Frank C T Smith

Local Versus Systemic Mechanisms Underlying Supervised Exercise Training for Intermittent Claudication

The mechanisms by which exercise training improves intermittent claudication remain unclear. In this article, the effects of local and systemic physiological factors on improved exercise tolerance after a supervised exercise program in claudicants are investigated. A total of 60 patients were randomized to 3 months of supervised exercise followed by 3 months of unsupervised exercise, or to exercise advice alone (control). Supervised exercise increased both pain-free and maximal walking distances. Heart rate during submaximal exercise and resting mean arterial pressure were lower after supervised exercise at 6 months. Serum lactate at maximum claudication increased significantly after 3 months in the supervised exercise group but this change had resolved by 6 months. Symptomatic improvement was accompanied by modest reductions in mean arterial pressure and submaximal heart rate on exercise. Increased serum lactate at maximum claudication subsequently declined despite continued improvement in walking distance, suggesting local adaptations to improve efficiency of muscle oxygen delivery and/or utilization.

Sympathetic skin response and patient satisfaction on long-term follow-up after throacoscopic sympathectomy for hyperhidrosis

Objectives: To determine effect of sympathectomy for hyperhidrosis on sympathetic skin response (SSR) during long-term follow-up. Patient satisfaction was assessed and surgical complications noted. Design: Prospective, Open, Non-randomised study. Materials and Methods: Patients who had undergone bilateral thoracoscopic sympathectomy for hyperhidrosis underwent postoperative assessment of SSRs. A 15mA stimulus was applied over the median nerve contralateral to the sympathectomy and evoked electrodermal activity was recorded from the sympathectomised palm using a Dantec Counterpoint Mk 2. Patient satisfaction with surgery was assessed by questionaire and visual analogue score (0–1.0). Results: Of 26 patients, 21 were female. Mean (range) age was 23 (9–36) years. Mean (range) follow up was 39 (4–138) months. 12% of cases had residual or recurrent symptoms. Median (range) patient satisfaction was 0.83 (0.06–1.0). In 7/52 palms recurrent SSRs were not detected. Repeated measures analysis of variance found amplitude of SSR to be of low significance with respect to time since surgery (F=0.48; p=0.49) and incidence of compensatory sweating (F=2.38; p=0.14). Conclusion: Thoracoscopic sympathectomy for hyperhidrosis is an effective procedure. Following sympathectomy SSRs are not permanently abolished, but return of SSRs does not correspond with symptom recurrence. As such, SSRs are a poor tool for objective assessment of long-term outcome following sympathectomy.

Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation - the CASCADE study.

