1
|
Patel B, Green S, Hennessy C, Adamu-Biu F, Ghani Y, Kankate R. 77 Lessons Learnt from Managing Orthopaedic Trauma During the First Wave of the COVID-19 Pandemic at a UK District General Hospital. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.966] [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: 11/13/2022]
Abstract
Abstract
Background
The Coronavirus disease (COVID-19) pandemic has contributed to over 900,000 deaths worldwide. Hospitals responded by expanding services to accommodate the forecasted rise in COVID-19-related admissions. We describe the effects these changes had on management of orthopaedic trauma and patient outcomes at a district general hospital in Southern England.
Method
Data were extrapolated retrospectively from two separate six-week periods in 2019 and 2020 (1st April - 13th May) using electronic records of patients referred to the orthopaedic team. Soft tissue injuries were included where a confirmed diagnosis was made with radiological evidence. Patients were excluded if no orthopaedic intervention was required. Data were compared between the two time periods.
Results
There were fewer attendances to hospital in 2020 compared with 2019 (178 vs 328), but time from presentation to surgery significantly increased in 2020 (2.94 days vs 4.91 days, p = 0.009). There were fewer operative complications in 2020 (36/145 vs 11/88, p < 0.001). However, ordinal logistic regression analysis found a significantly greater complication severity in 2020 including death (p = 0.039). Complication severity was unrelated to COVID-19 status.
Conclusions
Restructuring of orthopaedic services in response to the COVID-19 pandemic has been associated with significant delays to surgery and higher post-operative complication severity. Our results demonstrate the need for fast-track emergency operative orthopaedic services in UK district general hospitals whilst the COVID-19 pandemic continues.
Collapse
Affiliation(s)
- B Patel
- Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, United Kingdom
| | - S Green
- University of Oxford, Oxford, United Kingdom
| | - C Hennessy
- University of Oxford, Oxford, United Kingdom
| | - F Adamu-Biu
- Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, United Kingdom
| | - Y Ghani
- Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, United Kingdom
| | - R Kankate
- Buckinghamshire Healthcare NHS Trust, Stoke Mandeville, United Kingdom
| |
Collapse
|
2
|
Patel BA, Green SF, Henessy C, Adamu-Biu F, Davda K, Chennagiri R, Kankate R, Ghani Y. Lessons Learnt from Managing Orthopaedic Trauma During the First Wave of the COVID-19 Pandemic at a UK District General Hospital. Indian J Orthop 2021; 55:1037-1045. [PMID: 34024932 PMCID: PMC8130789 DOI: 10.1007/s43465-021-00419-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Coronavirus disease (COVID-19) pandemic has contributed to over 1,000,000 deaths worldwide. Hospitals responded by expanding services to accommodate the forecasted rise in COVID-19-related admissions. We describe the effects these changes had on management of orthopaedic trauma and patient outcomes at a district general hospital in Southern England. METHODS Data were extrapolated retrospectively from two separate 6-week periods in 2019 and 2020 (1st April-13th May) using electronic records of patients referred to the orthopaedic team. Soft tissue injuries were included where a confirmed diagnosis was made with radiological evidence. Patients were excluded if no orthopaedic intervention was required. Data were compared between the two time periods. RESULTS There were fewer attendances to hospital in 2020 compared with 2019 (178 vs. 328), but time from presentation to surgery significantly increased in 2020 (2.94 days vs. 4.91 days, p = 0.009). There were fewer operative complications in 2020 (36/145 vs. 11/88, p < 0.001). However, ordinal logistic regression analysis found a significantly greater complication severity in 2020 including death (p = 0.039). Complication severity was unrelated to COVID-19 status. CONCLUSIONS Restructuring of orthopaedic services in response to the COVID-19 pandemic has been associated with significant delays to surgery and higher post-operative complication severity. Our results demonstrate the need for fast-track emergency operative orthopaedic services in UK district general hospitals whilst the COVID-19 pandemic continues.
