Gout in primary care: Can we improve patient outcomes?

In the United Kingdom, gout represents one of the most common inflammatory arthropathies predominantly managed in the primary care setting. Gout is a red flag indicator for cardiovascular disease and comorbidity. Despite this, there are no incentivised treatment protocols and suboptimal management in the primary care setting is common. A computer based retrospective search at a large inner city GP practice between January 2014-December 2014 inclusive, identified 115 patients with gout. Baseline measurements revealed multiple gout related consultations, poor medication compliance, high uric acid levels and deficiencies in uric acid monitoring. A series of improvement cycles were conducted. A telephone questionnaire conducted in January 2015, identified that patient education was suboptimal. The following improvement cycles aimed to educate patients, improve uric acid monitoring and support medication compliance. It was ultimately hoped that these measures would reduce gout flares and GP practice attendance. The improvement cycles contributed towards reduction in uric acid levels from 0.37 to 0.3 (p=0.14), 20% reduction in patients experiencing one or more gout flares and 77% reduction in GP related consultations between March 2015-March 2016 compared to baseline. The proportion of patients fully compliant with taking their urate lowering therapies improved from 63% to 91% (p=0.0001). A follow up series of PDSA cycles were performed between July-December 2016. The purpose of these cycles was to assess the sustainability of the improved medication compliance demonstrated by the improvement cycles. Three months following the completion of the improvement cycles, full medication compliance dropped from 91% to 70% (p=0.0001). The introduction of a paper calendar saw sustained and maintained improvement in medication compliance to 100% (p=0.0001) at the end of the study period. The improvement and PDSA cycles have demonstrated that simple interventions can be a sustainable way of improving disease control and patient outcomes.

An Anatomic Appraisal of Biplanar Muscle-Splitting Breast Augmentation.

BACKGROUND: Biplanar muscle-splitting (BMS) breast augmentation is a relatively new technique for which the safe regions of dissection have not been delineated. OBJECTIVES: The authors performed cadaver dissections to elucidate the surgical anatomy of the BMS pocket and to infer the safety of this method. METHODS: The breasts and chest regions of 5 female cadavers were dissected to identify anatomic landmarks and to ascertain the optimal split site in the pectoralis major. CS was defined as the lateral junction of the middle and caudal one-third of the sternum, and the sternal index was defined as the ratio of the length of the sternum to the distance from CS to the most medial major nerve branch. RESULTS: Initiating the muscle split at CS is likely to avoid nerve injury. The mean distance from CS to the most medial nerve branch was 15.36 cm. The sternal index is a reproducible marker of the extension of the nerve branches in relation to chest size. The sternal length and the cranio-caudal length of the pectoralis major were similar, enabling reliable planning of the muscle split site. CONCLUSIONS: If dissection is limited to the safe regions delineated herein, BMS breast augmentation is likely to be a safe procedure for most patients. By maintaining the connections between the pectoralis major and its origins, a breast deformity associated with muscle contraction may be avoidable.

Analgesia in hip fractures. Do fascia-iliac blocks make any difference?

Despite recent national advances in the care for the hip fracture patient, significant morbidity and mortality persists. Some of this morbidity is attributable to the analgesia provided in the hospital setting. The National Institute of Health and Care Excellence and the Association of Anaesthetists of Great Britain and Ireland recommend the use of simple oral analgesia including opioids, with fascia-iliac blocks (FIB) used as an adjunct. Literature review reveals a paucity of evidence on this. The aim of this project was to evaluate the proportion of patients receiving a fascia-iliac block prior to operative intervention. A secondary aim was to evaluate the efficacy of these blocks through analysis of pre and post-operative opioid usage, post-operative delirium, time to bowel opening, and naloxone use. Patients who received a fascia-iliac block received significantly less post-operative and total analgesia (p=0.04, p=0.03), had lower rates of delirium (p=0.03) and those patients which were discharged directly home had a shorter inpatient stay (p=0.03). No patients who received a fascia-iliac block (FIB) needed naloxone to reverse opioid toxicity, whilst two without fascia-iliac block did. The results of the project eventually led to the introduction of a hip fracture care pathway which incorporates a single shot fascia-iliac block for all patients who are eligible. Within a two year study period, compliance with fascia-iliac blocks improved from 54% to 90%. Our experience shows a great improvement in compliance with fascia-iliac blocks in the pre-operative period. This work has also underpinned the introduction of a new hip fracture care pathway ultimately to better patient care and outcomes.

The partial myocutaneous gluteal flap reconstruction of extralevator abdominoperineal defects in irradiated patients.

Reconstruction of the irradiated perineum has posed a consistent reconstructive challenge historically. The evolution of reconstructive techniques must mirror advances in neoadjuvant treatment and surgery for low rectal cancer. The purpose of this study was to evaluate the perineal healing in a cohort of patients, of whom a majority had laparoscopic tumor excision and partial myocutaneous gluteal flap reconstruction. There were 11 patients in this cohort; 8 primary reconstructions and 3 salvage cases. Complete healing was measured as the cessation of all dressings. There were no returns to theater for flap-related surgery. Mean postreconstruction inpatient stay was 16.5 days. All patients healed completely. Mean time to healing was 42 days. This method has been successful for primary and salvage reconstruction in patients having laparoscopic or open surgery; thus, averting the major morbidity associated with failed reconstruction as reported for most of other reconstructive modalities in these patients.

