Swindon, United Kingdom
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Odak S.,Great Western Hospital | Ivory J.,Great Western Hospital | Ivory J.,Arrowe Park Hospital
Bone and Joint Journal | Year: 2013

Deficiency of the abductor mechanism is a well-recognised cause of pain and limping after total hip replacement (THR). This can be found incidentally at the time of surgery, or it may arise as a result of damage to the superior gluteal nerve intra-operatively, or after surgery owing to mechanical failure of the abductor muscle repair or its detachment from the greater trochanter. The incidence of abductor failure has been reported as high as 20% in some studies. The management of this condition remains a dilemma for the treating surgeon. We review the current state of knowledge concerning post-THR abductor deficiency, including the aetiology, diagnosis and management, and the outcomes of surgery for this condition. ©©2013 The British Editorial Society of Bone & Joint Surgery.


Boyages J.,University of Sydney | Jayasinghe U.W.,University of Sydney | Coombs N.,Great Western Hospital
European Journal of Cancer | Year: 2010

Purpose: The objective of this study is to determine whether the aggregate tumour size of every focus in multifocal breast cancer more accurately predicts 10-year survival than current staging systems which use the largest or dominant tumour size. Patients and methods: This study examined the original histological reports of 848 consecutive patients with invasive breast cancer treated in New South Wales (NSW), Australia between 1 April 1995 and 30 September 1995. Multifocal tumours were assessed using two estimates of pathologic tumour size: largest tumour focus diameter and the aggregate diameter of every tumour focus. The 10-year survival of patients with multifocal tumours measured in both ways was compared to that with unifocal tumours. Results: At a median follow-up of 10.4 years, 27 of 94 patients (28.7%) with multifocal breast cancer have died of breast cancer compared to 141 of 754 (18.7%) with unifocal breast cancer (P = .022). Ten-year survival was not affected by size for tumours measuring 20 mm or less, whether or not dominant tumour size (87.9%) or aggregate tumour size (87.0%) was used for multifocal tumours, compared to unifocal tumours (88.1%). For tumours larger than 20 mm, 10-year survival was 72.1% for unifocal tumours compared to 54.7% (P = .008) for multifocal tumours using dominant tumour size, but this was 69.5% and not significant when multifocal tumours were classified using aggregate tumour size (P = .49). Multivariate analysis also confirmed the above-mentioned results after adjustment for important prognostic factors. Conclusion: Aggregate size of every focus should be considered along with other prognostic factors for metastasis when treatment is planned. The current convention of using the largest (dominant) lesion as a measure of stage and associated breast cancer survival needs further validation. © 2010 Elsevier Ltd. All rights reserved.


Palazzo S.,University of Oxford | Hocken D.B.,Great Western Hospital
Journal of Hospital Infection | Year: 2010

Infection in hospitals is a serious problem. Attempting to address the spread of infection, many UK National Health Service trusts have adopted a 'bare-below-the-elbows' and tie-less dress-code policy. This followed publication of Department of Health guidelines on staff uniforms in September 2007. Although the potential for colonisation of clothing with pathogens has been investigated, patients' opinions on dress-code and policy change have not. This survey of 75 patients in Great Western Hospital, Swindon, UK, used questionnaires to address this. The survey showed that, although patients did feel that doctors' dress was important, neckties and white coats were not expected. Moreover, surgical scrubs were considered acceptable forms of attire. Problems of identifying doctors and determining their grade were repeatedly raised. Patients were generally unaware of the new dress-code, and few knew anything of its relationship to infection control. This work demonstrates that more 'traditional' dress is not expected. Given the problems of identification and perception of surgical scrubs as suitable, their introduction as a 'uniform for doctors' should be considered. Furthermore, work needs to be done to advertise policy change and increase patient awareness of infection control. © 2009 The Hospital Infection Society.


