1
|
Scrimgeour DSG, Brennan PA, Griffiths G, Lee AJ, Smith FCT, Cleland J. Does the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination predict 'on-the-job' performance during UK higher specialty surgical training? Ann R Coll Surg Engl 2018; 100:1-7. [PMID: 30286650 PMCID: PMC6204508 DOI: 10.1308/rcsann.2018.0153] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The Intercollegiate Membership of the Royal College of Surgeons (MRCS) is a mandatory examination to enter higher surgical specialty training in the UK. It is designed to help to ensure that successful candidates are competent to practice as higher surgical trainees. The annual review of competence progression (ARCP) assesses trainees' competence to progress to the next level of training and can be interpreted as a measure of 'on-the-job' performance. We investigated the relationship between MRCS performance and ARCP outcomes. MATERIALS AND METHODS All UK medical graduates who passed MRCS (Parts A and B) from 2007 to 2016 were included. MRCS scores, attempts and sociodemographics for each candidate were crosslinked with ARCP outcomes (satisfactory, unsatisfactory and insufficient evidence). Multinomial logistic regression was used to identify potential independent predictors of ARCP outcomes. RESULTS A total of 2570 trainees underwent 11,064 ARCPs; 1589 (61.8%) had only satisfactory outcomes recorded throughout training; 510 (19.9%) had at least one unsatisfactory outcome; and 471 (18.3%) supplied insufficient evidence. After adjusting for age, gender, first language and Part A performance, ethnicity (non-white vs white, OR 1.36, 95% CI 1.08 to 1.71), Part B passing score (OR 0.98, 95% CI 0.98 to 1.00) and number of attempts at Part B (two or more attempts vs one attempt, OR 1.50, 95% CI 1.16 to 1.94) were found to be independent predictors of an unsatisfactory ARCP outcome. CONCLUSIONS This is the first study to identify predictors of ARCP outcomes during higher surgical specialty training in the UK and provides further evidence of the predictive validity of the MRCS examination.
Collapse
Affiliation(s)
- DSG Scrimgeour
- Centre for Healthcare Education Research and Innovation, University of Aberdeen, Aberdeen, Scotland, UK
- Department of Colorectal Surgery, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
- Intercollegiate Committee for Basic Surgical Examinations, UK
| | - PA Brennan
- Intercollegiate Committee for Basic Surgical Examinations, UK
| | - G Griffiths
- Department of Vascular Surgery, Ninewells Hospital, Dundee, Scotland, UK
| | - AJ Lee
- Medical Statistics Team, University of Aberdeen, Aberdeen, Scotland, UK
| | - FCT Smith
- Intercollegiate Committee for Basic Surgical Examinations, UK
| | - J Cleland
- Centre for Healthcare Education Research and Innovation, University of Aberdeen, Aberdeen, Scotland, UK
| |
Collapse
|
2
|
Mushtaq F, O’Driscoll C, Smith FCT, Wilkins D, Kapur N, Lawton R. Contributory factors in surgical incidents as delineated by a confidential reporting system. Ann R Coll Surg Engl 2018; 100:401-405. [PMID: 29543056 PMCID: PMC5956595 DOI: 10.1308/rcsann.2018.0025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2018] [Indexed: 12/20/2022] Open
Abstract
Background Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. Methods One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. Results The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) - with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures - those closest in time and space to the adverse event - pointed to frequent coupling with latent, systems-related contributory factors. Conclusions Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.
