Glycemic Variability as a Predictor of Graft Failure Following Infrainguinal Bypass for Peripheral Arterial Disease: A Retrospective Cohort Study.

BACKGROUND: Glycemic variability (GV), measured as the change in visit-to-visit glycated hemoglobin (HbA1c), increases the risk of multiple adverse outcomes. However, the impact of GV on graft patency following infrainguinal bypass (IIB) is unknown. A retrospective cohort study was undertaken to assess the impact of GV on graft patency. METHODS: A 3-year single-center retrospective case notes analysis of all people undergoing IIB between 2017 and 2019. Rutherford stage, graft conduit, level of bypass, procedure details, baseline demographics, comorbidities, and GV were assessed. Time to reintervention, ipsilateral amputation, or death was recorded to determine primary patency (PP). RESULTS: One hundred six IIB outcomes were analyzed: mean (± standard deviation) age 68.0 (9.2) years; 69 (65.1%) male, 37 (33.9%), 75 (70.8%) had diabetes mellitus; and 46 (43.4%) underwent elective procedures. GV > 9.1% was associated with significantly lower median PP than GV < 9.1%, 198 (97-753.5) vs. 713 (166.5-1,044.5) days (P = 0.045). On univariate analysis, GV > 9.1% vs. < 9.1% was significantly associated with PP (hazard ratio [HR] 1.85 [confidence interval {CI} 1.091-3.136], P = 0.022). Bypass level was also a univariate predictor, with below knee bypasses (HR 2.31 [CI 1.164-4.564], P = 0.017), and tibial (HR 2.00 [CI 1.022-3.090], P < 0.043) having lower PP than above knee bypasses. On multivariate adjustment, GV > 9.1% and level of bypass remained independent predictors of PP, HR 1.96 (95% CI: 1.12-3.42, P = 0.018) and HR 2.54 (95% CI: 1.24-5.22, P = 0.011), respectively. CONCLUSIONS: GV is an independent predictor of PP following infrainguinal bypass, thus optimizing GV should be a therapeutic target.

Relationship between the m-FI 11 score and 2-year survival in octogenarians undergoing colorectal cancer resection.

Introduction: The modified Frailty Index (m-FI) offers a simple scoring tool, predicting short-term outcomes in elderly colorectal cancer (CRC) patients. However, links between m-FI scores and 2-year postoperative mortality in octogenarian CRC resection patients remain underexplored. A streamlined frailty index can aid in preoperative assessments to identify elderly patients who are likely to live longer after curative resection surgery to then tailor postoperative care. Our study aims to assess the association between m-FI scores and 2-year postoperative mortality in elderly CRC surgery patients. Methods: A retrospective analysis was conducted on a cohort of consecutive patients aged older than or equal to 80 years who underwent colorectal cancer resection at a tertiary referral centre between 2010 and 2017. The m-FI-11 scores less than or equal to two denoted the non-frail category, whereas m-FI scores equal to or exceeding 3 were categorised as frail. The primary outcome measure was defined as 2-year all-cause mortality. Results: A total of 337 patients were studied. The 2-year overall survival rate was 83% with an overall median survival time of 84 months (95% CI: 74-94 months). Patients with m-FI scores less than or equal to 2 had a 2-year survival rate of 85% and a median survival time of 94 months (95% CI: 84-104 months). Conversely, patients with m-FI scores greater than or equal to 3 had a 2-year survival rate of 72% and a median survival time of 69 months (95% CI: 59-79 months). An m-FI score greater than or equal to 3 showed a hazard ratio of 1.73 (95% CI: 0.92-3.26, P=0.092) for 2-year mortality compared to an m-FI score less than or equal to 2. Conclusion: Higher m-FI scores significantly correlate with an increased 2-year mortality risk among octogenarian CRC resection patients. This highlights the potential of the m-FI as a preoperative tool for identifying patients likely to survive longer post-surgery. Its integration aids in tailored postoperative care strategies, ensuring efficient recovery to functional baselines in this cohort.

