An audit of consenting practices in a district general hospital. Can we improve?

INTRODUCTION: Informed consent, as the declaration of patients' will, forms the basis of legality of medical procedures. A standard form based on the Department of Health model is widely used in the National Health Service (NHS). The aim of this audit process was to assess the current consent practice in comparison to the UK's General Medical Council guidance and local policy and make any appropriate improvements. PATIENTS AND METHODS: 254 adult consent forms were reviewed during the patients' admission. Data collected included legible documentation, grade of health professional completing the consent form, providing additional written information, use of abbreviations, securing the consent form in the medical records and, providing a copy to the patient. After initial assessment, interventions in an attempt to improve adherence to guidelines were introduced. A repeat audit of a further set of 110 notes was completed to assess the effectiveness of our interventions. RESULTS: Our baseline assessment of 254 consent forms comprised of 198 (78%) elective and 56 (22%) emergency procedures. 87 (34%) consent forms were secure in the medical records. Grade of health professional was recorded in 211 (83%). 191 (75%) forms were legible. 48 (19%) patients were given copy of the consent. Only 24 (9%) patients were given additional written information. Abbreviations were used in 68 (27%) forms. Only 12 (5%) of consent forms met all criteria simultaneously. Re-audit after intervention assessed 110 consent forms; 30 (27%) for elective and 80 (72%) for emergency procedures. 52 (47%) of consent forms were secure in medical records, grade of health professional was recorded in 94 (85%), 101 (75%) forms were legible, 42 (38%) patients received copy of consent and 41 (37%) of patients received additional written information. CONCLUSION: Initially only 5% of consent forms completely met GMC guidelines. This demonstrates an alarmingly poor adherence to such guidance that plays a vital role in patient safety, patient ethics autonomy, not to mention potential medico-legal and clinical governance implications for surgical practice. Our intervention has improved the quality of consenting within our hospital according to these guidelines. With these interventions set to continue and further develop, we expect that the quality of the consenting process will continue to provide patients with all that it is designed to.

The final outcome of indeterminate cytology of thyroid nodules in a District General Hospital.

BACKGROUND: Diagnostic thyroid lobectomy is performed to resolve the dilemma of indeterminate (Thy3) cytology of thyroid nodules. But on final histology most nodules are benign thereby subjecting this group of patients to surgery with its associated risks. AIM: To determine the proportion of cancers in patients with indeterminate thyroid nodules. PATIENTS AND METHODS: This is a retrospective observational study of 621 patients who underwent fine needle aspiration cytology (FNAC) of their thyroid nodules over a 60 month period in a district general hospital. Patient demographics, cytology and final histology results were extracted from the hospital database. RESULTS: On final analysis, 48 patients had an indeterminate cytology (7.7%) and 12 patients had cancer in this group (25%) following diagnostic lobectomy. CONCLUSION: Till an alternative robust technology becomes widely available we need to continue to perform diagnostic lobectomy in patients with indeterminate cytology in view of the high incidence of thyroid cancer in this group of patients.

Pre-operative ultrasound for breast tumour measurements: is there potential for mismanagement?

The pre-operative size of breast tumour is the most important factor in determining feasibility of breast conserving surgery in operable breast cancer. Currently there is no consensus on the most accurate modality to measure tumour size. A prospective study of consecutive and unselected symptomatic patients with invasive breast cancer who had primary surgery between January 2006 and December 2007 was conducted. Patients with multi-focal and multi-centric tumours were excluded. The aim of this study was to find the correlation between histological size of invasive breast cancer and pre-operative tumour size as measured by ultrasound. Over this two year period, data for 192 patients was analysed for this study. The mean tumour diameter on ultrasound and histology was 19.5mm and 29 mm respectively. The difference between the means in the two modalities was found to be statistically significant (P<0.001).Ultrasound underestimates the true size of breast tumours as determined histologically. Inaccurate tumour size measurements may result in re-operations to achieve adequate margins.

A hip fracture nurse specialist has a positive outcome on the length of stay for patients with hip fractures.

AIM: To determine if recruitment of a hip fracture nurse specialist has a reduction in length of stay for hip fracture patients. METHOD: Primary data was extracted from the National Hip Fracture Database (NHFD). The length of stay of hip fracture patients from 2011-2014 was compared to the period 2014-17, following appointment of a hip fracture nurse specialist in 2014. RESULTS: The average length of stay in the first group (2011-2014) was 19.94 days and in the second group (2014-2017) was 16.52 days. There was a reduction of 3.42 days (17.15%) and was statistically significant. There was also a reduction in the time to surgery (1.38 days versus 1.15 days) and the crude 30-day mortality (10% versus 6.06%) both of which were statistically significant. The two groups were well-matched with regards to age, female: male ratio and severity of co-morbidities (based on American Society of Anaesthesiologists physical status classification system). CONCLUSION: The introduction of a dedicated hip fracture nurse specialist has a positive outcome on hip fracture patients by reducing length of stay, time to surgery and the crude 30-day mortality.