Collapse
Affiliation(s)
- F Mushtaq
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - C O’Driscoll
- Division of Psychiatry, University College London, London, UK
| | - FCT Smith
- Faculty of Health Sciences, University of Bristol, UK
| | | | - N Kapur
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - R Lawton
- School of Psychology, Faculty of Medicine and Health, University of Leeds, Leeds, UK
- Bradford Institute for Health Research, Bradford, UK
| |
Collapse
|
3
|
Bloor J, Shukla N, Smith FCT, Angelini GD, Jeremy JY. Folic acid administration reduces neointimal thickening, augments neo-vasa vasorum formation and reduces oxidative stress in saphenous vein grafts from pigs used as a model of diabetes. Diabetologia 2010; 53:980-8. [PMID: 20182861 PMCID: PMC3596781 DOI: 10.1007/s00125-010-1680-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 12/14/2009] [Indexed: 01/13/2023]
Abstract
AIMS/HYPOTHESIS There is evidence that plasma homocysteine augments vein graft failure and that it augments both micro- and macro-angiopathy in patients with diabetes mellitus. It is therefore suggested that homocysteine may augment vein graft thickening, a major cause of vein graft failure, in diabetic patients, as well as impairing adaptive growth of a new vasa vasorum, possibly through overproduction of superoxide. In order to test these proposals, the effect of folic acid administration, which lowers plasma homocysteine, on vein graft thickening and microvessel density was studied in pigs used as a model of diabetes. METHODS Non-ketotic hyperglycaemia was induced in Landrace pigs by intravenous injection of streptozotocin, and folic acid was fed daily for 1 month. Vein grafts were excised and the thickness of the neointima and media and microvessel density were assessed by planimetry and superoxide formation. RESULTS Plasma total homocysteine was significantly reduced by folic acid in both control and diabetic pigs, whereas glucose was unchanged. Compared with controls, diabetic pigs showed increased neointimal thickness and superoxide formation and decreased adventitial microvessel density. Folic acid reduced neointimal thickness and superoxide formation and augmented microvessel density in diabetic but not in control pigs. CONCLUSIONS Folic acid administration reduces neointimal thickening, augments vasa vasorum neoformation and reduces oxidative stress in saphenous vein grafts from diabetic pigs. Folic acid may therefore be particularly effective in reducing vein graft failure in diabetic patients.
Collapse
Affiliation(s)
- J. Bloor
- Department of Vascular Surgery, University of Bristol, Bristol, UK
| | - N. Shukla
- Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
| | - F. C. T. Smith
- Department of Vascular Surgery, University of Bristol, Bristol, UK
| | - G. D. Angelini
- Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK
| | - J. Y. Jeremy
- Bristol Heart Institute, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK,
| |
Collapse
|
4
|
Williams DJ, McCarthy R, Day J, Smith FCT, Lamont PM, Baird RN. Improvement in operative training since the introduction of the Calman plan. ACTA ACUST UNITED AC 2005. [DOI: 10.1308/147363505x59480] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
5
|
Wolowczyk L, Nevin M, Day A, Smith FCT, Baird RN, Lamont PM. The Effect of Acute Normovolaemic Haemodilution on the Inflammatory Response and Clinical Outcome in Abdominal Aortic Aneurysm Repair—Results of a Pilot Trial. Eur J Vasc Endovasc Surg 2005; 30:12-9. [PMID: 15933977 DOI: 10.1016/j.ejvs.2005.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To determine the effect of acute normovolaemic haemodilution (ANH) on the inflammatory response and clinical outcome in elective open abdominal aortic aneurysm (AAA) repair. DESIGN Randomised controlled clinical trial. METHODS Thirty-six patients were randomised to undergo ANH or act as controls. Cell salvage was permitted in both groups. Heterologous blood was transfused according to pre-determined triggers. Outcome measures were markers of the systemic inflammatory response in serum and urine observed at multiple time points, and clinical recovery. RESULTS Median 890 (range 670-1620) ml of blood was removed at ANH in 16 patients. There were no differences in peri-operative changes in neutrophil count ( P = 0.13), serum C-reactive protein ( P = 0.38), interleukin-6 ( P = 0.50), total antioxidant capacity ( P = 0.73), urinary secretion of albumin ( P = 0.97) or retinol binding protein ( P = 0.41). There were no differences in the mortality and morbidity rates, systemic inflammatory response syndrome, ITU or hospital stay. CONCLUSIONS ANH, when used in combination with cell salvage, made no impact on systemic inflammatory response and clinical outcome when compared to cell salvage alone after AAA repair. ANH cannot be recommended for routine use in patients undergoing abdominal aortic aneurysm surgery when cell salvage is available.
Collapse
Affiliation(s)
- L Wolowczyk
- Vascular Unit, University Department of surgery, Bristol Royal Infirmary, Bristol, UK.