BACKGROUND Type 1 diabetes (T1D) in children and young people is increasing worldwide with a particular increase in children under the age of 5 years. Fewer than one in six children and young people achieve glycosylated fraction of haemoglobin (HbA1c) values in the range identified as providing best future outcomes. There is an urgent need for clinic-based pragmatic, feasible and effective interventions that improve both glycaemic control and quality of life (QoL). The intervention offers both structured education, to ensure young people know what they need to know, and a delivery model designed to motivate self-management. OBJECTIVE To assess the feasibility of providing a clinic-based structured educational group programme incorporating psychological approaches to improve long-term glycaemic control, QoL and psychosocial functioning in a diverse range of young people. DESIGN The study was a pragmatic, cluster randomised control trial with integral process and economic evaluation. SETTING Twenty-eight paediatric diabetes services across London, south-east England and the Midlands. RANDOMISATION Minimised by clinic size, age (paediatric or adolescent) and specialisation (district general hospital clinic or teaching hospital/tertiary clinic). ALLOCATION Half of the sites were randomised to the intervention arm and half to the control arm. Allocation was concealed until after clinics had consented and the first participant was recruited. Where possible, families were blind to allocation until recruitment finished. PARTICIPANTS Forty-three health-care practitioners (14 teams) were trained in the intervention. The study recruited 362 children aged 8-16 years, diagnosed with T1D for > 12 months, with a mean 12-month HbA1c level of ≥ 8.5%. INTERVENTION Two 1-day workshops taught intervention delivery. A detailed manual and resources were provided. The intervention consists of four group education sessions led by a paediatric diabetes specialist nurse with another team member. OUTCOMES The primary outcome was glycaemic control, assessed at the individual level using venous HbA1c values, measured at baseline, 12 and 24 months. Secondary outcomes were directly and indirectly related to diabetes management, including hypoglycaemic episodes, hospital admissions, diabetes regimen, knowledge, skills and responsibility for diabetes management, intervention compliance, clinic utilisation, emotional and behavioural adjustment, and general and diabetes-specific QoL. PROCESS EVALUATION Questionnaires, semistructured interviews, informal discussion following observation sessions, fieldwork notes and case note review were used to collect qualitative and quantitative data from key stakeholder groups at specific time points in the trial. STATISTICAL ANALYSES Primary and secondary analyses were intention-to-treat comparisons of outcomes at 12 and 24 months, using analysis of covariance with a random effect for clinic. Prespecified subgroup analyses based on age, gender, initial HbA1c value and socioeconomic status were estimated from models that included an interaction term. The economic analysis compared long-term costs and predicted quality-adjusted life-years (QALYs). RESULTS The intervention did not improve HbA1c at 12 months [intervention effect 0.11; 95% confidence interval (CI) -0.28 to 0.50; p = 0.584] or 24 months (intervention effect 0.03; 95% CI -0.36 to 0.41; p = 0.891). A total of 298/362 patients (82.3%) provided blood samples at 12-month follow-up, and 284/362 (78.5%) provided blood samples at 24-month follow-up. Follow-up questionnaires were completed by 307 patients (85.3%) at 12 months and by 295 patients (81.5%) at 24 months. Intervention group parents at 12 months (95% CI 0.74; 0.03 to 1.52) and young people at 24 months (0.85; 95% CI 0.03 to 1.61) had higher scores on the diabetes family responsibility questionnaire. Young people reported reduced happiness with body weight at 12 months (-0.56; 95% CI -1.03 to -0.06). Only 68% of groups were run. Of the 180 families recruited, 96 (53%) attended at least one module. Reasons for low uptake included difficulties organising groups, and work and school commitments. Young people with higher HbA1c levels were less likely to attend. Parents and young people who attended groups described improved family relationships, improved knowledge and understanding, greater confidence and increased motivation to manage diabetes. Twenty-four months after the intervention, nearly half of the young people reported that the groups had made them want to try harder and that they had carried on trying. A high-quality, complex, pragmatic trial of structured education can be delivered alongside standard care in NHS diabetes clinics. Health-care providers benefited from behaviour change skill training and can deliver pragmatic aspects of a National Institute for Health and Care Excellence (NICE)-compliant structured education programme after relatively brief training. The process evaluation provides insight into aspects of the model, and highlights strengths and aspects that may have contributed to the failure to influence primary and secondary outcomes. Current NHS practice dominates CASCADE (Child and Adolescent Structured Competencies Approach to Diabetes Education) in that it achieves the same number of QALYs at a lower cost. The mean cost of providing the intervention was £5098 per site or £683 per child. Members of paediatric diabetes services trained to deliver the CASCADE structured education package using behaviour change techniques did not improve glycaemic control in patients compared with control subjects 1 and 2 years after the intervention. The training workshops for practitioners were well evaluated; however, more intensive training was needed. The intervention cost £683 per patient but was not cost-effective because it did not improve metabolic control. CONCLUSIONS A high-quality, complex, pragmatic trial of structured education can be successfully conducted alongside standard care in NHS diabetes clinics. Pragmatic components of a NICE-compliant structured education programme can be successfully delivered following a relatively brief 2-day training while paediatric health-care professionals benefit from training in behaviour change skills. The study provides invaluable information on barriers and opportunities regarding future, similar interventions. A low dropout rate and good attendance for the subgroup that attended the intervention suggests there might be improved uptake if offered to young people with lower HbA1c. Testing whether this approach can be more successful with a robust ongoing supervisory element should be a target of further research. TRIAL REGISTRATION Current Controlled Trials ISRCTN52537669. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 20. See the NIHR Journals Library website for further project information.

