2020

Solving the preoperative breast MRI conundrum: design and protocol of the MIPA study (2020)

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Type of publication:Journal article

Author(s):Sardanelli F, Trimboli RM, Houssami N, Gilbert FJ, Helbich TH, Alvarez Benito M, Balleyguier C, Bazzocchi M, Bult P, Calabrese M, Camps Herrero J, Cartia F, Cassano E, Clauser P, de Andrade DA, de Lima Docema MF, Depretto C, Forrai G, Girometti R, Harms SE, Hilborne S, Ienzi R, Lobbes MBI, Losio C, Mann RM, Montemezzi S, Obdeijn IM, *Ozcan, Umit A., Pediconi F, Preibsch H, Raya-Povedano JL, Sacchetto D, Scaperrotta GP, Schlooz M, Szabo BK, Ulus OS, Taylor DB, Van Goethem M, Veltman J, Weigel S, Wenkel E, Zuiani C, Di Leo G.

Citation:European Radiology. 2020 Oct;30(10):5427-5436.

Abstract:Despite its high diagnostic performance, the use of breast MRI in the preoperative setting is controversial. It has the potential for personalized surgical management in breast cancer patients, but two of three randomized controlled trials did not show results in favor of its introduction for assessing the disease extent before surgery. Meta-analyses showed a higher mastectomy rate in women undergoing preoperative MRI compared to those who do not. Nevertheless, preoperative breast MRI is increasingly used and a survey from the American Society of Breast Surgeons showed that 41% of respondents ask for it in daily practice. In this context, a large-scale observational multicenter international prospective analysis (MIPA study) was proposed under the guidance of the European Network for the Assessment of Imaging in Medicine (EuroAIM). The aims were (1) to prospectively and systematically collect data on consecutive women with a newly diagnosed breast cancer, not candidates for neoadjuvant therapy, who are offered or not offered breast MRI before surgery according to local practice; (2) to compare these two groups in terms of surgical and clinical endpoints, adjusting for covariates. The underlying hypotheses are that MRI does not cause additional mastectomies compared to conventional imaging, while reducing the reoperation rate in all or in subgroups of patients. Ninety-six centers applied to a web-based call; 36 were initially selected based on volume and quality standards; 27 were active for enrollment. On November 2018, the target of 7000 enrolled patients was reached. The MIPA study is presently at the analytic phase. Key Points • Breast MRI has a high diagnostic performance but its utility in the preoperative setting is controversial. • A large-scale observational multicenter prospective study was launched to compare women receiving with those not receiving preoperative MRI. • Twenty-seven centers enrolled more than 7000 patients. The study is presently at the analytic phase.

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Quality improvement project: improving junior doctors' confidence in prescribing at end of life for acute inpatients (2022)

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Type of publication:Conference abstract

Author(s):*Dewhirst L.; *Hudson H.

Citation:BMJ Supportive and Palliative Care. Conference: Palliative Care Congress 1 Specialty: 3 Settings – Home, Hospice, Hospital. Telford United Kingdom. 10(Supplement 1) (pp A14), 2020. Date of Publication: March 2020

Abstract:Background Junior doctors are often at the forefront of prescribing for acute inpatients. It is imperative that they are equipped with the knowledge and confidence to prescribe appropriately for patients at the end of their life. We felt that there was reduced awareness of the need for individualised prescribing for patients with relatively common chronic diseases such as Parkinson's disease and epilepsy. Recognising that prescribing end of life medications for patients with such diseases can differ, we looked to improve symptom management by focussing on improving end of life prescribing. Methods A pre-intervention questionnaire was used to assess subjective confidence levels in prescribing anticipatory medications, syringe drivers, and individualised prescribing for patients with Parkinson's disease, end-stage renal disease, epilepsy, end-stage heart failure, and diabetes mellitus. Based on these findings a prescribing handbook was produced, incorporating consultant advice from relevant specialities. Teaching sessions were carried out using case-based discussions alongside the handbook content. A local press release facilitated dissemination of the handbook. A post-intervention questionnaire was then distributed to reassess prescribers' confidence levels. Results Twenty-five allied health professionals (mainly foundation doctors) completed the questionnaires. The preintervention questionnaire found that the majority were confident in prescribing anticipatory medication but were significantly less confident in prescribing syringe drivers and in individualised prescribing. Following formal education and release of the prescribing handbook, higher confidence levels were reported throughout all themes of the questionnaire. Conclusions This quality improvement project has significantly increased prescribers' confidence levels in end of life prescribing. It has also increased awareness of the need for alternative approaches to prescribing for certain individuals and diseases at the end of life. It was stressed that the handbook is to be used as a guide and should not replace the need to escalate concerns to the relevant specialities and the in-house palliative care team.