The effect of different types of oral or intravenous corticosteroids on capillary blood glucose levels in hospitalized inpatients with and without diabetes.

PURPOSE: This study investigated: (1) the type of corticosteroid associated with the greatest degree of hyperglycemia, assessed using bedside capillary blood glucose monitoring, in hospitalized patients; and (2) the pattern of hyperglycemia throughout the day with the use of each type of corticosteroid. METHODS: This single-center, retrospective study used data from 964 adult inpatients receiving oral or IV corticosteroids. Data on capillary blood glucose concentrations and time taken over 7 days were collected. A mixed model for repeated measures was applied to investigate changes in glucose concentration over time with the use of four different corticosteroids. An autoregressive covariance structure was used to model correlations between repeated measurements. FINDINGS: Across all 7 days, the mean blood glucose concentration was greater with dexamethasone compared to that with hydrocortisone (mean difference, 16.6 mg/dL [95% CI, 8.1-24.8] [0.92 mmol/L (95% CI, 0.45-1.38)]) or prednisolone (mean difference, 20.0 mg/dL [95% CI, 14.2-25.7] [1.11 mmol/L (95% CI, 0.79-1.43)]). The mean blood glucose concentration was greater with methylprednisolone compared to that with hydrocortisone (mean difference, 23.9 mg/dL [95% CI, 11.3-36.4] [1.33 mmol/L (95% CI, 0.63-2.02)]), and with methylprednisolone versus prednisolone (mean difference, 27.4 mg/dL [95% CI, 16.4-38.3] [1.52 mmol/L (95% CI, 0.91-2.13)]). There were no significant differences in the patterns of hyperglycemia at six time points of the day with each type of corticosteroid. IMPLICATIONS: Treatment with oral or IV dexamethasone or methylprednisolone was associated with greater hyperglycemia in comparison to prednisolone and hydrocortisone. More vigorous monitoring and intervention, when necessary, are suggested in adult inpatients receiving corticosteroids, in particular dexamethasone and methylprednisolone.

How do medical students want to learn ENT? Perspectives from a consensus forum.

OBJECTIVE: The UK Medical Licensing Assessment curriculum represents a consensus on core content, including ENT-related content for newly qualified doctors. No similar consensus exists as to how ENT content should be taught at medical school. METHOD: A virtual consensus forum was held at the 2nd East of England ENT Conference in April 2021. A syllabus of ENT-related items was divided into 'Presentations', 'Conditions' and 'Practical procedures'. Twenty-seven students, 11 foundation doctors and 7 other junior doctors voted via anonymous polling for the best three of nine methods for teaching each syllabus item. RESULTS: For 'Presentations' and 'Conditions', work-based or clinical-based learning and small-group seminars were more popular than other teaching methods. For 'Practical procedures', practical teaching methods were more popular than theoretical methods. CONCLUSION: Students and junior doctors expressed a clear preference for clinical-based teaching and small-group seminars when learning ENT content. E-learning was poorly favoured despite its increasing use.

Comparison of Disease-Specific, Generic, and Hearing-Specific Instruments Assessing Health-Related Quality of Life in Patients Undergoing Middle Ear Surgery for Chronic Otitis Media: A Prospective Correlational Study.

