Barnstaple, United Kingdom
Barnstaple, United Kingdom

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Daykin H.,North Devon District Hospital
British Journal of Pain | Year: 2017

Opioids remain the mainstay of analgesia for the treatment of moderate to severe acute pain. Even in the young, the use of opioids can be associated with an increased incidence of post-operative complications such as respiratory depression, vomiting, pruritus, excessive sedation, slowing of gastrointestinal function, and urinary retention. The need to manage acute pain in the older patient is becoming more common as the population ages, and increasingly older patients are undergoing more major surgery. Medical conditions are more common in older people and can result in the requirement of systemic analgesia for fractures, malignancy, nociceptive or neuropathic pain and peripheral vascular disease. Effective pain control can be difficult in older patients as there is a higher incidence of coexistent diseases, polypharmacy and age-related changes in physiology, pharmacodynamics and pharmacokinetics. Consequently, due to the fear of respiratory depression in older people, this leads to inadequate doses of opioid being given for the treatment of their pain. Lidocaine has analgesic, anti-hyperalgesic and anti-inflammatory properties and is metabolized by the liver which is limited by perfusion, and heart failure or drugs can alter this, affecting its clearance. Therefore, there are concerns regarding safety in older patients as plasma concentrations have both intersubject and intrasubject variability. The aim of this literature review is to assess the efficacy and safety of intravenous lidocaine as an adjuvant in pain management for the older patient. In total, 12 studies fulfilled the criteria. Lidocaine infusions were found to reduce pain scores and be opioid sparing in abdominal and urological surgery, in patients with opioid-refractory malignancy pain, neuropathic pain and critical limb ischaemia. Patients with malignancy were more likely to develop adverse effects, but no patients required treatment for lidocaine toxicity. © 2016, © The British Pain Society 2016.


Pulcini C.,Nancy University Hospital Center | Pulcini C.,University of Lorraine | Botelho-Nevers E.,Service de Maladies Infectieuses | Botelho-Nevers E.,Jean Monnet University | And 2 more authors.
Clinical Microbiology and Infection | Year: 2014

Given the current bacterial resistance crisis, antimicrobial stewardship programmes are of the utmost importance. We present a narrative review of the impact of infectious disease specialists (IDSs) on the quality and quantity of antibiotic use in acute-care hospitals, and discuss the main factors that could limit the efficacy of IDS recommendations. A total of 31 studies were included in this review, with a wide range of infections, hospital settings, and types of antibiotic prescription. Seven of 31 studies were randomized controlled trials, before/after controlled studies, or before/after uncontrolled studies with interrupted time-series analysis. In almost all studies, IDS intervention was associated with a significant improvement in the appropriateness of antibiotic prescribing as compared with prescriptions without any IDS input, and with decreased antibiotic consumption. Variability in the antibiotic prescribing practices of IDSs, informal (curbside) consultations and the involvement of junior IDSs are among the factors that could have an impact on the efficacy of IDS recommendations and on compliance rates, and deserve further investigation. We also discuss possible drawbacks of IDSs in acute-care hospitals that are rarely reported in the published literature. Overall, IDSs are valuable to antimicrobial stewardship programmes in hospitals, but their impact depends on many human and organizational factors. © 2014 European Society of Clinical Microbiology and Infectious Diseases.


Dyar O.J.,North Devon District Hospital | Pagani L.,Bolzano Central Hospital | Pulcini C.,Nancy University Hospital Center | Pulcini C.,University of Paris Descartes
Clinical Microbiology and Infection | Year: 2015

As people are living longer the demand for long-term care facilities (LTCFs) continues to rise. For many reasons, antimicrobials are used intensively in LTCFs, with up to a half of this use considered inappropriate or unnecessary. Over-use of antimicrobials can have direct adverse consequences for LTCF residents and promotes the development and spread of resistant bacteria. It is therefore critical that LTCFs are able to engage in antimicrobial stewardship programmes, which have the potential to minimize the antibiotic selective pressure, while improving the quality of care received by LTCF residents. To date, no antimicrobial stewardship guidelines specific to LTCF settings have been published. Here we outline the scale of antimicrobial use in LTCFs and the underlying drivers for antibiotic over-use. We further describe the particular challenges of antimicrobial stewardship in LTCFs, and review the interventional studies that have aimed to improve antibiotic use in these settings. Practical recommendations are then drawn from this research to help guide the development and implementation of antimicrobial stewardship programmes. © 2014 European Society of Clinical Microbiology and Infectious Diseases.


