Postoperative serum C-reactive protein dynamics after pharyngolaryngectomy with jejunal free-flap reconstruction

INTRODUCTION

Pharyngolaryngectomy with jejunal free-flap (JFF) reconstruction can be offered for locally advanced hypopharyngeal cancer. However, the procedure carries significant morbidity. Postoperative serial serum C-reactive protein (CRP) has been shown to be a marker predicting postoperative complications, and the aim of this study was to describe the dynamics and value of CRP in this patient group.

METHODS

Retrospective analysis of pharyngolaryngectomies with JFF reconstruction was performed in our institution. Daily postoperative CRP values were analysed within the first 14 days, as were complications.

RESULTS

Twenty-one cases were included. Total morbidity was 57.1% including 14.3% (temporary) anastomotic leaks and 14.3% flap failures. Patients in the normal group showed peak CRP levels around postoperative day 2 (2.2). Increased CRP levels on or after day 4 were associated with complications (p<0.01) with a sensitivity of 83.3% and specificity of 77.8%. In keeping with CRP kinetics from other surgical studies, peak CRP values on day 2 or 3 are expected, followed by a decline. Peaks in CRP on day 4 or later raise the suspicion of complications. CRP is not specific for any one complication but rather can help guide early appropriate clinical assessment and management.

CONCLUSIONS

The natural postoperative CRP response peaks around postoperative day 2 (2.2) and declines thereafter. Rising CRP levels after postoperative day 3 are suspicious of surgical complications (p<0.01) with positive and negative predictive values of 83.3% and 77.8%, respectively. Therefore, serial postoperative CRP can be used as an adjunct to monitor outcomes in this group.

Rapid on-site assessment of specimens by biomedical scientists improves the quality of head and neck fine needle aspiration cytology

OBJECTIVE

Immediate rapid on-site assessment (ROSA) of fine needle aspiration cytology (FNAC) specimens by biomedical scientists (BMS), the UK equivalent of cytotechnologists, or by pathologists may improve specimen quality and cellular adequacy rates for lymph node, head and neck and thyroid FNAC. The aim of this study was to evaluate the effect of introducing ROSA by BMS in an outpatient clinic setting.

METHODS

The adequacy rate and sensitivity of histological diagnosis for lymph node, thyroid and salivary gland FNAC samples were determined before and after the introduction of BMS ROSA. The additional financial costs and time required to perform this service were also estimated.

RESULTS

Thirty-one patients underwent ultrasound (US)-guided FNAC with ROSA and 151 without. ROSA reduced the number of FNAC insufficient in quality for diagnosis from 43% to 19% (P = 0.0194). The estimated additional cost for pathology per patient for ROSA was between £52.05 and £70.74, equivalent to €65.40/US $83.90 and €88.89/US $114.0, respectively, an increase of between 28% and 49% from the original cost. ROSA necessitated an additional 6 minutes clinic time per patient, reducing the number of patients that could be seen in an average clinic from 13 to 10 as well as requiring increased laboratory time for FNAC slide assessment.

CONCLUSION

ROSA by suitably trained biomedical scientists and with appropriate consultant pathologist support can improve the quality of FNAC sampling for head and neck lesions. Although ROSA resulted in both additional financial and time costs, these are more than likely to be offset by a reduction in patients returning to clinic for repeat FNAC or undergoing unnecessary surgery.

How we do it: Analysing GP referral priorities: the unforeseen effect of 'Choose and Book'

The introduction of Choose and Book may have a significant effect on the proportion of urgent referrals seen by ENT surgeons. Much of the responsibility for prioritisation will be transferred to the GP. Patients who are considered urgent by the ENT surgeon will be added to those considered urgent by the GP. Our results show that there was little agreement between GPs and ENT surgeon on what constitutes an urgent referral. The combined effect of joint prioritisation and the removal of the 'soon' category resulted in a 270% increase in 'urgent' referrals in our sample. This potentially unforeseen consequence of the Choose and Book system should be taken into consideration by ENT departments to allow for an expansion of the 'urgent' category.

How much do healthcare professionals know about informed consent? A Bristol experience

BACKGROUND

It is important that healthcare professionals have a thorough knowledge of consent practice. The purpose of this study was to compare understanding against the agreed standards found in consent guidelines and UK case law.

METHOD

Twelve 'true or false' questions testing knowledge of the consent process were completed by 118 healthcare professionals from the United Bristol Healthcare NHS Trust. The questions addressed areas of fundamental importance, difficult clinical situations, and common consent dilemmas. The answers were marked against pre-validated answers determined using published guidelines and case law. Results were analysed for differences between pre-determined population sub-groups.

RESULTS

A 100% response rate was achieved. Significant areas of weakness were identified including the role of consent forms, Gillick competence and mentally-ill patients. Performance was generally better by medical staff, those in surgical specialties, and more junior doctors. For example, 30.9% of doctors versus 62% of non-doctors (p=0.05) thought, incorrectly, that if an adult is unable to provide consent for an emergency procedure, the patient's next of kin must sign the consent form. Doctors also demonstrated a greater understanding of Gillick case law and scored significantly higher than non-doctors (68% vs. 48.5%, p=0.027).

CONCLUSIONS

National guidelines and case law provide the gold standard for ideal consent practice. Many healthcare professionals have either not read these documents or are unable to reliably recall them. Improvements in knowledge and practice could be possible with further education, particularly targeting those most closely involved in the consent process