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Reducing intra-hospital telephone communication time using app technology (2020)

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Type of publication:
Conference abstract

Author(s):
*Hamid M.

Citation:
BMJ Leader. Conference: Leaders in Healthcare Conference 2020. Virtual. 4(Supplement 1) (pp A42), 2020. Date of Publication: November 2020.

Abstract:
Background Lengthy switchboard waiting times result in delayed communication between healthcare professionals in a hospital. Wasted time impedes patient care, costs the Trust a substantial financial sum and impacts healthcare professional's morale. Aim(s): To reduce intra-hospital telecommunication time utilising the Induction phone application, an easy to use, regularly updated telephone directory. Method(s): Initial audit: Five chosen specialities were contacted between 9-10 AM from the Emergency department for 2 consecutive weeks. The time taken to reach each speciality via switchboard was recorded. A survey seeking the number of calls made per day, the preferred method of contact and the feelings associated with telephone waiting times was sent to department doctors. PDSA cycle 1: One-month application advertisement and re-audit. PDSA2: Eye-catching tele-directory board with the most used extensions and bleeps displayed in the department. Satisfaction survey sent post PDSA2. Sustainability: New doctors were provided induction information. Result(s): Initial average waiting time via switchboard was 48 seconds. The average calls made per doctor each day was 12. This calculated to a total departmental loss of 20.16 hours per week waiting on the phone, equating an annual loss of 26, 208. PDSA1: Average waiting times reduced to 12 seconds utilising the application; saving an estimate ~19,656 per annum. PDSA2: Instant availability of contact details on the display board further reduced waiting times to an average 6 seconds. 84% of doctors (n=16) disliked waiting more than 20 seconds, with associated feelings of frustration. 100% preferred the display board, then the use of the application before resorting to switchboard. 100% Sustainability was recorded one year later. Conclusion(s): The use of application technology reduces wasted time which hampers patient care; reduces Trust running costs; and improves health care professional's morale at work.

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#OrthoTwitter: social media as an educational tool (2020)

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Type of publication:Journal article

Author(s):Sahu MA; Goolam-Mahomed Z; Fleming S; *Ahmed U

Citation:BMJ Simulation & Technology Enhanced Learning, 2020 Sep 07; Vol. 7 (5), pp. 277-284

Abstract:Aims: The increased use of social media creates opportunity for new, effective methods of delivering medical and clinical education. Twitter is a popular social media platform where users can post frequent updates and create threads containing related content using hashtags. This study aims to investigate and analyse the type of content relating to orthopaedic surgery that is being posted on the platform of Twitter.Methods: A retrospective search was performed for tweets containing the words 'orthopaedic surgery' or 'orthopedic surgery' or the use of the hashtag '#OrthoTwitter' between November 2018 to November 2019. A total of 5243 tweets were included.Results: Tweets containing 'orthopaedic surgery' or 'orthopedic surgery' most frequently contained promotional or marketing content (30% promotional, 21% marketing), and private organisations were the category of author to which the greatest number of tweets belonged (30%). Tweets containing educational or research content were the least common among all tweets containing 'orthopaedic surgery' or 'orthopedic surgery' (11%). In contrast, of the tweets containing the hashtag '#OrthoTwitter', 44% contained educational or research content, 15% contained promotional content and no tweets containing marketing content. Furthermore, 87% of all tweets using the hashtag '#OrthoTwitter' were from orthopaedic surgeons, and the least number of tweets were from private organisations (2%).Conclusion: Twitter is a widely used social media platform regarding orthopaedic surgery. We propose that the hashtag '#OrthoTwitter' can be used to create an online community of orthopaedic surgeons where members can assist one another through sharing reliable and educational content.

