Eric Edison

Improving Compliance with NICE Guidelines on Parkinson's isease: A Quality Improvement Study.

Parkinsons disease can progressively affect daily function and multidisciplinary teamwork is essential to provide high quality care. The National Institute of Health and Clinical Excellence (NICE) issued guidelines regarding diagnosis, follow-up, and multidisciplinary care. This quality improvement project sought to measure and improve the compliance of service provision against the guidelines. In total, 3 audit cycles were completed. Each audit involved reviewing notes of patients attending a Parkinsons disease outpatient clinic against the PD NICE guidelines audit criteria. The first and second audits showed compliance was high for the criteria relating to initial diagnosis and referral but poor for those criteria relating to multidisciplinary referral. A pro forma stamp was recommended to be placed in the notes at each regular Parkinsons outpatient review by a specified date (October 2009), with re-audit occurring in June 2011 as part of the official hospital audit plan. Compliance to the NICE criteria improved to 100% on all criteria measured. However, it was evident from the notes that the pro forma that had been recommended by the previous audit had been in use but was not at present. In fact the pro forma had been so successful that the clinicians had made each of the criteria a routine part of their consultations and so did not need to rely on it. Use of a checklist can have a lasting improvement on compliance with NICE guidelines, even if the intervention itself is transient.

Improving Compliance with Statins in Patients with Peripheral Arterial Disease: A Quality Improvement Study

Atherosclerosis is an inflammatory disease affecting medium sized arteries. The prevalence, health, and financial impact of the disease has made it a key target for public health and large scale intervention. The statin class of drugs improve morbidity and mortality for patients with peripheral arterial disease (PAD) through polymodal actions. This quality improvement study aimed to determine, and subsequently reduce, the percentage of patients with PAD discharged without statins. According to the Vascular Society of Great Britain and Ireland, and draft National Institute of Health and Clinical Excellence guidance, all patients undergoing major vascular procedures should be prescribed a statin. A baseline audit of patients with PAD under the care of the vascular team at our instituted was undertaken for the period Dec 2009–July 2010. Electronic discharge letters (EDLs) were analysed and compliance with statin prescription were recorded. A number of interventions aimed at improving compliance were then enacted and monitored through weekly PDSA cycles. Junior doctor leadership was key to identifying the problem and conceiving, implementing, and measuring changes. A second cycle was run, using similar data collection methods to the first, for the period August-October 2010. In the first cycle, EDLs pertaining to 113 patient admissions, involving 96 patients with PAD, were examined. Statins were not prescribed in 30.1%. In the second cycle, 86 patient admissions, involving 76 patients, were examined. Statins were not prescribed in 24.4%, representing an 18.9% decrease. Poorly compliant sub-groups included patients presenting with embolism or those for elective angioplasty.

Annals of Medicine and Surgery - A modern Journal for Modern Trainees

At its core, the purpose of healthcare is simple: to maximise quality and quantity of life. To achieve this vision, doctors have assumed an array of roles across a number of domains beyond the one-to-one patient-doctor interaction. Such domains include; teaching, research, leadership, management and clinical governance to name but a few. These roles and the healthcare systems in which they operate, have evolved over time to meet demand from patients, the profession, government and regulators. Further evolution is needed as we move into the 21st century to deal with the “perfect storm” of expensive technological advances, economic challenges and epidemiological changes.1 It is the trainees and students of today who will drive this progress in the future. Journals are a gateway to scientific progress and we believe there is a need for a journal to educate and develop the knowledge, skills and attitudes of trainees and students. Furthermore, over the past few years, the very nature of scientific journal publication has come under scrutiny.2 Hence we seek to establish a modern journal that deals with the challenges and opportunities of the 21st century.

Norman Barrett (1903–1979): Unorthodox pioneer of thoracic and oesophageal surgery

It is an interesting quirk of medical history that the legacy of Norman Barrett most ostensibly lies in the name of a disease the he was quite emphatically wrong about, at least when he first described it. Indeed, there are those who argue to remove the eponym in favour of the title ‘Columnar Lined Epithelium’, in part because of what little Barrett actually had to do with the correct initial characterisation of this disease. Yet the sum of Norman Barrett’s contributions to modern medicine is much more than a mistaken characterisation of a pathological process. Barrett was truly a pioneer of chest surgery in the UK – a speciality in its embryonic stages when he first qualified. He was also renowned as a teacher and academic of the highest calibre. In tracing the story of his life we can see how his natural attributes, life experiences and keen appreciation of the arts (especially history) facilitated personal success and such sharp insight into the vagaries of modern academic medicine.

