170 research outputs found
Recognition of skin malignancy by general practitioners: observational study using data from a population-based randomised controlled trial
No full textSkin malignancy is an important cause of mortality in the United Kingdom and is rising in incidence every year. Most skin cancer presents in primary care, and an important determinant of outcome is initial recognition and management of the lesion. Here we present an observational study of interobserver agreement using data from a population-based randomised controlled trial of minor surgery. Trial participants comprised patients presenting in primary care and needing minor surgery in whom recruiting doctors felt to be able to offer treatment themselves or to be able to refer to a colleague in primary care. They are thus relatively unselected. The skin procedures undertaken in the randomised controlled trial generated 491 lesions with a traceable histology report: 36 lesions (7%) from 33 individuals were malignant or pre-malignant. Chance-corrected agreement (?) between general practitioner (GP) diagnosis of malignancy and histology was 0.45 (0.36–0.54) for lesions and 0.41 (0.32–0.51) for individuals affected with malignancy. Sensitivity of GPs for the detection of malignant lesions was 66.7% (95% confidence interval (CI), 50.3–79.8) for lesions and 63.6% (95% CI, 46.7–77.8) for individuals affected with malignancy. The safety of patients is of paramount importance and it is unsafe to leave the diagnosis and treatment of potential skin malignancy in the hands of doctors who have limited training and experience. However, the capacity to undertake all of the minor surgical demand works demanded in hospitals does not exist. If the capacity to undertake it is present in primary care, then the increased costs associated with enhanced training for general medical practitioners (GPs) must be borne
A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial
No full textObjective: To determine whether there is equivalence in the competence of GPs and hospital doctors to perform a range of elective minor surgical procedures, in terms of the safety, quality and cost of care.Design: A prospective randomised controlled equivalence trial was undertaken in consenting patients presenting at general practices and needing minor surgery.Setting: The study was conducted in the south of England. Participants: Consenting patients presenting at general practices who needed minor surgery in specified categories for whom the recruiting doctor felt able to offer treatment or to be able to refer to a colleague in primary care.Interventions: On presentation to their GP, patients were randomised to either treatment within primary care or treatment at their local hospital. Evaluation was by assessment of clinical quality and safety of outcome, supplemented by examination of patient satisfaction and cost-effectiveness.Main outcome measures: Two independent observers assessed surgical quality by blinded assessment of wound appearance, between 6 and 8 weeks postsurgery, from photographs of wounds. Other measures included satisfaction with care, safety of surgery in terms of recognition of and appropriate treatment of skin malignancies, and resource use and implications.Results: The 568 patients recruited ( 284 primary care, 284 hospital) were randomised by 82 GPs. In total, 637 skin procedures plus 17 ingrowing toenail procedures were performed ( 313 primary care, 341 hospital) by 65 GPs and 60 hospital doctors. Surgical quality was assessed for 273 ( 87%) primary care and 316 ( 93%) hospital lesions. Mean visual analogue scale score in hospital was significantly higher than that in primary care [ mean difference = 5.46 on 100- point scale; 95% confidence interval ( CI) 0.925 to 9.99], but the clinical importance of the difference was uncertain. Hospital doctors were better at achieving complete excision of malignancies, with a difference that approached statistical significance [ 7/ 16 GP ( 44%) versus 15/20 hospital ( 75%), chi(2) = 3.65, p = 0.056]. The proportion of patients with post-operative complications was similar in both groups. The mean cost for hospital-based minor surgery was pound 1222.24 and for primary care pound 449.74. Using postoperative complications as an outcome, both effectiveness and costs of the alternative interventions are uncertain. Using completeness of excision of malignancy as an outcome, hospital minor surgery becomes more cost-effective. The 705 skin procedures undertaken in this trial generated 491 lesions with a traceable histology report: 36 lesions ( 7%) from 33 individuals were malignant or premalignant. Chance-corrected agreement ( kappa) between GP diagnosis of malignancy and histology was 0.45 ( 95% CI 0.36 to 0.54) for lesions and 0.41 ( 95% CI 0.32 to 0.51) for individuals affected by malignancy. Sensitivity of GPs for detection of malignant lesions was 66.7% ( 95% CI 50.3 to 79.8) for lesions and 63.6% ( 95% CI 46.7 to 77.8) for individuals affected by malignancy.Conclusions: The quality of minor surgery carried out in general practice is not as high as that carried out in hospital, using surgical quality as the primary outcome, although the difference is not large. Patients are more satisfied if their procedure is performed in primary care, largely because of convenience. However, there are clear deficiencies in GPs' ability to recognise malignant lesions, and there may be differences in completeness of excision when compared with hospital doctors. The safety of patients is of paramount importance and this study does not demonstrate that minor surgery carried out in primary care is safe as it is currently practised. There are several alternative models of minor surgery provision worthy of consideration, including ones based in primary care that require all excised tissue to be sent for histological examination, or that require further training of GPs to undertake the necessary work. The results of this study suggest that a hospital-based service is more cost-effective. It must be concluded that it is unsafe to leave minor surgery in the hands of doctors who have never been trained to do it. Further work is required to determine GPs' management of a range of skin conditions (including potentially life-threatening malignancies), rather than just their recognition of them. Further economic modelling work is required to look at the potential costs of training sufficient numbers of GPs and GPs with special interests to meet the demand for minor surgery safely in primary care, and of the alternative of transferring minor surgery large-scale to the hospital sector. Different models of provision need thorough testing before widespread introduction
