Kingston upon Thames, United Kingdom
Kingston upon Thames, United Kingdom

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Harrison S.C.W.,Pinderfields General Hospital | Lawrence W.T.,Eastbourne District General Hospital | Morley R.,Kingston Hospital | Pearce I.,Royal Infirmary | Taylor J.,Pinderfields General Hospital
BJU International | Year: 2011

OBJECTIVE: To report the British Association of Urological Surgeons' guidelines on the indications for, safe insertion of, and subsequent care for suprapubic catheters. METHODS A comprehensive literature search was conducted to identify the evidence base. This was reviewed by a guideline development group (GDG), who then drew up the recommendations. Where there was no supporting evidence expert opinion of the GDG and a wider body of consultees was used. RESULTS Suprapubic catheterisation is widely used, and generally considered a safe procedure. There is however a small risk of serious complications. Whilst the evidence base is small, the GDG has produced a consensus statement on SPC use with the aim of minimising risks and establishing best practice (Table 1). It should be of relevance to all those involved in the insertion and care of suprapubic catheters. Given the paucity of evidence, areas for future research and development are also highlighted. This review has been commissioned and approved by BAUS and the Section of Female, Neurological and Urodynamic Urology. Summary of recommendations for suprapubic catheters (SPCs) practice General considerations • Clinicians who are involved in the management of patients with long-term catheters should consider in each case whether an SPC would offer advantages to the patient over the use of a urethral catheter • Patients in whom an SPC is felt to be appropriate should have access to an efficient and expert service for SPC insertion • Patients who are undergoing SPC placement either as an isolated or as a combined procedure should undergo an appropriate consent procedure with best practice including the provision of both verbal and written information The suprapubic catheterization procedure • If appropriate expertise for SPC insertion is not available at a particular time, suprapubic aspiration of urine using a needle of up to 21 gauge can be used as a means of temporarily relieving the patient's symptoms (LE3) • A general or regional anaesthetic should be used if the bladder cannot be comfortably filled with at least 300 mL of fluid and in spinal cord injury patients with an injury level of T6 or above (LE3) • The use of antibiotic prophylaxis is recommended for patients where the urine is likely to be colonized with bacteria despite there being a lack of published data addressing this issue (LE3) • The different catheter insertion techniques and kits have not been compared in adequate clinical trials; the choice of technique is therefore a matter of individual preference. All of the closed (abdominal puncture) techniques run the risk of injury to intra-abdominal organs and the operator must have received training that allows the level of risk to be appreciated (LE3) • Ultrasonographic examination of the abdomen may be used as an adjunct to SPC insertion. However, the practitioner involved must have appropriate training and experience. Ultrasonography should only be used to look for interposing bowel loops along the planned catheter track by individuals who have received specific training and are experienced in this task. (LE3) • In the patient with a readily palpable bladder and no history of lower abdominal surgery, it is considered reasonable to insert a SPC using a closed technique providing that urine can be easily aspirated from the bladder using a needle passed along the planned catheter track (LE3) • In the patient in whom there is no history of lower abdominal surgery but where the distended (over 300 mL) bladder cannot be palpated because of obesity, it is considered that blind insertion should not be undertaken. In such circumstances, ultrasonography may be used to identify the distended bladder or cystoscopy may be used to ensure that an aspirating needle on the planned catheter track is entering the bladder at an appropriate point on the anterior bladder wall (LE3) • In the patient with either a history of lower abdominal surgery or a bladder that cannot be adequately distended, the SPC should either be inserted using an open technique or with the adjunct of imaging that can reliably exclude the presence of bowel loops on the intended catheter track. An open procedure must be performed in a manner that will reliably identify the bladder and allow mobilization of any interposing intestine away from the catheter track. Imaging to support a closed procedure would include the use of ultrasonography in skilled hands (see above) or CT scanning (LE3) Postoperative complications • Patients, carers and clinical staff must be made aware that urgent medical attention is needed if there are symptoms present that might suggest the presence of a catheter insertion-related visceral injury. Symptoms would include the persistence or worsening of lower abdominal pain or pain that is spreading away from the catheter insertion site (LE3) • Written instructions covering contact details and indications for seeking medical assistance should be given to patients and carers immediately after catheter insertion (LE3) Long-term SPC management • The use of a catheter valve as an alternative to continuous free drainage should always be considered where the bladder is known to provide safe urinary storage • The patient should have prompt and easy access to catheter change services and be offered the option of either them or their immediate carers being taught to change the catheter • Immediate access to a urology unit should be provided in the event of a failed catheter change • Antibiotic administration is indicated where there is evidence of cellulitis in the catheter site area or where there is evidence of symptomatic urinary tract infection (LE3) • Systemic antibiotics should not be used to treat uncomplicated pericatheter discharge or asymptomatic bacteruria (LE3) • Regular catheter bypassing or blockage should prompt referral to the local urology department for further investigation and management • Cystoscopy should be undertaken if repeated catheter blockages are occurring CONCLUSIONS It is hoped that these guidelines will assist in minimising morbidity associated with SPC usage. © 2010 BJU International.


