Royal Berkshire Research Articles

Surgical referrals from nursing homes; More evidence for a geriatric medicine liaison service

s / International Journal of Surgery 10 (2012) S53–S109 S90 ABSTRACTS 0962: SURGICAL REFERRALS FROM NURSING HOMES; MORE EVIDENCE FOR A GERIATRIC MEDICINE LIAISON SERVICE Daniel Burchette, Gagandeep Grover, Michael Booth, Margot Gosney. Royal Berkshire NHS Foundation Trust, Berkshire, UK Aims: To assess outcomes of inpatient stay in patients referred to acute surgical unit from residential homes, comparing with non-institutionalised patients with similar presenting complaints. Methods: 40 patients admitted from homes over six months were matched with following emergency surgical admission living independently aged >70. Data gathered via ‘take’ lists and discharge summaries. Results: Dementia was more prevalent in the residential care (45 vs. 28%), who also had more co-morbidities (4.4 vs. 2.6). Presenting complaints between groups were similar, abdominal pain and haematemesis being leading causes. Larger proportion of community residents underwent surgery during admission (28 vs. 5%) whilst greater proportion of residential care died during admission (15 vs. 2.5%). Residential care patients had a slightly longer average duration of stay in this study (5.5 vs 4.2 days). Conclusions: Whilst presenting with similar complaints, residential care patientsare lessoftensurgical candidates; fewerundergosurgeryanda larger proportion die during admission. This supports value of geriatric liaison, particularly discharge planning, including in those patients palliative needs, aswell asmedical optimisationof co-morbiditieswhensurgery is considered. Presented to the surgical and elderly care department: a new admission pathway for this group of patients was proposed to the trust, suggesting refferal via the geriatric team. 1045: OUTCOMES FOLLOWING EMERGENCY GENERAL SURGERY IN NONAGENARIANS Tim Sparkes, Gregory Jones, Charles Evans. Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, UK Aim: In 2010 NCEPOD highlighted concerns over outcomes of elderly patients undergoing emergency surgery. This study aimed to investigate outcomes in nonagenarians undergoing emergency surgery and identify predictive risk factors for mortality and the impact on care requirements. Method: All nonagenarian patients who underwent emergency general surgery operations between June 2005 and June 2010 within one NHS Trust were retrospectively reviewed. Risk factors analysed included age, sex, ASA grade, clinical parameters, preoperative blood tests (including Creactive protein (CRP)), preoperative care dependence, operation factors and surgeon factors. Kaplan-Meier survival analysis was performed using one year mortality rates. Results: Forty six patients (30 female) underwent surgery with an inpatient mortalityof32.6%andoneyearmortalityof54.3%.Patientsundergoingmajor index surgery, a CRP> 100 or who required any form of preoperative social care had significantly reduced survival (P1⁄4 0.013, P 100, requirement for social care preoperatively and major index surgery. 1096: LAPAROSCOPIC APPENDICECTOMY – A NEGATIVE IMPACT ON EMERGENCY OPERATING? Elisabeth Royston, Catherine Bradshaw, Peter Budny, Shaun Appleton. Stoke Mandeville Hospital, Aylesbury, UK Background: Acute appendicitis is commonly managed with laparoscopic appendicectomy. However, there is a perception that it takes longer than an open operation and may, therefore, impact on the efficiency of emergency operating lists. The purpose of this study was to 1) evaluate the increase in laparoscopic appendicectomies over a five year period; 2) assess whether operating times are increased and 3) identify how this effects the provision of emergency operating lists. Methods: Data was collected retrospectively for all appendicectomies performed in a single NHS trust from 2006 to 2011 and analysed over three time periods. Results: The total number of appendicectomies performed annually ranged from 336 to 399. The percentage performed laparoscopically has progressively increased from 9% in 2006 to 56% in 2011. The average time taken to perform a laparoscopic appendicectomywas eight minutes longer than for an open procedure (p<0.001). The average duration of laparoscopic appendicectomy has not changed since 2006. Conclusion: Although laparoscopic appendicectomies took consistently more time than open appendicectomies, the average difference was only eight minutes. Given the average number of appendicectomies performed per day is one, it is unlikely this increased operating time will negatively impact on the provision of emergency surgery. 1129: IS THE USE OF LAPAROSCOPY LEADING TO A RISE IN THE NEGATIVE APPENDICECTOMY? AmyWhiteford, Carole Neff, James Mansell. Hairmyres Hospital, Hairmyres,

