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Waydia S, Gunawardene A, Gilbert J, Cota A, Finlay IG. 23-Hour/Next Day Discharge Post-Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Surgery Is Safe. Obes Surg 2014; 24:2007-10. [DOI: 10.1007/s11695-014-1409-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Nicholson GA, Morrison DS, Finlay IG, Diament RH, Horgan PG, Molloy RG. Quality of care in rectal cancer surgery. Exploring influencing factors in the West of Scotland. Colorectal Dis 2012; 14:731-9. [PMID: 21831175 DOI: 10.1111/j.1463-1318.2011.02754.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To assess variability in the proportions of types of major resection for rectal cancer throughout the west of Scotland (WoS) and ascertain factors explaining the variability. METHOD Retrospective cohort study of a regional population clinical audit database. This was linked to cancer registrations and death certificates in order that outcome analyses could be derived. Univariate and multivariate binary logistic regression analyses were used to explore determinants of survival. RESULTS A total of 1574 patients met the inclusion criteria. The age range was from 22 to 97 years. The mean age was 67, median age 68 and the standard deviation was 11.5. The majority of patients (61%) were male. Unlike previous series, male patients and those with poorer socioeconomic circumstances (SEC) were no more likely to receive an abdominoperineal excision (APE) procedure for rectal cancer. CONCLUSION Variation exists in the west of Scotland regarding surgical treatment for rectal cancer. We found no difference in the type of procedure offered according to sex, intent of operation or socioeconomic circumstances with reference to APE and anterior resection (AR) for rectal cancer. We conclude therefore that our region provides an equitable service on grounds of sex and SEC. This demonstrates that an equitable surgical service has been provided for those suffering from rectal cancer. Circumferential margin positivity was four times more likely in an APE than an AR for rectal cancer. This is not explained by age, stage, sex, socioeconomic circumstances (SEC), volume of surgery, intent of operation, type of admission or year of incidence.
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Affiliation(s)
- G A Nicholson
- Department of Academic Surgery, University of Glasgow, Glasgow, UK.
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Harris DG, Finlay IG, Flowers S, Noble SIR. The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: a qualitative study. Palliat Med 2011; 25:691-700. [PMID: 21490117 DOI: 10.1177/0269216311401464] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Terminal haemorrhage is a rare but devastating event that may occur in certain advanced cancers. The focus of management involves administration of 'crisis medicine' with the intention of relieving patient distress through sedative doses of anxiolytics or opioids. This practice, whilst widely accepted, is based on limited evidence and has never been formally evaluated. AIM To evaluate the utility of crisis medication in the management of terminal haemorrhage, through the experiences of nurses who had personally managed such events. METHOD Semi-structured interviews exploring the experiences of palliative care and head and neck oncology nurses were recorded, transcribed verbatim and analysed using interpretative phenomenological analysis. Saturation of themes occurred after interviewing 11 nurses with cumulative experience of managing 37 terminal haemorrhages. RESULTS Participants reported crisis medication to have little, if any, role in the management of terminal haemorrhage, which was such a rapid event that patients died before it could be administered. As many events had not been predicted, anticipatory prescribing of crisis medication did not always occur. Staying with and supporting the patient, and using dark-coloured towels to camouflage blood were reported to be of more practical use. A focus on accessing crisis medicines had often been to the detriment of these simple yet beneficial measures. CONCLUSION Anticipatory prescribing of crisis medication rarely benefits the patient and may unintentionally detract from nursing care. Guidelines on the management of terminal haemorrhage should reconsider the emphasis on crisis medication and focus on non-pharmacological approaches to this invariably fatal event.
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Affiliation(s)
- D G Harris
- Department of Palliative Medicine, Cwm Taf Health Board, UK.
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Nicholson GA, Finlay IG, Diament RH, Molloy RG, Horgan PG, Morrison DS. Mechanical bowel preparation does not influence outcomes following colonic cancer resection. Br J Surg 2011; 98:866-71. [PMID: 21412756 DOI: 10.1002/bjs.7454] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2011] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Meta-analyses have indicated that preoperative mechanical bowel preparation (MBP) confers no clear benefit and may indeed be harmful for patients with colorectal cancer. The effects of bowel preparation on longer-term outcomes have not been reported. The aim was to compare long-term survival and surgical complications in patients who did or did not receive MBP before surgery for colonic cancer.
Methods
This was a retrospective cohort study of all patients undergoing potentially curative surgery for colonic cancer after routine hospital admission in the West of Scotland between January 2000 and December 2005. Clinical audit data were linked to cancer registrations and death certificates. Kaplan–Meier and Cox proportional hazards models were used to explore determinants of survival.
Results
A total of 1730 patients underwent potentially curative surgery for colonic cancer, of whom 886 (51·2 per cent) were men. The mean(s.d.) age was 69·7(10·6) years. Some 1460 patients (84·4 per cent) received MBP. Median follow-up was 3·5 (range 0·1–6·7) years. There were no statistically significant differences in 30-day postoperative complication rates between groups. The unadjusted hazard ratio (HR) for death from all causes for patients treated with MBP (versus no MBP) was 0·72 (95 per cent confidence interval 0·57 to 0·91). Multivariable analysis with adjustment for age, sex, socioeconomic circumstances, disease stage and presentation for surgery showed that MBP had no independent effect on all-cause mortality (HR 0·85, 0·67 to 1·10).
Conclusion
Neither postoperative complications nor long-term survival are improved by MBP before colonic cancer surgery.
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Affiliation(s)
- G A Nicholson
- West of Scotland Cancer Surveillance Unit, Section of Public Health and Health Policy, Faculty of Medicine, University of Glasgow, UK
| | - I G Finlay
- Department of Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - R H Diament
- Department of Surgery, Crosshouse Hospital, Kilmarnock, UK
| | - R G Molloy
- Department of Surgery, Gartnavel General Hospital, UK
| | - P G Horgan
- Department of Academic Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - D S Morrison
- West of Scotland Cancer Surveillance Unit, Section of Public Health and Health Policy, Faculty of Medicine, University of Glasgow, UK
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Finlay IG, George R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups--another perspective on Oregon's data. J Med Ethics 2011; 37:171-174. [PMID: 21071568 DOI: 10.1136/jme.2010.037044] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Battin et al examined data on deaths from physician-assisted suicide (PAS) in Oregon and on PAS and voluntary euthanasia (VE) in The Netherlands. This paper reviews the methodology used in their examination and questions the conclusions drawn from it-namely, that there is for the most part 'no evidence of heightened risk' to vulnerable people from the legalisation of PAS or VE. This critique focuses on the evidence about PAS in Oregon. It suggests that vulnerability to PAS cannot be categorised simply by reference to race, gender or other socioeconomic status and that the impetus to seek PAS derives from factors, including emotional state, reactions to loss, personality type and situation and possibly to PAS contagion, all factors that apply across the social spectrum. It also argues, on the basis of official reports from the Oregon Health Department on the working of the Oregon Death with Dignity Act since 2008, that, contrary to the conclusions drawn by Battin et al, the highest resort to PAS in Oregon is among the elderly and, on the basis of research published since Battin et al reported, that there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS.