Walter R.,Torbay Hospital | Kosy J.D.,Torbay Hospital | Cove R.,North Devon District Hospital
Foot and Ankle Surgery | Year: 2013

Background: Measurement of radiological angles can be useful in the planning of the management of patients with hallux valgus. A smartphone application offers an alternative way of measuring these angles in a clinic setting. We compared the reliability (inter- and intra-observer) of this method to the use of PACS. Methods: Radiographs of 30 feet from new patients referred with hallux valgus were examined and angles (HVA, IMA, and DMAA) recorded using the smartphone application and PACS. Results: The smartphone application provided good inter-observer reliability for HVA and IMA (r= 0.93 and r= 0.79 respectively). Intra-observer reliability for HVA and IMA was also found to be good (r= 0.93-0.97 r= 0.82-0.93 respectively). The inter- and intra-observer reliability for using this method to measure DMAA fell below useful levels (r< 0.60 in each case). Conclusions: This smartphone application provides a reliable method to measure HVA and IMA but we would not recommend it to measure DMAA. © 2012 European Foot and Ankle Society.


Dyar O.J.,North Devon District Hospital | Castro-Sanchez E.,Imperial College London | Holmes A.H.,Imperial College London
Journal of Antimicrobial Chemotherapy | Year: 2014

Objectives: Social media has reshaped individual and institutional communication. The unrestricted access to spontaneous views and opinions of society can enrich the evaluation of healthcare interventions. Antimicrobial resistance has been identified as a global threat to health requiring collaboration between clinicians and healthcare users.We sought to explore events and individuals influencing the discourse about antibiotics on Twitter. Methods: Aweb-based tool (www.topsy.com) was used to detect daily occurrences of the word 'antibiotic' from 24 September 2012 to 23 September 2013 in worldwide Tweets. Activity peaks (message frequency over three times that of baseline) were analysed to identify events leading to the increase. Results: Of 135 billion messages posted during the study period, 243000 (0.000002%) referred to 'antibiotic'. The greatest activity increases appeared after: (i) the UK Chief Medical Officer's (CMO's) declaration of antimicrobial resistance as a national risk (January 2013 and March 2013); (ii) the release of the US CDC's report on antimicrobial resistance (September 2013); and (iii) the US FDA announcement on azithromycin safety concerns (March 2013). The CMO report in March reached an estimated worldwide audience of 20 million users in a single day. However, the frequency of antibiotic Tweets returned to basal levels within 48 h of all four peaks in activity. Conclusions: Institutional events can rapidly amplify antibiotic discussions on social media, but their short lifespan may hinder their public impact. Multipronged strategies may be required to prolong responses. Developing methods to refine social media monitoring to evaluate the impact and sustainability of societal engagement in the antimicrobial resistance agenda remains essential. © The Author 2014.


Bickley J.,North Devon District Hospital
Journal of the Intensive Care Society | Year: 2016

Fairy Liquid® is a detergent used daily throughout the United Kingdom. Currently, Toxbase suggests ingestion only causes nausea, vomiting and diarrhoea; however, we report a patient who developed multi-organ failure following a large ingestion and subsequent aspiration of Fairy Liquid. © The Intensive Care Society 2015.