Patel N.K.,Kingston Hospital | Sarraf K.M.,Chelsea and Westminster Hospital | Joseph S.,Kingston Hospital | Lee C.,Kingston Hospital | Middleton F.R.,Kingston Hospital
Injury | Year: 2013

Background Hip fractures are common injuries in the elderly, with significant associated morbidity and mortality rates. The National Hip Fracture Database (NHFD) was implemented to audit care according to national standards thus improving its clinical and cost-effectiveness. Patients and methods We retrospectively examined the care pathway for all hip fractures after its introduction at our centre over 1 year, with an audit of care according to the BOA-BGS 'Blue Book' guidelines. Data between the first (period 1: initial audit) and second (period 2: re-audit) six months of the study period were compared. Results There were 372 patients (28% male, 72% female) in total with 190 in period 1 and 182 in period 2. For all patients, the median age was 85 years (range 33-101) and the median time to surgery was 24.5 h (1-519.3), with 251 (67.5%) within 36 h. Surgical delay was mainly due to lack of theatre space (37.6%) and medical reasons (54.7%). The median length of stay was 11 days (2-92) and the inpatient mortality rate was 6.2% (23). When comparing the two study periods, there were significantly more patients undergoing falls (p < 0.01) and bone protection (p < 0.01) assessments in period 2. Lack of theatre space was a significantly less common (p < 0.01), with a significantly shorter median time to surgery (p = 0.01) and length of stay (p < 0.01) in period 2. More patients were discharged to rehabilitation units and the mortality rate was non-significantly lower in period 2 (7.4% vs. 5%). The best practice tariff was met in 45.3% and 70.3% (p < 0.001) of patients in periods 1 and 2 respectively providing a total income of £95230.00 (GBP). Conclusions Implementing the NHFD has led to an improvement the quality of hip fracture care according to national guidelines. More patients were assessed by an orthogeriatrician, with a shorter time to surgery and length of stay following re-audit. There is potential for an improvement in mortality rates as well as significant financial income for hospitals. © 2013 Elsevier Ltd.


Calder J.D.,Basingstoke and North Hampshire Hospitals | Calder J.D.,Imperial College London | Sexton S.A.,Kingston Hospital | Pearce C.J.,Basingstoke and North Hampshire Hospitals
American Journal of Sports Medicine | Year: 2010

Background: Posterior ankle impingement syndrome (PAIS) was first described in ballet dancers but is increasingly being diagnosed in other sports. Operative treatment may be indicated when nonoperative measures have failed. Traditionally, operative treatment has involved an open approach; more recently, posterior ankle arthroscopy has been employed. Purpose: This study was conducted to describe the factors that influence return to play in professional athletes after posterior ankle arthroscopy for posterior ankle impingement syndrome. Study Design: Case series; Level of evidence 4. Methods: A consecutive series of 28 elite professional soccer players who had clinically and radiologically diagnosed posterior ankle impingement syndrome that failed to respond to nonoperative treatment underwent posterior ankle arthroscopy for bony or soft tissue posterior ankle impingement syndrome over 5 years. Results: Of the 28 players, 27 were available for follow-up. Five had a diagnosis of soft tissue impingement and underwent debridement with flexor hallucis longus release, 13 had a symptomatic os trigonum that was excised arthroscopically, and 9 had removal of a bony avulsion fragment from the posterior ankle ligament complex. The mean length of time to return to training postoperatively was 34 days and return to playing was 41 days (range, 29-72 days). The duration of symptoms before surgery and excision of bony impingement were significantly correlated with the time to return to training and playing. There were no major complications and no reoperations at an average of 23 months of follow-up (range, 15-49 months). Conclusion: Posterior ankle arthroscopy is safe and effective in the treatment of posterior ankle impingement syndrome in the elite soccer player, with return to training expected at an average of 5 weeks.