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Affiliation(s)
- I G Finlay
- Cardiff University, Velindre Hospital, Cardiff CF14 2TL, UK.
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Harris DG, Owen RE, Finlay IG. Delivery of safe and effective care out of hours: the impact of the shared clinical record on a patient's out-of-hours contact with specialist palliative care. Clin Med (Lond) 2011; 11:92-3. [PMID: 21404797 PMCID: PMC5873817 DOI: 10.7861/clinmedicine.11-1-92] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Access to adequate clinical information is essential for out-of-hours palliative care teams and general practitioners, specific examples to illustrate and justify this need are surprisingly rare in the medical literature. Without access to the full clinical background the patient in this lesson may have been inappropriately admitted to a palliative care unit and delayed investigations would have misguided the admitting doctor's assessment, planned investigations and management.
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Affiliation(s)
- D G Harris
- Palliative Care Department, Prince Charles Hospital, Merthyr Tydfil.
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van Heest FB, Finlay IG, Kramer JJE, Otter R, Meyboom-de Jong B. Telephone consultations on palliative sedation therapy and euthanasia in general practice in The Netherlands in 2003: a report from inside. Fam Pract 2009; 26:481-7. [PMID: 19833823 DOI: 10.1093/fampra/cmp069] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND GPs with a special interest and with specific training in palliative medicine (GP advisors) supported professional carers (mostly GPs) through a telephone advisory service. Each telephone call was formally documented on paper and subsequently evaluated. OBJECTIVE Data from 2003 were analysed independently to reveal how often and in what way palliative sedation and euthanasia were discussed. METHODS The telephone documentation forms and corresponding evaluation forms of two GP advisors were systematically analysed for problems relating to the role of sedation and/or euthanasia both quantitatively and qualitatively. RESULTS In 87 (21%) of 415 analysed consultations, sedation and/or euthanasia were discussed either as the presenting question (sedation 26 times, euthanasia 37 times and both 10 times) or arising during discussion (sedation 11 times and euthanasia three times). Qualitative analysis revealed that GPs telephoned to explore therapeutic options and/or wanted specific information. Pressure on the GP (either internal or external) to relieve suffering (including shortening life by euthanasia) had often precipitated the call. On evaluation, 100% of the GPs reported that the advice received was of value in the patient's care. CONCLUSION GPs caring for patients dying at home encountered complex clinical dilemmas in end-of-life care (including palliative sedation therapy and euthanasia). They valued practical advice from, and open discussion with, GP advisors. The advice often helped the GP find solutions to the patient's problems that did not require deliberately foreshortening life.
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Affiliation(s)
- Florien B van Heest
- Department for Palliative Medicine, Integraal Kankercentrum Noord Oost, 9700 AH Groningen, The Netherlands.
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Fisher B, Finlay IG, Vipond MN. Duodenal obstruction by gallstone in the absence of cholecystoenteric fistula, an unusual complication of total gastrectomy: report of a case. Ann R Coll Surg Engl 2009; 91:W1-2. [PMID: 19416577 DOI: 10.1308/147870809x401010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We present a case of gallstone obstruction of the duodenum in a post total gastrectomy patient without a cholecystoenteric fistula. The patient presented with epigastric pain. On abdominal computed tomography and percutaneous transhepatic choangiography imaging, the patient was found to have duodenal obstruction. At operation, the cause of obstruction was found to be a large gallstone in the third part of the duodenum, but there was no associated cholecystoenteric fistula. This report is the first to describe duodenal obstruction by a gallstone formed within the duodenum, in a patient post total gastrectomy with Roux-en-Y reconstruction, and highlights what can be a difficult diagnosis in such patients.
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Affiliation(s)
- B Fisher
- Department of Upper GI Surgery, Gloucestershire Royal Hospital, Gloucester, UK.
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El Muhtaseb MS, Talwar D, Duncan A, St J O'reilly D, McKee RF, Anderson JH, Foulis A, Finlay IG. Free radical activity and lipid soluble anti-oxidant vitamin status in patients with long-term ileal pouch-anal anastomosis. Colorectal Dis 2009; 11:67-72. [PMID: 18400037 DOI: 10.1111/j.1463-1318.2008.01517.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Ileal pouch-anal anastomosis (IPAA) is the operation of choice for patients with ulcerative colitis. Free radical activity and the status of lipid soluble antioxidant vitamins have not been previously assessed in patients with IPAA. The aim of the present study was to measure the plasma concentrations of lipophyllic antioxidants and free radical activity in IPAA patients and compare them with normal subjects. METHOD Forty-eight IPAA patients and 50 healthy controls were studied. A dietary assessment of vitamin E (alpha-tocopherol) and carotene was undertaken and plasma antioxidant status was assessed. Plasma malondialdehyde (MDA) was measured to assess the extent of free radical damage. In IPAA patients, association between the degree of inflammation in the pouch mucosa and the plasma concentration of lipophyllic antioxidants and extent of free radical activity was investigated. RESULTS The dietary intake of carotene was similar in both groups. Intake of vitamin E was significantly lower in patients than controls (P = 0.01). In the IPAA group plasma concentrations of alpha-carotene, beta-carotene and lycopene were significantly lower (P < 0.001) and alpha-tocopherol:cholesterol ratio significantly higher (P < 0.001). Free radical damage was significantly greater in patients than controls (P < 0.01). There were no significant correlations between the degree of inflammation in the pouch and plasma concentrations of MDA, carotenoids, alpha-tocopherol:cholesterol ratio or intake of vitamins. CONCLUSION Compared with normal subjects, patients with IPAA have significantly lower plasma concentrations of lipophyllic antioxidants alpha-carotene, beta-carotene and lycopene and higher free radical activity suggesting increased oxidative stress. These differences do not appear to be related to diet and do not correlate with histological severity of pouch inflammation.