OBJECTIVE: This study aimed to determine the responsiveness of three instruments (disease-specific, generic, and hearing-specific) assessing health-related quality of life (HRQoL) in adult patients undergoing surgery for chronic otitis media (COM). STUDY DESIGN: Prospective correlational study. SETTING: Two otology referral centers in England, United Kingdom. PATIENTS: Consecutive adult patients undergoing middle ear surgery for COM. MAIN OUTCOME MEASURES: HRQoL assessment and audiometry were performed preoperatively and 12 months after surgery. HRQoL was assessed using disease-specific (Chronic Otitis Media Questionnaire-12 [COMQ-12]), generic (Euro-Qol-5D-5L), and hearing-specific (Hearing Handicap Inventory for Adults [HHIA]) instruments. RESULTS: A total of 52 patients (mean [standard deviation {SD}] age, 47.3 [18.3] yr) were included, with 42 patients completing both preoperative and postoperative COMQ-12 forms. COMQ-12 and HHIA total scores significantly improved after surgery (COMQ-12: mean [SD], 28.3 [11.6] versus 14.8 [10.6]; p < 0.001; HHIA: 42.9 (28.4) versus 32.6 (27.5); p = 0.012). General HRQoL measured with the Euro-Qol-5D-5L was unaffected by surgery ( p > 0.05). The standardized response means for the COMQ-12 and HHIA total scores were 1.21 and 0.44, respectively. Postoperative air conduction thresholds were moderately correlated with the postoperative COMQ-12 ( r = 0.46, p = 0.005) and HHIA ( r = 0.41, p = 0.012) total scores. CONCLUSIONS: Middle ear surgery significantly improved both disease-specific and hearing-specific HRQoL, whereas general HRQoL did not change. Only the COMQ-12 is highly responsive to surgical intervention. This study supports the use of the COMQ-12 to monitor patient-reported outcomes in both research and routine clinical settings.

The Association Between Glycaemic Control, Renal Function and Post-operative Ophthalmic Complications in People With Diabetes Undergoing Cataract Surgery-A Single-Centre Retrospective Analysis.

INTRODUCTION: In general surgery, it has been shown that poor peri-operative diabetes control, as measured by glycated haemoglobin (HbA1c), is associated with adverse post-operative outcomes. National data for the UK suggest that the post-operative complication rate for cataract surgery is 2.8%. It is unknown whether people with diabetes who undergo cataract surgery are also at increased risk. METHODS: This single-centre retrospective study looked at the association of peri-operative HbA1c and estimated glomerular filtration rate (eGFR) with the risk of post-operative complications in people undergoing phacoemulsification and intraocular lens implantation under local anaesthesia during 2016. RESULTS: 4401 individuals had cataract surgery. Of these, 34.6% (1525) had diabetes. Of those with diabetes, 114 (7.5%) developed a post-operative ophthalmological complication (as defined by the Royal College of Ophthalmologists) necessitating at least one eye clinic appointment. Mean HbA1c did not differ between those who did and those who did not develop complications (52 vs 50 mmol/mol, p = 0.12). After adjustment, HbA1c was not a significant risk (OR 1.00; 95% CI: 0.99-1.05; p = 0.85). However, eGFR had a small but statistically significant effect on outcome (OR 0.99; 95% CI: 0.98-1.00; p = 0.02). CONCLUSIONS: This study has shown that more people who undergo cataract surgery have diabetes than previously reported. Also, people with diabetes are at higher risk of developing complications than previously reported. HbA1c concentration was not a factor in these adverse post-operative outcomes. However, eGFR was a predictor of risk. More focus should be placed on pre-operatively optimising co-morbidities than diabetes control in those undergoing cataract surgery.

People with suboptimally controlled diabetes (as measured by glycated haemoglobin, HbA_1c) who have an operation are at increased risk of post-operative complications. However, whether this risk extends to cataract surgery is unknown. Our single-centre study showed that 34.6% of all cataract operations during the calendar year 2016 were performed on someone with diabetes­a number far higher than previously reported. In addition, we looked at the post-operative outcomes of the 1525 people with diabetes who had a cataract operation. We showed that, overall, more people with diabetes had complications than previously reported: 7.5%. However, in the whole cohort, HbA_1c did not differ between those who did and those who did not develop complications. The factors that were associated with differences in the risk of developing complications were whether the person was looked after in secondary care for their diabetes and whether they had any kidney disease.

Brief psychological screening for trapeziectomy: Identifying patients at high risk of a poor functional outcome.