The safety and effectiveness of different methods of ear wax removal: a systematic review and economic evaluation
No full textEar wax (cerumen) is a natural secretion produced to protect the inner ear from dirt and other fragments by moving these particles towards the outer ear. If this process does not happen properly, wax may build up causing blockage in the ear canal and the possibility of impaction. People with a build up of ear wax may suffer from hearing loss, discomfort and, on occasions, infection. It may present problems in assessing hearing, blocking the view of the ear drum during medical examination and interfering with the fitting or function of hearing aids. Although it is thought to affect between 2% and 6% of the population in the England and Wales, some groups may be at a higher risk, such as those using hearing aids or with small ear canals and/or skin conditions. Recurrence is thought to be high among some of these groups. The consequences of the build up of ear wax in the ear canal are thought to be a common reason for consultation and cost in general practice with over 2 million consultations per year in the NHS.Methods of removal of ear wax include drops, flushing with water in general practice, and removal with suction or probes in specialist clinics. The relative safety and benefits of these different methods of removal remains uncertain. This research will systematically review published and unpublished evidence on the clinical and cost effectiveness of different methods for the removal of ear wax. Where appropriate, it will develop an economic model using data from this systematic review and other relevant sources to estimate the relative costs and benefits of different methods. In addition, the project will provide recommendations for future research to try to help answer any remaining areas of uncertainty
Friendship or Facilitation: People with Learning Disabilities and Their Paid Carers
No full textThis article compares the composition and characteristics of the social networks of 14 people with learning disabilities with those of 24 of their paid support staff. In doing so the article not only establishes the differences in the diversity, durability and density of each group\'s social set, but highlights the disparity in perspective that the service users and the support staff have about their shared relationships. This is followed by a sociological discussion of why those with learning disabilities perceive their support staff as friends, while the support staff seldom consider the service users in this way, preferring to view themselves as facilitators to these individuals\' friendships. The article concludes by discussing the consequences of the staff and service users\' differing perspectives about their relationships, in terms of the tensions it generates in staff about their caring role and the effect it may have upon those with learning disabilities\' broader social inclusion.Learning Disabilities, Paid Carers, Friendship
Acute PresentatiOn of coLorectaL cancer - an internatiOnal snapshot (APOLLO): Protocol for a prospective, multicentre cohort study
No full textAim: The primary aim of the study is to describe the variation in the operative and non operative management of emergency presentations of colon and rectal cancer in an international cohort. Secondary aims will be to develop a risk prediction model for mortality and primary anastomosis and validate risk criteria of large bowel obstruction (LBO) in patients with previously known colorectal cancer undergoing neoadjuvant chemotherapy or awaiting elective surgery.Method: This prospective, multicentre audit will be conducted via the student-and trainee led EuroSurg Collaborative network internationally over 2023 with 90 day follow up. Data will be collected on consecutive adult patients presenting to the hospital in an unplanned and urgent manner with colorectal cancer (CRC) due to malignant LBO, perforation, CRC-related haemorrhage, or other related reasons. Primary outcome is 90 day mortality. Secondary outcomes include rates of stomas, primary anastomosis, stenting, preoperative imaging, and complications or readmissions.Conclusion: This protocol describes the methodology for the first international audit on the management of acutely presenting CRC. This study will utilise a large collaborative network with robust data validation and assurance strategies. APOLLO will provide a comprehensive understanding of current practice, develop risk prediction tools in this setting, and validate existing trial results
Randomized clinical trial of short-term outcomes following purse-string <i>versus</i> conventional closure of ileostomy wounds
No full textAbstract
Background
Ileostomy closure is an operation with an underappreciated morbidity, including surgical-site infection, small bowel obstruction and anastomotic leakage. Surgical-site infections, in particular, are a frequent occurrence following closure of contaminated wounds. This randomized controlled trial compared a purse-string closure technique with conventional linear closure.
