1119 Readdressing Consent in Head & Neck Free Flap Surgery: The Nottingham Experience

Aim

The Montgomery vs NHS Lanarkshire case in 2015 led to a paradigm shift in the consent process within surgery. It became incumbent upon clinicians to outline all “material risks” prior to a procedure. Within head and neck surgery, the Enhanced Recovery After Surgery (ERAS) pathway addresses this obligation through a multi-disciplinary approach. The aim of this audit was to assess the effect of the existing ERAS pathway on the consent process.

Method

35 head and neck oncology cases involving free flap reconstruction were identified across two audit cycles. Cases pre- and post-introduction of the ERAS pathway were analysed to assess whether the existing pathway led to improvement in consent quality.

8 key consent elements were identified based on a review of current literature and guidelines. This was our gold standard. A tick-box system was devised, and each case assigned a percentage score based on compliance with these criteria. A consent checklist was introduced within the ERAS pathway file alongside multi-disciplinary documentation which would follow the patient from the pre-operative environment through to discharge.

Results

Prior to the introduction of the ERAS pathway, there was a 58% compliance with the gold standard. Upon implementation of the ERAS protocol, compliance rose to 65%. Following introduction of the checklist, compliance rose further to 85%. This resulted in an overall increase in compliance of 27%.

Conclusions

We recommend the introduction of a focused consent checklist within any unit providing major head and neck reconstruction procedures in order to ensure informed consent, mitigating medico-legal risks post-operatively.

Indirubin inhibits inflammatory reactions in delayed-type hypersensitivity

Polygonum tinctorium Lour. (P. tinctorium) is known to have the ability to suppress inflammation. We attempted to isolate the active compounds from P. tinctorium based on their inhibitory effects on the production of interferon-gamma, which is a well-known inflammatory cytokine. We thus isolated indirubin, an isomer of indigo. Indirubin exerted its inhibitory effects not only on interferon-gamma production by human myelomonocytic HBL-38 cells but also on interferon-gamma and interleukin-6 production by murine splenocytes with no influence on the proliferation of either cells. Because of its inhibitory activity on interferon-gamma production, we further investigated the effects of indirubin on 2,4, 6-trinitro-l-chlorobenzene (TNCB)-induced delayed-type hypersensitivity as a representative inflammatory reaction. When injected intraperitoneally, indirubin significantly inhibited the ear swelling of TNCB-elicited mice. The amount of interferon-gamma in the culture supernatants of elicited mouse lymphocytes was inhibited by indirubin treatment. These results suggest that indirubin is a compound with anti-inflammatory effects.

Illness and health behaviour in Addis Ababa and rural central Ethiopia

This paper examines the results of health surveys among 544 randomly selected households (2829 people) in seven kebele (urban dwellers' associations) in Addis Ababa and Kaliti, an industrial suburb of Addis Ababa, and in four rural villages in two peasant associations. The major objective was to study illness distribution and health behaviour among different socioeconomic and cultural groups in urban and rural communities within the context of available health resources, national health policy and planning. Results show that in spite of the rapid expansion of health services since the Ethiopian revolution serious problems of allocation and access persist. Higher illness prevalance rates were found in rural areas (23.2%), Kaliti (25.5%) and in the low socioeconomic kebele in Addis Ababa (23.9%) than in the high socioeconomic kebele (16.5%), but rural/urban and intraurban differences were greater than reported here due to underreporting. One-third of all illnesses were treated by modern services, 19.9% by self care and 26.0% by traditional medicine and transitional healers, with 21.5% of all illnesses not being treated. Utilization rates varied with type and duration of illness, socioeconomic level, age, sex and place of residence. The role of distance and other contact barriers, treatment outcome and availability of private clinics and alternative health resources in utilization is also evaluated. Coverage of the modern health services was associated with socioeconomic status and mobility of patients as well as availability of health services.