Specialist Nurse-led Clinic Research Articles

Characteristics and outcomes of patients with heart failure with preserved ejection fraction referred to a community specialist nurse-led clinic

Characteristics and outcomes of patients with heart failure with preserved ejection fraction referred to a community specialist nurse-led clinic

OGBN P05 Specialist Nurse-Led Reflux Clinic – Streamlining the pathway to specialist care for gastro-oesophageal reflux disease

Abstract Background Gastro-oesophageal reflux disease (GORD) is a common condition that can have a significant impact on patients’ quality of life and be associated with serious complications. Our institution offers daycase laparosopic anti-reflux surgery to patients with severe GORD or those refractory to medical management. However, the referral pathway is often prolonged, due to multiple investigations under gastroenterology or the long waiting list for outpatient appointments. A nurse-led reflux clinic (NLRC), with surgeon oversight, was therefore developed to facilitate earlier access to secondary care assessment and investigation, thus aiming to reduce the ultimate time to consultant surgeon decision making. Methods A standardised electronic ‘tick box’ proforma was developed for completion by the upper GI nurse specialists, incorporating common and atypical symptoms, Eckardt score, ‘red flag’ symptoms, weight, comorbidity, investigation results and free-text. Appropriate further investigations were selected and a clinic outcome was coded electronically to generate an electronic patient letter, thus requiring no secretarial support. Surgeon oversight was provided by the lead investigator and following completion of investigations (e.g. oesophageal physiology) patients were booked to the next available Consultant Upper GI surgeon clinic. Data on patient satisfaction was collated using a validated questionnaire and referral times also recorded. Results 64-referrals to the NLRC between September 2021 and September 2022. Median waiting time to first appointment was 10 weeks (range 2.7 - 28.4) and 32 weeks to decision making (range 4.4 - 87.1). This was compared with 31-referrals prior to November 2020 with median waiting time to the first appointment of 7 weeks (range 0.3 - 124.7), and to decision making of 39 weeks (range 12.1 - 125.6). Completed satisfaction surveys showed more than 95% of patients were either “very satisfied” or “satisfied” with the overall care, explanation of tests, how they were treated, knowledge and skill of nurse and the timing of consultation. Conclusions Although there was no significant difference in the waiting time to the first appointment, NLRC helped reduce the overall waiting time to decision making. Introduction of a specialist nurse led-reflux clinic, with surgeon oversight, offers an effective solution for managing patients that may require anti-reflux surgery in a more timely manner, with good patient satisfaction.

397 The Effects of a Virtual Specialist Nurse-Led Clinic on Plastics Outpatient Services at a Major Trauma Centre: A Closed Loop Audit

Abstract Aim To reduce the number of plastic surgery clinics working over capacity due to the effects of both increasing caseload and the COVID-19 pandemic by implementing a virtual specialist nurse-led clinic. Method Outpatient activity was audited due to the number of patients being overbooked into the plastic surgery outpatient clinics. A virtual specialist nurse-led clinic was implemented to bridge gaps between appointments, maintain early triaging of complications, and reduce clinics working over-capacity. Suitable patients were identified and offered virtual follow-up in place of face-to-face appointments. Outpatient activity was re-audited after implementation, to assess effects on force bookings and number of new/follow-ups seen in consultant clinics. Results Following virtual clinic implementation, there was a significant reduction in consultant clinics working over-capacity (95% to 71.8%, p = 0.002) and forced bookings (54 to 10, p = 0.006) in the audited period. The average number of new patients seen in consultant clinics each month increased by 15.3% (p = 0.019). Conclusions Introduction of a virtual clinic reduced forced bookings and clinics working over-capacity. This increased capacity for new patients to be seen face-to-face, created a manageable clinic while maintaining early identification of complications, and reduced delays between clinic appointments. Early virtual assessment of wounds and identification of complications enabled patients to be booked into urgent face-to-face plastic appointments, triaging them away from A&E and GP services. The virtual clinic also allowed the team to reassure patients with ongoing concerns between appointments, further reducing A&E and GP burden.