Combined ultrasound and Sestamibi scintigraphy provides accurate preoperative localisation for patients with primary hyperparathyroidism.

INTRODUCTION: Minimally invasive parathyroidectomy has advantages over the traditional bilateral neck exploration for the surgical treatment of primary hyperparathyroidism. It requires accurate localisation of the parathyroid pathology prior to surgery. The best method of preoperative localisation in a district general hospital setting is not well understood. METHODS: All patients who underwent parathyroidectomy for primary hyperparathyroidism from 2008 to 2016 were identified from a prospectively maintained database. Operative findings were correlated with radiological and histological results. Sensitivity and specificity of ultrasound, sestamibi scintigraphy and the two together were calculated for diagnostic precision and compared. RESULTS: One hundred and eighty-four patients met the inclusion criteria, of whom 81.5% had a histological diagnosis of a parathyroid adenoma. Ultrasound had higher sensitivity than sestamibi scintigraphy. Used together, ultrasound and sestamibi scintigraphy performed better than either ultrasound or sestamibi scintigraphy alone (P< 0.001). Twenty-two of 184 cases had no lesion located by either ultrasound or sestamibi scintigraphy preoperatively. Where neither ultrasound nor sestamibi scintigraphy located the lesion, additional computed tomography led to the excision of parathyroid pathology in one in ten patients. CONCLUSION: The combination of ultrasound and sestamibi scintigraphy provides the highest sensitivity of preoperative localisation. This approach led to a high success rate of minimally invasive parathyroidectomy. Where preoperative localisation is not achieved with ultrasound or sestamibi scintigraphy, computed tomography adds little additional benefit. In this setting other modalities of localisation such a selective venous sampling, intraoperative methylene blue or intraoperative parathyroid hormone levels could be considered.

Dosage of haloperidol for schizophrenia.

Eighty-seven newly admitted inpatients with schizophrenia were randomized to receive 10, 30, or 80 mg/d of oral haloperidol. They were treated under double-blind conditions for 6 weeks, less if their acute symptoms remitted sooner. Survival analysis showed no differences among the three treatments. Side effects were minimal in all three treatment groups, and there were no differences in side effects among the groups. These results suggest that dosages higher than 10 mg/d of haloperidol for most patients have no additional beneficial effect in the treatment of acute or exacerbated schizophrenia.

The prevalence of anxiety disorders in patients with chronic obstructive pulmonary disease.

Fifty consecutive outpatients with stable chronic obstructive pulmonary disease were evaluated for lifetime prevalence of psychiatric morbidity. Eight percent had a diagnosis of panic disorder. This finding suggests that this patient population should be monitored for panic disorder.

Benzodiazepine use and abuse by patients at outpatient clinics.

The charts of 2,719 patients from several outpatient clinics were reviewed for evidence of use and abuse of benzodiazepines. According to the chart data and interviews with physicians, no patient met the criteria for benzodiazepine abuse or dependence.

Stability of the postpsychotic depression syndrome.

Fifteen consecutively identified patients with syndromally defined postpsychotic depression were followed prospectively over three consecutive weekly ratings to assess the stability of that syndrome. In 8 cases, the condition persisted with undiminished intensity. Five cases remitted spontaneously, and in 2 cases the syndrome appeared to be a harbinger of psychotic relapse. The implications for the timing of therapeutic interventions in patients with postpsychotic depressions are discussed.

A single institution experience with skin sparing mastectomy and immediate breast reconstruction.

INTRODUCTION: Skin sparing mastectomies (SSMs) represent a surgical approach that preserves the natural skin envelope of the breast and, when combined with immediate reconstruction, offers a good cosmetic outcome. The aim of this retrospective study was to compare the risk of local recurrence (LR) in this series with the known rate of recurrence following a conventional mastectomy. METHODS: A total of 108 patients with breast cancer who underwent an SSM and immediate breast reconstruction over a 6-year period were reviewed. RESULTS: A follow-up of more than eight years showed that three patients (2.78%) had developed LR. CONCLUSIONS: The rate of LR is low with SSMs and is comparable to that seen with conventional mastectomies.

The effect of processing history on physical behavior and cellular response for tyrosine-derived polyarylates.

Polyarylates have shown promise as fully degradable polymers for drug delivery as well as for structural implant applications due to their range of physicomechanical properties. Processing history, however, could have a significant impact on their overall performance in biologically relevant environments. More specifically, structural changes at the molecular level can occur that will affect a polymer's physical properties and subsequent, cell attachment and growth. The present study was aimed at comparing cell growth on tyrosine-derived polyarylates with that of polylactic acid (PLLA) in their original state and after processing (i.e. undrawn and drawn forms). Two polyarylates having distinct molecular structures were chosen. Strictly, amorphous poly(DTE adipate), denoted as poly(DT 2,4), and poly(DTD) dodecandioate, denoted as poly(DT 12,10), having a more complex, non-crystalline organization, were compared with semi-crystalline PLLA. The degree of shrinkage, thermal characterization, air-water contact angle and surface morphology were determined for each polymer in its undrawn and drawn states. Poly(DT 2,4) and PLLA after processing resulted in greater shrinkage and a slight decrease in hydrophilicity whereas poly(DT 12,10) had minimal shrinkage and became slightly more hydrophilic in its drawn state. Surface morphology or roughness was also altered by processing. In turn, the rate of cell growth and overall cell numbers were reduced significantly on drawn forms of poly(DT 2,4) and PLLA, whereas more favorable growth rates were supported on drawn poly(DT 12,10). These findings indicate that processing effects in amorphous as well as oriented polymeric structures can significantly alter their biological performance.