A retrospective study of axillary lymph node clearance for patients diagnosed with early breast cancer and axillary lymph node involvement

A retrospective study of axillary lymph node clearance for patients diagnosed with early breast cancer and axillary lymph node involvement

Audit on Autistic Spectrum Disorder (April 2006 to April 2007)

Background: Autistic Spectrum disorder is a triad of impairments with 1. Impairment in social reciprocity, 2. Repititive, stereotyped, rigid patterns of unusual behavior and 3. Language abnormalitiesAim: To analyze 1 Number of children diagnosed with Autistic spectrum disorder in a year's time (April 2006 to April 2007), 2 Number of appointments needed to make ar a definite diagnosis and 3 To evaluate the co morbidities associated with ASD Methods: Study period was from April 2006 to April 2007. All children (New & follow up) who attended Developmental Language Clinic(DLC) were included. Numbers were obtained from 1 Outcome list from Dr Fulford (Specialist Paediatrician) and 2 Clinic letters from Paediatric Administration file, Royal Berkshire Hospital, Reading. Results: 270 children were analysed. 72% were diagnosed to have ASD/Asperger's syndrome and 24% were diagnosed to have Specific language delay or social communication disorder.Among the 193 with ASD/Asperger's syndrome, 139 (72%) were diagnosed to have ASD and 55 (28%) as Asperger's syndromePeak age at diagnosis was 4 years(range 2 - 11 years ). 46% were referred by GP, 28% by Speech & Language Therapist(SALT) and 22% by Paediatricians.83% were diagnosed within 2 visits and 93% were diagnosed within 3 visitsAmong the comorbidities, 6% had Sensory Modulation Disorder and 4% had Developmental Co-ordination disorderConclusion: About three quarters of children referred to DLC were diagnosed to have ASD. 83% of them were diagnosed within 2 visits. All of them were referred to support groups appropriately.

An unusual application for a Urobag

A theatre team from the Royal Berkshire Hospital recently spent two weeks operating in north-west India, close to the Tibet border. To reach the clinic in the Spiti Valley, it is necessary to cross the lower Himalayas via the Rohtang Pass (altitude 3978 metres) and Kunzum Pass (altitude 4547 metres). Much of the route is unsurfaced and somewhat tortuous: the usual services associated with European motoring are absent, as is mobile phone coverage. At approximately 4pm, 40 kilometres from the nearest habitation, the diesel engine of our minibus suddenly stopped as a result of a rock penetrating the primary fuel filter while travelling over the potholed mountain passes.

Locked bucket-handle tear of the anterior labrum causing persistent subluxation of a dislocated shoulder

Department of Radiology, Royal Berkshire Hospital, Reading, UKPersistent subluxation of a dislocated shoulder afterreduction is uncommon. We present a case-report ofpersistent subluxation caused by a locked bucket-handletear of the anterior labrum extending superiorly. This wastreated arthroscopically with resection of the lockedbucket-handle tear and biceps tenotomy, with immediatereduction of the shoulder.

Patient Satisfaction Survey of the Enhanced Recovery Programme School for Colorectal Surgery at the Royal Berkshire NHS Foundation Trust

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Evidence-based Practice and Quality Improvement

George Barnet Forbes

George Barnet Forbes (“Jock”) spent over 40 years as a pathologist, starting as a trainee pathologist in 1938 at the Royal Berkshire Hospital, Reading, under Dr J Mills. Soon after...