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Affiliation(s)
- M S El Muhtaseb
- Department of Coloproctology, Lister Department of Surgery, Glasgow Royal Infirmary
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11
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Abstract
Despite level 1 evidence supporting the use of low-molecular weight heparin thromboprophylaxis in hospitalised cancer patients, only 7% of specialist palliative care units (SCPU) have thromboprophylaxis guidelines. The reasons for this are unclear. To explore specialist palliative care units (SPCU) directors' views on thromboprophylaxis in the inpatient unit, audiotaped semi-structured interviews were conducted with SCPU medical directors to explore factors influencing thromboprophylaxis practice. Purposive sampling of units known not to have thromboprophylaxis guidelines was conducted (as identified from previous research). The hospice directory was used to sample from units in each region of Great Britain and Ireland to ensure representation across the specialty. Interviews were transcribed and analysed using interpretative phenomenological analysis (IPA). Four major and four sub themes were identified. Participants were progressive in their attitudes to palliative care and comfortable with instigating active interventions for patient benefit. Symptomatic venous thromboembolism (VTE) was rarely seen and therefore not considered important enough to warrant guidelines. There was concern that evidence informing thromboprophylaxis guidelines in the general population was not transferable to the advanced cancer population and that the outcome measures from these studies were less meaningful to a palliative care patient. Thromboprophylaxis was considered a life prolonging intervention which may result in a poorer death than one because of VTE. Nevertheless, participants were receptive to change if presented with convincing evidence derived from a representative population. Until the true prevalence and symptomatic burden of VTE is known, the role of thromboprophylaxis in the SPCU setting will remain controversial. There is a need for a well-designed study to explore the utility of thromboprophylaxis in the palliative care inpatient setting. However, this will require meaningful outcome measures to be used within a clinically applicable population.
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Affiliation(s)
- S I R Noble
- Department of Palliative Medicine, Cardiff University and Royal Gwent Hospital, Gwent, UK.
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12
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Abstract
BACKGROUND It is possible that patients with advanced cancer, who are from the medical profession, have different or additional care needs than other patients. Previous training, professional experiences and access to information and services may influence their needs and subsequent illness behaviour. Caring for ;one of our own' may also evoke particular feelings and emotions from health professionals involved in their care and pose unique challenges in the delivery of equitable patient-centred care. AIM To explore the experiences of palliative care physicians when caring for members of the medical profession with advanced incurable cancer. PARTICIPANTS AND METHODS Semi-structured interviews exploring the experiences of senior palliative care physicians were recorded and transcribed verbatim. Transcripts were analysed using interpretative phenomenological analysis (IPA) for emergent themes. Data were collected from ten senior palliative care physicians with a combined total of 107 years of palliative care career experience, caring for a reported combined estimate of 120 doctor-patients. RESULTS On the basis of their reflections, palliative care physicians reported that doctor-patients appear to find it difficult to assume a patient role, especially at a time they are likely to be truly vulnerable. This patient group will routinely attempt to maintain control of their care and environment using various strategies. These include self-referrals, accessing their own tests, directing the consultation and putting barriers up to psychosocial aspects of palliative care. Doctor-patients' general practitioners are at risk of exclusion from the management of care, and referral to palliative care services appears to occur later in the illness journey of doctor-patients compared to lay patients. Participants recalled how caring for colleagues evokes powerful emotional responses, such as a strong desire to provide the best care possible as well as feelings of anxiety. They frequently find themselves under pressure to disclose confidential information from medical colleagues not involved in the doctor-patients' care. Doctor-patients frequently receive what other healthcare professionals perceive as preferential treatment, which may unintentionally result in suboptimal care. CONCLUSION The core needs of doctors with advanced cancer could be assumed to be the same as other patients. However, the juxtaposition of role from professional to patient appears to evoke unique care needs from the patient, and behaviour responses from the professional. Forewarning and awareness of these issues may help prevent potential problems in this patient group's cancer journey as well as the experience of the professionals involved in their management.
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Affiliation(s)
- S I R Noble
- Department of Palliative Medicine, Cardiff University and Royal Gwent Hospital, Wales.
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Noble SIR, Hood K, Finlay IG. The use of long-term low-molecular weight heparin for the treatment of venous thromboembolism in palliative care patients with advanced cancer: a case series of sixty two patients. Palliat Med 2007; 21:473-6. [PMID: 17846086 DOI: 10.1177/0269216307080816] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The advantages of low-molecular weight heparin (LMWH) over warfarin, in the treatment of cancer associated venous thromboembolism (VTE) are well reported. However the studies supporting LMWH include few patients representative of the palliative care population. Although LMWH has advantages over warfarin it is still unclear, within the palliative care environment, how long anticoagulation should be continued, what dose of LMWH should be used and whether palliative care patients experience different complication rates such as bleeding, heparin-induced thrombocytopenia and osteoporosis. We report a case series of 62 patients with advanced malignancy and VTE treated with long-term LMWH according to either the CLOT (full dose) or Montreal (reduced dose) regime. Seventy-four percent of patients self-administered LMWH, whereas 24% had it given by a carer and 2% by the district nurse. LMWH was given for median duration of 97 days; the most common reason for discontinuation of therapy being admission to die or commencement of the care pathway (n = 50, 81%). A further 11% (n = 7) stopped after 6 months of treatment. Of these 3 (43%) developed clinical symptomatic recurrence of VTE. The overall minor bleeding rate was 8.1% (95% confidence interval 3.5-17.5%), and this was not associated with NSAID or steroid use. No major bleeding events were observed. No patients developed evidence of heparin-induced thrombocytopenia or osteoporosis.Long-term LMWH appears effective in treatment of VTE in the palliative care population with advanced cancer. A randomised control trial is required to identify the best dose required to ensure optimum efficacy and safety.
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Affiliation(s)
- S I R Noble
- Palliative Medicine, Cardiff University, Cardiff and Royal Gwent Hospital, Newport, UK.