863 Improving the Outcomes of Inpatient Admissions and Optimising Referrals to a Regional Burns Unit Through Introduction of a Specialist Nurse-Led Burns Clinic

Abstract Aim We aimed to measure the effect of a specialist nurse-led clinic and referral pathway on admission rate, patient length of stay (LOS), and total bed days. We hypothesised that this intervention would contribute to the optimisation of the patient pathway in a regional burn's unit. Method Retrospective analysis of inpatient records in a six-month period over three years at a regional burn's unit (June-November 2018,2019,2020). Analysis of demographics, TBSA, admissions, and length of stay before and after clinic introduction. Statistical analysis included one-way ANOVA. Results A reduction in admissions was observed in 2020 compared to 2019 and 2018 (7.3% and 6.7%) for a patient group with equivalent median TBSA (2%) and comparable median age (41 vs. 43.5 and 42.5). Median LOS was significantly shortened compared to 2019 (42.9%, F=4.07, p=0.046) and 2018 (42.9%, F=6.59, p=0.011). Minor burns showed reduced admission rates compared to 2019 (8.5%), and reduced median LOS (42.9% and 33.3%), and reduced total bed days (29.4% and 27.1%) compared to 2019 and 2018 respectively. Referrals to the regional burn's unit as a percentage total of regional A&E burns presentations increased in 2020 compared to 2019 and 2018 (16% vs. 14.4% and 12.1%). Conclusions The results suggest that the introduction of a specialist clinic has shortened in-patient stay with a significant effect on minor burns, against a backdrop of increased referrals. We suggest that continuity between clinic and inpatient care by a specialist nursing team has helped to optimise the regional burns unit.

Implementation of a nurse-led lower urinary tract symptoms (LUTS) clinic reduces general urology clinic workload in a Model 4 Hospital: a pilot study in Tallaght University Hospital.

BackgroundWith among the lowest urologist per population ratios in Europe, the demand for urology specialist review in Ireland far exceeds supply. Lower urinary tract symptoms (LUTS) account for a significant number of referrals. The traditional paradigm of every patient being reviewed in a consultant-led clinic is unsustainable. New models of care with nurse-led clinics represent an opportunity to optimise limited resources.MethodsExisting long-waiting male LUTS referrals were triaged to a specialist nurse-led LUTS clinic. After urology CNS assessment, charts were reviewed by a consultant urologist and a plan formulated. Relevant data were prospectively collected and analysed.ResultsFifty-eight new male patients with LUTS were seen over a 6-month period with an average waiting time of 15.8 months. Patients were assessed with uroflowmetry, IPSS and DRE. Mean age was 64, IPSS 14.5, Qmax 18.3 ml/s and PVR 89 ml. Thirty patients (52%) were discharged directly with lifestyle modification and medical therapy.Twenty-eight patients (48%) required one or more further investigations and subsequent review; 11 had flexible cystoscopy, 4 had urodynamics, 5 had prostate MRI, and 2 patients were listed for surgery (TURP and circumcision). The remaining 10 patients were for review post trial of lifestyle modifications and/or medical treatment. After review/investigations, 4 more patients were discharged. A total of 32 patients (55%) were discharged or listed for surgery after initial assessment. This total increased to 62% after a second review/investigations.ConclusionIntroduction of a CNS-led LUTS clinic has significantly reduced the number of patients requiring follow-up in general urology clinics, representing a quality improvement in service provision.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11845-020-02428-8.

Evaluation of a primary to secondary care referral pathway and novel nurse-led one-stop clinic for patients with suspected non-alcoholic fatty liver disease

ObjectiveNon-alcoholic fatty liver disease (NAFLD) affects approximately one in four adults of the general population, with an important minority of cases at high risk of developing cirrhosis. We evaluated the...

Improving access to digital ulcer care through nurse-led clinic: a service evaluation.

