2018

Factors associated with physiotherapists' preference for MRI in primary care patients with low back and leg pain (2018)

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Type of publication:
Journal article

Author(s):
*Ely S. ; Stynes S.; Ogollah R.; Foster N.E.; Konstantinou K.

Citation:
Musculoskeletal Science and Practice; Dec 2018; vol. 38 ; p. 46-52

Abstract:
Background: Criticisms about overuse of MRI in low back pain are well documented. Yet, with the exception of suspicion of serious pathology, little is known about factors that influence clinicians' preference for magnetic resonance imaging (MRI) at first consultation. Objective: To explore factors associated with physiotherapists' preference for MRI for patients consulting with benign low back and leg pain (LBLP) including sciatica. Design: Cross-sectional cohort study. Methods: Data were collected from 607 primary care LBLP patients participating in the ATLAS cohort study. Following clinical assessment, physiotherapists documented whether he/she wanted the patient to have an MRI. Factors potentially associated with physiotherapists' preference for imaging were selected a priori from patient characteristics and clinical assessment findings. A mixed-effects logistic regression model examined the associations between these factors and physiotherapists' preference for MRI. Results: Physiotherapists expressed a preference for MRI in 32% (196/607) of patients, of whom 22 did not have a clinical diagnosis of sciatica (radiculopathy). Factors associated with preference for MRI included; clinical diagnosis of sciatica (OR 4.23: 95% CI 2.29, 7.81), greater than 3 months pain duration (2.61: 1.58, 4.30), high pain intensity (1.24: 1.11, 1.37), patient's low expectation of improvement (2.40: 1.50, 3.83), physiotherapist's confidence in their diagnosis (1.19: 1.07, 1.33), with greater confidence associated with higher probability for MRI preference. Conclusion: A clinical diagnosis of sciatica and longer symptom duration were most strongly associated with physiotherapists' preference for MRI. Given current best practice guidelines, these appear to be justifiable reasons for MRI preference at first consultation.

Results of a multicentre randomised controlled trial of cochlear-sparing intensity-modulated radiotherapy versus conventional radiotherapy in patients with parotid cancer (COSTAR; CRUK/08/004) (2018)

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Type of publication:
Journal article

Author(s):
Nutting , Morden JP, Beasley M, Bhide S, Cook A, De Winton E, Emson M, Evans M, Fresco L, Gollins S, Gujral D, Harrington K, Joseph M, Lemon C, Luxon L, van den Blink Q, Mendes R, Miah A, Newbold K, Prestwich R, Robinson M, Sanghera P, Simpson J, Sivaramalingam M, *Srihari NN, Sydenham M, Wells E, Witts S, Hall E; COSTAR Investigators.

Citation:
European Journal of Cancer; Nov 2018; vol. 103 ; p. 249-258

Abstract:
Purpose: About 40-60% of patients treated with post-operative radiotherapy for parotid cancer experience
ipsilateral sensorineural hearing loss. Intensity-modulated radiotherapy (IMRT) can reduce radiation dose to the cochlea. COSTAR, a phase III trial, investigated the role of cochlear-sparing IMRT (CS-IMRT) in reducing hearing loss. Methods: Patients (pT1-4 N0-3 M0) were randomly assigned (1:1) to 3-dimensional conformal radiotherapy (3DCRT) or CS-IMRT by minimisation, balancing for centre and radiation dose of 60Gy or 65Gy in 30 daily fractions. The primary end-point was proportion of patients with sensorineural hearing loss in the ipsilateral cochlea of >=10 dB bone conduction at 4000 Hz 12 months after radiotherapy compared using Fisher's exact test. Secondary end-points included hearing loss at 6 and 24 months, balance assessment, acute and late toxicity, patient-reported quality of life, time to recurrence and survival. Results: From Aug 2008 to Feb 2013, 110 patients (54 3DCRT; 56 CS-IMRT) were enrolled from 22 UK centres. Median doses to the ipsilateral cochlea were 3DCRT: 56.2Gy and CS-IMRT: 35.7Gy (p < 0.0001). 67/110 (61%) patients were evaluable for the primary end-point; main reasons for non-evaluability were non-attendance at follow-up or incomplete audiology assessment. At 12 months, 14/36 (39%) 3DCRT and 11/31 (36%) CS-IMRT patients had >=10 dB loss (p = 0.81). No statistically significant differences were observed in hearing loss at 6 or 24 months or in other secondary end-points including patient-reported hearing outcomes. Conclusion: CS-IMRT reduced the radiation dose below the accepted tolerance of the cochlea, but this did not lead to a reduction in the proportion of patients with clinically relevant hearing loss.