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Abstract
OBJECTIVE Restorative proctocolectomy (RP) involves terminal ileal resection and formation of a small bowel reservoir that predisposes to bacterial overgrowth. It was anticipated that these patients would be at risk of vitamin B12 deficiency. METHOD Vitamin B12 levels were measured sequentially in 171 patients who underwent RP. Prospective results were obtained from all 20 patients undergoing pouch formation after the commencement of the study. Further results were obtained retrospectively from case notes and computerized laboratory records of the 151 patients who underwent RP prior to the commencement of the study and these were correlated with the results of follow-up samples taken prospectively from the same patients after the commencement of the study. The median age of the patients was 40 years (range: 13-67) and the median duration of follow up was 5.4 years (range: 1-12). Patients with an abnormally low serum B12 level underwent both a Schilling and a hydrogen breath test. Eight of these patients were then treated with oral vitamin B12. RESULTS Abnormally low serum B12 levels were found in 25% of patients. Forty per cent of our patient group had three or more sequential B12 measurements and of these, 66% showed steadily declining B12 levels. Ninety-four per cent of patients with low B12 had a normal Schilling test and were negative for bacterial overgrowth. CONCLUSION Subnormal vitamin B12 levels develop in almost one-quarter of patients after pouch surgery. The exact mechanism for B12 deficiency in these patients is uncertain. In the majority of patients undergoing RP, vitamin B12 levels fall on sequential measurement. Serum B12 levels should be measured during follow up and pouch patients with subnormal B12 levels, should see them successfully restored to a normal value after treatment with oral B12 replacement therapy.
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Affiliation(s)
- D B Coull
- Department of Coloproctology, Lister Surgical Unit, Glasgow Royal Infirmary, Glasgow, UK.
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Coull DB, Lee FD, Anderson JH, McKee RF, Finlay IG, Dunlop MG. Long-term cancer risk of the anorectal cuff following restorative proctocolectomy assessed by p53 expression and cuff dysplasia. Colorectal Dis 2007; 9:321-7. [PMID: 17432983 DOI: 10.1111/j.1463-1318.2006.01118.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Restorative proctocolectomy (RP) for ulcerative colitis (UC) retains a 'cuff' of columnar rectal epithelium that has unknown risk of malignant change. Markers of malignant potential in UC include aberrant p53 expression and dysplasia. We undertook a prospective study comprising serial surveillance biopsy and assessed the occurrence of aberrant p53 expression, epithelial dysplasia and carcinoma in the retained anorectal cuff following stapled RP. METHOD A total of 110 patients who underwent stapled RP for UC between 1988 and 1998 were followed up by cuff surveillance biopsies under general anaesthesia. Histological samples were analysed by a specialist colorectal pathologist for the presence of rectal mucosa, dysplasia and carcinoma. Immunohistochemistry for p53 expression was performed for each most recent cuff biopsy. Median follow-up was 56 months (12-145) and median time since diagnosis of UC was 8.8 years (2-32). RESULTS Rectal mucosa was obtained from the cuff in 65% of biopsies. No overt carcinomas developed during the follow-up period and there was no dysplasia or carcinoma in any cuff biopsy. The p53 overexpression was identified in 38 specimens (50.6%), but was also identified in controls (3/3 colitis, 3/3 ileal pouch and 6/6 stapled haemorrhoidectomy donuts). CONCLUSION The lack of carcinoma and dysplasia in the columnar cuff epithelium specimens is reassuring. The lack of stabilized p53 and absence of a relationship between p53 stabilization and dysplasia up to 12 years after pouch formation suggests neoplastic transformation is a rare event. Furthermore, p53 expression was not useful in surveillance of cuff biopsies from patients who have undergone RP for UC and the search should continue for alternative predysplastic markers. These data suggest that in patients who do not have high-grade dysplasia or colorectal cancer at the time of RP, cuff surveillance in the first decade after pouch formation is unnecessary. However, we consider regular cuff surveillance biopsies should continue for patients with high-grade dysplasia, whether or not there was a carcinoma in the original colectomy specimen.
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Affiliation(s)
- D B Coull
- Department of Coloproctology, Glasgow Royal Infirmary, Glasgow, UK.
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Fowell A, Johnstone R, Finlay IG, Russell D, Russell IT. Design of trials with dying patients: a feasibility study of cluster randomisation versus randomised consent. Palliat Med 2006; 20:799-804. [PMID: 17148534 DOI: 10.1177/0269216306072554] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is little rigorous evidence to underpin clinical guidelines for palliative care. However, research in palliative care is difficult, especially with dying patients. Consent is a major issue, since staff do not wish to invite dying patients to participate in trials. We, therefore, conducted a feasibility study in two units within the North West Wales NHS Trust. We explored two novel approaches to research in palliative care -cluster randomisation and randomised consent. All patients admitted to the two units during the study were asked for permission to use their data for research. We allocated the two units, at random, to use cluster randomisation or randomised consent for three months, and then to crossover to the other design. Of 24 patients dying during cluster-randomised phases, 13 gave consent on admission to use their data and were, thus, eligible to enter the trial; however, defined eligibility criteria reduced these to six active participants. Of 29 patients dying during randomised consent phases, seven gave consent on admission to use their data; although two were eligible for randomisation, neither entered the trial. We judge that cluster randomisation is the more effective design for research with dying patients. Computer simulation, based on data from 1500 dying patients on the Welsh Integrated Care Pathway, shows that crossover cluster trials need much smaller samples than simple cluster trials. Furthermore, this study has shown that crossover cluster trials are entirely feasible. We recommend a 'definitive' trial to test the crossover design more widely.
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Affiliation(s)
- A Fowell
- North West Wales NHS Trust, Gwynedd, UK
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Abstract
OBJECTIVE To find out what inpatients with advanced cancer who are receiving palliative care think about the effect of thromoprophylaxis on overall quality of life. DESIGN Qualitative study using audiotaping of semistructured interviews. SETTING Regional cancer centre in Wales. PARTICIPANTS 28 inpatients with advanced metastatic cancer receiving palliative care and low molecular weight heparin. MAIN OUTCOME MEASURES Recurring themes on the effect of thromboprophylaxis on overall quality of life. RESULTS Major emerging themes showed that patients knew about the risks of venous thromboembolism and the purpose of treatment with heparin. Media coverage had raised awareness about venous thromboembolism, and many had previous experience of thromboprophylaxis. All found low molecular weight heparin an acceptable intervention, and many said that it improved their quality of life by giving them a feeling of safety and reassurance. Antiembolic stockings were considered uncomfortable and had a negative impact on quality of life. Patients were concerned that because they had advanced disease they might not be eligible for thromboprophylaxis. CONCLUSION Low molecular weight heparin is acceptable to inpatients with advanced cancer receiving palliative care and has a positive impact on overall quality of life. Antiembolic stockings are an unacceptable intervention in this patient group. Guidelines on thromboprophylaxis are urgently needed for palliative care inpatient units and hospices.