Introduction: This study investigates if the psychological subscale from the STarT Back Screening Tool (STarT Psych-sub) identifies patients at high risk of a poor functional outcome after a trapeziectomy based on modifiable psychological factors. Methods: A total of 83 patients completed the STarT Psych-sub, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand), Patient Evaluation Measure (PEM) and a numeric pain rating scale (NPRS) before trapeziectomy. QuickDASH, PEM and NPRS were completed at 6 weeks, 16 weeks and 1 year after the trapeziectomy. Results: The STarT Psych-sub stratified 24 patients (29%) as 'high-risk' and 59 (71%) as 'not high-risk' of a poor outcome. The 'high-risk' group reported worse function and pain (QuickDASH = 72.7, PEM = 81.1, NPRS = 8.3) at baseline than the 'not high-risk' group (QuickDASH = 56.1, PEM = 66.4, NPRS = 7.2). This difference remained constant at all time points after the trapeziectomy with 1-year scores on the QuickDASH = 39.6; PEM = 47.1 and NPRS = 3.7 for the 'high-risk' group and QuickDASH = 24.3; PEM = 33.3 and NPRS = 1.9 for the 'not high-risk' group. Conclusions: Brief psychological screening shows that patients with psychological risk factors experience improved pain and function outcomes following trapeziectomy, however their outcomes are significantly worse than patients who do not have psychological risk factors.

Presentation of dizziness in individuals with chronic otitis media: data from the multinational collaborative COMQ-12 study.

PURPOSE: In chronic otitis media (COM), disease chronicity and severity of middle ear inflammation may influence the development of inner ear deficits, increasing the risk of vestibular impairment. This secondary analysis of the multinational collaborative Chronic Otitis Media Questionnaire-12 (COMQ-12) dataset sought to determine the prevalence of vestibular symptoms in patients with COM and identify associated disease-related characteristics. METHODS: Adult patients with a diagnosis of COM in outpatient settings at nine otology referral centers across eight countries were included. We investigated the presence of vestibular symptoms (dizziness and/or disequilibrium) using participant responses to item 6 of a native version of the COMQ-12. Audiometric data and otoscopic assessment were also recorded. RESULTS: This analysis included 477 participants suffering from COM, with 56.2% (n = 268) reporting at least mild inconvenience related to dizziness or disequilibrium. There was a significant association between air conduction thresholds in the worse hearing ear and presence of dizziness [adjusted odds ratio (AOR), 1.01; 95% CI 1.00-1.02; p = 0.0177]. Study participants in European countries (AOR 1.53; 95% CI 1.03-2.28; p = 0.0344) and Colombia (AOR 2.48; 95% CI 1.25-4.92; p = 0.0096) were more likely to report dizziness than participants in Asian countries. However, ear discharge and cholesteatoma showed no association with dizziness in the adjusted analyses. CONCLUSION: Vestibular symptoms contribute to burden of disease in patients with COM and associates with hearing disability in the worse hearing ear. Geographical variation in presentation of dizziness may reflect financial barriers to treatment or cultural differences in how patients reflect on their health state.

The Association Between Mean Glycated Haemoglobin or Glycaemic Variability and the Development of Retinopathy in People with Diabetes: A Retrospective Observational Cohort Study.

INTRODUCTION: To determine the association between mean glycated haemoglobin (HbA1c) or glycaemic variability and the development of diabetic retinopathy (DR) in people with diabetes. METHODS: An observational cohort study with people registered with a DR eye screening service between October 2012 and October 2017. Those who had no DR at the start of the study were followed for a maximum of 5 years. HbA1c measures were used to calculate HbA1c variability and mean HbA1c to assess any relationship between these and the risk of developing new onset DR. RESULTS: A total of 2511 individuals were followed up for up to 5 years. Of these, 542 (21.6%) developed DR. After adjustment, HbA1c variability was not significantly associated with the development of DR (p = 0.3435). However, the mean HbA1c was (p < 0.0001). Those with type 1 diabetes had an odds of 1.63 (95% CI 1.11-2.40) of a retinopathy diagnosis compared to those with type 2 diabetes. CONCLUSIONS: We have shown that mean HbA1c is associated with an increased risk of developing diabetic retinopathy. However, after adjustment for sex, age, diabetes type and the mean, the HbA1c variability no longer remained significant. Our data suggest that optimizing long-term glycaemic control remains paramount.

