misuse died at an average age of 38.ConclusionsThose dying of substance misuse-related causes died much younger than the average homeless patient did.

Principles and indications of extracorporeal life support in general thoracic surgery.

The role of extracorporeal life support (ECLS) has expanded rapidly over the past 15 years to become an important tool in advanced general thoracic surgery practice. Intra-operative and in some cases continued post-operative ECLS is redefining the scope of complex surgical care. ECLS encompasses a spectrum of temporary mechanical support that may remove CO2, oxygenate or provide hemodynamic support or a combination thereof. The most common modalities used in general thoracic surgery include extracorporeal membrane oxygenation (ECMO), interventional lung assist device (iLA® Novalung®, Heilbronn, Germany), and extracorporeal CO2 removal (ECCO2R). The ECMO and Novalung® devices can be used in different modes for the short term or long-term support depending on the situation. In this review, the principles and current applications of ECLS in general thoracic surgery are presented.

Do Regional Medical Campuses Contribute to the Production of General Surgeons? A Study of 789 Medical School Graduates from 3 Campuses Who Matched into General Surgery Residencies over 40 Years: 1974 to 2015

Background&#x0D; A Regional Medical Campus (RMC) is a medical school campus separate from the main medical school at which a portion of preclinical&#x0D; or clinical training of medical students is carried out. The College of Community Health Sciences of The University of Alabama&#x0D; in Tuscaloosa, Alabama is the Tuscaloosa Regional Campus of the University of Alabama School of Medicine (UASOM). The question&#x0D; we sought to answer with this study is whether or not regional campuses produce general surgeons.&#x0D; Design, Setting and Participants&#x0D; Publicly available data for 6271 graduates of the University of Alabama School of Medicine from the Birmingham, Tuscaloosa and&#x0D; Huntsville campuses from 1974 to 2015 was obtained by using Google Search Engine. The list was expanded to include the data&#x0D; described by the variables in Table 1.&#x0D; Results&#x0D; Between 1974 and 2015, 789 graduates of the University of Alabama School of Medicine assigned to the Birmingham, Tuscaloosa&#x0D; and Huntsville Campuses matched into Categorical Surgery. All three campuses matched similar percentages of students ranging&#x0D; from 10.4% to 13.3% (Table 2). The main campus at Birmingham matched 599 medical students into general surgery and 202&#x0D; practice general surgery. The Tuscaloosa Regional Campus matched 88 medical students into general surgery and 47 practice&#x0D; general surgery. The Huntsville Regional Campus matched 103 medical students into general surgery and 41 practice general surgery&#x0D; (Table 2).&#x0D; Conclusions&#x0D; A comparable percentage of medical students at each campus matched into general surgery. The main campus contributed a larger&#x0D; absolute number of practicing general surgeons while regional medical campuses contributed a higher percentage of practicing&#x0D; general surgeons. Regional medical campuses contribute significantly to the deficit of general surgeons in this country.

Complications of laparoscopic surgery in general surgical practice and their management

Background: Any new technique is associated with the development of new complication. Laparoscopic surgery has gained popularity over last 20 years, owing to many advantages for patients in terms of smaller scar, less post-operative pain and quicker recovery. Despite the relative safety of laparoscopic techniques, inadvertent serious injuries to bowel, bladder and vascular structures do occur. Therefore, the need has arisen to study the various complications and their management inherent in this technique. The objective was to determine percentage of complications in laparoscopic surgeries of abdomen and also to study their management.Methods: Inpatients of Ramaiah hospitals undergoing abdominal laparoscopic surgeries from October 2014 to October 2015 who are above 14 years of age and undergoing elective or emergency surgeries or diagnostic laparoscopy for acute/chronic appendicitis, cholelithiasis and inguinal hernia repair. Demographic information, clinical findings, intra operative and postoperative findings will be noted. Follow up of the patient is done for 4 weeks.Results: Out of the 272, 134(49.3%) were male patients and 138 (50.7%) were female patients, age group ranging between 31-40 years. Four patients (1.4%) showed CBD injury, three patients (1.1%) showed bowel injury, twelve (4.4%) showed bile leak, all these 9 (3.3%) patients were managed by converting the laparoscopic cholecystectomy into open cholecystectomy. Sixteen patients (5.9%) had laparoscopy converted into open procedure due to the intraoperative complications. Statistically significant impact was noted on the outcome of surgery due the complication that patient underwent during the study.Conclusions: Laparoscopy is a safe, effective and well tolerated procedure if conducted in the skilled and experienced hands. The morbidity and mortality are dependent on age, general condition, presence/ absence of comorbidities and hence preoperative thorough work up is imperative. Large proportions of these complications occur during the initial learning curve of the inexperienced laparoscopic surgeon.

Acceptability of latent tuberculosis testing of migrants in a college environment in England

ObjectivesThe majority of tuberculosis (TB) cases in England occur from reactivation of latent tuberculosis infection (LTBI) in the settled migrant population. The National Institute for Health and Clinical Excellence recommends that new entrants from high-incidence countries are screened to detect LTBI. This article seeks to describe an outreach programme and testing for LTBI in an innovative setting—ESOL (English for Speakers of Other Languages) classes at a community college (CC) with evaluation of acceptability. Study designPartnership working with mixed methods used for evaluation of acceptability. MethodsA pre-existing network from the local TB partnership designed an outreach intervention and screening for LTBI among students from an ESOL programme at a CC. Screening for LTBI with interferon gamma release assay was the culmination of a programme of health improvement activities across the college. Any student on the ESOL programme younger than the age of 35 years and resident in the UK for less than 5 years was eligible for testing. LTBI testing was carried out on-site, and the experience was evaluated by questionnaires to staff, students and partners. A facilitated debrief among the partners gave further data. ResultsA total of 440 eligible students were tested. One hundred and seventy-two student feedback questionnaires were completed, and 36 partner questionnaires were received with 18 CC staff responding. Students, tutors and healthcare professionals found the setting acceptable with some concerns about insufficient resource for timely follow-up. ConclusionsStudents, tutors, community organisations and health professionals found the exercise worthwhile and the method and setting acceptable. There were resource issues for the clinical team in follow-up of students with positive results for such a large screening event. Unexpected barriers were found by the CC as this kind of activity was not recognised for external quality review purposes. There were concerns about reputational loss and stigma of being involved in a TB project. As current initiatives aim to divert workload from stretched general practice surgeries, this may be an important addition to primary care screening.

Do NHS GP surgeries employing GPs additionally trained in integrative or complementary medicine have lower antibiotic prescribing rates? Retrospective cross-sectional analysis of national primary care prescribing data in England in 2016

ObjectiveTo determine differences in antibiotic prescription rates between conventional General Practice (GP) surgeries and GP surgeries employing general practitioners (GPs) additionally trained in integrative medicine (IM) or complementary and alternative...