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MacDonald A, Baxter JN, Bessent RG, Gray HW, Finlay IG. Gastric emptying in patients with constipation following childbirth and due to idiopathic slow transit. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02741.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Finlay IG. Colon and Rectal Surgery. 3rd ed. M. L. Corman (ed.). 260 × 207 mm. Pp. 1328. Illustrated. 1992. Philadelphia, Pennsylvania: J. B. Lippincott. £175. Br J Surg 2005. [DOI: 10.1002/bjs.1800800764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- I G Finlay
- Glasgow Royal Infirmary, Glasgow G4 0SF, UK
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Brown AJ, Nicol L, Anderson JH, McKee RF, Finlay IG. Prospective study of the effect of rectopexy on colonic motility in patients with rectal prolapse. Br J Surg 2005; 92:1417-22. [PMID: 16187266 DOI: 10.1002/bjs.4990] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients with rectal prolapse have abnormal hindgut motility. This study examined the effect of rectal prolapse surgery on colonic motility. METHODS Twelve patients undergoing sutured rectopexy were studied before and 6 months after surgery by colonic manometry, colonic transit study and clinical assessment of bowel function. The results were compared with those from seven control subjects. RESULTS Before surgery colonic pressure was greater in patients than controls (P < 0.050). Controls responded to a meal stimulus by increasing colonic pressure; this increase was absent in patients. After rectopexy, colonic pressure reduced towards control values and patients' colonic pressure response to a meal returned. High-amplitude propagated contractions (HAPCs) were seen in all controls but in only three patients before and two patients after surgery. Three patients had prolonged colonic transit before and eight after rectopexy. CONCLUSION Patients with rectal prolapse have abnormal colonic motility associated with reduced HAPC activity. Rectopexy reduces colonic pressure but fails to restore HAPCs, reduce constipation or improve colonic transit. These observations help explain the pathophysiology of constipation associated with rectal prolapse.
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Affiliation(s)
- A J Brown
- Department of Coloproctology, Lister Surgical Unit, Glasgow Royal Infirmary, 16 Alexandra Parade, Glasgow G31 2ER, UK
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23
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Abstract
Doctors in the United Kingdom can accompany their patients every step of the way, up until the last. The law stops them helping their patients take the final step, even if that is the patient's fervent wish. Next month's debate in the House of Lords could begin the process of changing the law. To help doctors decide where they stand we publish a range of opinions
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Affiliation(s)
- R J D George
- Centre for Bioethics and Philosophy of Medicine, University College London UB1 3HW.
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Finlay IG, Wheatley VJ, Izdebski C. The House of Lords Select Committee on the Assisted Dying for the Terminally III Bill: implications for specialist palliative care. Palliat Med 2005; 19:444-53. [PMID: 16218156 DOI: 10.1191/0269216305pm1062oa] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Assisted Dying for the Terminally III Bill proposed to legalise both euthanasia and physician-assisted suicide for those with a terminal illness in the UK. A House of Lords Select Committee was convened to scrutinise this Bill and has recently published its report, which will be debated in Parliament on October 10th 2005. The written and oral evidence submitted to the Select Committee represented a wide range of views on 'assisted dying'. Much of the evidence from those countries which have legalised euthanasia/physician-assisted suicide (The Netherlands, Belgium, Switzerland and Oregon, USA) dealt with the practicalities of ending life, and the legal procedures and safeguards instigated in these countries. All the written and oral evidence in the public domain was scrutinised by the authors whilst the Select Committee was sitting. We have extracted those themes relevant to specialist palliative care practice and present them in this paper. We hope that this will provide a useful resource to inform the forthcoming public debate on assisted dying. The evidence of harms inherent in making such a change in the law, as presented to the Select Committee, has moved all three authors to oppose a change in the law.
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Affiliation(s)
- I G Finlay
- Department of Palliative Medicine, Velindre Hospital NHS Trust, Whitchurch, Cardiff CF14 2TL, UK
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25
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Poon FW, McDonald A, Anderson JH, Duthie F, Rodger C, McCurrach G, McKee RF, Horgan PG, Foulis AK, Chong D, Finlay IG. Accuracy of thin section magnetic resonance using phased-array pelvic coil in predicting the T-staging of rectal cancer. Eur J Radiol 2005; 53:256-62. [PMID: 15664289 DOI: 10.1016/j.ejrad.2004.03.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2003] [Revised: 03/11/2004] [Accepted: 03/15/2004] [Indexed: 12/26/2022]
Abstract
Magnetic resonance (MR) imaging may contribute to staging rectal cancer and inform the decision regarding administration of pre-operative radiotherapy. The accuracy of MR has been debated. The aim of the present study was to determine the accuracy of thin section T2-weighted MR images in rectal cancer patients. MR results were compared with histological assessment of resection specimens. Over a 2-year period, 42 patients were studied. Histological staging was pT2 n = 13, pT3 n = 25 and pT4 n = 4. MR diagnostic accuracy was 74%. MR sensitivity and specificity was 62% and 79% for pT2 lesions, 84% and 59% for pT3 lesions and 50% and 76% for pT4 lesions. Estimation of tumour penetration by thin section MR imaging of rectal cancers using pelvic phased-array coil has moderate diagnostic accuracy. The limitations of MR should be acknowledged when selecting rectal cancer patients for pre-operative radiotherapy.
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Affiliation(s)
- F W Poon
- Department of Radiology, Royal Infirmary, Alexandra Parade, Glasgow, Scotland, UK.
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26
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Abstract
Abstract
Background
Recent reports based on registry data have shown that survival after surgery for colorectal cancer is improving in the UK. It is not clear whether these improvements are due to earlier presentation or more effective treatment.
Methods
Outcome for 645 patients with colorectal cancer admitted to Glasgow Royal Infirmary between 1974 and 1979 was compared with that for 354 patients admitted between 1991 and 1994.