| | | | | | | | | | | |
Collapse
|
6
|
Giannoukas AD, Labropoulos N, Smith FCT, Venables GS, Beard JD. Management of the Near Total Internal Carotid Artery Occlusion. Eur J Vasc Endovasc Surg 2005; 29:250-5. [PMID: 15694797 DOI: 10.1016/j.ejvs.2004.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The risk of stroke in patients with near total internal carotid artery (ICA) occlusion is perceived to be high as stroke risk increases with severity of the stenosis. The management of this entity has not been addressed specifically in the existing randomised trials and thus it remains controversial. METHODS Systematic review of the relevant literature. RESULTS The management of patients with near total ICA occlusion remains controversial: some favour intervention whereas others have condemned it as dangerous or of no benefit. A prospective multicentre randomised trial regarding intervention versus best medical treatment for patients with symptomatic near total ICA occlusion seems difficult because of the large number of patients required to power the study. Nevertheless, it appears hard to decline surgery based on the current evidence. CONCLUSIONS Because of the current controversy over the best management of the near total ICA occlusion, prospective observational studies are needed to demonstrate its prevalence in the symptomatic and asymptomatic population and any associated excess stroke risk. Based on the current evidence, surgery is the treatment of choice in most centres but its validity over best medical treatment remains untested.
Collapse
Affiliation(s)
- A D Giannoukas
- Sheffield Vascular Institute, Northern General Hospital, Sheffield, UK.
| | | | | | | | | |
Collapse
|
7
|
Smith FCT. Medical statistics made clear. An introduction to basic concepts. A. Banerjee. 155 × 233 mm. Pp. 131. Illustrated. 2003. The Royal Society of Medicine Press: London. Br J Surg 2003. [DOI: 10.1002/bjs.4415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- F C T Smith
- Division of Surgery, Bristol Royal Infirmary, Bristol BS2 8HW, UK
| |
Collapse
|
8
|
Wolowczyk L, Nevin M, Smith FCT, Baird RN, Lamont PM. Haemodilutional Effect of Standard Fluid Management Limits the Effectiveness of Acute Normovolaemic Haemodilution in AAA Surgery—Results of a Pilot Trial. Eur J Vasc Endovasc Surg 2003; 26:405-11. [PMID: 14512004 DOI: 10.1016/s1078-5884(03)00255-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the impact of standard fluid management on the effectiveness of ANH as a blood conservation method in elective open AAA repair. DESIGN Prospective randomised controlled study. METHODS Thirty-four patients undergoing elective AAA repair were randomised to have ANH (16) or act as controls (18). Intra-operative cell salvage was permitted in both groups. Haemoglobin (Hb) concentrations were determined at variable intervals peri-operatively. Blood loss and the use of heterologous blood were recorded. RESULTS The pre- and post-operative Hb concentrations, surgical blood loss and the use of cell salvage were similar in both groups. Hb concentration (median, range) decreased significantly from pre-operative to aortic clamping (with blood loss <100 ml) in ANH patients from 8.8 (7.5-10.2) to 5.7 (4.2-6.6)mmol/l following ANH but also in controls from 8.6 (7.5-9.7) to 7.0 (4.5-9.0)mmol/l due to fluid infusion (P<0.01 for every comparison). Bank blood requirements were similar: median 2 units in ANH and 2.5 units in control patients (P=0.68). CONCLUSIONS Large volumes of fluids infused during AAA repair already conserve blood by the mechanism of hypervolaemic haemodilution. When cell salvage is used with standard fluid management during AAA repair, additional ANH is ineffective in saving blood.
Collapse
Affiliation(s)
- L Wolowczyk
- Department of Surgery, Bristol Royal Infirmary, Bristol, UK
| | | | | | | | | |
Collapse
|
9
|
Stewart AHR, McGrath CM, Cole SEA, Smith FCT, Baird RN, Lamont PM. Reoperation for neurological complications following carotid endarterectomy. Br J Surg 2003; 90:832-7. [PMID: 12854109 DOI: 10.1002/bjs.4121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There remains a dilemma whether or not to re-explore the carotid artery when a neurological complication occurs after carotid endarterectomy. This study reviewed the indications for, findings and clinical outcomes following re-exploration. METHODS Patients who experienced transient or permanent neurological events following carotid endarterectomy were identified from a prospectively compiled computerized database. Case notes were retrieved to determine time to onset of symptoms, use of carotid artery imaging and details about patients who had surgical re-exploration, and outcomes. RESULTS Some 780 consecutive carotid endarterectomies were performed over 16 years, with an incidence of major stroke or death of 2.3 per cent (18 patients). Fifty-one patients experienced transient or permanent neurological events following surgery, 25 of whom underwent re-exploration. The findings included carotid thrombosis (ten patients), flap or other technical cause (three), haematoma (two) and no abnormality (ten). The neurological outcome after 30 days was similar, whether or not the carotid artery was re-explored. CONCLUSION Carotid artery re-exploration was undertaken in approximately half of the patients who developed neurological complications following carotid endarterectomy. Although the cause was identified and a secondary procedure was undertaken in 14 of 25 patients, there was no improvement in clinical outcome at 30 days compared with that of patients managed non-operatively.