The iron lung – a polio patient's story

I developed polio in 1949 when I was about 7 years old. I remember not feeling very well and not being able to get out of bed. It then transpired that I was paralysed down the left side. The doctor came and I was taken to the Royal Berkshire Hospital. I was in hospital over Christmas which I remember quite fondly because it was quite fun really, although I couldn’t sit up. I know my parents spent Christmas Day with me. After that I cannot remember the details but I was taken to Oxford, I think it was to the Churchill. At that time it was thought a good idea to put patients out in the cold. I remember being pushed out of the veranda windows in the bed in February. I was sent home still unable to walk fully. I did not have callipers or anything like that but I was too weak down the left side. When I went back to school for half-days I had to be taken in a wheel-chair. But by the time I got to about 10, I was ‘normal’ apart from the fact that my back had started to curve: my spine was curved, but it did not stop me doing anything.

S1350 Efficacy of Nasal Bridles in Preventing Nasogastric Tube Displacement. the Royal Berkshire Experience

Introduction Rates of accidental removal of nasogastric feeding tubes (NGT) within hospital can reach up to 60% which exposes patients to risk from repeat procedures as well as consuming resources. Nasal bridles are not routinely used in the UK despite demonstrating a reduction in NGT removal rates, reducing the occurrence of unnecessary percutaneous gastrostomy (PEG) placements and increasing nutrition delivery. At the Royal Berkshire Hospital patients are deemed suitable for bridle placement if three or more NGT have been removed unintentionally, there is no history of nasal trauma and not so confused as to risk causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest x-ray. We audited our practice to assess whether bridles are effective and safe. Methods Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. Results fifty-one patients were referred for bridle placement during the 27-month audit period. Median age was 72 years (range 36–90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3–8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. One patient required bridle replacement and only one experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1–32). Of these only two required long-term PEG feeding and 21 were able to have their bridles removed as they were no longer required. Fifteen patients with bridles died for reasons unrelated to their bridle. An additional 147 chest x-rays had been used prior to referral while only one additional x-ray was required to confirm NGT position after bridle placement. Conclusion Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high-risk groups if patients are assessed carefully by trained staff.

PTH-055 Efficacy of nasal bridles in preventing nasogastric tube displacement. The Royal Berkshire experience

<h3>Introduction</h3> Rates of accidental removal of nasogastric feeding tubes (NGT) within hospital can reach up to 60% which exposes patients to risk from repeat procedures as well as consuming resources. Nasal bridles are not routinely used in the UK despite demonstrating a reduction in NGT removal rates, reducing the occurrence of unnecessary percutaneous gastrostomy (PEG) placements and increasing nutrition delivery. At the Royal Berkshire Hospital patients are deemed suitable for bridle placement if three or more NGT have been removed unintentionally, there is no history of nasal trauma and not so confused as to risk causing themselves nasal septal injury. All patients are assessed by a clinical nurse specialist. It is Trust policy to confirm all NGT placements with a chest x-ray. We audited our practice to assess whether bridles are effective and safe. <h3>Methods</h3> Database records for all patients referred for NG bridles between June 2007 and September 2009 were reviewed. Where additional information was required, case notes were obtained. Radiology exposure was also assessed. <h3>Results</h3> fifty-one patients were referred for bridle placement during the 27-month audit period. Median age was 72 years (range 36–90). Cerebrovascular accident was the most common reason for referral (82%). All patients had had at least 3 NGT placed prior to referral (median 3 range 3–8). 38 of the 51 patients (74.5%) had bridles attached using 39 devices in total. One patient required bridle replacement and only one experienced significant nasal trauma. The reasons for not placing a bridle included; 2 were too unwell, 6 were already eating, 3 refused and 2 were too difficult to place. Of these 5 went straight to PEG feeding. The 38 bridle patients received 308 days of NGT feeding (median 7 range 1–32). Of these only two required long-term PEG feeding and 21 were able to have their bridles removed as they were no longer required. Fifteen patients with bridles died for reasons unrelated to their bridle. An additional 147 chest x-rays had been used prior to referral while only one additional x-ray was required to confirm NGT position after bridle placement. <h3>Conclusion</h3> Bridle fixation reduces the number of NGT re-insertions, inappropriate PEG tubes and helps to prevent delay of nutrition restoration. They also reduce repeated radiation exposure from recurrent x-rays and overall hospital costs. Bridles have a very low incidence of complication and help reduce unnecessary PEG insertions in high-risk groups if patients are assessed carefully by trained staff.