It has been known for a long time that if an individual's diabetes is not as well controlled as it could be, then they are at increased risk of developing complications over many years. These complications include diabetes-related eye disease (retinopathy). For many years, the way of measuring how well someone's diabetes was controlled was by measuring glycated haemoglobin (HbA_1c) which looked at how much glucose was attached to a red cell. This study looked at whether variation in HbA_1c over 5 years of follow-up was associated with greater risk of developing retinopathy, and if this relationship was stronger than just measuring HbA_1c alone. Previous work has shown that people with greater variation in HbA_1c are at increased risk of poor wound healing in those with diabetes-related foot ulcers. The present study looked at 2511 people who had no diabetes-related eye disease at the start of the study and who had been followed for 5 years. We found that variability in HbA_1c was not associated with an increased risk of developing diabetes-related eye disease, but confirmed that the average HbA_1c had the strongest relationship. Our data confirm that the focus of preventing diabetes-related eye disease should be on lowering HbA_1c.

Impact of Hearing Disability and Ear Discharge on Quality-of-Life in Patients with Chronic Otitis Media: Data from the Multinational Collaborative COMQ-12 Study.

OBJECTIVE: This study aimed to assess how two disease-related factors, hearing disability and ear discharge, affect health-related quality-of-life (HRQoL) in patients with chronic otitis media (COM). STUDY DESIGN: Multinational prospective cohort study. SETTING: Nine otology referral centers in eight countries. PATIENTS: Adult patients suffering from COM. MAIN OUTCOME MEASURES: Hearing disability and ear discharge were assessed by audiometry (Department of Health and Social Security formula) and otoscopy, respectively. Participants completed a native version of the Chronic Otitis Media Questionnaire-12 (COMQ-12). We determined how the two disease-related factors affect HRQoL by performing two separate analyses: (1) using a 6-item score combining responses to COMQ-12 items independent of hearing loss and ear discharge and (2) using item 12 alone as a proxy for global HRQoL. RESULTS: This study included 478 participants suffering from COM. There was a significant association between HRQoL and hearing disability in the adjusted analysis. For every unit increase in the Department of Health and Social Security average hearing threshold (1) there was an increase of 0.06 (95% CI [0.007, 0.121], p = 0.0282) in the 6-item score and (2) the adjusted odds of having a higher item 12 score was 1.03 (95% CI [1.01, 1.04], p = 0.0004). There was no association between the presence of ear discharge and HRQoL in both COMQ-12 score analyses. CONCLUSIONS: Knowledge of disease-related factors that influence HRQoL will aid interpretation of patient-reported measures for COM. Patients with a greater degree of hearing impairment appear to have poorer HRQoL, which is not exacerbated by the presence of ear discharge. The magnitude of postoperative hearing improvement rather than the attainment of a dry ear may be a better indicator of surgical success from the patient's perspective.

Multinational Appraisal of the Chronic Otitis Media Questionnaire 12 (COMQ-12).

OBJECTIVES: The Chronic Otitis Media Questionnaire-12 (COMQ-12) assesses patient-reported health-related quality of life. A multinational collaborative project was performed to translate and appraise the psychometric properties of the COMQ-12 across Europe, Asia, and South America. METHODS: Eight otology units from seven countries (China, Colombia, France, Italy, Japan, Korea, Turkey) created native versions of the COMQ-12 by the process of translation and back-translation. Questionnaire reliability was assessed on the basis of internal consistency by calculating Cronbach's coefficient alpha. Exploratory factor analysis was performed to identify underlying correlations between individual questionnaire items. RESULTS: This study included 478 participants from 8 countries. Calculated values for Cronbach's coefficient alpha were between 0.71 and 0.90. Exploratory factor analysis allowed the identification of three dominant factors, the primary factor (related to hearing problems) explaining 42% of the total variance, the secondary factor (related to daily activities) explaining 30% of the variance, and the third factor (related to acute disease activity) explaining 28% of the variance. CONCLUSIONS: This is a large study of patients with chronic otitis media, from centers from within many different countries spanning Europe, Asia, and South America. This study supports the use of the COMQ-12 within the individual countries where it was tested.