Collapse
Affiliation(s)
- A H R Stewart
- Department of Vascular Surgery, Bristol Royal Infirmary, Bristol, UK.
| | | | | | | | | | | |
Collapse
|
10
|
Gadsdon P, Bulbulia R, Smith FCT, Angelini GD, Jeremy JY. Biodegradable External Stents Inhibit Saphenous Vein Graft Thickening in the Pig. J Card Surg 2003. [DOI: 10.1046/j.1540-8191.2002.101429.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- P Gadsdon
- John Moores Liverpool University, Liverpool, UK
| | - R Bulbulia
- The Department of Surgery, Bristol Royal Infirmary
| | - FCT Smith
- The Department of Surgery, Bristol Royal Infirmary
| | | | | |
Collapse
|
11
|
Bulbulia RA, Smith FCT, Lamont PM, Baird RN, Angelini GD, Jeremy JY, Yim A, Wan S. An endothelin type A receptor antagonist inhibits neointimal hyperplasia and increases luminal area in porcine vein grafts. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2001.01757-13.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
Neointimal hyperplasia is responsible for the majority of cases of vein graft failure. To date, no pharmacological intervention has proved successful in preventing this process in humans. Endothelin (ET) 1 is a potent vasoconstrictor and promotes the proliferation of vascular smooth muscle cells in vitro. The authors have shown previously that porcine vein grafts contain high levels of ET-1 and ET type A (ETA) receptor subtypes. The aim was to investigate the effect of an ETA receptor antagonist, BSF 302146, on luminal area and graft wall dimensions in a porcine model of arteriovenous bypass grafting.
Methods
Bilateral saphenous vein–carotid artery interposition grafting was performed in two groups of Large White pigs (26–32 kg; n = 5 per group). BSF 302146 (10 mg kg−1 day−1) was administered orally to animals in group 1; group 2 animals acted as controls. After 4 weeks the grafts were explanted and pressure-fixed ex vivo. Histological sections were obtained and graft dimensions assessed by means of computer-aided planimetry.
Results
BSF 302146 significantly reduced both neointimal hyperplasia and medial thickening, and increased luminal area by 77 per cent.
Conclusion
The ETA receptor antagonist BSF 302146 inhibits neointimal hyperplasia and increases luminal area in a porcine model of saphenous vein bypass grafting.
Collapse
Affiliation(s)
- R A Bulbulia
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| | - F C T Smith
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| | - P M Lamont
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| | - R N Baird
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| | - G D Angelini
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| | - J Y Jeremy
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| | - A Yim
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| | - S Wan
- Bristol Royal Infirmary, Bristol, UK and Prince of Wales Hospital, Lowloon, Hong Kong
| |
Collapse
|
12
|
Wolowczyk L, Bulbulia RA, Stewart A, Nevin M, Day A, Smith FCT, Baird RN, Lamont PM. Randomized controlled trial of acute normovolaemic haemodilution in aortic aneurysm repair. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2001.01757-16.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
Previous studies have suggested that acute normovolaemic haemodilution (ANH) reduces the need for heterologous blood transfusion in abdominal aortic aneurysm (AAA) surgery and may thus improve postoperative outcome by reducing the systemic inflammatory response. Controlled studies are lacking. The aim of this randomized controlled trial was to evaluate the effects of ANH on the systemic inflammatory response, clinical outcome and use of bank blood after AAA repair.
Methods
Patients undergoing elective AAA repair were randomized to ANH (n = 16) or control (n = 18) groups. Intraoperative cell salvage and heterologous blood were used in both groups according to predetermined transfusion triggers. Inflammatory markers in serum and urine were measured to assess the acute-phase response. Clinical outcome was determined using mortality, morbidity and the incidence of the systemic inflammatory response syndrome (SIRS).