Surgical and procedural skills training at medical school – a national review

This national study quantifies procedural and surgical skills training at medical schools in the United Kingdom (UK), a stipulated requirement of all graduates by the General Medical Council (GMC). A questionnaire recorded basic procedural and surgical skills training provided by medical schools and surgical societies in the UK. Skills were extracted from (1) GMC Tomorrows Doctors and (2) The Royal College of Surgeons Intercollegiate Basic Surgical Skills (BSS) course. Data from medical school curricula and extra-curricular student surgical societies were compared against the national GMC guidelines and BSS course content. Data were analysed using Mann-Whitney U tests. Representatives from 23 medical schools completed the survey (71.9% response). Thirty one skills extracted from the BSS course were split into 5 categories, with skills content cross referenced against GMC documentation. Training of surgical skills by medical schools was as follows: Gowning and gloving (72.8%), handling instruments (29.4%), knot tying (17.4%), suturing (24.7%), other surgical techniques (4.3%). Surgical societies provided significantly more training of knot tying (64.4%, P = 0.0013) and suturing (64.5%, P = 0.0325) than medical schools. Medical schools provide minimal basic surgical skills training, partially supplemented by extracurricular student surgical societies. Our findings suggest senior medical students do not possess simple surgical and procedural skills. Newly qualified doctors are at risk of being unable to safely perform practical procedures, contradicting GMC Guidelines. We propose a National Undergraduate Curriculum in Surgery and Surgical Skills to equip newly qualified doctors with basic procedural skills to maximise patient safety.

Compression ultrasonography for false femoral artery aneurysms: Hypocoagulability is a cause of failure

OBJECTIVES False femoral artery aneurysm is an occasional complication of percutaneous cardiovascular radiological procedures. Compression ultrasonography causes thrombosis non-invasively, reducing need for operative intervention. The technique fails in a proportion of cases. Analysis was undertaken to identify causes of failure. DESIGN Prospective open study. MATERIALS AND METHODS Patients presenting with false femoral artery aneurysm since 1984 were identified from a computerised database (BIPAS). Since 1993 compression ultrasonography has been performed as first line treatment according to a standard protocol. Prospectively collected ultrasonographic data and case notes were reviewed to identify causes of failed compression. RESULTS False femoral artery aneurysm occurred as a complication in 32/26,687 (0.12%) cardiovascular radiological procedures. Eighteen aneurysms were treated by compression. The technique was successful in 11/18 (61%) cases but primary failure occurred in seven cases. Six out of seven had bleeding abnormalities (Chi-squared analysis with Yates correction 10.55, p = 0.0012), four were anticoagulated and compression was subsequently successful following reversal of warfarin therapy in three of these patients. In 4/18 cases surgical repair was necessary. CONCLUSION Compression ultrasonography is an effective treatment of false femoral aneurysms, however, hypocoagulability is a significant cause of failure. For patients in whom anticoagulation cannot be reversed, primary surgical repair should be considered.

The progression and correction of duplex detected velocity shifts in angiographically normal vein grafts

OBJECTIVES To review the sensitivity of duplex scanning and angiography at detecting vein graft stenoses in patients on a graft surveillance programme. DESIGN Prospective, open, non-randomised study. PATIENTS AND METHODS Since February 1993, 143 patients with 148 grafts (70% in situ, 30% reversed) have attended postoperative infrainguinal vein graft surveillance for a minimum of 6 weeks. Fifty-seven graft stenoses in 57 grafts were identified by duplex scanning as a localised high velocity jet. Angiography was performed in all except 12 patients. RESULTS Angiography confirmed a duplex abnormality in all but 10 patients. Of these, five patients remain stable and asymptomatic with a persisting duplex abnormality. The remaining five patients, although asymptomatic, exhibited disease progression on duplex and surgical intervention confirmed significant stenoses, which were successfully treated. CONCLUSION The results suggest that duplex scanning is a reliable imaging modality for detecting vein graft stenoses. Selection for surgical correction can be made, in some circumstances on the basis of clinical and ultrasound criteria alone.