Digital ulcers (DU) remain one of the most burdensome co-morbidities in systemic sclerosis. The objectives of the study were to describe patient-level stratification and to evaluate a nurse-led DU clinic service development. A nurse-led digital ulcer clinic was established to identify patients with DU and manage them. Patients were recruited through scleroderma clinics, GP referrals, and self-referrals. The clinic involved patients being treated with appropriate treatment. Patients were stratified according to their DU risk level based on number and severity of ulcers. Among these, 22 patients were asked to complete a patient satisfaction survey. Data were analyzed descriptively. Seventy-five patients were seen in the clinic, 46 (61%) were 56 years of age and above. Patients were identified as high (23%), medium (51%) or low risk (26%) for development of DU. The duration of DU history was from 7 months to 40 years. Prior to attending the nurse-led DU clinic, 90% of patients had received up to six courses of antibiotics for their DU, 76% had attended A&E, and 90% had unscheduled appointments. 90% had been seen by the GP due to DU and subsequently required hospital admissions. During the nurse-led clinic follow-up, only two patients had emergency admission. All patients reported that their needs in personal care of DU were met. There are a significant number of people with SSc who have DUs affecting their quality of life as well as needing more healthcare services. A dedicated specialist nurse-led DU clinic may improve overall care of patients.

P782The evaluation of a nurse-led Sacubitril/Valsartan initiation and titration clinic

Abstract Background Sacubitril/Valsartan is a new NICE-approved treatment for heart failure patients with NYHA 2–4 symptoms, LVEF<35% and on a stable dose of ACEi/ARB medication. The PARADIGM-HF trial was stopped early after showing an absolute risk reduction of cardiovascular death/hospitalisation of 5%. NICE specify that it should be initiated by a heart failure specialist with access to a multidisciplinary team. We set up a secondary care specialist nurse-led clinic in our trust in North England for Sacubitril/Valsartan initiation and monitoring. Purpose To assess compliance to NICE guidelines and establish the number of clinic visits required for dose titration. To compare demographics and treatment outcomes of our patients with the trial population. Methods A retrospective analysis of all patients prescribed Sacubitril/Valsartan over two years with a minimum follow up of 6 months. Data was collected from patient records and compared with NICE guidelines and the PARADIGM-HF trial (total population and Western European subset). Results 159 patients commenced Sacubitril/Valsartan. Table 1 shows demographic and therapy data and demonstrates our cohort is largely similar to the Western Europe cohort of Paradigm-HF. However, our patients had higher rates of MRA and complex device treatments. Prescribing was compliant with NICE guidelines in 97%. Failure to exceed the target 50% ACEi/ARB dose was the main reason for non-compliance in 60% (3/5). These 3 patients all discontinued. Overall 16% discontinued the drug (42% for hypotension) compared to 18% in the trial. No serious adverse reactions occurred. Mean number of clinic visits was 3.7±1.4. Table 1. Demographic and therapy data Cohort size Age Female % Ischaemic Aetiology % LVEF B-Blocker % MRA % CRT % ICD % North England 159 69.3±11.1 20 59 27 90 73 23 47 PARADIGM-HF full trial 8442 63.8±11.5 21 60 30 93 54 7 15 Western European Subset 1680 68.3±9.9 18 30 95 44 12 33 Conclusion Our cohort closely reflects the trial and the resultant NICE guidelines. More of our patients are treated with MRA and complex devices compared to PARADIGM-HF. This may be due to the quality of our service or may reflect our patient selection. Similar tolerability in our patients is reassuring as study patients are highly selected. Those receiving suboptimal ACE/ARB doses (therefore not NICE compliant) prior to initiation all failed to tolerate the new drug which cautions against straying from guidance. Our data shows a specialist nurse-led service can be delivered safely and effectively achieving therapeutic doses with a small number of patient visits. This data supports its deliverability in a non-trial setting.