Maternal Choice in the UK Should Be Promoted Despite the Current Era of Financial Austerity

With the ‘Nicholson challenge’ to cut costs by £20 billion over four years defining the current financial climate of the NHS,1 spiralling healthcare costs must be contained. Part of the reason for these increases is that the most modern interventions are often demanded by patients, even when the incremental health benefits are far outweighed by their cost. Maternity care is a major success of western medicine, and widespread maternal choice of location and type of treatment is increasingly expected in the developed world, and approved in recent NICE guidance6. Though desirable to many, rarely in medicine is such a choice available where patients may demand that which is not clinically indicated, and for it to be provided free of charge. In considering the ethical, economic, and empirical evidence for this debate, the four principles of medical ethics provide a useful framework: non-maleficence and beneficence (empirical evidence of risk and benefit), justice (economics), and autonomy (tantamount to maternal choice). Does increasing maternal autonomy provide benefits that outweigh any risks of harm to mothers and/or economic losses, and thus is current guidance justifiable?

The Methodological Quality of Randomised Controlled Trials in Plastic Surgery: 2009-2011

IntroductIon: Randomized controlled trials (RCTs) represent the criterion standard in evaluating healthcare interventions. However, RCTs can yield biased results if they lack methodological rigour, especially where surgical techniques are involved. Surgical RCTs have a number of unique challenges and can be performed poorly. Our objective was to assess the methodological quality of RCTs in Plastic Surgery.

Commentary on: Combat-related gunshot wounds in the United States military: 2000–2009

Gunshot wounds are an important cause of both morbidity and mortality within the military. With the deployment of the United States military into a two theater campaign over the past decade, the role of gunshot wounds in military personnel has come to the forefront. Gunshot wounds are often used and glamourized in popular culture. They are also fascinating to clinicians due to the difficulty in assessing such patients for injuries and treatment options.(1) Gunshot wounds also provide an opportunity to develop certain aspects of trauma management.(2) Walker et al. provide a coherent analysis of gunshot wounds to US military personnel during this period.(3).

Commentary on: Preoperative shockwave treatment enhances ischemic tissue survival in a rat flap model

1743-9191/

Randomised controlled trials in plastic surgery: a systematic review of reporting quality.

e see front matter 2011 Surgical Asso doi:10.1016/j.ijsu.2011.06.001 Skin flaps are a vital tool in plastic surgery and used to treat and manage a variety of conditions. However, necrosis of distal flap regions continue to have a high prevalence and often lead to postsurgical complications such as infection and the need for repeat surgery. Extracorporeal shock wave therapy (ESWT) has a range of functions in medicine including lithotripsy in the field of urology and for the treatment of musculoskeletal disorders.1 The potential role of ESWT in improving skin flap survival has now been explored by several studies in animal models.2e10 Meirer and colleagues were the first to indicate a use for ESWT in the maintenance of skin flap viability. Epigastric skin flaps were raised on Wistar rats with application of ESWT immediately postsurgery.2 This was shown to significantly reduce the total necrotic zones found compared with the control group. Similarly there was an increase in VEGF expression within this study. Recently, Keil et al. showed preoperative exposure of the flap segment to ESWT was successful in increasing tissue survival.3 A single ESWT exposure, seven days prior to flap retrieval increased the area of surviving tissue compared with the control group; this builds on the results of a previous study.4 Direct visualisation of increased micro-vessel density was observed following ESWT, this was associated with a rise in VEGF to total protein ratio within the flap. Both these markers indicate an increased likelihood of flap survival.3 This increase in vascular density may open a potential therapeutic avenue for ESWT in the treatment of vascular conditions for example associated with Diabetes Mellitus.12 This technique has been further expanded by the work examining the use of repeated ESWT on skin flaps both concomitantly