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Patient experience within the adult congenital heart disease outreach network: A questionnaire-based study (2018)

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Type of publication:
Journal article

Author(s):

Georgina Ooues, Paul Clift, Sarah Bowater, Sayqa Arif, Andrew Epstein, Neeraj Prasad, Dawn Adamson, Mandy Cummings, Charles Spencer, Paul Woodmansey, Jenny Borley, *Thomas Ingram, Adrian Morley-Davies, William Roberts, Najmi Qureshi, Susan Hawkesford, Nichola Pope, James Anthony, Thomas Gaffey, Sara Thorne, Lucy Hudsmith and On behalf of The West Midlands ACHD Network, UK

Citation:
Journal of Congenital Cardiology; Sep 2018; vol. 2 (no. 1)

Abstract:
Background: Specialist multi-disciplinary care improves outcomes of Adult Congenital Heart Disease (ACHD) patients. Following the NHS England Congenital Heart Disease standards review, the aim is to deliver high quality, patient-centred, care closer to patients' homes. Cardiac investigations performed on the same day of outpatient appointments reduce the non-attendance rates. This young cohort of patients, benefits from comprehensive multi-disciplinary management. We developed a Patient Questionnaire across our West Midlands ACHD network to measure patient experience. Methods: Patient questionnaires were distributed to patients attending outpatient clinics in all 8 Outreach Centres and the Level 1 ACHD Centre (University Hospitals Birmingham). Results: 71 males (55%) and 59 females (45%), median age range 25-34years old (range between 16 and 75years old), returned the questionnaires (n=130). Most patients travelled less than one hour to hospital (93%, n=120) and less than 20miles (86%, n=99). The mean travel distance was 14+/-12.3miles (range 1 to 160miles), with Level 1 ACHD Centre patients travelling a significantly longer distance (mean 29.6+/-44miles) compared to the local Outreach Centres (mean 11.3+/-9miles, p=0.0037). There was a wide variability in the provision of parking, although most patients found the appointment time and location convenient (91%, n=117 and 95%, n=121 respectively). There was also marked variation in the number of electrocardiograms (19-100%) and echocardiograms (0-60%) performed on the same day as their clinic appointment. Most patients felt they were given enough information regarding their condition (85%, n=98), with no significant differences between the centres (p=0.24). Conclusion: To our knowledge, this is the first questionnaire-based study assessing patient experience within the NHS ACHD Outreach network with significantly reduced travel times and maintained high patient satisfaction. There was a wide variation ininvestigations performed and patient information leaflets provided. Standardisation of services is required at allcentres to ensure equity of care, with Specialist Nurses' input and more availability of tests on the day of clinicappointments in all centres.

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Benign testicular tumour in non-palpable scrotal lesions in patients with abnormal testicular ultrasound (2018)

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Type of publication:
Conference abstract

Author(s):
*Phan Y.; *Loh A.; *Rosli M.; *Anankumar A.; *Lynn N.

Citation:
Journal of Clinical Urology; Jun 2018; vol. 11 ; Supp 1; p. 74

Abstract:
Introduction: Radical orchidectomy may represent a life changing experience for patients. Clinicians strive to accurately diagnose testicular malignancy through careful scrotal examination and testicular ultrasound prior to surgery. Nevertheless, no investigation is 100% accurate. We aim to find out the occurrence of benign testicular tumour in men without palpable scrotal lesions but with abnormal testicular ultrasound. Methodology: All pathological outcomes of orchidectomies from Jan 2011 to Dec 2016 were retrospectively analysed. Results: 220 orchidectomies were performed during this period. 146 patients with a mean age of 44 years old underwent radical inguinal orchidectomies for possible malignancies due to abnormal testicular ultrasound findings with or without palpable lesions. 115 of these patients had palpable scrotal lesions. 101(88%) of these men had malignant tumours on histopathology. 31 patients had no palpable scrotal lesion but had abnormal testicular ultrasound findings that are suspicious of a testicular tumour. Of these patients, 15 (48%) had malignant tumours while 16 patients (52%) had benign testicular tumours. Conclusions: 88% patients with clinically palpable scrotal tumour and ultrasound abnormality were found to have malignant tumour. In contrast, only 52% patients were found to have malignant tumours with ultrasound abnormality without a palpable lesion. Whilst this may not change the need for surgical excision, it is an important consideration in the pre-operative counseling of these men and offer ultrasound surveillance in these men.

A patient centred, self-management app providing digital support and follow up care for citizens with prostate cancer (2018)

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Type of publication:
Conference abstract

Author(s):
*Elves A.; *Dunk S.; *Perry S.; *Srihari N.; Khanduri S.; Redgrave R.; Pope R.

