The virtual knee clinic - A tool to streamline new outpatient referrals

INTRODUCTION

Traditionally it has been the case for orthopaedic consultants to review GP referrals for the orthopaedic outpatient clinic where possible in amongst other clinical commitments. This could sometimes lead to unsuitable patients being reviewed and both patients and clinicians becoming frustrated. Building on the virtual fracture clinic, a new screening tool was implemented to streamline new referrals. The aim of this study is to investigate the change in patients given outpatient appointments following the introduction of a new streamlining protocol.

METHODS

Referrals had to meet the criteria of BMI under 40 or evidence of weight loss effort, recent radiographs and appropriate clinical details in keeping with Getting It Right First Time (GIRFT). Consultant were given dedicated clinical time to review and either triage the patient to the most appropriate clinic type, or return the referral with advice to the GP. 10 months of data was collected prior to the protocol and 10 months after implementation.

RESULTS

1781 patients were referred pre-protocol with an average of 14.2% of these being returned. Post protocol there were 2110 patients referred with 31.2% returned. There was an increase in 195% of referrals returned to the GP (p < 0.0001). The highest proportion of these was for mild to moderate osteoarthritis on the radiograph which has been proven to be unsuitable for intervention. At 12 month analysis there was no significant increase in patients re-referred to the service (p = 0.53) DISCUSSION: The new screening tool allows more appropriate referrals to be seen in clinic allowing less frustration to clinicians and patients by reducing therapeutic inertia. Furthermore it allows new referrals to be seen by the most appropriate sub-specialist. It allows advice to be given to GPs on further management for the patient. 619 appointments were saved. At a cost of £120 per appointment, this leads to a real terms cost saving of £74,280, with further savings in time and travel.

High-dose carmustine (BCNU), etoposide (VP-16), cytarabine (Ara-C), and cyclophosphamide-BVAC with autologous transplant (ASCT) in relapsed and refractory Hodgkin disease (HD): Long-term follow-up of 89 patients

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Background: High dose chemotherapy followed by ASCT has been established as the therapy for refractory and relapsed HD. Relapse remains the primary contributor to an unsuccessful outcome after ASCT. Intensification of the conditioning regimen is one means of decreasing relapse and improving results. We report our experience with an augmented preparative regimen in patients (pts) with relapsed or refractory HD undergoing ASCT. Methods: Retrospective analysis of 89 consecutive pts from October 1984 to October 2004. All pts received high-dose chemotherapy with BCNU 600mg/m2 IV day -8, Etoposide 400mg/m2/day days -7, -6, -5, and -4, Ara-C 3gm/m2 IV every 12 hours for 8 doses starting day -7, and Cyclophosphamide 90mg/kg IV on day-2 followed by bone marrow (40 pts), peripheral blood (43 pts) or both (6 pts) rescue. Ten pts received planned XRT post-transplant. Survival data were estimated using Kaplan-Meier curves. Cox proportional hazards regression was used to assess the impact of variables on disease-free survival (DFS) and overall survival (OS). Results: A total of 89 pts were identified. Median age was 31 (range 16–62); 51 pts (57.3%) had received one prior therapy at the time of transplant. At transplant only 28 pts (34.6%) were in CR; 79.8% had sensitive disease (CR plus PR).Time to transplant was < 1 year for 17% of pts. With a median follow-up of 811 days, the 5 and 10-year DFS rates were 63.3% and 60.4%, respectively. The estimated 5 and 10- year OS rates were 47.3% and 33.7%. The rate of secondary malignancies at 10 years was 7.8%. Lack of B symptoms and stage at transplant were associated with improved DFS (p= 0.01 and p= 0.0005, respectively) and OS (p=0.002 and p=0.02, respectively). Patients with primary induction failure and resistant relapse did as well as patients with sensitive disease. Conclusions: Though ASCT has been beneficial in prolonging DFS and OS in pts with chemosensitive HD, there has been conflicting data regarding refractory disease. We propose that an intensified regimen, i.e. BVAC, may be of benefit in that setting. Only a large randomized trial can determine whether intensification of the preparative regimen can improve OS for such a population.

No significant financial relationships to disclose.

Results for serum cholesterol and triglycerides by gas-liquid chromatography, as compared with a continuous-flow technique

We assessed the usefulness of gas-liquid chromatography forthe routine and reference measurement of cholesterol and triglycerides (triacylglycerols). Compared with results obtained by an AutoAnalyzer II method, correlation was good with both serum specimens (triglycerides, r = 0.88; cholesterol, r = 0.90) and lipoprotein fractions isolated by ultracentrifugation (triglycerides, r = 0.98; cholesterol, r = 0.98). However, none of the comparisons was completely free of analytical bias, and in general the AutoAnalyzer method underestimated the cholesterol value and overestimated triglycerides. The obvious advantage of the AutoAnalyzer is its greater analytical speed, but the chromatographic method appeared to be more accurate and precise and to suffer less from interfering substances, and in addition gave information about the cholesterol ester and triglyceride composition. We expect gas-liquid chromatography to be of major importance in the calibration of other analytical methods.

Experimental Observation of Convective Cell Formation due to a Fast Wave Antenna in the Large Plasma Device

An experiment in a linear device, the Large Plasma Device, is used to study sheaths caused by an actively powered radio frequency (rf) antenna. The rf antenna used in the experiment consists of a single current strap recessed inside a copper box enclosure without a Faraday screen. A large increase in the plasma potential was observed along magnetic field lines that connect to the antenna limiter. The electric field from the spatial variation of the rectified plasma potential generated E[over →]×B[over →]_{0} flows, often referred to as convective cells. The presence of the flows generated by these potentials is confirmed by Mach probes. The observed convective cell flows are seen to cause the plasma in front of the antenna to flow away and cause a density modification near the antenna edge. These can cause hot spots and damage to the antenna and can result in a decrease in the ion cyclotron range of frequencies antenna coupling.