Perioperative outcomes after laparoscopic cholecystectomy in the elderly patients: Asystematic review and meta-analysis (2020)

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Type of publication:
Conference abstract

Author(s):
Kew T.; Lin A.; Ekeozar C.; Bundred J.; Evans R.; Griffiths E.; Kamarajah S.; *Karri S.; Singh P.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 5-6

Abstract:
Aim: The need to perform elective and emergency cholecystectomy in an ever ageing population increases yet these risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population.
Method(s): A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted and a meta-analysis was performed in accordance with the recommendations of the Cochrane Library and PRISMA guidelines.
Result(s): This review identified 99 studies incorporating 333,041 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.33, CI95%: 2.00-2.71, p<0.001), major complication (OR 2.32, CI95%: 1.52-3.54, p<0.001), risk of conversion to open cholecystectomy (OR 2.32, CI95%: 1.95-2.76, p<0.001), risk of bile leaks (OR 2.05, CI95%: 1.18-3.55, p<0.001), risk of postoperative mortality (OR 5.99, CI95%: 3.77-9.52, p<0.001) and was significantly associated with increased length of stay (MD 2.12 days, CI95%: 1.01-3.24, p<0.001).
Conclusion(s): Post-operative outcomes such as overall and major complications are significantly higher in all age cut-offs. There is six-fold increase in perioperative mortality which increases by nine-fold in patients >80 years old. This study confirms preconceived suspicions of risk in elderly patients undergoing cholecystectomy and will aid treatment planning and informed consent.

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Is pain properly managed in children presenting with fractures? A retrospective audit of children presenting to the emergency department (2020)

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Type of publication:
Conference abstract

Author(s):
*Rafie A

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 68

Abstract:
Aim: Pain is a common problem in the surgical field, especially when treating children – but how well is it managed, and documented? In this audit we aim to answer a few key questions. Is analgesia administered prehospital? Are pain scores recorded, and re-evaluated? And is analgesia offered and/or administered in the Emergency Department(ED)? Method: A retrospective audit was carried out between two hospitals on 100 patients aged between 5-15 presenting to the ED. A search was carried out using SNOMEDand ICD10 codes, to find patients presenting with fractures – and the ED CAS cards reviewed.
Result(s): The data showed poor compliance between both hospitals – pain scores were seldom recorded, or reevaluated; and in 58% of cases analgesia was not offered and no reason was documented. 28% of patients were given pre-hospital analgesia and only 2% of patients had an analgesia review.
Conclusion(s): Adequate pain management is vital, especially in children – as they often don't self-report pain. The study found that the worst compliance was in documentation of pain scores, and their re-evaluation. However, more concerningly analgesia was only administered in 19% of cases – and in many cases there was no documentation as to why it wasn't offered.

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Radiation and body mass index, are your overweight patients more at risk? astudy looking at radiation doses during intervention for renal tract calculi (2020)

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Type of publication:
Conference abstract

Author(s):
Lefroy R.; Johnson A.; McCrea J.; *Dunk S.; *Elves A.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 226-227

Abstract:
Aim: Renal tract stones are more common in overweight individuals as part of metabolic syndrome. Modern fluoroscopic devices used during ureteroscopy adjust exposure, providing high imaging quality. Consequently, total radiation doses in this group is increased compared to patients with lower BMIs. Patients with obesity and stone disease will potentially be exposed to more radiation, increasing the risk of developing malignancy. We assessed the radiation doses that our stone population received during fluoroscopic ureteroscopic procedures and how this varied with BMI.
Method(s): 62 consecutive patients undergoing fluoroscopic ureteroscopic laser procedures were identified between March and August 2018, ten of these were uretorenoscopies and were therefore excluded from analysis. Radiation exposure was corrected for dose/unit time and BMI was defined by criteria set by NHS Choices.
Result(s): There was significant association between BMI and radiation exposure as measured does/unit time. The exposure for those with the highest BMI was up to four times that of the lowest BMI.
Conclusion(s): Fluoroscopy in patients with high BMI should seek to limit radiation exposure. This could be achieved by use of snap imaging and ureteroscopy under direct vision where appropriate. Consideration of radiation exposure should be given within the consent process especially when compared to alternative therapies.