Collapse
Affiliation(s)
- B. A. Patel
- grid.413032.70000 0000 9947 0731Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK ,grid.499457.20000 0004 4667 5409Health Education Thames Valley, Oxford School of Surgery, Oxford, OX4 2GX UK
| | - S. F. Green
- grid.413032.70000 0000 9947 0731Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK ,grid.416201.00000 0004 0417 1173Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
| | - C. Henessy
- grid.413032.70000 0000 9947 0731Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK ,grid.4991.50000 0004 1936 8948Faculty of Health Sciences, St Catharine’s College, Oxford University, Oxford, OX1 3UJ UK
| | - F. Adamu-Biu
- grid.413032.70000 0000 9947 0731Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK ,grid.8348.70000 0001 2306 7492John Radcliffe Hospital, Oxford, OX3 9DU UK
| | - K. Davda
- Department of Trauma and Orthopaedics, Buckinghamshire NHS Healthcare Trust, Amersham, HP21 8AL UK
| | - R. Chennagiri
- grid.413032.70000 0000 9947 0731Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK ,Department of Trauma and Orthopaedics, Buckinghamshire NHS Healthcare Trust, Amersham, HP21 8AL UK
| | - R. Kankate
- Department of Trauma and Orthopaedics, Buckinghamshire NHS Healthcare Trust, Amersham, HP21 8AL UK
| | - Y. Ghani
- grid.413032.70000 0000 9947 0731Stoke Mandeville Hospital, Buckinghamshire NHS Foundation Trust, Aylesbury, UK ,Department of Trauma and Orthopaedics, Buckinghamshire NHS Healthcare Trust, Amersham, HP21 8AL UK
| |
Collapse
|
3
|
Parker S, Nagra NS, Kulkarni K, Pegrum J, Barry S, Hughes R, Ghani Y. Inadequate pelvic radiographs: implications of not getting it right the first time. Ann R Coll Surg Engl 2017; 99:534-539. [PMID: 28682132 DOI: 10.1308/rcsann.2017.0095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction Pelvic radiography is a frequent investigation. European guidelines aim to ensure appropriate use and adequate quality. When initial images are inadequate, repeat radiographs are often required, which may have significant patient safety and economic implications. Objectives The study aimed to assess the adequacy of pelvic imaging across three orthopaedic centres, to identify causes for inadequate imaging and to establish the cost of inadequate imaging from financial and patient safety perspectives. Methods Pelvic radiographs were identified on Picture Archiving and Communication System software at three UK hospitals. Radiographs were assessed against European guidelines and indications for repeat imaging were analysed. Results A total of 1,531 sequential pelvic radiographs were reviewed. The mean age of patients was 60 years (range 5 months to 101 years). Of this total, 51.9% of images were suboptimal, with no significant difference across the three hospitals (P > 0.05). Hospital 3 repeated radiographs in 6.3% of cases, compare with 18.1% and 19.7% at hospitals 1 and 2, respectively (P > 0.05). Hospital 3 identified pathology missed on the initial radiograph in 1% of cases, compared with 5.4% and 5.5% at hospitals 1 and 2, respectively (P > 0.05). Out-of-hours imaging is associated with a higher rate of suboptimal quality (69.1%) compared with normal working hours (51.3%; P = 0.006). Adequacy rates vary with age (χ 2 = 43.62, P < 0.001). Risk of having a suboptimal radiograph increases above the age of 60-years (χ 2 = 4.45, P < 0.05). The annual cost of repeat radiographs was £56,200 per hospital. Discussion and conclusion High rates of pelvic radiograph inadequacy can lead to missed pathology and the requirement for repeat imaging, which has significant patient safety and financial implications. Risk factors for inadequate radiographs include older patients and those having out-of-hours imaging.
Collapse
Affiliation(s)
- S Parker
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital , Reading , UK
| | - N S Nagra
- Oxford University Clinical Academic Graduate School, John Radcliffe Hospital , Oxford , UK
| | - K Kulkarni
- Department of Trauma and Orthopaedics, East and North Herts NHS Trust, Lister Hospital , Stevenage , UK
| | - J Pegrum
- Department of Orthopaedics, Nuffield Orthopaedic Centre, Headington , Oxford , UK
| | - S Barry
- Department of Radiology, John Radcliffe Hospital , Oxford , UK
| | - R Hughes
- Department of Radiology, Stoke Mandeville Hospital , Aylesbury , UK
| | - Y Ghani
- Department of Trauma and Orthopaedic Surgery, Stoke Mandeville Hospital , Aylesbury , UK
| |
Collapse
|
4
|
Abstract
Plastic surgery is one of the most competitive surgical specialties in the UK. There is a nationalised recruitment system in place and in 2011 there was a competition ratio of applicants to successful candidates of 10:1, with 177 applicants applying for a final number of 18 posts. 1 In 2012 the corresponding ratio was 17:1, with 166 applicants for 10 posts. 2 With such a high number of applicants for so few ST3 posts, candidates must be aware of the requirements to attain a national training number (NTN) early in their surgical career.
Collapse
Affiliation(s)
| | - Y Ghani
- Buckinghamshire Healthcare NHS Trust
| | | |
Collapse
|
5
|
Abstract
Tendon ruptures associated with ankle fractures and dislocations or subtalar dislocations are very rare entities with only a few reports of these in the literature. We report a case of an open subtalar dislocation and associated isolated proximal rupture of the flexor digitorum longus tendon at the musculotendinous junction, following a relatively low energy trauma. The finding of the avulsed flexor digitorum longus tendon was intraoperative, and management involved thorough washout of the joint and a primary side-to-side tenodesis with the flexor hallucis longus tendon. The patient has made a good functional recovery from his injuries. This case is reported because of the rarity of this combination of injuries and the associated management dilemma with which it presented us.