Excellent Survival and Good Outcomes at 15 Years Using the Press-Fit Condylar Sigma Total Knee Arthroplasty

BackgroundWe report 15-year survival, clinical, and radiographic follow-up data for the Press-Fit Condylar Sigma total knee arthroplasty. MethodsBetween October 1998 and October 1999, 235 consecutive TKAs were performed in 203 patients. Patients were reviewed at a specialist nurse-led clinic before surgery and at 5, 8-10, and 15 years postoperatively. Clinical outcomes, including Knee Society Score, were recorded prospectively at each clinic visit, and radiographs were obtained. ResultsOf our initial cohort, 99 patients (118 knees) were alive at 15 years, and 31 patients (34 knees) were lost to follow-up. Thirteen knees (5.5%) were revised; 5 (2.1%) for infection, 7 (3%) for instability, and 1 (0.4%) for aseptic loosening. Cumulative survival with the end point of revision for any reason was 92.3% at 15 years and with revision for aseptic failure as the end point was 94.4%. The mean Knee Society Score knee score was 77.4 (33-99) at 15 years, compared with 31.7 (2-62) preoperatively. Of 71 surviving knees for which X-rays were available, 12 (16.9%) had radiolucent lines and 1 (1.4%) demonstrated clear radiographic evidence of loosening. ConclusionThe Press-Fit Condylar Sigma total knee arthroplasty represents a durable, effective option for patients undergoing knee arthroplasty, with excellent survival and good clinical and radiographic outcomes at 15 years.

A prison based nurse-led specialist diabetes service for detained individuals

This study aimed to examine whether providing a nurse-led specialist diabetes service within the prison setting can improve the management of diabetes by reducing HbA1c – thus reducing hospital admissions for hypoglycaemia and diabetic ketoacidosis and, in turn, reducing UK National Health Service costs. Monthly nurse-led clinics were carried out to review prisoners’ diabetes management and control.The study prospectively monitored the care of diabetic men serving a prison sentence in a large English prison during a 12-month period within a specialist nurse-led diabetes clinic, and compared the outcomes to the previous 12 months before the clinic was set up. The study subjects comprised 27 male prisoners – of whom 37% have type 1 diabetes and 63% have type 2 diabetes – all detained in one prison, HM Prison Risley, in the north west of England. Main outcome measures were: reduction in hospital and accident and emergency (A&E) admissions; reduction in the rate of failed attendance at hospital outpatient clinic appointments (‘did not attend’) and in the rate of cancelled consultant outpatient clinic appointments; and improvement in diabetes management and control.The results showed that hospital admission rates reduced, with only two admissions in 12 months. One was due to hypoglycaemia (overdose) and one due to infection. There were no admissions for diabetic ketoacidosis. Baseline HbA1c was 74mmol/mol (8.9%); range 39–108mmol/mol (5.7–12.0%). At one-year follow up, HbA1c had decreased to 58mmol/mol (7.5%); range 56–119mmol/mol (7.3–13.0%). The number of episodes of severe hypoglycaemia in the preceding 12 months was greatly reduced from 17 to 1 (p<0.001).It was concluded that prisoners should be offered care that meets national standards. They should have access to medication and education to help manage their diabetes. Commissioning of services for prisoners with diabetes needs to be addressed if this has not already been done. A comprehensive approach to the care of people with diabetes can be an effective way in which to improve overall health and prevent acute/chronic complications. Providing a prison based nurse-led specialist diabetes service within a prison can reduce hospital admissions, reduce the number of hospital outpatient clinic appointments, improve patient outcomes and ultimately save the UK National Health Service a substantial amount of money.

Evaluation of a specialist nurse-led hypertension clinic with consultant backup in two inner city general practices: randomized controlled trial

Although practice nurses are increasingly involved in hypertension management, there is little robust evidence of effectiveness. To evaluate the effect of a specialist nurse-led hypertension clinic with consultant backup on change in systolic blood pressure. Randomized trial. Two inner city general practices. Participants. Three hundred and fifty-three patients, mean age 62 years (range 18-99), with last recorded blood pressure ≥ British Hypertension Society audit standard were randomly allocated to the nurse-led clinic or usual care. Intervention. Patients received a letter informing them that their last blood pressure was over target and inviting them to the clinic. After assessment at the clinic, the nurse discussed any changes in anti-hypertensive treatment with a visiting consultant and the patient's GP, and followed up the patient over 6 months until blood pressure targets were achieved. Reduction in systolic blood pressure, assessed using two audits of the practices' computerized records where blood pressure was measured independently by practice staff before and after the intervention period. Follow-up was 89% (313/353). There was greater reduction in systolic blood pressure in the clinic group (n = 144) than usual care group (n = 169, adjusted difference 4.4 mmHg; 95% CI 0.7 to 8.2). Of 167 patients randomly selected for the clinic, 91 (55%) attended, 49 had blood pressure above target when measured according to protocol and 26 had their anti-hypertensive treatment intensified by their GP. Invitation to a specialist nurse-led hypertension clinic with consultant back up was associated with reduced systolic blood pressure.