Outcomes of post-operative duplex ultrasound following arteriovenous fistula formation: A pragmatic single-centre experience.

BACKGROUND: Duplex ultrasound surveillance with pre-emptive treatment of an identified stenosis is increasingly being utilised to help maintain arteriovenous fistula patency. This study aims to determine whether post-operative duplex ultrasound surveillance can improve fistula patency at 12 months and improve the proportion of 'pre-haemodialysis' patients commencing haemodialysis via a usable fistula. METHODS: All arteriovenous fistulae formed between 1st January 2015 and 31st August 2017 in a single, tertiary vascular centre were included. Primary and secondary patency at 12 months, along with the proportion of pre-haemodialysis patients commencing haemodialysis via a usable arteriovenous fistula, were compared between the fistulae undergoing duplex ultrasound surveillance and 'standard practice'. RESULTS: Two hundred forty-one arteriovenous fistulae were created in 216 patients. A higher proportion of brachiobasilic transposition arteriovenous fistula and patients undergoing arteriovenous fistula creation following a previously failed access were identified in the duplex ultrasound surveillance group. Primary patency at 12 months (hazard ratio = 0.43, 95% confidence interval = 0.30-0.61, p < .001) was significantly lower in the duplex ultrasound surveillance group compared with the 'standard practice' group. Despite this, no difference was identified in secondary patency at 12 months (hazard ratio = 1.82, 95% confidence interval = 0.87-3.80, p = .112). No difference was also identified in the proportion of pre-haemodialysis patients starting haemodialysis with a usable arteriovenous fistula (duplex ultrasound surveillance = 65.0% vs standard practice = 77.8%; odds ratio = 0.53, 95% confidence interval 0.58-1.19, p = .279). CONCLUSION: Post-operative duplex ultrasound surveillance following arteriovenous fistula formation is associated with higher rates of post-operative intervention; however, this does not translate into improved secondary patency or the proportion of pre-haemodialysis patients commencing HD via their fistula.

Eye movement desensitization and reprocessing as a treatment for tinnitus.

OBJECTIVES/HYPOTHESIS: To determine the effectiveness of eye movement desensitization and reprocessing (EMDR) as a treatment for tinnitus. STUDY DESIGN: Single-site prospective interventional clinical trial at a university hospital in the United Kingdom. METHODS: Participants were provided with tEMDR. This is a bespoke EMDR protocol that was developed specifically to treat individuals with tinnitus. Participants received a maximum of 10 sessions of tEMDR. Outcome measures including tinnitus questionnaires and mood questionnaires were recorded at baseline, discharge, and at 6 months postdischarge. RESULTS: Tinnitus Handicap Inventory and Beck Depression Inventory scores demonstrated a statistically significant improvement at discharge after EMDR intervention (P = .0005 and P = .0098, respectively); this improvement was maintained at 6 months postdischarge. There was also a moderate but not significant (P = .0625) improvement in Beck Anxiety Inventory scores. CONCLUSIONS: This study has demonstrated that the provision of tEMDR has resulted in a clinically and statistically significant improvement in tinnitus symptoms in the majority of those participants who took part. Furthermore, the treatment effect was maintained at 6 months after treatment ceased. This study is of particular interest, as the study protocol was designed to be purposefully inclusive of a diverse range of tinnitus patients. However, as a small uncontrolled study, these results do not consider the significant effects of placebo and therapist interaction. Larger high-quality studies are essential for the verification of these preliminary results. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2384-2390, 2019.

Assessing the Effect of Piperacillin/Tazobactam on Hematological Parameters in Patients Admitted with Moderate or Severe Foot Infections.