Results
There was no difference between the ANH and control group in serial measurements of median (range) white cell count (maximum at 2 days after operation: 11·9 (7·7–21·4) versus 10·3 (7·8–20·6) × 109 l−1; P = 0·25), serum C-reactive protein level (maximum at 3 days: 150 (1–274) versus 169 (7–238) mg ml−1; P = 0·76), interleukin 6 level (maximum at 6 h: 142 (32–793) versus 105 (29–509) pg ml−1; P = 0·89), total antioxidant capacity (lowest at 1 h: 0·83 (0·67–1·22) versus 0·83 (0·68–1·23) mmol l−1; P = 0·45) or urinary albumin/creatinine ratio (maximum at 30 min after clamp release: 41 (2–923) versus 124 (4–376) mg ml−1; P = 0·10). SIRS was observed in ten of 16 patients having ANH and in 11 of 18 control patients (P = 0·99). There was no significant difference in mortality and morbidity between the groups. Similarly, there was no difference in median (range) blood loss (ANH 1800 (400–12 000) ml versus control 1600 (500–7500) ml; P = 0·55), use of cell salvage (600 (0–4740) versus 520 (0–2420) ml; P = 0·60) or heterologous blood transfusion (2 (0–32) versus 2 (0–9) units; P = 0·68).
Conclusion
In the setting of a randomized controlled trial ANH added no additional benefit, when used in combination with cell salvage, in reducing the requirements for heterologous blood transfusion, and made no impact on systemic inflammatory response and clinical outcome after AAA repair.
Collapse
Affiliation(s)
| | | | - A Stewart
- Bristol Royal Infirmary, Bristol, UK
| | - M Nevin
- Bristol Royal Infirmary, Bristol, UK
| | - A Day
- Bristol Royal Infirmary, Bristol, UK
| | | | - R N Baird
- Bristol Royal Infirmary, Bristol, UK
| | | |
Collapse
|
13
|
Baird RN, Baker AR, Hine C, Lamont PM, Lear PA, Loveday E, Mitchell DM, Morse M, Munro EN, Murphy KP, Rees MR, Smith FCT, Thornton MJ. Interhospital provision of emergency vascular services for a large population: early outcomes and clinical results. Br J Surg 2002. [DOI: 10.1046/j.1365-2168.2001.01757-59.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
In 1999 an emergency vascular service for Bristol and Avon (including Weston-Super-Mare) (population approximately 1 million) was initiated.
Methods
Collaboration between Bristol Royal Infirmary, Frenchay and Southmead Hospitals provides week-on–week-off vascular cover for patients requiring urgent and emergency interventions within 24 h. The rota accommodates National Confidential Enquiry into Perioperative Deaths and Vascular Surgical Society of Great Britain and Ireland recommendations, governance issues, and enhances emergency vascular care for Avon residents. Prospectively collected data for the first year (May 1999 to April 2000) are reviewed.
Results
There were 289 emergency admissions. (In-hospital referrals were not transferred but contributed up to 40 per cent of the extra emergency workload per unit.) Referrals were also accepted from seven Trusts outside the designated catchment area. Caseload included 86 patients with a ruptured or acutely symptomatic aortic aneurysm, of whom 69 underwent operation (30 per cent mortality rate); 17 patients were not operated on. Some 136 patients had critical leg ischaemia (43 acute, 93 chronic); angiography or duplex ultrasonography was performed in 105 cases (77 per cent); 39 patients (29 per cent) had undergone previous intervention for peripheral vascular disease; the mortality rate was 18 (13 per cent) of 136; 18 (13 per cent) of 136 patients required an amputation. Other cases included: upper limb ischaemia, 20 (7 per cent); paediatric emergency, seven (2 per cent); symptomatic carotid disease, five (2 per cent; four endarterectomies with no death or stroke). Some 5 per cent of referrals were inappropriate (venous ulcer, spinal stenosis, etc.). No outcomes were compromised by interhospital transfers. Vascular surgeons operated on nine high-risk patients away from their ‘base’ hospital. A consultant was the principal or assistant operator in more than 95 per cent of operations but, despite trainee rota adjustments, a designated vascular trainee was present in only about 40 per cent of cases.
Conclusion
Interhospital provision of emergency vascular services for a large population is feasible, does not compromise quality of care, and regulates emergency workload. Further attention to training issues is indicated.