Clinical microsystems in designing TRUS-biopsy services – A closed-loop audit of a specialist nurse-led triage clinic for men with suspected prostate cancer

Clinical microsystems in designing TRUS-biopsy services – A closed-loop audit of a specialist nurse-led triage clinic for men with suspected prostate cancer

Ten-year results of the Press Fit Condylar Sigma total knee replacement

We report ten-year clinical and radiological follow-up data for the Sigma Press Fit Condylar total knee replacement system (Sigma PFC TKR). Between October 1998 and October 1999 a total of 235 consecutive PFC Sigma TKRs were carried out in 203 patients. Patients were seen at a specialist nurse-led clinic seven to ten days before admission and at six and 18 months, three, five and eight to ten years after surgery. Data were recorded prospectively at each clinic visit. Radiographs were obtained at the five- and eight- to ten-year follow-up appointments. Of the 203 patients, 147 (171 knees) were alive at ten years and 12 were lost to follow-up. A total of eight knees (3.4%) were revised, five for infection and three to change the polyethylene insert. The survival at ten years with an endpoint of revision for any reason was 95.9%, and with an endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society Score (AKSS) was 79 (10 to 99) at eight to ten years, compared with 31 (2 to 62) pre-operatively. Of 109 knee with radiographs reviewed, 47 knees had radiolucent lines but none showed evidence of loosening.

A Specialised Foreskin Clinic

PURPOSE 10,594 circumcisions were performed on children in England during 2006 making it one of the most commonest paediatric operations. Whilst the overall incidence of balanitis xerotica obliterans (BXO) remains controversial, Rickwood et al reported an incidence of 84% in those with cicatrising phimosis. The assessment of foreskins, to determine those that are likely to have BXO and require cicumcision, significantly contributes to the paediatric surgeon's outpatient workload. At our centre we have established a specialist nurse-led foreskin clinic for this purpose. We present our preliminary results. MATERIAL AND METHODS The foreskin clinic was set up in November 2004. It has a caseload of 20 patients bi-monthly. The clinics are nurse-led and run in conjunction with a Paediatric Urology clinic to ensure that consultant advice is available if required. There is a set treatment plan for presenting symptoms and follow-up. RESULTS Over a two year period of 2005-2006, 776 patients were referred to the clinic for assessment of their foreskins. Of these 122 (16%) did not attend. Of the 654 patients seen, the majority 482 (74%) were found to have entirely normal foreskins with only physiological phimosis. In these cases the nurse was able to reassure the patients, give advice regarding foreskin care, and discharge. 23 patients (3.5%)showed evidence of BXO and were referred for circumcision. 132 (20%) were successfully treated with topical trimovate. 12 (1.8%) patients were referred to other speciality clinics, eg dermatology. One patient was found to have previously undiagnosed hypospadias. 4 (0.6%) patients required no treatment but were followed up due to parental anxiety. CONCLUSIONS Providing a nurse-led specialist clinic has improved the continuity of care for boys with foreskin problems, decreased outpatient waiting times and reduced the number of circumcisions being undertaken for medical reasons at our centre. 10,594 circumcisions were performed on children in England during 2006 making it one of the most commonest paediatric operations. Whilst the overall incidence of balanitis xerotica obliterans (BXO) remains controversial, Rickwood et al reported an incidence of 84% in those with cicatrising phimosis. The assessment of foreskins, to determine those that are likely to have BXO and require cicumcision, significantly contributes to the paediatric surgeon's outpatient workload. At our centre we have established a specialist nurse-led foreskin clinic for this purpose. We present our preliminary results. The foreskin clinic was set up in November 2004. It has a caseload of 20 patients bi-monthly. The clinics are nurse-led and run in conjunction with a Paediatric Urology clinic to ensure that consultant advice is available if required. There is a set treatment plan for presenting symptoms and follow-up. Over a two year period of 2005-2006, 776 patients were referred to the clinic for assessment of their foreskins. Of these 122 (16%) did not attend. Of the 654 patients seen, the majority 482 (74%) were found to have entirely normal foreskins with only physiological phimosis. In these cases the nurse was able to reassure the patients, give advice regarding foreskin care, and discharge. 23 patients (3.5%)showed evidence of BXO and were referred for circumcision. 132 (20%) were successfully treated with topical trimovate. 12 (1.8%) patients were referred to other speciality clinics, eg dermatology. One patient was found to have previously undiagnosed hypospadias. 4 (0.6%) patients required no treatment but were followed up due to parental anxiety. Providing a nurse-led specialist clinic has improved the continuity of care for boys with foreskin problems, decreased outpatient waiting times and reduced the number of circumcisions being undertaken for medical reasons at our centre.