INTRODUCTION: Piperacillin/tazobactam is a commonly used antibiotic for the empirical treatment of severe diabetic foot infections. One of the most feared complications of this drug is the development of pancytopenia. The aim of this study was to determine whether the use of piperacillin/tazobactam caused any hematological changes in patients admitted with severe diabetes-related foot infections from a specialist multidisciplinary foot clinic. Specifically, looking at whether it caused anemia, leukopenia, neutropenia, or thrombocytopenia. METHODS: A 1-year retrospective analysis of patients admitted to a tertiary care center for treatment of diabetes-related foot infection using piperacillin/tazobactam. Hematological indices, urea and electrolytes, and C-reactive protein (CRP) were recorded pretreatment, during treatment, and posttreatment. HbA1c, vitamin B12, folate, thyroid-stimulating hormone, and free thyroxin were also analyzed to exclude any potential confounders as a cause of pancytopenia. RESULTS: A total of 154 patients were admitted between 1 January 2016 and 31 December 2016 who received piperacillin/tazobactam for severe diabetes-related foot infection. On admission, white cell count and CRP were raised and fell significantly within the first 48 h. Other hematological factors did not change. Five patients developed a mild pancytopenia, of which three were unexplained. CONCLUSION: In this relatively small cohort, pancytopenia did not occur. As such, piperacillin/tazobactam appeared to have a low risk of adverse hematological outcomes and remains the treatment of choice for severe diabetes-related foot infections.

The impact of glycaemic variability on wound healing in the diabetic foot - A retrospective study of new ulcers presenting to a specialist multidisciplinary foot clinic.

AIMS: Glycaemic variability - the visit-to-visit variation in HbA1c - plays a possible role in the development of micro and macrovascular disease in patients with diabetes. Whether HbA1c variability is a factor determining wound healing in diabetic foot ulcers remains unknown. We aimed to determine whether HbA1c variability is associated with foot ulcer healing time. METHODS: A retrospective analysis of patients presenting to our specialist multidisciplinary foot clinic between July 2013 and March 2015, with at least three HbA1c measurements within five years of presentation and more than two follow-up reviews. HbA1c variation was measured by magnitude of standard deviation. RESULTS: 629 new referrals were seen between July 2013 and March 2015. Of these, 172 patients had their number of days to healing recorded and sufficient numbers of HbA1c values to determine variability. The overall geometric mean days to heal was 91.1 days (SD 80.8-102.7). In the low HbA1c variability group the geometric mean days to heal was 78.0 days (60.2-101.2) vs 126.9 days (102.0-158.0) in the high Hb1Ac variability group (p = .032). Those with low HbA1c (<58 mmol/mol) and low variability healed faster than those with high HbA1c and high variability (73.5 days [59.5-90.8] vs 111.0 days [92.0-134.0], p = .007). Additionally, our results show that time to healing is more dependent on the mean HbA1c than the variability in HbA1c (p = .007). CONCLUSIONS/INTERPRETATION: Our data suggest that there was a significant association between HbA1c variability and healing time in diabetic foot ulcers.

The Seasonal Variation of Benign Paroxysmal Positional Vertigo.

OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is characterized by recurrent episodes of positional vertigo due to dislodged otoconia debris within the semicircular canals. Many studies have proposed a correlation between Vitamin-D deficiency and recurrent BPPV. In the UK, serum Vitamin-D falls during the winter, reaching its lowest level in May and it is highest level in September. We hypothesize that if there is a relationship between BPPV and Vitamin-D levels, one would expect to see a seasonal variation in the incidence of BPPV among UK residents. METHODS: A retrospective review of clinic letters and general practitioner referrals for patients presenting to a University Otolaryngology department over a 4-year period. Patients were divided into two groups: those presenting during the months associated with low serum Vitamin-D levels, and those presenting during the months associated with high serum Vitamin-D levels. RESULTS: Three hundred thirty-nine patients were identified with posterior canal BPPV as a consequence of having had a positive Dix-Hallpike maneuver recorded in the clinical notes between October 2012 and October 2016. A Wilcoxon rank-sum test demonstrated there to be a statistically significant difference between the low serum Vitamin-D group and the high serum Vitamin-D group (p = 0.0367). CONCLUSION: The results confirm that there is a seasonal variation in the incidence of BPPV. This study is important as it adds to the mounting literature suggesting an association between serum Vitamin-D levels and BPPV. Second, it suggests a therapeutic strategy to improve outcomes in affected patients. Third, it adds significance to the hypothesized role of calcium metabolism for the development of inner ear disease.