Collapse
Affiliation(s)
- R N Baird
- Bristol Royal Infirmary, Bristol, UK
| | | | - C Hine
- Frenchay Hospital, Bristol, UK
| | | | | | | | | | - M Morse
- Southmead Hospital, Bristol, UK
| | | | | | - M R Rees
- Bristol Royal Infirmary, Bristol, UK
| | | | | |
Collapse
|
14
|
Abstract
AIMS AND METHODOLOGY the aim of this review is to provide an overview of the aetiology of neointima formation in vein grafts and to highlight the use of an external support to modulate this phenomenon. A systematic literature review was performed via computerised search on MEDLINE, OVID and the Cochrane Library. The search terms initially employed were broad-based; "vein graft", "neointima" and "external stent". Subsequently, more specific search terms were utilised; "perivenous mesh", "external prosthesis" and "varicose vein". Articles from indexed journals relevant to the objective, external venous supports, from the earliest reports in the 1960's to the latest in 2001 were included to obtain an exhaustive list. Reviews, abstracts and proceedings of scientific meetings, case reports and the results of both animal model investigations and human clinical trials in all languages were included. Articles describing an external support employed in both peripheral and aortocoronary bypass investigations were included.
Collapse
Affiliation(s)
- V Vijayan
- Vascular Studies Unit, Bristol Royal Infirmary, Bristol, UK
| | | | | | | | | |
Collapse
|
15
|
Stewart AHR, Lucas A, Smith FCT, Baird RN, Lamont PM. Pre-operative hand-held Doppler run-off score can be used to stratify risk prior to infra-inguinal bypass surgery. Eur J Vasc Endovasc Surg 2002; 23:500-4. [PMID: 12093065 DOI: 10.1053/ejvs.2002.1651] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to investigate the relationship between calf vessel run-off assessed by hand-held Doppler, graft patency and patient survival following infra-inguinal graft surgery. DESIGN prospective cohort study of 258 consecutive patients undergoing infra-inguinal bypass grafts in one centre between 1995-99. MATERIALS AND METHODS ankle Doppler auditory waveform characteristics were documented for patients considered for infra-inguinal bypass grafting. Doppler signals from the anterior tibial, posterior tibial and dorsalis pedis arteries were scored triphasic/biphasic (2), monophasic (1) or absent (0). A total Doppler run off score (0-6) was calculated. Following surgery graft surveillance was undertaken using duplex ultrasound at 6, 12, 26 and 52 weeks. Graft and patient survival were analysed using Cox regression analysis. RESULTS overall primary assisted graft patency at one year was 80%. With an increasing Doppler score from 0 to 6, primary assisted graft patency steadily rose from 50% to 100% (p = 0.0002), accompanied by a steady fall in patient mortality from 50% to 5% (p = 0.0003).
Collapse
Affiliation(s)
- A H R Stewart
- Vascular Studies Unit, Bristol Royal Infirmary, Bristol, UK
| | | | | | | | | |
Collapse
|
16
|
McGrath C, Robb R, Lucas AJ, Stewart AHR, Underwood CL, Horridge JK, Lamont PM, Smith FCT, Baird RN. A randomised, double blind, placebo-controlled study to determine the efficacy of immune modulation therapy in the treatment of patients suffering from peripheral arterial occlusive disease with intermittent claudication. Eur J Vasc Endovasc Surg 2002; 23:381-7. [PMID: 12027463 DOI: 10.1053/ejvs.2002.1635] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES this study examined the effect of immune modulation therapy (IMT) on claudication distances. MATERIALS AND METHODS a double-blind placebo controlled trial was performed on patients with disabling intermittent claudication with randomisation stratified for short and long distance IC. For IMT, following exposure to UV light, oxidisation and 42.5 degrees C, 10 ml of citrated autologous blood was administered by intra-muscular injection. One course consisted of 6 injections in 3-weeks followed by 3-weeks rest. Patients received 2, 3 or 4 courses depending on response. The primary end-point was the number of responders (>50% increase in initial claudication distance (ICD)) in each group. Secondary end-points included percentage changes in ICD and change in quality of life. RESULTS at week 24, there were more responders in the IMT group (20/31, 65%) compared to placebo (16/39, 41%) (p=0.06). In the subgroup of short distance claudicants this difference reached significance (IMT 17/26, 65%) (Placebo 12/33, 36%) (p=0.04). The median increase in ICD was significantly greater in the IMT group (81%) compared to placebo (44%, p=0.04). These results were supported by quality of life measurements. CONCLUSIONS; IMT is a safe and apparently effective treatment for patients with short distance claudication.
Collapse
Affiliation(s)
- C McGrath
- Department of Vascular Surgery, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, U.K
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Smith FCT, Shearman CP. Acute intestinal ischaemia. West J Med 1991. [DOI: 10.1136/bmj.302.6768.114-d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|