Currie A.,Kingston Hospital | Christmas C.,University of Cambridge | Aldean H.,Kingston Hospital | Mobasheri M.,Kingston Hospital | Bloom I.T.M.,Kingston Hospital
Colorectal Disease | Year: 2014

Aim: Colorectal obstruction due to benign disease is likely to become more prevalent. Self-expanding stents have been shown to be effective in reducing morbidity and allowing one-stage resection or improved palliation in colorectal cancer. This review assessed the use of self-expanding stents in benign colorectal obstruction. Method: A systematic review was performed using PubMed, Embase and the Cochrane Library. Keywords included: 'benign disease' 'colorectal obstruction', 'stent', 'endoprosthesis' and 'prosthesis' Original articles from all relevant listings were sourced. These were hand searched for further articles of relevance. The main outcome measures assessed were technical and clinical success, perforation, reobstruction and stoma avoidance in the bridge to surgery population. Results: The search strategy identified 130 articles; the 21 included studies yielded a pooled analysis of 122 patients. Diverticulitis was the predominant aetiology (66/122, 54%). Technical success was achieved in 115/122 (94%) and clinical success in 108/120 (87%) patients. Overall, the perforation rate was 12% (15/122) and the reobstruction rate was 14% (17/122). A stoma was avoided in 48% (23/48) of bridge to surgery patients. Perforation and stoma avoidance in the bridge to surgery group were worse with an aetiology of diverticulitis. Conclusion: Complication rates in stenting for benign colorectal obstruction are higher than for malignant obstruction. On the basis of limited published evidence, stenting cannot be recommended for benign colorectal obstruction. © 2013 The Association of Coloproctology of Great Britain and Ireland.


Cook M.I.,Kingston Hospital | Qureshi Y.A.,Kingston Hospital | Todd C.E.C.,Kingston Hospital | Cummins R.S.,Kingston Hospital
Journal of Clinical Endocrinology and Metabolism | Year: 2012

Introduction: Parathyroid carcinomas are very rare tumors and may arise in the normally located or ectopic gland. The latter present certain diagnostic difficulties, and there are no specific guidelines on their management. We present a case of parathyroid carcinoma arising within an ectopically located intrathyroid gland and discuss the diagnosis, management, and difficulties encountered. Furthermore, we review all six previously reported cases of this rare event and demonstrate the patterns in presentation, as well as the differences in management. Case Presentation: A 39-yr-old male presented with a right neck mass with biochemical derangement suggestive of a parathyroid lesion. However, radiological investigations were inconclusive as to the true nature of this lesion because they demonstrated a mass within the right thyroid lobe. A sestamibi 99mtechnetium subtraction study was performed, which suggested an intrathyroid parathyroid carcinoma. The patient underwent successful surgical intervention. Conclusion: Although rare, ectopically located parathyroid glands can harbor malignant disease. Those located within the thyroid gland can be difficult to diagnose, and thus a combination of radiological modalities, including sestamibi 99mtechnetium studies, need to be utilized. Although surgical resection is the most effective treatment, there arenospecific guidelines as to the radicality of such treatment. Copyright © 2012 by The Endocrine Society.


Nagendran M.,University of Oxford | Maruthappua M.,University of Oxford | Sugand K.,Kingston Hospital
Interactive Cardiovascular and Thoracic Surgery | Year: 2011

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether double lung transplantation should be performed with or without cardiopulmonary bypass (CPB) in order to improve postoperative clinical outcomes. Altogether 386 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All 14 papers assessed a range of postoperative outcomes and broadly speaking, six papers found significantly worse outcomes with CPB use, six found no difference and two found a mixture of both depending on the specific outcomes assessed. Dalibon et al. wJ Cardiothorac Vasc Anesth 2006;20:668-672x found that mortality was significantly worse in the CPB group at 48 h, one month and one year wPs0.001, odds ratio (OR)s246.1; Ps0.083, ORs2.6; Ps0.001, ORs5.3, respectivelyx. Other papers revealed poor outcomes in the CPB group in a range of measures including diffuse alveolar damage (Ps0.009), chest radiograph infiltrate score (Ps0.005), longer intubation time (Ps0.002), longer intensive care unit stay (Ps0.05), and greater incidence of pulmonary reimplantation response (Ps0.03). However, Myles et al. wJ Cardiothorac Vasc Anesth 1997;11:177-183x found that only acute postoperative outcomes were significantly worse in their CPB group (P-0.001); medium- and long-term survival outcomes were not significantly different (Ps0.055). de Boer et al. wTransplantation 2002;73:1621-1627x even found that there was an improved one-year survival rate with CPB use (ORs0.25, Ps0.038) and that the number of human leukocyte antigen DR (HLA-DR) mismatches influenced this effect. Those papers suggesting no deleterious effects of CPB generally measured similar postoperative outcomes to those mentioned above, with one study also assessing incidence of primary graft failure, which was not significantly different (Ps0.37). We conclude that CPB should continue to be used where clinically indicated for a specific reason (for example, where there is pulmonary hypertension or a requirement for concomitant cardiac repair). However, given that the evidence for using CPB for all elective cases is relatively weak, and the fact that there are strong arguments in the literature for both methods, either approach would be clinically acceptable. © 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.