Early Versus Delayed Appendicectomy During Admission With Lower Abdominal Pain

Early Versus Delayed Appendicectomy During Admission With Lower Abdominal Pain

Is Surgical Training Excellent in the United Kingdom? – Preliminary Results of an Ongoing Prospective Survey

Is Surgical Training Excellent in the United Kingdom? – Preliminary Results of an Ongoing Prospective Survey

Laparoscopic Anti-Reflux Surgery Improves Daytime Somnolence

Laparoscopic Anti-Reflux Surgery Improves Daytime Somnolence

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

Cost-Effective Laparoscopic Cholecystectomy

There is wide variation in costs, both theatre and ward, for the same operation performed in different hospitals. The aim of this study was to compare the true costs for a large number of consecutive laparoscopic cholecystectomy (LC) cases using re-usable equipment with those from an adjacent trust in which the policy was to use disposable LC equipment. Data were collected prospectively between January 2001 and December 2007 inclusive for all consecutive patients undergoing LC by two upper gastrointestinal (UGI) consultants at the Royal Berkshire Hospital. Data were collected for all the instruments used, in particular any additional disposable instruments used at surgeons' preference. Sterilisation costs were calculated for all re-usable instruments. Costs were also obtained from an adjacent NHS trust which adopted a policy of using disposable ports and clip applicators. Disposable equipment such as drapes, insufflation tubing, and camera sheath were not considered as additional costs, since they are common to both trusts and not available in a re-usable form. Over 7 years, a total of 1803 LCs were performed consecutively by two UGI consultants at the Royal Berkshire Hospital. The grand total for 1803 LC cases for the re-usable group, including initial purchasing, was pound89,844.41 (an average of pound49.83 per LC case). The grand total for the disposable group, including sterilisation costs, was pound574,706.25 (an average of pound318.75 per LC case). Thus the saving for the trust using re-usable trocars, ports and clip applicators was pound268.92 per case, pound69,265.98 per annum and pound484,861.84 over 7 years. This study has demonstrated that considerable savings occur with a policy of minimal use of disposable equipment for LC. Using a disposable set, the instrument costs per procedure is 6.4 times greater than the cost of using re-usable LC sets. It behoves surgeons to be cost-effective and to reduce unnecessary expenditure and wastage. There is no evidence to support use of once-only laparoscopic instruments on grounds of patient safety, ease of use or transmission of infection. If the savings identified in this study of two surgeons' work (savings of pound484,861.84 in a 7-year period) was extended not only across the hospital but across the NHS, large savings could be made for laparoscopic cholecystectomy. Even greater savings would accrue if the results were extrapolated to cover all laparoscopic surgery of whatever discipline.

Use of glyceryl trinitrate patches in the treatment of accidental digital injection of epinephrine from an autoinjector

Royal Berkshire Hospital, Reading, Berkshire, UK Correspondence to Mr Jangam Nagaraj MS, FRCS, Royal Berkshire Hospital, London Road, Reading, Berkshire rg1 5an, UK Tel: +44 118 977 2514; fax: +44 118 987 8662; e-mail: [email protected] Received 21 September 2005 Accepted 1 November 2005

Optical coherence tomography of the effects of stromal hydration on clear corneal incision architecture