Results
More patients in the later period had Dukes' A or B tumours and fewer had evidence of metastatic spread (P < 0·001); more underwent potentially curative resection (57·6 versus 49·9 per cent; P < 0·001) and fewer underwent palliative diversion. The overall postoperative mortality rate fell from 14·1 to 8·5 per cent (P = 0·017). Overall and cancer-specific 5-year survival after potentially curative resection increased from 40·1 to 60·5 per cent and from 47·3 to 71·7 per cent respectively (both P < 0·001). Compared with the earlier period, the adjusted hazard ratio for cancer-specific survival following potentially curative resection was 0·452 (95 per cent confidence interval 0·329 to 0·622; P < 0·001).
Conclusion
The observed improvement in survival was mainly due to improvements in the quality of surgery and in perioperative care rather than earlier presentation.
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Affiliation(s)
- C S McArdle
- University Department of Surgery, Royal Infirmary, University of Glasgow, Glasgow, UK.
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27
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Noble SIR, Finlay IG. Is long-term low-molecular-weight heparin acceptable to palliative care patients in the treatment of cancer related venous thromboembolism? A qualitative study. Palliat Med 2005; 19:197-201. [PMID: 15920933 DOI: 10.1191/0269216305pm1008oa] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Venous thromboembolism (VTE) is common in patients with terminal cancer. Current treatment practice with warfarin has a high incidence of complications, including bleeding, poor control and recurrent VTE. Long-term low-molecular-weight heparin (LMWH) therapy is safer and more efficacious in this patient group, but there are concerns that daily therapy may have a negative impact on quality of life. A qualitative study was carried out to determine whether LMWH was acceptable in palliative care patients, both in the community and in-patient units. Forty palliative care patients receiving LMWH for VTE were interviewed. Participants found LMWH to be an acceptable intervention, allowing them freedom from blood tests and optimism regarding their care. It was considered a preferable therapy to warfarin, which had a negative impact on participant's quality of life. The findings of this study support the use of LMWH, first line in the treatment of established VTE in the palliative care setting.
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Affiliation(s)
- Simon I R Noble
- Department of Palliative Medicine, Velindre Hospital, Whitchurch, Cardiff, UK.
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Lua PL, Salek MS, Finlay IG, Boay AGI, Rahimah MS. The feasibility, reliability and validity of the Malay McGill Quality of Life Questionnaire--Cardiff Short Form (MMQOL-CSF) in Malaysian advanced cancer population. Med J Malaysia 2005; 60:28-40. [PMID: 16250277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Health-related quality of life (HRQoL) assessment is important in healthcare outcomes. This study aimed to determine the feasibility, reliability and validity of the Malay McGill Quality of Life Questionnaire--Cardiff Short Form (MMQOL-CSF) in advanced cancer population. Patients either completed the MMQOL-CSF alone or in addition to its long version. The study recruited 116 participants (average age = 44 years old). On average, MMQOL-CSF was completed in 5.4 minutes. Most domains showed evidence of reliability (Cronbach's alpha = 0.76-0.92). Correlation with its long version was moderate to strong (r(s) = 0.54-0.87). The MMQOL-CSF was a feasible, reliable and valid HRQoL instrument in this population.
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Affiliation(s)
- P L Lua
- Psychology and Social Health Research Unit, Universiti Malaysia Sabah, Locked Bag 2073, 88999 Kota Kinabalu, Sabah
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29
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Abstract
Abstract
Background
A novel prosthetic anal sphincter (PAS) has been developed that aims to occlude by flattening and angulating the bowel, reproducing the action of the puborectalis muscle. The safety of the PAS has been confirmed in biomechanical, in vitro and long-term animal survival studies. The Medical Devices Agency approved implantation in 12 patients.
Methods
The PAS was placed in the pelvis around the anorectal junction via a transabdominal approach in 12 patients with severe faecal incontinence. The device was activated 6 weeks after surgery. Fibreoptic examination of the mucosa below the device was undertaken at various intervals during review.
Results
At a median follow-up of 59 (range 30–72) months nine of the 12 patients had a functioning PAS. There were no device-related infective complications after the initial operation but one patient developed pseudomembranous colitis and had the device removed. The PAS was effective in restoring continence in ten of 11 patients. Median (range) Cleveland Clinic continence scores improved from 16 (7–20) before to 3 (0–7) after surgery. In two patients the PAS was eventually removed owing to infection after revisional surgery. There was no clinical or histological evidence of gastrointestinal mucosal ischaemia.
Conclusion
The PAS was effective in restoring continence. There was no device-related infection after the initial operation, no device erosion and no clinical or histological evidence of gastrointestinal ischaemia.
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Affiliation(s)
- I G Finlay
- Department of Coloproctology, Lister Surgical Unit, Glasgow Royal Infirmary, Glasgow, UK.
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30
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Abstract
OBJECTIVE An 'occult' rectal prolapse may be diagnosed during investigation of altered bowel habit. It has been suggested that the outcome of surgery for these patients may be associated with results that are inferior to those achieved in patients with overt rectal prolapse. This study compares the results of surgery for 'occult' and overt rectal prolapse in terms of mortality, morbidity and change in bowel habit. PATIENTS AND METHODS A retrospective review was undertaken of consecutive patients undergoing surgery for rectal prolapse during the decade 1988-98. Resection rectopexy was the treatment of choice except in patients with faecal incontinence who underwent sutured rectopexy. Those patients who were unfit for an abdominal operation were offered a perineal procedure. Outcome measures were mortality, morbidity, prolapse recurrence, constipation and faecal incontinence. Data were retrieved from case note review, clinical assessment, telephone consultation or postal questionnaire. RESULTS Rectal prolapse surgery was undertaken in 69 patients with an overt prolapse and 74 patients with an 'occult' prolapse. Patients in the 'occult' prolapse group were significantly younger than those with overt prolapse (P = 0.0002). There were significantly more perineal procedures in the overt prolapse group compared with the 'occult' prolapse group (54% vs 5%, P = 0.0001). There were no deaths within 28 days of surgery. Major surgical complications occurred in 5 patients (3.5%). Seven patients (10%) experienced recurrent prolapse. Rectal prolapse surgery reduced the incidence of St. Mark's grade 4 faecal incontinence from 38% to 19% in the overt prolapse group (P = 0.023) and from 49% to 22% in the 'occult' prolapse group (P < 0.001). Following surgery the incidence of constipation increased in the 'occult' group from 39% to 50% but decreased in the overt prolapse group from 42% to 35%. CONCLUSIONS Surgery for an 'occult' rectal prolapse is unlikely to benefit patients whose principle symptom is constipation. Approximately half of those patients whose 'occult' rectal prolapse is associated with faecal incontinence will have their bowel habit improved by prolapse surgery.
