The Use of a Structured Form during Urology Out-patient Consultations

Objectives: To compare the completeness of documentation in the medical record using a structured form (SF) versus a traditional medical record (TMR).

Methods: Randomised controlled trial comparing the use of SF and TMR in urology out-patient clinics for documentation of 15 items of clinical information, time taken to complete and acceptability to clinicians assessed by a self-completion questionnaire. in a teaching and district general hospitals

Results: Four hundred new urology patient consultations, 11 clinicians. Completeness of information was compared between groups based on the medical record alone (SF vs. TMR), medical record plus letter to GP and letter alone. SFs were significantly (p<0.0001) more complete than TMRs for the majority of the items in all three groups. There was no significant difference in the time taken to document information using either type of record. The clinicians generally found the SF acceptable for routine use.

Conclusions: Structured forms significantly improved the completeness of documentation for new out-patient consultations in urology.

Baseline Urinary Phytoestrogen Levels and the Natural History of Untreated, Localised Prostate Cancer in a British Population

Aim

To determine whether urinary concentrations of phytoestrogens are associated with the rate of disease progression in men with untreated, localised prostate cancer.

Patients and methods

Patients with untreated, localised prostatic adenocarcinoma on a prospective clinical study of active surveillance had urine samples collected at baseline. Patients underwent monitoring with serial PSA levels and repeat octant prostate biopsies. Disease progression was defined as either adverse histology on repeat biopsy (primary Gleason grade ≥4, or >50% positive cores) or radical treatment for PSA velocity >1 ng/mL/year. Time to disease progression was analysed with respect to baseline urinary levels of genistein, enterolactone, daidzein and equol, assayed using liquid chromatography/tandem mass spectrometry.

Results

191 patients were evaluable, with a median follow-up of 2.5 years. 71 patients experienced disease progression. No significant association was seen between time to disease progression and baseline urinary levels of daidzein (p=0.85), genistein (p=0.81), enterolactone (p=0.085) or equol (p=0.33). No significant association was seen between adverse histology on repeat biopsy and urinary levels of either daidzein (p=0.85), genistein (p=0.58), enterolactone (p=0.88) or equol (p=0.71). There was no significant correlation between PSA velocity and urinary levels of daidzein (p=0.90), genistein (p=0.98), enterolactone (p=0.10) or equol (p=0.60).

Conclusion

These data do not support the hypothesis that phytoestrogens prevent disease progression in men with localised prostate cancer.

Neuromuscular changes and the rapid adaptation following a bout of damaging eccentric exercise

INTRODUCTION

An initial bout of eccentric exercise is known to protect against muscle damage following a repeated bout of the same exercise; however, the neuromuscular adaptations owing to this phenomenon are unknown.

AIM

To determine whether neuromuscular disturbances are modulated following a repeated bout of eccentric exercise.

METHODS

Following eccentric exercise performed with the elbow flexors, we measured maximal voluntary force, resting twitch force, muscle soreness, creatine kinase (CK) and voluntary activation (VA) using motor point and motor cortex stimulation at baseline, immediately post-exercise and at 1, 2, 3, 4 and 7 days post-exercise on two occasions, separated by 3 weeks.

RESULTS

Significant muscle damage and fatigue were evident following the first exercise bout; maximal voluntary contraction (MVC) was reduced immediately by 35% and remained depressed at 7 days post-exercise. Soreness and CK release peaked at 3 and 4 days post-exercise respectively. Resting twitch force remained significantly reduced at 7 days (-48%), whilst VA measured with motor point and motor cortex stimulation was reduced until 2 and 3 days respectively. A repeated bout effect (RBE) was observed with attenuated soreness and CK release and a quicker recovery of MVC and resting twitch force. A similar decrement in VA was observed following both bouts; however, following the repeated bout there was a significantly smaller reduction in, and a faster recovery of, VA measured using motor cortical stimulation.

CONCLUSION

Our data suggest that the RBE may be explained, partly, by a modification in motor corticospinal drive.

Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK

Background

Since the global financial crisis, UK NHS spending has reduced considerably. Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Under the remit of ‘prudent healthcare’ championed by the Welsh Health Minister, a Programme Budgeting Marginal Analysis (PBMA) of the North Wales respiratory care pathway was conducted.

Methods

A PBMA panel of directors of medicines management, therapies finance, planning, public health and healthcare professionals used electronic voting to establish criteria for decision-making and vote on candidate interventions in which to disinvest and invest.

Results

A sum of £86.9 million was spent on respiratory care in 2012–13. Following extensive discussion of 13 proposed candidate interventions facilitated by a chairperson, 4 candidates received recommendations to disinvest, 7 to invest and 2 to maintain current activity. Marginal analysis prioritized mucolytics and high antibiotic prescribing as areas for disinvestment, and medicines waste management and pulmonary rehabilitation for investment.

Conclusions

This exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and investment decisions. Initial progress has begun with communication from the Medical Director in relation to the disinvestment in mucolytics prescribing and possible redirection of funding options being explored.

The impact of complications and errors on surgeons

Do surgeons need support – and, if so, what kind?