Assessing the quality of primary care referrals to surgery of patients with diabetes in the East of England: A multi-centre cross-sectional cohort study.

AIM: Peri-operative hyperglycaemia is associated with an increased incidence of adverse outcomes. Communication between primary and secondary care is paramount to minimise these harms. National guidance in the UK recommends that the glycated haemoglobin (HbA1c) should be measured within 3 months prior to surgery and that the concentration should be less that 69 mmol/mol (8.5%). In addition, national guidance outlines the minimum dataset that should be included in any letter at the time of referral to the surgeons. Currently, it is unclear how well this process is being carried out. This study investigated the quality of information being handed over during the referral from primary care to surgical outpatients within the East of England. METHODS: Primary care referrals to nine different NHS hospital Trusts were gathered over a 1-week period. All age groups were included from 11 different surgical specialties. Referral letters were analysed using a standardised data collection tool based on the national guidelines. RESULTS: A total of 1919 referrals were received, of whom 169 (8.8%) had previously diagnosed diabetes mellitus (DM). However, of these, 38 made no mention of DM in the referral letter but were on glucose-lowering agents. Only 13 (7.7%) referrals for patients with DM contained a recent HbA1c, and 20 (11.8%) contained no documentation of glucose-lowering medication. CONCLUSION: This study has shown that the quality of referral letters to surgical specialties for patients with DM in the East of England remain inadequate. There is a clear need for improving the quality of clinical data contained within referral letters from primary care. In addition, we have shown that the rate of referral for surgery for people with diabetes is almost 50% higher than the background population with diabetes.

Pharmacist provided medicines reconciliation within 24†hours of admission and on discharge: a randomised controlled pilot study.

BACKGROUND: The UK government currently recommends that all patients receive medicines reconciliation (MR) from a member of the pharmacy team within 24 hours of admission and subsequent discharge. The cost-effectiveness of this intervention is unknown. A pilot study to inform the design of a future randomised controlled trial to determine effectiveness and cost-effectiveness of a pharmacist-delivered service was undertaken. METHOD: Patients were recruited 7 days a week from 5 adult medical wards in 1 hospital over a 9 month period and randomised using an automated system to intervention (MR within 24 hours of admission and at discharge) or usual care which may include MR (control). Recruitment and retention rates were determined. Length of stay (LOS), quality of life (EQ-5D-3L), unintentional discrepancies (UDs) and emergency readmission (ER) within 3 months were tested as outcome measures. The feasibility of identifying and measuring intervention-associated resources was determined. RESULT: 200 patients were randomised to either intervention or control. Groups were comparable at baseline. 95 (99%) patients in the intervention received MR within 24 hours, while 62 (60.8%) control patients received MR at some point during admission. The intervention resolved 250 of the 255 UDs identified at admission. Only 2 UDs were identified in the intervention group at discharge compared with 268 in the control. The median LOS was 94 hours in the intervention arm and 118 hours in the control, with ER rates of 17.9% and 26.7%, respectively. Assuming 5% loss to follow-up 1120 patients (560 in each arm) are required to detect a 6% reduction in 3-month ER rates. CONCLUSIONS: The results suggest that changes in outcome measures resulting from MR within 24 hours were in the appropriate direction and readmission within 3 months is the most appropriate primary outcome measure. A future study to determine cost-effectiveness of the intervention is feasible and warranted. TRIAL REGISTRATION NUMBER: ISRCTN23949491.