Delay in pathological tissue processing time vs. mortality in oral cancer: short communication.

Several factors have been identified to affect morbidity and mortality in oral cancer patients. The time taken to process a resected cancer specimen in a patient presenting with primary or recurrent disease can be of interest as delay can affect earlier interventions post-surgery. We looked at this variable in a group of 168 consecutive oral cancer patients and assessed its relationship to mortality from the disease at 3 and 5 years. It is expected that delay in pathological processing time of surgical specimens acquired from patients with recurrent disease may increase or contribute to the increased rate of mortality. Further high evidence-based studies are required to confirm this.

The effect of tobacco and alcohol and their reduction/cessation on mortality in oral cancer patients: short communication.

BACKGROUND: The use of tobacco is known to increase the incidence of developing oral cancer by 6 times, while the additive effect of drinking alcohol further increases the risk leading to higher rate of morbidity and mortality. In this short communication, we prospectively assessed the effect of tobacco smoking and alcohol drinking in oral cancer patients on the overall mortality from the disease, as well as the effect of smoking and drinking reduction/cessation at time of diagnosis on mortality in the same group. MATERIALS AND METHODS: A cohort, involved 67 male patients who were diagnosed with oral squamous cell carcinoma, was included in this study. The smoking and drinking habits of this group were recorded, in addition to reduction/cessation after diagnosis with the disease. Comparisons were made to disease mortality at 3 and 5 years. RESULTS: Follow-up resulted in a 3-year survival of 46.8% and a 5-year survival of 40.4%. Reduction of tobacco smoking and smoking cessation led to a significant reduction in mortality at 3 (P < 0.001) and 5 (P < 0.001) years. Reduction in drinking alcohol and drinking cessation led to a significant reduction in mortality at 3 (P < 0.001) and 5 (P < 0.001) years. CONCLUSION: Chronic smoking and drinking does have an adverse effect on patients with oral cancer leading to increased mortality from cancer-related causes. Reduction/cessation of these habits tends to significantly reduce mortality in this group of patients. Smoking and drinking cessation counseling should be provided to all newly diagnosed oral cancer patients.

cTNM vs. pTNM: the effect of not applying ultrasonography in the identification of cervical nodal disease.

Accurate clinical staging of oral squamous cell cancer can be quite difficult to achieve especially if nodal involvement is identified. Radiologically-assisted clinical staging is more accurate and informs the clinician of loco-regional and distant metastasis.In this study, we compared clinical TNM (cTNM) staging (not including ultrasonography) to pathological TNM (pTNM) staging in 245 patients presenting with carcinoma of the oral cavity and the oro-pharyngeal region. Tumour size differences and nodal involvement were highlighted. US reports of the neck were then added to the clinical staging and results compared.Tumour size was clinically underestimated in 4 T1, 2 T2 and 2 T3 oral diseases. Also 20 patients that were reported as nodal disease free had histological proven N1 or N2 nodal involvement; while 3 patients with cTNM showing N1 disease had histologically proven N2 disease.Overall the agreement between the 2 systems per 1 site was 86.6% (Kappa agreement = 0.80), per 2 sites 90.0% (Kappa agreement = 0.68) and per 3 sites 90.5% (Kappa agreement 0.62).An accurate clinical staging is of an utmost importance. It is the corner stone in which the surgical team build the surgical treatment plan and decide whether an adjuvant therapy is required to deal with any possible problem that might arise. The failure to achieve an accurate staging may lead to incomplete surgical planning and hence unforeseen problems that may adversely affect the patient's survival.

A comparison of the outcome of aneurysmal subarachnoid haemorrhage before and after the introduction of an endovascular service.

There has been a rapid change from predominantly surgical to endovascular treatment of ruptured intracranial aneurysms giving the opportunity to assess change in patient outcome during this transition. We identified and followed 139 patients with subarachnoid haemorrhage (SAH) treated in the year prior to (group 1) and following (group 2) the introduction of an endovascular service in a retrospective, cross-sectional study. A total of 78.7% of patients in group 1 underwent surgical treatment, 10.7% underwent endovascular treatment and 10.7% received no treatment, whereas patients in group 2 received 29.7%, 65.7% and 4.7%, respectively. MRS scores were obtained in 91% of patients in group 1 and in 89% of patients in group 2. A total of 30.7% and 24.0% of patients had a poor outcome in groups 1 and 2 respectively (p=0.34). The overall change in the management of ruptured cerebral aneurysms in the post-International Subarachnoid Aneurysm Trial (ISAT) era has not significantly changed cross-sectional outcome, although absolute differences appear to reflect difference in outcome noted in the ISAT.