Jones A.D.R.,North Devon District Hospital
British Journal of Health Care Management | Year: 2013

To display the difficulties in introducing team briefing and debriefing (part of the World Health Organization's (WHO) 5 Steps to Safer Surgery) and to calculate the impact its use has on efficiency in theatre. Twenty-two surgeons, anaesthetists, managers, scrub nurses and operating department practitioners filled in questionnaires asking about attitudes to the pre-existing 'sign in, time out, sign out' surgical safety checklist, attitudes to the introduction of team briefing and debriefing and attitudes to how it was implemented. Orthopaedic theatre efficiency before and after the introduction of team briefing was calculated. There was resistance to the implementation of team briefing and debriefing among some professional groups. Surgeons and anaesthetists were more likely to resist change, citing lack of engagement from management, briefings delaying the start of theatre lists and lack of evidence base for change. The number of operations performed in the three month period after the introduction of briefing and debriefing increased from 4.47 per list to 5.19 per list (p = 0.012). Attitudes to culture change are mixed, with staff more likely to resist change when they have not been consulted beforehand. The use of briefing and debriefing correlates with an increase in efficiency in theatre.


Bunting D.M.,North Devon District Hospital
Journal of the Society of Laparoendoscopic Surgeons | Year: 2011

Background: Port-site hernia is a rare but potentially serious complication of laparoscopic cholecystectomy. This study aimed to review the current literature, assess the incidence and causes of port-site hernias, and identify methods to reduce the risk. Methods: A systematic search of the literature published in English from 1995 to 2010 was conducted using PubMed to identify all reports of port-site, trocar-site, or incisional hernia following laparoscopic cholecystectomy. Studies in over 100 patients were identified before the application of defined exclusion criteria. The incidence of port-site hernia was calculated and compared with historical data. Predisposing factors were reviewed. Results: Seven studies met the search criteria, with 99 port-site hernias in 5984 patients. The overall incidence of port-site hernia was 1.7% (range, 0.3% to 5.4). The most important factors were older age, higher body mass index, preexisting hernia, trocar design, trocar diameter, increased duration of surgery, and extension of the port site for gallbladder extraction. Conclusion: The incidence of port-site hernia is low but likely to be underestimated and has not declined over time. Awareness of the predisposing factors and modification of techniques may help to reduce the risk. © 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.


Jones A.D.R.,North Devon District Hospital | Wafai A.M.,North Devon District Hospital | Easterbrook A.L.,North Devon District Hospital
European Spine Journal | Year: 2014

Study design: Prospective clinical observational study of low back pain (LBP) in patients undergoing laminectomy or laminotomy surgery for lumbar spinal stenosis (LSS). Objectives To quantify any change in LBP following laminectomy or laminotomy spinal decompression surgery. Patients and methods 119 patients with LSS completed Oswestry Disability Index questionnaire (ODI) and Visual Analogue Scale for back and leg pain, preoperatively, 6 weeks and 1 year postoperatively. Results: There was significant (p < 0.0001) reduction in mean LBP from a baseline of 5.14/10 to 3.03/10 at 6 weeks. Similar results were seen at 1 year where mean LBP score was 3.07/10. There was a significant (p < 0.0001) reduction in the mean ODI at 6 weeks and 1 year postoperatively. Mean ODI fell from 44.82 to 25.13 at 6 weeks and 28.39 at 1 year. Conclusion: The aim of surgery in patients with LSS is to improve the resulting symptoms that include radicular leg pain and claudication. This observational study reports statistically significant improvement of LBP after LSS surgery. This provides frequency distribution data, which can be used to inform prospective patients of the expected outcomes of such surgery. © Springer-Verlag 2013.


Budge P.,North Devon District Hospital
Nursing standard (Royal College of Nursing (Great Britain) : 1987) | Year: 2010

Diabetes is a complex metabolic disorder that is more common in patients with cancer than in the general population. The ethical dilemmas facing many healthcare professionals in the management of diabetes during the terminal phase of life include the timing of withholding or withdrawing treatment. Communication can also be difficult between healthcare professionals, patients and their families at this time. If the patient's preferences have not been discussed at an earlier stage in the illness trajectory, mismanagement of diabetes may occur. Local protocols on diabetes management at the end of life have been developed in some areas, but there are no national or standardised guidelines. This can result in fragmented care. This article explores the need for better communication and the development of national guidelines so that the quality of end of life care for patients with diabetes can be improved.

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