A systematic assessment of the comorbidity of DSM-III-R personality disorders in alcoholic outpatients.

To our knowledge, this is the first study to examine the systematic comorbidity of DSM-III-R personality disorders (PDs) in a sample of alcoholic outpatients. The extent and direction of overlap can provide a measure of heterogeneity and descriptive validity. Fifty sober alcoholic outpatients enrolled in a treatment program were assessed by Structured Clinical Interview for DSM-III (SCID) instruments for the presence of axis I and axis II disorders; 80% had either a coexistent axis I or II disorder, with 66% having an axis I disorder, 64% an axis II disorder, and 50% both axis I and II disorders. There were 84 PD diagnoses among the 32 PD patients (2.6/patient), with multiple diagnoses in 20 (62%). The most prevalent PD diagnoses were paranoid (44%), antisocial (20%), avoidant (20%), passive-aggressive (18%), and borderline (16%). Overlap was extensive and not confined to any one of the three designated axis II clusters. Poorer outcome was associated with the presence of PD. Personality variables may offer a means of further characterizing the heterogeneity observed in axis I disorders. Further refinement of the current system of PD classification and investigation into alternate models is needed.

Religious and other predictors of psychosocial adjustment in cancer patients.

The authors tested the hypothesis that religious variables, such as a person's belief that his/her illness was God's will, would predict psychosocial adjustment in 50 patients who were predominantly Catholic Hispanic women attending a medical oncology clinic (42 women, 8 men). The patients were free of an Axis I mental disorder, cognitive impairment, and severe pain and were not undergoing intensive chemotherapy. By using the Psychosocial Adjustment to Illness Scale as the outcome measure, the authors found few associations with religious variables, but many to clinical variables.

Dose and blood levels of haloperidol in treatment of mania.

Three doses of haloperidol, 10 mg/day, 30 mg/day, and 80 mg/day, were compared in 47 newly admitted manic patients. There was no difference in outcome within 6 weeks among the three doses. Four blood levels of plasma and red blood cell (RBC) haloperidol and reduced haloperidol showed no linear or curvilinear relationships to clinical response.

Blood levels of haloperidol and clinical outcome in schizophrenia.

Haloperidol levels in blood were measured in 55 acutely psychotic inpatients with schizophrenia, who were randomly assigned to three fixed doses of oral haloperidol. Nineteen of these subjects received 10 mg/day, 18 received 30 mg/day, and 18 of them received 80 mg/day. All of the subjects were treated under double-blind conditions for 6 weeks or until remission. Haloperidol and reduced haloperidol levels were measured in plasma and red blood cells at the end of 2, 4, and 6 weeks of treatment. There were statistically significant linear correlations between the dose of haloperidol and levels in blood. An examination of data for linear and curvilinear relationships between levels in blood and clinical response did not yield any statistically significant relations. The data did not support the concept of a "therapeutic window." The ratio of reduced haloperidol to haloperidol levels in plasma or red blood cells did not yield any statistically significant correlations to clinical outcome.

Dosage of haloperidol for mania.

BACKGROUND: We compared three doses of a neuroleptic as a treatment for mania. METHOD: Forty-seven newly admitted in-patients with mania were randomised to receive 10, 30, or 80 mg a day of oral haloperidol, under double-blind conditions for up to six weeks. All subjects received prophylactic benztropine. RESULTS: Repeated-measures analysis of variance and survival analysis showed no difference in outcome by the different doses. Excluding drop-outs (38%), most of whom left the study during the first two weeks, 72% of the subjects responded. Side-effects were minimal; there were no differences among the three doses. Non-responders received more adjunctive lorazepam than responders. CONCLUSIONS: The limited data suggest that more than 10 mg a day of haloperidol offers no advantage in mania.

Discovery of association rules in medical data.

Data mining is a technique for discovering useful information from large databases. This technique is currently being profitably used by a number of industries. A common approach for information discovery is to identify association rules which reveal relationships among different items. In this paper, we use this approach to analyse a large database containing medical-record data. Our aim is to obtain association rules indicating relationships between procedures performed on a patient and the reported diagnoses. Random sampling was used to obtain these association rules. After reviewing the basic concepts associated with data mining, we discuss our approach for identifying association rules and report on the rules generated.