A Specialised Foreskin Clinic

PURPOSE 10,594 circumcisions were performed on children in England during 2006 making it one of the most commonest paediatric operations. Whilst the overall incidence of balanitis xerotica obliterans (BXO) remains controversial, Rickwood et al reported an incidence of 84% in those with cicatrising phimosis. The assessment of foreskins, to determine those that are likely to have BXO and require cicumcision, significantly contributes to the paediatric surgeon's outpatient workload. At our centre we have established a specialist nurse-led foreskin clinic for this purpose. We present our preliminary results. MATERIAL AND METHODS The foreskin clinic was set up in November 2004. It has a caseload of 20 patients bi-monthly. The clinics are nurse-led and run in conjunction with a Paediatric Urology clinic to ensure that consultant advice is available if required. There is a set treatment plan for presenting symptoms and follow-up. RESULTS Over a two year period of 2005-2006, 776 patients were referred to the clinic for assessment of their foreskins. Of these 122 (16%) did not attend. Of the 654 patients seen, the majority 482 (74%) were found to have entirely normal foreskins with only physiological phimosis. In these cases the nurse was able to reassure the patients, give advice regarding foreskin care, and discharge. 23 patients (3.5%)showed evidence of BXO and were referred for circumcision. 132 (20%) were successfully treated with topical trimovate. 12 (1.8%) patients were referred to other speciality clinics, eg dermatology. One patient was found to have previously undiagnosed hypospadias. 4 (0.6%) patients required no treatment but were followed up due to parental anxiety. CONCLUSIONS Providing a nurse-led specialist clinic has improved the continuity of care for boys with foreskin problems, decreased outpatient waiting times and reduced the number of circumcisions being undertaken for medical reasons at our centre.

Effectiveness of a specialist nurse-led intervention clinic in the management of cardiovascular risk factors in diabetes

AbstractAim: To evaluate the effectiveness of a specialist nurse-led, protocol-driven and doctor-supervised clinic in the management of cardiovascular risk factors, particularly hypertension and hyperlipidaemia.Methods: Patients with type 2 diabetes attending the diabetes specialist service, who had uncontrolled hypertension or hyperlipidaemia, were recruited to participate in the study. Patients were followed in a specialist nurse-led intervention clinic for effective control of blood pressure (BP), lipid profile and other vascular risk factors. Antihypertensive agents and lipid-lowering drugs were sequentially introduced and dose titrated according to protocols. Patients were discharged once target BP (<140/80 mmHg) and/or target lipid profile were achieved.Results: Ninety-four patients were managed in the clinic between April 2003 and March 2004. The mean age of the patients was 62±9 years and their duration of diabetes was 18±14 years. Seventy-seven patients were hypertensive at first visit and antihy...