Methods
Sixty-one patients were randomized to conventional or purse-string closure of ileostomy wounds. The primary endpoint was the incidence of surgical-site infection, including infections requiring hospital or community treatment.
Results
Purse-string closure resulted in fewer surgical-site infections than conventional closure: two of 30 versus 12 of 31 respectively (P = 0·005).
Conclusion
The purse-string method results in a clinically relevant reduction in surgical-site infections after ileostomy closure. Registration number: ACTRN12609000021279 (Australian New Zealand Clinical Trials Registry: http://www.anzctr.org.au/).
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Postoperative variations in anaemia treatment and transfusions (POSTVenTT): protocol for a prospective multicentre observational cohort study of anaemia after major abdominal surgery
No full textAim: Perioperative anaemia is common and is associated with increased postoperative complications, delayed recovery and increased morbidity and mortality. However, current management of anaemia after surgery is variable. This student- and trainee-led collaborative study aims to audit the postoperative variations in anaemia treatment and transfusions (POSTVenTT) and quantify its impact on patient outcomes after major abdominal surgery. Method: This is the first Australian and Aotearoa New Zealand multicentre study in surgical patients conducted by networks of trainees, students and consultants. Data will be prospectively collected on consecutive adult patients undergoing elective and emergency major abdominal surgery with follow-up to 30 days after hospital discharge. The primary endpoint will be adherence to anaemia management guidelines. Secondary outcomes will include postoperative anaemia, blood transfusion, postoperative complications as per the Clavien–Dindo classification, length of stay and hospital readmission at 30 days. Discussion: This protocol describes the first Australian and Aotearoa New Zealand collaborative study by medical students and surgical trainees. The collaboration will aim to provide a clear understanding of current practices regarding the management and risk factors for anaemia and association with patient outcomes after major abdominal surgery
‘I am not someone who gets skin cancer’: Risk, time and malignant melanoma
No full text‘Delay’ is a term used in the cancer literature since the 1930s to describe the period between self-detection of a concerning sign of possible disease and presentation to a health professional. This linguistic choice carries an implication of blame for apparent failure to manage a risk appropriately, drawing attention away from the contemporaneous perspectives of those who respond to suspicious indicators more or less quickly. We present findings from a grounded theory study of accounts given by 45 patients about their slower or quicker journeys to a diagnosis of cutaneous malignant melanoma, a cancer which can ‘hide in plain sight’. There has been little research exploring in qualitative detail patients’ perspectives on their decision-making about what subsequently turn out to have been signs of this most risky of skin cancers. The findings frame referral time-lapses in terms of normalisation of symptoms, sometimes buttressed by reassurance derived from health promotion messages, disconfirmation of patients’ concerns by their general practitioners and prioritisation of other life concerns. We argue that a shared sense of urgency surrounding melanoma self-referral derives from a clinical representation of current knowledge which conceals numerous evidential uncertainties
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