Upchurch E.,Great Western Hospital
British Journal of Hospital Medicine | Year: 2014

Acute pancreatitis is seen commonly on the surgical take. It can be complicated by the development of pseudocysts and necrosis. This review discusses each of these in turn and outlines the different management strategies now on offer. © 2014 MA Healthcare Ltd.


Lim J.C.E.,Great Western Hospital | Beale A.,Great Western Hospital | Ramcharitar S.,Great Western Hospital
Nature Reviews Cardiology | Year: 2011

Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2-2.0% of the population. In the majority of individuals, ACAOS has no hemodynamic or prognostic implications, but in a minority of cases, typically where the anomalous coronary artery takes an interarterial course to reach its correct myocardial territory, it can precipitate ischemia and sudden cardiac death (SCD). With the growing use of CT coronary angiography (CTCA) in the investigation of ischemic heart disease, we can expect increasing rates of incidental detection of this anomaly. Although CTCA and magnetic resonance coronary angiography can effectively characterize these lesions anatomically, they fail to describe and quantitatively assess the basic defect that leads to coronary insufficiency, such as mural intussusception. The key challenge lies in the identification of which patients are at risk of SCD and, therefore, who should be offered corrective surgical or (potentially) percutaneous intervention. Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment. © 2011 Macmillan Publishers Limited. All rights reserved.


Vaughan-Shaw P.G.,Southampton General Hospital | Cannon C.,Great Western Hospital
Phlebology | Year: 2011

Objective: Medical inpatients have been shown to be at risk of venous thromboembolism (VTE) including fatal pulmonary emboli. Several studies have shown that pharmacological thromboprophylaxis significantly reduces the rates of VTE, yet studies published to date have shown a considerable underuse of thromboprophylaxis in medical patients. This study assesses the current use of thromboprophylaxis in medical patients at our institution and aims to identify simple strategies to improve practice. Design: A prospective study of thromboprophylaxis prescription was undertaken on three occasions over a 12-month period. Patients were stratified according to the number of risk factors and standards of thromboprophylaxis assessed according to risk. After the first round of data collection, results were presented, a local guideline was developed and a risk assessment was added to the clerking pro forma. Results: There were 122 patients in the first round, 101 in the second and 163 in the third. Eligible moderate and high-risk patients receiving a low molecular weight heparin (LMWH) increased from 31% to 63% (P < 0.005) over the study period. Prescription of thromboembolic deterrent (TED) stockings in those contraindicated to LMWH increased from 23% to 35% although this was not statistically significant (P = 0.08), and the percentage of high-risk patients correctly receiving LMWH, TED stockings or both increased from 22% to 62% (P < 0.0005). Documentation of contraindications to thromboprophylaxis increased from 0% to 59% (P < 0.0005). Conclusion: This paper demonstrates an initial rate of thromboprophylaxis use considerably less than the ENDORSE trial. However the strategies employed following initial audit resulted in a significant increase in the prescription of both mechanical and pharmacological thromboprophylaxis. This example demonstrates the role of audit education and a risk assessment in stimulating change. Such strategies could be used to ensure compliance to recently published National Institute of Clinical Excellence VTE guidelines. Furthermore this example could be generalized to improve other aspects of care.


Candy D.,Great Western Hospital
The journal of family health care | Year: 2011

Childhood constipation is generally idiopathic and has a prevalence of five to 30 per cent. It can have significant implications on the quality of life for both the child and their family. Families may delay presentation as they may feel embarrassed or fear receiving a negative response from the healthcare professionals. Parents may report different symptoms as "constipation" depending on their own beliefs and previous experiences. A detailed history taken with the parents, along with a review of the Bristol Stool Form Scale chart will help in establishing a clinical diagnosis of constipation in the child. Suspicion of any "red flag" symptoms, such as delay in passage of meconium for greater than 48 hours after birth, toothpaste-like stool, etc, should initiate early referral to the paediatric services. Dietary intervention alone is not sufficient in treating constipation. Laxative therapy alongside dietary and lifestyle modifications will help manage constipation in the community. Health visitors in contact with the families concerned can help in early intervention, which is known to produce better outcomes.