To evaluate the effects of stromal hydration on clear corneal incision (CCI) architecture immediately after surgery using anterior segment optical coherence tomography (AS-OCT). Department of Ophthalmology, Royal Berkshire Hospital, Reading, United Kingdom. Clear corneal incisions in adult eyes were examined using a Visante AS-OCT imaging system within 1 hour of surgery. Half the CCIs had stromal hydration with a balanced salt solution and half did not. Incisions were made with a 2.75 mm steel keratome. Intraocular pressure (IOP) was measured within 90 minutes after surgery. The CCI length and corneal thickness at the CCI site were measured using software built into the AS-OCT system. Thirty CCIs were evaluated. Stromal hydration significantly increased the measured CCI length (P<.05, t test); this was the result of a trend toward increased corneal thickness at the CCI site with hydration (P<.1, t test). The mean CCI length was 1.69 mm +/- 0.27 (SD) (range 1.31 to 2.32 mm) with hydration and 1.51 +/- 0.23 mm (range 1.30 to 1.95 mm) without hydration. The mean IOP was 20.9 +/- 8.18 mm Hg and 15.8 +/- 8.20 mm Hg, respectively. The IOP tended to be higher with hydration (P<.1, t test). Local detachment of Descemet membrane was more likely with stromal hydration (63%) than without (25%). Stromal hydration significantly increased CCI length and tended to leave the eye with a higher early postoperative IOP, showing the importance of taking stromal hydration into account when designing similar OCT studies of CCI architecture.

How to Write a Good PhD Proposal: The Experience of Novice Researchers

A good PhD proposal will normally include three basic sections: the introduction to your topic and the background for your research work, a review of the literature and a description of the methodology. The introduction section includes a description of the background surrounding the issue you plan to study, questions that your research hopes to answer, the important contribution to knowledge and practical benefits of your study, and the theoretical basis for your study. The review of the literature section normally presents and discusses the literature focusing on what research has been done on your topic or area, the gaps and issues involved and highlights of the theoretical disagreements, controversies, contradictory research and the practical issues that give the issue importance. The final methodology section should show precisely how you plan to carry out your research. It should describe the general approach of field work vs. desk work, methodological diversities (qualitative vs. quantitative; descriptive vs. analytical) as well as theoretical perspective. Your proposal will be assessed by various people from your University before you can proceed to conduct your research. The box below outlines some elements of an outstanding dissertation proposal.

Factors affecting outcome of punctoplasty surgery: a review of 205 cases

Aim:We reviewed retrospectively the indications, surgical techniques and outcomes of punctoplasty surgery for 205 consecutive patients in order to identify factors that influence success.Methods:We identified all patients who underwent punctoplasty...

Prioritisation of vascular outpatient appointments cannot be based on referral letters alone

Vascular referrals include patients with conditions varying from varicose veins of cosmetic nuisance to patients with critical ischaemia, transient ischaemic attacks and abdominal aortic aneurysms. A large number of such referrals are received each week from general practitioners. It is important to prioritise patients with conditions that need to be dealt with quickly. We prospectively reviewed referral letters to two vascular units, one in South Wales and one in the Oxford region to assess whether prioritisation can be made on the basis of referral letters. All GP referral letters were studied for four months. Only patients with lower limb ischaemic symptoms were included. Degree of urgency requested by the GP was also noted. Of 174 referrals for potential lower limb ischaemia analysed, 145 (83%) proved to be due to peripheral vascular disease. Of these 145 referrals, 72% were referred for claudication. Only 37% and 13% respectively mentioned claudication distance and/or rest pain. Risk factors with reference to diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, atrial fibrillation, cerebrovascular disease and smoking were made in 19%, 43%, 23%, 23%, 10%, 14%, 31% of letters respectively. Clinical signs were poorly documented, with 90% of referrals failing to mention presence or absence of critical ischaemic signs. The GP's own assessment of urgency was not stated in 66% of letters, without which only 3% of patients were seen in the clinic within four weeks, compared with 22% in those in whom urgency was stated. Six per cent of patients when reviewed in outpatients were found to have sufficiently severe symptoms to warrant immediate admission. Regional variation was observed with 57% of Royal Glamorgan Hospital referral letters documenting degree of urgency compared with only 23% of Royal Berkshire Hospital letters (p = < 0.0001). Most referral letters were poorly documented with regard to key symptoms, risk factors and clinical signs. The degree of urgency was often not stated. The creation of referral protocols is now being considered.