Gemenetzi M.,Kingston Hospital | Lotery A.J.,University of Southampton
Eye (Basingstoke) | Year: 2016

In the age-related macular degeneration (AMD) 'inflammation model', local inflammation plus complement activation contributes to the pathogenesis and progression of the disease. Multiple genetic associations have now been established correlating the risk of development or progression of AMD. Stratifying patients by their AMD genetic profile may facilitate future AMD therapeutic trials resulting in meaningful clinical trial end points with smaller sample sizes and study duration. © 2016 Macmillan Publishers Limited.


Currie A.,Kingston Hospital | Chong K.,Kingston Hospital | Davies G.L.,Kingston Hospital | Cummins R.S.,Kingston Hospital
European Journal of Surgical Oncology | Year: 2012

Background: Electrocautery has advanced the practice of mastectomy but significant morbidity, such as seroma and blood loss, remains a concern. This has led to newer forms of dissection being introduced including the ultrasonic dissection devices, which are thought to reduce tissue damage. The aim of this systematic review was to compare the outcomes after mastectomy using novel ultrasonic dissection or standard electrocautery in published trials. Methods: Medline, Embase, trial registries, conference proceedings and reference lists were searched for comparative trials of ultrasonic dissection versus electrocautery for mastectomy. The primary outcomes were total postoperative drainage, seroma development and intra-operative blood loss. Secondary outcomes were operative time and wound complications. Odds ratios were calculated for categorical outcomes and standardised mean differences for continuous outcomes. Results: Six trials were included in the analysis of 287 mastectomies. There was no effect in total postoperative drainage (pooled analysis weight mean difference: -0.21 (95% CI: -0.70-0.29); p = 0.41) or seroma development (pooled analysis odds ratio: 0.77 (95% CIs 0.43-1.37); p = 0.37). Intra-operative blood was slightly less for ultrasonic dissection compared to standard electrocautery (pooled analysis weight mean difference: -1.04 (95% CI: -2.00 to -0.08); p = 0.03). Ultrasonic dissection and standard electrocautery had similar outcomes with regard to operative time and wound complications. Conclusion: Ultrasonic dissection and standard electrocautery appear to deliver similar results in the mastectomy setting. Further cost-effectiveness analysis may guide surgeon selection in the use of new technologies for mastectomy. © 2012 Elsevier Ltd. All rights reserved.


Touquet R.,Kingston Hospital | Harris D.,Kingston Hospital
Alcohol and Alcoholism | Year: 2012

Alcohol misuse is a common presentation to the Emergency Department (ED). The International Classification of Diseases ICD-10 for alcohol misuse, both under F10 and Y90/Y91, is not straightforward. The practicalities of coding ED attendances reveal an increasing detachment from ICD-10 (currently under review). Early identification [sometimes using blood alcohol concentrations (BACs)] and brief advice (IBA) can reduce unscheduled alcohol-related ED re-attendance. The UK Government Department of Health has implemented use of the terms 'Hazardous Drinking', 'Harmful Drinking' and 'Dependent Drinking' in its Public Service Agreements aimed at reducing harm by alcohol. Simplifying coding might increase IBA usage. We suggest that coding improvements in ICD-11 should update Y91 (currently 'clinical assessment')-with ICD-10 Y90 remaining for BAC to classify a patient's 'alcohol status'. Y90 and Y91 together would indicate the urgency for early IBA and/or speciality referral, aiming to reduce the prevalence of 'Dependent Drinking'. © The Author 2012. Medical Council on Alcohol and Oxford University Press. All rights reserved.


Izadi M.,Kingston Hospital
Primary dental care : journal of the Faculty of General Dental Practitioners (UK) | Year: 2010

AIM: To assess the quality of information included in referral letters sent to the orthodontic department at Kingston Hospital, Surrey, UK. METHODS: Referral letters sent by both general dental practitioners (GDPs) and specialist orthodontists were analysed retrospectively in order to ascertain the percentage meeting the inclusion criteria as suggested by Mossey (2006) and the British Orthodontic Society (2008) for the quality of information included in an ideal orthodontic referral letter. Thirty-five consecutive letters sent between May and September 2005 and 206 letters sent in the same period in 2008 were collected by hand and analysed against the inclusion criteria. The numbers of referral letters received from GDPs, specialist orthodontists, and others sources were also determined. RESULTS: Most of the referrals sent in 2005 and 2008 included 40-50% of the referral inclusion points. This was despite an almost twofold increase in the number of referral letters received from specialist orthodontic practitioners in 2008. The majority of the letters, from both GDPs and specialists, did not include details of the oral hygiene or caries status of the patient, or an indication of their motivation towards treatment. None of the referral letters included a plaque score. CONCLUSION: The main weaknesses in the quality of information provided in referral letters were that in more than 80% of the letters there was no mention of the patient's medical history and no comment on caries status, the standard of oral hygiene, patient motivation for treatment, or an Index of Orthodontic Treatment Need score. The quality of information included in referral letters sent to Kingston Hospital orthodontic department needs to be improved.

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