Monkhouse S.,Great Western Hospital
Clinical Teacher | Year: 2010

Background: Surgical teaching and training has a long tradition of apprenticeship-style mentoring, which has been widely revered and respected. The teaching style and learning was feared by some, but appreciated by all. The basis of this teaching was a strong relationship between teacher and trainee that was formed over many years of close working. However, modern legislation in the form of the European Working Time Directive (EWTD) has made this relationship difficult to achieve. Shifting working patterns have broken the continuity. We need to find new ways to learn the art of surgery and to maximise the limited time that is available on the 'shop floor'. Context: The surgical standard working day is analysed in this article to highlight opportunities for learning, and how to exploit them. Every clinical encounter can be used for educational purposes. Innovations: Novel approaches to ward rounds are discussed, together with modifications to intraoperative training. These make teaching an active process, with the learner taking control and self-directing the process. Implications:: The EWTD need not be a disaster for surgical training. We need to rationalise and re-think our approaches, but surgical training should not be seriously detrimented by the reduction in hours. Two hours of focused surgical training is worth more than 8 hours of chaotic, random educational encounters, characteristic of previous systems. © Blackwell Publishing Ltd 2010.


Reddy-Kolanu G.,Great Western Hospital | Alderson D.,Torbay Hospital
Annals of the Royal College of Surgeons of England | Year: 2011

Introduction: The Chief Medical Officer's 2008 annual report highlighted the importance of simulation in medical training. 1 Simulator development has focused on increasing authenticity and fidelity. Development has not necessarily been guided by evidence for educational improvement. On reviewing 34 years of literature, Issenberg et al identified ten features of highfidelity medical simulators that facilitate learning. 2 This study compares cadaveric temporal bone (CTB) simulation with the Voxel-Man TempoSurg (VT) virtual reality simulator in addressing these features. Subjects and Methods: A questionnaire was designed comparing the VT with CTB. Fourteen trainees and six consultants completed the questionnaire after using the simulator. Results: The VT is better at allowing repetitive practice, ease of control of difficulty, and capturing clinical and pathological variation. The VT is as good as CTB in curriculum integration, allowing multiple learning strategies, providing a controlled environment, individualising learning and defining benchmarks. It appears worse with regards to face validity and feedback. Conclusions: Virtual reality simulation and CTB have features that allow effective learning. Some of these are common to both, in some CTB is better and in others virtual reality is better. Virtual reality could be a significant mode of learning supplementary to CTB and experience in the operating theatre.


Dawson S.,Great Western Hospital
Journal of Hospital Infection | Year: 2014

Blood cultures are an essential diagnostic tool. However, contamination may impact on patients' care and lead to increased patient stay, additional tests, and inappropriate antibiotic use. The aim of this study was to review the literature for factors that influence the rate of blood culture contamination. A comprehensive literature search was performed using Medline and CINAHL on blood culture contamination. Hospitals/units should have in place a protocol for staff on how to take blood cultures, incorporating use of an aseptic technique. Studies have shown that several key factors in the process may lower contamination rates such as adherence to a protocol, sampling by peripheral venepuncture route rather than via an intravascular catheter, use of sterile gloves, cleaning tops of blood culture bottles with antiseptics and inoculating blood culture bottles before other blood tubes, samples being taken by a phlebotomy team, monitoring contamination rates, and providing individual feedback and retraining for those with contaminants. Although skin antisepsis is advocated there is still debate on which antiseptic is most effective, as there is no conclusive evidence, only that there is benefit from alcohol-containing preparations. In conclusion, hospitals should aim to minimize their blood culture contamination rates. They should monitor their rate regularly and aim for a rate of ≤3%. © 2014 The Healthcare Infection Society.

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