Citation:
Journal of Clinical Urology; Jun 2018; vol. 11 ; p. 26

Abstract:
Introduction: The challenges of increasing cancer survivors, National Survivorship Programme/Recovery package and drive to stratified care combined with funding and workforce constraints require novel approaches to follow-up care. We describe a web-based App facilitating stratified care through remote patient self management for patients undergoing follow-up for prostate cancer. Method: Patients with stable prostate cancer were eligible for recruitment. The App was offered as a replacement to face to face follow-up or for communication and support. App functionalities include remote follow-up, self-reporting of disease/treatment effects, multimedia information/sign posting and secure messaging to a clinical nurse specialist. Outcomes included up-take, use of App functionalities, number of follow-ups delivered, escalations in care and user satisfaction. Results: One hundred and twenty patients identified were eligible for the App. Sixty five patients recruited gen-erated 342 messages and 627 patient self-reported disease/treatment effect entry sessions providing 3036 readings. Sexual health and hormone side effects were most common reported issues.Sixty-six per cent of users were over 69 years. Forty four patients received digital follow-up over the 10 month period. Clinician concerns about disease progression or user lack of internet access or device were the principle obstacle to recruitment. Conclusion: The App was safe and allowed patients to provide feedback upon symptoms, wellbeing and interact proactively with their healthcare team on an ad hoc basis as well as regular follow-up. This fundamental change in approach to delivery of clinical care has wider application to a range of urological conditions.

Sparing the superficial lobe of the parotid during radical radiotherapy for oropharyngeal carcinoma (2018)

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Type of publication:
Conference abstract

Author(s):
*Pettit L.; *Welsh A.G.; *Williams M.T.; *Puzey C.H.

Citation:
Radiotherapy and Oncology; Apr 2018; vol. 127

Abstract:
Purpose or Objective: Parotid sparing IMRT has been shown to reduce incidence of xerostomia, leading to
recovery of salivary function and subsequently improve quality of life. It is usual to contour the whole parotid gland (WPG) which is considered a parallel organ. It can be challenging to meet dose constraints of the WPG even with VMAT. The general consensus in the U.K. has been to use a simple planning constraint of mean < 24 Gy to the WPG. However, this is not always achievable, especially with large tumours. Previous work suggests if only part of the parotid was spared this may be enough for preservation of saliva function. Material and Methods A retrospective dosimetric analysis of ten previous unselected patients who had received bilateral radical radiotherapy 65 Gy in 30 fractions for squamous cell carcinoma of the oropharynx that were identified from ARIA. Demographics were recorded on an excel spreadsheet. The deep lobe (DL) and superficial lobe (SL) of the ipsilateral (IL) and contralateral (CL) parotid gland were contoured on each CT planning slice. Mean dose to the deep lobe (DL) and superficial lobe (SL) was calculated from the original plan with the volume of the WPG. V40 and D50 were recorded. All treatment was replanned using a SL tolerance of V40 < 33% and D50 < 50% without compromise to the PTV's or change to other OAR. The DL of the parotid was not considered an organ at risk (OAR) for the re-plan. Results 10 patients were identified. 8 male, 2 female. All had squamous cell carcinoma of the oropharynx, 7 had tonsilar primaries, 2 base of tongue and 1 posterior pharyngeal wall. 7 were positive for p16. 9 also received concurrent platinum based chemotherapy. As expected the mean volume of the IL and CL parotid were similar (32.8 cc IL (7.8 cc DL, 24.7 cc SL, 31.9 cc CL (7.6 cc DL, 23.7 cc SL). On average, the DL accounted for 24.8% of the IL parotid and 25.1% of the CL parotid. Average IL SL mean dose was significantly reduced from 36.1 Gy to 33.9 Gy, average CL SL mean dose reduced from 28.3 Gy to 25.5 Gy (p = 0.02 t-test). Conclusion Our retrospective study confirmed that tolerances to the superficial lobe only are relatively easy and practical to meet. Previous work suggests that D50 may be a more reliable predictor of recovery of parotid function than mean dose to whole gland. Following this retrospective study our department will change dose constraints to superficial lobe V40 < 33% and D50 < 50% and no longer consider the deep lobe an OAR. Prospective data will investigate preservation of salivary function using D50/V40. (Figure Presented).

Three-layered technique to repair an oroantral fistula using a posterior-pedicled inferior turbinate, buccal fat pad, and buccal mucosal advancement flap (2018)

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Type of publication:
Journal article

Author(s):
*Darr, A; *Jolly, K; Martin, T; Monaghan, A; Grime, P; Isles, M; Beech, T; Ahmed, S

Citation:
British Journal of Oral and Maxillofacial Surgery; Volume 56, Issue 7, September 2018, Pages 638-639