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Affiliation(s)
- A J Brown
- Department of Coloproctology, The Royal Infirmary, Glasgow, UK.
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31
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Abstract
PURPOSE Reports of outcome after surgery for rectal prolapse predominantly relate to single operative procedures. A single surgical operation is not appropriate for all patients with rectal prolapse. We describe a selective policy based on clinical criteria. METHODS Patients were offered surgery according to the following broad clinical protocol. Those who were unfit for abdominal surgery had a perineal operation. The remainder had a suture abdominal rectopexy. A sigmoid resection was added for patients in whom incontinence was not a predominant symptom. RESULTS Surgery was performed in 159 patients. Of these, 57 had a perineal operation, 65 had fixation rectopexy, and 37 had resection rectopexy. There were no in-hospital deaths, and major complications occurred in five patients (3.5 percent). Minimum follow-up was 3 years. Of the 143 patients with long-term follow-up, recurrence occurred in 7 (5 percent). Constipation increased from 41 to 43 percent (59-61/143) and incontinence decreased from 43 to 19 percent (61 to 27/143). CONCLUSIONS A selective policy has improved outcome compared with reports of a single operation. Future studies might consider an objective method of selecting the type of operation for rectal prolapse.
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Affiliation(s)
- A J Brown
- Department of Coloproctology, Glasgow Royal Infirmary, Glasgow, UK.
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32
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Abstract
Abstract
Background
Damage Control Surgery (DCS) is well established in the management of trauma. This study assessed the results of DCS in the management of critically ill patients who had not had trauma.
Methods
This was a prospective series of patients treated by DCS. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth predictor equation (P-POSSUM) were used to predict the risk of death, which was compared with the observed mortality rate.
Results
Fourteen patients were studied. Nine had sepsis from gastrointestinal perforation. Eight of these underwent bowel resection without anastomosis or stoma formation at the initial laparotomy. Six patients later underwent bowel anastomosis and two had an end stoma formed at second laparotomy. A further three patients had a ruptured aortic aneurysm, one had a reactionary haemorrhage after elective aortic surgery, and one had a retroperitoneal bleed; all required haemostatic packing that was removed at second laparotomy. Mortality rates predicted by POSSUM and P-POSSUM scoring were 64·5 and 49·6 per cent respectively. One patient (7·1 per cent) died after operation, giving an observed mortality rate significantly lower than predicted (P = 0·002 and P = 0·038 versus values predicted by POSSUM and P-POSSUM, respectively).
Conclusion
The use of DCS in the treatment of critically ill patients resulted in a lower mortality rate than that predicted by POSSUM or P-POSSUM. DCS should not be restricted to trauma.
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Affiliation(s)
- I G Finlay
- Department of General Surgery and Ministry of Defence Hospital Unit, Derriford Hospital, Plymouth, UK
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33
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34
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Finlay IG, Higginson IJ, Goodwin DM, Cook AM, Edwards AGK, Hood K, Douglas HR, Normand CE. Palliative care in hospital, hospice, at home: results from a systematic review. Ann Oncol 2003; 13 Suppl 4:257-64. [PMID: 12401699 DOI: 10.1093/annonc/mdf668] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- I G Finlay
- University of Wales College of Medicine, Velindre NHS Trust, Velindre Hospital, Cardiff, UK
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35
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36
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Coull DB, Lee FD, Henderson AP, Anderson JH, McKee RF, Finlay IG. Risk of dysplasia in the columnar cuff after stapled restorative proctocolectomy. Br J Surg 2003; 90:72-5. [PMID: 12520578 DOI: 10.1002/bjs.4007] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stapled restorative proctocolectomy (SRP) for ulcerative colitis retains a 'cuff' of columnar epithelium, which carries a risk of undergoing malignant change. The risk of neoplastic transformation was studied in a series of patients who underwent SRP for ulcerative colitis. METHODS One hundred and thirty-five patients who underwent SRP for ulcerative colitis between 1988 and 1998 were followed up by cuff surveillance biopsy. The median follow-up was 56 (range 12-145) months and the median time since diagnosis of ulcerative colitis was 8.8 (range 2-32) years. RESULTS The cuff biopsies showed no dysplasia or carcinoma. The accuracy of obtaining cuff mucosa in the biopsy was 65 per cent. Chronic inflammation was present in 94 per cent of cuff biopsies. CONCLUSION This study shows no evidence of either dysplasia or carcinoma in the columnar cuff mucosa, up to 12 years after pouch formation. This suggests that cuff surveillance in the first decade after SRP, in the absence of dysplasia or carcinoma in the original colectomy specimen, may be unnecessary. Regular cuff surveillance biopsies after SRP should continue for patients with high-grade dysplasia or carcinoma in the original resection specimen.
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Affiliation(s)
- D B Coull
- Department of Coloproctology, Glasgow Royal Infirmary, Glasgow G31 2ER, UK.
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37
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38
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Affiliation(s)
- A M Cook
- Velindre NHS Trust and Holme Tower, Marie Curie Centre, Cardiff
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39
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Abstract
BACKGROUND Several surgical procedures have been used to treat idiopathic megabowel. A structured approach to the surgical management of megarectum/colon is reported. METHODS Twenty-eight consecutive patients with megabowel referred for surgery were reviewed. All patients had conservative treatment for 6 months. Those failing to improve underwent full-thickness biopsy of the anorectal junction, anorectal physiology studies, colonic transit studies and evacuation proctography. Surgery involved excision of the abnormal large bowel and formation of an anastomosis (coloanal or ileoanal) using 'normal' bowel identified either by a defunctioning stoma or colonic motility studies. RESULTS Eight patients responded to conservative management. Two patients were lost to follow-up and one died from unrelated causes. Two of the 17 patients who underwent full-thickness biopsy were cured by the procedure. Anorectal physiology, colonic transit and evacuation studies did not aid selection of the surgical procedure performed in 15 patients: proctectomy and coloanal anastomosis (six), restorative proctocolectomy (three), panproctocolectomy (one) and defunctioning stoma (five). At a median follow-up of 3.6 years, 13 of 15 evaluable patients had a satisfactory outcome. CONCLUSION Approximately 40 per cent of patients with megabowel referred for surgery responded to conservative treatment. The remaining patients may be treated successfully by surgery. The use of either a 'diagnostic' defunctioning stoma or colonic motility studies may aid in the choice of surgical procedure.