An audit of a specialist nurse-led rapid-access chest pain clinic

Objective: Rapid-access chest pain clinics, typically run by doctors, allow the rapid assessment of suspected new-onset angina. Five years ago specialist nurse-led rapid-access chest pain clinics were established at Royal Albert Edward Infirmary. The objective of this audit was to assess safety and effectiveness of these clinics. Method: Retrospective data were collected from all patients from January 2002 to December 2006. Results: GPs referred 1464 patients. Of those, 1349 (92.14%) patients were seen within the 14-day government target. The clinic had 1417 (96.8%) patients who under went exercise testing and 234 (16%) of these were positive. Of those patients 143 (61.8%) under went cardiac catheterization. Coronary artery disease was found in 110 patients. Eighty one patients under went revascularization and 29 patients were treated medically. Conclusions: This audit demonstrates that specialist nurse–led rapid -access chest pain clinics are safe and effective. They identify patients who are more likely to have coronary artery disease, therefore allowing early medical/surgical intervention and reducing patient morbidity and mortality. The burden on doctors is reduced and government targets are met.

Developing a service for children with iron deficiency anaemia

The IDEAS (Iron Deficiency Early Anaemia Services) project is a programme aimed at detecting and offering a system of care for children with iron deficiency anaemia. It is designed and run by health visitors and nurses in an inner-city area of Bradford. Children with low haemoglobin are referred by the health visitor to the specialist nurse-led clinic. Dietary advice consistent with tradition and culture is given and appropriate referrals made to the GP for iron supplementation, and to the consultant paediatrician or haemoglobinopathy adviser when appropriate. An important development has been the identification of a previously undiagnosed abnormal haemoglobin trait.

Counselling of women with epilepsy on anti-epileptic drugs: The value of nurse-led clinics

Objective: To improve the information received by women with epilepsy of childbearing age about gender-specific issues. Methods: The case-notes of 100 women of childbearing age (including pubertal adolescents) attending epilepsy clinics were examined before and after the introduction of a specialist nurse-led clinic. Data were collected on the documentation of counselling about contraception, pregnancy and the genetic risk of epilepsy. Results: The introduction of a nurse-led clinic for women demonstrated an increase in the amount of information given. There was a 30% increase in advice given about contraception, 89.7% of those on enzyme-inducing anti-epileptic drugs were informed of the risk of failure of the oral contraceptive pill compared to 53.2% before the intervention. Information given about the risks associated with experiencing generalized tonic-clonic seizures during pregnancy, as well as the need for compliance, increased by 40%. Conclusions: The introduction of a nurse-led clinic resulted in an increase in the amount of information given, and has also provided a better basis for evaluating that information.

Five-year results of the Sigma total knee arthroplasty

The DePuy Sigma total knee arthroplasty (TKA) was introduced in 1997 as a modification of the Press Fit Condylar Knee (PFC) TKA and has been used extensively in the United Kingdom and worldwide. It is the most commonly used TKA in England and Wales, where it accounts for 36% of all primary TKA. The PFC was well established, with reported 10-year survival rates of 93–97%, but this study reports the first 5-year clinical and radiographic follow-up data for the Sigma TKA. Over a 10-month period, 212 Sigma TKAs were performed in 180 patients. Patients were seen at a specialist nurse-led clinic 7 to 10 days before admission and at 6 months, 18 months, 3 years and 5 years after surgery. Data were recorded prospectively at each visit. Radiographs were obtained at the 5-year follow-up appointment. Of 212 knees, 178 (151 patients) were alive at 5 years. Three were lost to follow up. Six knees (3.0%) were revised, five for infection and one underwent change of polyethylene insert at 4.9 years. Five-year survival with an endpoint of revision for any reason was 97.0%; with an endpoint of revision for aseptic failure it was 99.5%. The median American Knee Society knee rating score was 93 out of 100 at 5 years compared with 25 out of 100 at admission. Of 147 radiographs, none showed radiographic loosening of either component. Seventeen (11.6%) showed radiolucent lines. Twenty-eight (19.0%) had alignment outside the range of 7 ± 3° valgus. These results suggest that the Sigma TKA gives acceptable clinical results after 5 years. Further follow-up studies are required to see if this performance is maintained in the long term.