Adolescent experiences of anti-obesity drugs

Only two anti‐obesity drugs (AODs) are frequently prescribed in paediatric obesity, orlistat and metformin. Meta‐analyses show modest benefit in clinical trials, yet analyses of prescribing databases show high levels of discontinuation in routine clinical practice. Increased understanding of young peoples experiences taking AOD could result in improved prescribing and outcomes. Semi‐structured interviews were conducted with young people aged 13–18 years and their parents from three specialist obesity clinics, analysed using a general thematic coding methodology. Theme saturation was achieved after interviews with 15 young people and 14 parents (13 parent–child dyads). Three models were developed. Model 1 explored factors influencing commencement of AOD. Six themes emerged: medication as a way out of obesity, enthusiasm and relief at the prospect of pharmaceutical treatment, last ditch attempt for some but not all, passive acceptance of medication, fear as a motivating factor, and unique treatments needed for unique individuals. Model 2 described the inter‐relationship between dosing and side effects; side effects were a significant experience for many young people, and few adhered to prescribed regimens, independently changing lifestyle and dosage to tolerate medications. Model 3 described the patient‐led decision process regarding drug continuation, influenced primarily by side effects and efficacy. Use of AODs is challenging for many adolescents. Multiple factors were identified that could be targeted to improve concordance and maximize efficacy.

Anomalous right subclavian artery and coarctation-related aneurysm repaired with bilateral subclavian-to-carotid transposition and exclusion stent-grafting.

INTRODUCTION Aortic arch anomalies are common; however, the presence of concomitant pathology may present a complex management problem. REPORT A 42 year old lady with anomalous right subclavian artery was found to have recurrent coarctation of the aorta and an aneurysm related to the previous repair. Management of the aneurysm was complicated by the proximity of subclavian artery origins. Bilateral subclavian-to-carotid transposition was undertaken to preserve antegrade vertebral artery flow, with subsequent exclusion stent-grafting of the aneurysm and coarctation. DISCUSSION This case illustrates combined surgical and interventional radiological repair to deal with a complex thoracic aortic clinical problem.

Surgical Safety Training of World Health Organization Initiatives

Undergraduate training in surgical safety is essential to maximize patient safety. This national review quantified undergraduate surgical safety training. Training of 2 international safety initiatives was quantified: (1) World Health Organization (WHO) “Guidelines for Safe Surgery” and (2) Department of Health (DoH) “Principles of the Productive Operating Theatre.” Also, 13 additional safety skills were quantified. Data were analyzed using Mann-Whitney U tests. In all, 23 universities entered the study (71.9% response). Safety skills from WHO and DoH documents were formally taught in 4 UK medical schools (17.4%). Individual components of the documents were taught more frequently (47.6%). Half (50.9%) of the additional safety skills identified were taught. Surgical societies supplemented safety training, although the total amount of training provided was less than that in university curricula (P < .0001). Surgical safety training is inadequate in UK medical schools. To protect patients and maximize safety, a national undergraduate safety curriculum is recommended.

Into Africa: Basic Surgical Skills Trainingin Northern Tanzania

The intercollegiate Basic surgical skills (BSS) course is a rite of passage for UK surgical trainees and this approach to teaching skills is used in daily practice to ensure our trainees develop good surgical techniques and habits. We take it for granted that formal courses are delivered by the surgical royal colleges and now via the schools of surgery; however, this form of teaching is only now being introduced throughout other parts of the world. On the back of the success achieved by BSS in the UK, it has been successfully implemented in over 45 countries, including Barbados, 2 El Salvador, 3 Jordan 4 and dubai 5 in the past 5 years alone. The Education department of the RCS recently visited Tanzania to encourage inception of a surgical skills course programme.