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Quinn A.C.,General Infirmary at Leeds | Milne D.,Pinderfields General Hospital | Columb M.,University of Manchester | Gorton H.,General Infirmary at Leeds | Knight M.,University of Oxford
British Journal of Anaesthesia

BackgroundThere are few national figures on the incidence of failed tracheal intubation during general anaesthesia in obstetrics. Recent small studies have quoted a rate of one in 250 general anaesthetics (GAs). The aim of this UK national study was to estimate this rate and identify factors that may be predictors.MethodsUsing the UK Obstetric Surveillance System (UKOSS) of data collection, a survey was conducted between April 2008 and March 2010. Incidence and associated risk factors were recorded in consultant-led UK delivery suites. Units reported the details of any failed intubation (index case) and the two preceding GA cases (controls). Predictors were evaluated using multivariable logistic regression, significance P<0.05 (two-sided).ResultsWe received 57 completed reports (100% response). The incidence using a unit-based estimation approach was one in 224 (95% confidence interval 179-281). Univariate analyses showed the index cases to be significantly older, heavier, with higher BMI, with Mallampati score recorded and score >1. Multivariate analyses showed that age, BMI, and a recorded Mallampati score were significant independent predictors of failed tracheal intubation. The classical laryngeal mask airway was the most commonly used rescue airway (39/57 cases). There was one emergency surgical airway but no deaths or hypoxic brain injuries. Gastric aspiration occurred in four (8%) index cases. Index cases were more likely to have maternal morbidities (P=0.026) and many babies in both groups were admitted to the neonatal intensive care unit: 21 (37%) vs 29 (27%) (NS). Three babies died-all in the control group. © The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. Source

Wolff K.-D.,TU Munich | Bauer F.,TU Munich | Kunz S.,Ludwig Maximilians University of Munich | Mitchell D.A.,Pinderfields General Hospital | Kesting M.R.,TU Munich
Head and Neck

Background A posterolateral calf free flap is anatomically assessed and its usefulness for intraoral reconstruction is described. Methods Records of 42 cadaver dissections including anatomic parameters of the superficial lateral sural artery serving as pedicle were analyzed. Data of 20 patients with primary oral cancer who underwent reconstructions with posterolateral calf free flaps are presented. Results The superficial lateral sural artery was present in 36 of 42 of all cadavers (85.8%). In all, 25 specimens of 36 were suitable as flaps (69.4%). It originated from the lateral sural and the popliteal artery (31% vs 69%). It was accompanied by 1 vein (40.5%) or 2 veins (59.5%). The artery pierced the crural fascia on average 3 cm lateral to the midline and 0 to 12 cm below the fibular head. Eight patients had inadequate superficial lateral sural vessels and were reconstructed by peroneal perforator flaps. One flap was lost. Conclusions Cutaneous flaps from the posterolateral calf can be a useful alternative for reconstruction of moderate sized defects with minimal donor site morbidity. © 2011 Wiley Periodicals, Inc. Source

Ford A.A.,Pinderfields General Hospital | Ogah J.A.,University of Cumbria
International Urogynecology Journal and Pelvic Floor Dysfunction

Introduction and hypothesis: Stress urinary incontinence is a common problem affecting 12-46 % of women. A cohort of women have a more severe form of stress urinary incontinence usually due to intrinsic urethral sphincter deficiency that has traditionally resulted in lower success rates with standard treatment modalities. We aim to address the question of whether transobturator sling insertion is more effective than retropubic sling insertion in the treatment of intrinsic sphincter deficiency-related stress urinary incontinence in women. Methods: We searched MEDLINE, CINAHL, CENTRAL, journals, and major conferences (up to 30 June 2014). All randomised controlled trials in women with stress urinary incontinence or mixed urinary incontinence with associated intrinsic sphincter deficiency who underwent a retropubic or transobturator mid-urethral sling operation were included in this meta-analysis. The Cochrane risk of bias tool and the GRADE system were used to assess the quality of evidence. Results: Fifty-five randomised controlled trials compared transobturator and retropubic mid-urethral slings. Twelve trials included women with intrinsic sphincter deficiency, but only 8 trials (399 women) reported data specifically for this cohort. There was a statistically significant difference in short- and medium-term (≤5 years) subjective cure rates, with the number of women reporting a cure in the transobturator group at 150 out of 199 and the retropubic group at 171 out of 200. This gives a 12 % relative risk reduction in achieving cure with the transobturator route (RR 0.88, 95 % CI 0.80 to 0.96, I2 = 0 %, moderate quality evidence [GRADE]). Objective cure was reported by five trials of 324 women and showed no statistically significant difference between the two groups, with a rate of 110 out of 159 in the transobturator group and 126 out of 165 in the retropubic group (RR 0.90, 95 % CI 0.79 to 1.03). Post-operative voiding dysfunction and de novo urgency or urgency urinary incontinence in the two treatment groups showed no significant difference. The need to undergo repeat incontinence surgery in the long term (≥5 years) was higher with the transobturator route (RR 14.4, 95 % CI 1.95 to 106, 147 women). Conclusions: Mid-urethral slings are effective in treating women with intrinsic sphincter deficiency-associated stress urinary incontinence. The retropubic route resulted in higher subjective cure rates compared with transobturator routes. Both routes improved the overall quality of life. © 2015, The International Urogynecological Association. Source

Mitropoulos D.,National and Kapodistrian University of Athens | Artibani W.,University of Verona | Biyani C.S.,Pinderfields General Hospital | Bjerggaard Jensen Jo.,Aarhus University Hospital | And 3 more authors.
European Urology

Context A standardised system to report outcomes and complications of urologic procedures has recently been proposed by an ad hoc European Association of Urology (EAU) Guidelines panel. To date, no studies have used these criteria to evaluate the quality of reports of outcomes and complications after partial nephrectomy (PN). Objective To address the quality of reporting of PN complications. Design, setting, and participants A systematic review of papers reporting outcomes of PN was conducted through the electronic search of databases, including Medline, PubMed, Embase, Scopus, and the Cochrane Database of Systematic Reviews. Outcome measurements and statistical analysis Analysis was carried out on structured forms. The quality criteria that the EAU Working Group proposed for reporting complications were recorded for each paper, and adherence to the Martin criteria was assessed. Results and limitations Standardised criteria to report and grade complications were used in 71 out of 204 evaluable studies (34.8%). Only six studies (2.9%) fulfilled all criteria that the EAU Guidelines Office ad hoc panel proposed. The mean number did not change significantly by time or by surgical approach used. The most underreported criteria (in <50% of the studies) were who collected the data (18.6%), whether he or she were involved in the treatment (13.7%), duration of follow-up (47.1%), mortality data and causes of death (33.8%), definition of procedure-specific complications (39.2), separate reporting of intra- and postoperative complications (45.1%), complication severity or grade (32.4%), risk factors analysis (44.1%), readmission rates (12.7%), and percentage of patients lost to follow-up (6.9%). The mean number fulfilled was 6.5 ± 2.9 (mean plus or minus standard deviation) and did not change significantly by time or by surgical approach used. Conclusions The only way to improve the quality of the surgical scientific literature and to allow sound comparisons among different approaches, especially with the lack of randomised trials, is the use of more rigorous methodology than the one recently proposed to report outcomes and complications. Patient summary A rigorous methodology is mandatory when surgeons report about complications after surgery. Otherwise, the rate of adverse events is underestimated. © 2014 European Association of Urology. Source

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

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. 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