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Impact of gastrografin in clinical practice in the management of small bowel obstruction of various etiologies (2020)

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Type of publication:
Conference abstract

Author(s):
*Karim M.O.; *Jamshed M.H.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 204

Abstract:
Aim: Gastrografin has shown to accelerate the resolution of small bowel obstruction of certain etiologies. This audit aims to review the outcome of oral gastrografin (OG) in patients with the small bowel obstruction of diverse causes diagnosed on radiological investigation.
Method(s): A retrospective study of 57 patients who had oral gastrograffin for small bowel obstruction
between 1st June 2018 to 30th June 2019 was included in this study.
Result(s): After excluding 9 patients, 48 included in the study who met the inclusion criterion. 31 patients had adhesive small bowel obstruction (ASBO), of these symptoms resolved in 52% after OG, all patients with postoperative ileus (9), Crohn's stricture (3) and constipation with small bowel dilatation (1) showed resolution of obstructive symptoms with oral gastrografin. 2 patients out of 3 with serosal/peritoneal metastasis showed response to oral gastrografin.
Conclusion(s): Gastrografin is beneficial and safe to use as a therapeutic agent in a carefully selected patient with certain GI conditions including adhesive small bowel obstruction, postoperative ileus, Crohn's stricture, constipation, serosal metastasis (peritoneal cancer). Appropriate use of gastrografin can reduce the need for surgical intervention and hospital stay.

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Boat propeller transection of hemithorax-successful multidisciplinary surgical reconstruction (2020)

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Type of publication:
Conference abstract

Author(s):
*Cheruvu S.; Oo K.T.M.; Erel E.; Satur C.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 37

Abstract:
A 69 year old man fell into canal and was drawn into the propeller of his canal boat that resulted in transection of the right thoracic cavity and the right upper arm. Emergency helicopter transfer was made to our major trauma centre for multidisciplinary surgical care. Injuries included a full thickness antero-posterior transection from the sternum to beyond the tip of the scapula, and an open right midshaft humeral fracture with wound extending obliquely into the axilla. The entire thoracic cavity was contaminated by canal water. There was severe haemodynamic and cardiorespiratory compromise requiring level 3 intensive care. Following emergency resuscitative management, multidisciplinary surgical care was provided by the cardiothoracic, plastic and orthopaedic surgery teams utilising innovative operative techniques. Multistage operative management of chest wall required initial damage control surgery with debridement and negative pressure therapy. After 4 days of intensive care physiological stabilisation, reconstruction of the thoracic defect was undertaken with specialist thoracic titanium implants and the chest wall was reconstructed. This was a major thoracic trauma case treated successfully using revolutionary surgical techniques at the Royal Stoke Hospital. The subsequent impact on practice for thoracic polytrauma has led to improved survival rates by 75%.

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Assessing the adequacy of radiographs for hip fractures (2020)

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Type of publication:
Conference abstract

Author(s):
*Mulrain J.; *Omar N.; *Burston B.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 138

Abstract:
Aim: Radiographs for the assessment of femoral neck fractures are frequently inadequate for the visualisation of the proximal femur. A low centred radiograph of both hips offers enough information but is rarely achieved.We sought to determine the proportion of hip fractures where initial radiographs adequately visualised the femur to encompass the proposed surgical management.We also sought to find the proportion of patients who required repeat radiographs and whether this was affected by time of presentation. Method(s): A retrospective review of the radiographs of hip fractures presenting to our institution, over a three-month period was undertaken. The timings, number and adequacy of radiographs was assessed. Result(s): Radiographs of 89 patients were reviewed. Most radiographs were taken between 8am and 5pm. Radiographs of 58 patients were centred on the pelvis rather than the hips. Patients presenting overnight were more likely to have adequate radiographs. Despite a duplicate x-ray rate of 48%, most patients (55%) had inadequate visualisation of the proximal femur. The average excess radiation exposure by duplicate radiographs was 2.31mSv per patient. Conclusion(s): The majority of patients had inadequate visualisation of the fractured proximal femur on their radiographs.Many had excessive radiographs performed. This was not improved by increased staffing levels during daylight hours.

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