Same-day assessment and management of urgent (2-week wait) colorectal referrals: an analysis of the outcome of 1606 patients attending an endoscopy unit-based colorectal clinic.

AIM: The Rapid Access Diagnosis and Remedy (RADAR) clinic combines 2-week wait (TWW) specialist consultation with 'straight-to-test' flexible sigmoidoscopy (FS) for left-sided 'red-flag' TWW criteria (excluding right-sided mass or iron-deficiency anaemia). The study aims were to determine the effectiveness of RADAR in differentiating colorectal cancer from benign disease and to evaluate the need for whole colonic investigation (WCI) following FS, in symptomatic patients. METHOD: Prospectively collated data of all RADAR patients from November 2005 to November 2009 were analysed, excluding patients referred internally for a FS. The local histology database was later interrogated to detect any missed cancers. RESULTS: Of 1690 patients (729 men; median (range) age: 68 (18-96) years) assessed in RADAR, 84 were excluded. Colorectal cancer (CRC) was diagnosed in 117 (7.3%). Eighty-seven cancers were diagnosed on the day of attendance and a further 13 within a week (88.9% overall). Two patients after a cancer-free FS were found to have a right-sided CRC on WCI (0.24%) and one synchronous cancer was found. No patient with a cancer-free FS having a WCI was subsequently found to have CRC at a median of 35 (12-58) months. CONCLUSION: Flexible sigmoidoscopy, in the context of an endoscopy unit TWW clinic, allows same-day diagnosis of most patients referred with left-sided symptoms, and immediate reassurance and treatment of most benign diagnoses. For these patients, the use of routine WCI following a cancer-free FS does not appear to be beneficial. Adopting this system would significantly reduce the number of barium enemas and colonoscopies currently performed.

Pre-made consent for elective inguinal hernia repair: the need for standardisation-a survey of all UK NHS Trusts.

PURPOSE: Elective inguinal hernia repair (IHR) is one of the most commonly performed operations in the UK. As with all procedures, informed consent is essential. Pre-made consent forms have been suggested to improve consenting practice. This study aimed to assess the usage and quality of pre-made hernia-specific consent forms (PCF) in the UK. METHODS: A freedom of information request was sent to all UK NHS Trusts asking: (1) does the trust perform IHRs; (2) do they have a PCF; and (3) to send a copy. Complications lists on received forms were reviewed and compared to those listed on the British Hernia Society (BHS) "patient information" webpage. RESULTS: 157/185 Trusts (85%) responded. 117/157 (75%) perform IHRs; 16/117 (14%) use PCFs. The number of reported risks was variable (range 4-18), as was the content of each form (28 different risks were listed). Quoted percentage risks were inconsistent (e.g. recurrence range < 1-5%). The frequency of each BHS-quoted risk was (open/laparoscopic): Bleeding 62/75%; infection 85/92%; seroma 31/42%; damage to testicular blood supply 69/75%; damage to abdominal contents NA/25%; haematoma 62/67%; venous thromboembolism 54/50%; recurrence 85/83%; chronic pain 77/58%; mesh infection 23/8%. Zero forms contained all BHS-quoted risks. CONCLUSIONS: Whilst the consent form only provides documentation of the consent process, this study suggests that PCFs do not improve the quality of consent as both the type and likelihood of quoted complications were highly variable between Trusts. As follow-up for elective procedures is rare, it is unlikely that this variability reflects actual measured outcomes.

Current use of procedure specific consent forms for laparoscopic cholecystectomy.

Introduction Procedure specific consent forms (PSCFs) have been shown to improve consenting practice for a standardised list of complications. The aim of this study was to assess the current usage and quality of PSCFs in the National Health Service (NHS) for cholecystectomy, specifically comparing the listed complications with those mentioned on the NHS website. Methods A freedom of information request was sent to all NHS trusts asking whether they perform laparoscopic cholecystectomy and whether they have a PSCF for this. A copy of the PSCF was also requested. Complications stated on these forms were compared with those on the NHS Choices website. Results Overall, 162 (88%) of the 185 trusts responded, with 121 of these performing cholecystectomies. Among these, 20 (17%) currently use PSCFs; all provided a copy. Five (25%) of the PSCFs contained all eight risks mentioned on the NHS website. The number of risks listed varied from 4 to 18 per form. Only bile duct injury was listed on every PSCF. The least frequently mentioned complication (45% of forms) was the risk from general anaesthetic. Conclusions This study suggests that too few trusts are using PSCFs and that those PSCFs that are in use contain too little detail on the risks of cholecystectomy. The listed risks and incidences on each PSCF were highly variable. More trusts should begin to use PSCFs during the informed consent process and each PSCF should include a nationally standardised list of potential complications to act as a prompt for discussion (and documentation) of risk.

Psychiatric manifestations of systemic illness.

Many behavioral manifestations of systemic disease exist, including delirium, psychosis, mania, catatonia, depression, and anxiety. The features and medical causes of each of those manifestations are described. The indications from history and physical examination that suggest underlying medical illness are reviewed. The psychiatric presentations of several specific conditions are discussed in detail.

Indoor rock climbing: who gets injured?

OBJECTIVES: To determine the frequency of overuse injury in indoor climbers, the common sites of such injury, and the factors that influence the probability that a climber will have sustained an overuse injury while climbing indoors. METHOD: A semisupervised questionnaire was used to survey overuse injury in 295 spectators and competitors at the Entre-Prises World Climbing Championships held in Birmingham 3-5 December 1999. Statistical analysis included simple cross tabulations, calculation of odds ratios, and multiple logistic regression to explore the effect of several factors simultaneously. RESULTS: Some 44% of respondents had sustained an overuse injury, 19% at more than one site. The most common site of injury was the fingers. Univariate analysis showed that the probability of having sustained a climbing injury is higher in men (p = 0.009), those who have climbed for more than 10 years (p = 0.006), those who climb harder routes (p<0.0005), and those who boulder or lead more than they top rope (p<0.0005). The relation between lead grade and climbing injury is linear. Multivariate analysis removed the effect of sex as an independent predictor. CONCLUSIONS: Many climbers sustain overuse injury. The most at risk are those with the most ability and dedication to climbing. Climbers should be aware of the risk factors that influence injury and be able to spot the signs and symptoms of injury once they occur.