Collapse
Affiliation(s)
- Y Ghani
- Great Western Hospitals NHS Foundation Trust, UK
| | | | | |
Collapse
|
6
|
Jukes P, D’acquisto F, Pepper R, Ghani Y, Perretti M, Salama A, Little M. Investigating Annexin-A1 in ANCA vasculitis and glomerulonephritis. Presse Med 2013. [DOI: 10.1016/j.lpm.2013.02.090] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
7
|
Ghani Y, Isah N, Saleh S, Soid NFM. Evaluation of enforcement programme to increase seatbelt use: a case study in precinct 8, Putrajaya. Inj Prev 2012. [DOI: 10.1136/injuryprev-2012-040590w.20] [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: 11/04/2022]
|
8
|
Ghani Y, Md Junoh AR, Yussof A. TOWARDS SAFER ROADS IN PUTRAJAYA THROUGH COMMUNITY BASED PROGRAMME. Inj Prev 2012. [DOI: 10.1136/injuryprev-2012-040580a.29] [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: 11/04/2022]
|
9
|
Ghani Y, Soid NFM, Isah N, Saleh S. The effectiveness of enforcement programme in promoting proper helmet wearing among motorcyclists in precinct 8, Putrajaya. Inj Prev 2012. [DOI: 10.1136/injuryprev-2012-040590w.40] [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: 11/04/2022]
|
10
|
Xue S, Gao L, Gillmore R, Bendle G, Holler A, Downs AM, Tsallios A, Ramirez F, Ghani Y, Hart D, Alcock S, Tranter A, Stauss HJ, Morris E. WT1-targeted immunotherapy of leukaemia. Blood Cells Mol Dis 2005; 33:288-90. [PMID: 15528146 DOI: 10.1016/j.bcmd.2004.08.018] [Citation(s) in RCA: 16] [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] [Received: 08/06/2004] [Indexed: 11/17/2022]
Abstract
Since malignant cells are derived from normal cells, many tumour-associated antigens are also expressed in normal tissues. For examples, WT1 is expressed at elevated levels in most leukaemias, but it is also expressed at reduced levels in normal CD34+ haematopoietic stem cells and in progenitor cells of other tissues. Antigen expression in normal tissues is likely to trigger immunological tolerance and thus blunt T cell responses. This could explain the observation that WT1 vaccination in mice frequently fails to stimulate high avidity cytotoxic T cell responses. In order to circumvent tolerance, we have isolated from HLA-A2-negative donors high avidity CTL specific for HLA-A2-presented peptide epitopes of WT1. These allorestricted CTL efficiently kill HLA-A2-positive leukaemia cells but not normal CD34+ haematopoietic stem cells. However, adoptive cellular therapy with allorestricted CTL could only be performed in leukaemia patients rendered tolerant to the infused CTL by prior allogeneic stem cell transplantation. In order to circumvent this limitation, we propose to exploit the TCR of allorestricted CTL as therapeutic tool. TCR gene transfer can be used to take advantage of the specificity of allorestricted CTL and transfer it to patient CTL, while avoiding the transfer of immunogenic alloantigens from the donor CTL to the patient.
Collapse
Affiliation(s)
- S Xue
- Tumour Immunology Section, Department of Immunology, Imperial College London, London W12-0NN, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Xue S, Gillmore R, Gao L, Bendle G, Holler A, Downs AM, Tsallios A, Ramirez F, Ghani Y, Hart D, Alcock S, Tranter A, Morris E, Stauss HJ. Use of the allogeneic TCR repertoire to enhance anti-tumor immunity. J BIOL REG HOMEOS AG 2004; 18:131-3. [PMID: 15471216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
It is well established that antigen-specific T lymphocytes can inhibit tumor growth in humans and in mice, leading to complete tumor elimination in some cases. However, in many cases T cell immunity is unable to successfully control tumor progression. Since tumors are derived from normal tissues, most antigens are shared with normal tissues, although expression levels are usually elevated in malignant cells. Nevertheless, low-level expression in normal cells can be sufficient to render autologous T cells tolerant and thus unable to mount effective immune responses against tumors. Here, we review how allogeneic T cells can be used to isolate T cells that effectively recognise and kill tumor cells, but not normal cells with low level of antigen expression. The TCR of allogeneic T cells can be introduced into patient T cells to equip them with anti-tumor specificity that may not be present in the autologous T cell repertoire.
Collapse
Affiliation(s)
- S Xue
- Department of Immunology, Tumour Immunology Section, Imperial College London, Hammersmith Hospital, London, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|