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40
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Abstract
A systematic review into palliative care team effectiveness was undertaken which has, inherent in its methodology, grey literature searching. Over 100 letters were written to a systematically chosen range of service providers, commissioners, and experts in combination with requests for information in six UK national cancer/palliative care organization newsletters. In addition, the System for Information on Grey Literature (SIGLE ) database was searched. As a result, 25 document hard copies were received. The documents were, in all but one case (this one study was also highlighted by the SIGLE search), not relevant as they were predominated by annual reports, service descriptions, and needs assessments. In terms of obtaining unpublished studies for possible inclusion in the review, this comprehensive search was unsuccessful and, therefore, it would appear that grey literature searching is not a useful tool in palliative care systematic reviews.
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Affiliation(s)
- A M Cook
- Velindre NHS Trust, Holme Tower Marie Curie Centre, Cardiff, United Kingdom
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41
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Finlay IG, Stewart GJ, Shirley P, Woolfe S, Pourgholami MH, Morris DL. Hepatic arterial and intravenous administration of 1,25-dihydroxyvitamin D3--evidence of a clinically significant hepatic first-pass effect. Cancer Chemother Pharmacol 2001; 48:209-14. [PMID: 11592342 DOI: 10.1007/s002800100333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE We have previously shown that 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] inhibits the proliferation of a number of human cancers, including colorectal and hepatocellular carcinoma, both of which affect the liver and are major causes of cancer death. However, the clinical use of 1,25(OH)2D3 and analogues has been restricted by the development of hypercalcaemia upon systemic administration. We hypothesized that a clinically significant hepatic first-pass effect may exist upon the administration of 1,25(OH)2D3 as a hepatic arterial infusion, and that such an effect may allow high levels of 1,25(OH)2D3 to be delivered to the liver whilst avoiding high systemic levels. METHODS To examine this hypothesis, two groups of Landrace pigs were given identical doses of 1,25(OH)2D3 as continuous infusions, one group systemically, the other as a hepatic arterial infusion. Serum levels of 1,25(OH)2D3, calcium, phosphate and a number of liver and kidney function tests were performed regularly. RESULTS Concentrations of 1,25(OH)2D3 and calcium remained normal in the hepatic arterial infusion animals, in contrast to the intravenous infusion animals which developed elevated levels of 1,25(OH)2D3 and hypercalcaemia. Hepatic arterial infusion of 1,25(OH)2D3 did not produce any adverse effects upon renal or hepatic function. CONCLUSION The present findings support the existence of a clinically significant hepatic first-pass effect when 1,25(OH)2D3 is administered as a continuous hepatic arterial infusion. Hepatic arterial infusion of 1,25(OH)2D3 has great potential in the treatment of hepatic cancers.
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Affiliation(s)
- I G Finlay
- University of New South Wales, Department of Surgery, St George Hospital, Kogarah, Sydney, Australia
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42
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Finlay IG, King P, Cawthorn SJ. A new technique for local anaesthesia in breast surgery. Ann R Coll Surg Engl 2001; 83:362-3. [PMID: 11806569 PMCID: PMC2503403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Affiliation(s)
- I G Finlay
- Breast Care Centre, Frenchay Hospital, Bristol, UK.
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43
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Saghir JH, McKenzie FD, Leckie DM, McCourtney JS, Finlay IG, McKee RF, Anderson JH. Factors that predict complications after construction of a stoma: a retrospective study. Eur J Surg 2001; 167:531-4. [PMID: 11560389 DOI: 10.1080/110241501316914911] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To find out our incidence of complications of stoma surgery and identify variables that predict outcome. DESIGN Retrospective study. SETTING Teaching hospital, Scotland. SUBJECTS All 121 patients who had 126 stomas constructed during 1996. INTERVENTIONS Follow up until the end of 1999. MAIN OUTCOME MEASURES Morbidity and mortality. RESULTS There were 64 men and 57 women, median age 58 years, range 16-83. Forty-three stomas were constructed for malignancy (34%). Forty-two stomas were raised during emergency operations (33%). Colorectal surgeons created 96 stomas (76%). Sixty-one of 92 potentially reversible stomas were closed (66%). Two patients died (2%) perioperatively. Overall stoma-related morbidity was 68% (n = 85). The rate of major stoma-related complications was 26% (n = 33). Nine major complications resulted in a reoperation rate of 7%. On univariate analysis, age, American Society of Anesthesiologists (ASA) grade, and surgeon's speciality were significant predictive variables of major stomal complications (p < or = 0.002, 0.02, and 0.05 respectively). Multivariate analysis showed that the age of the patient was the only factor that independently influenced the outcome of stoma surgery (p < or = 0.001). CONCLUSIONS Optimising the perioperative health status of the patients, particularly the elderly, may reduce morbidity. The results also support specialist surgical care of patients undergoing stomal surgery.
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Affiliation(s)
- J H Saghir
- Directorate of Surgery, Monklands Hospital, Airdrie, UK
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44
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Abstract
A model of undergraduate education based on a one to one relationship between a student and a patient with cancer has become a core module within the University of Wales College of Medicine undergraduate curriculum. The project combines the powerful impact of a one to one interaction with an active investigative and reflective approach to issues triggered from that patient's cancer journey. The aim is to provide each medical student with an understanding of the impact of a malignant disease and its treatment on patients and their families through the experience of one patient with cancer. The benefits of the project cover the areas of attitudes, skills and knowledge. Students are assessed on their involvement with the patient, in tutorials and on their portfolio, in which they record all aspects of the project. Student evaluations indicate high levels of appreciation of the project, despite its potentially strong emotional content.
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45
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Súilleabháin CB, Horgan AF, McEnroe L, Poon FW, Anderson JH, Finlay IG, McKee RF. The relationship of pudendal nerve terminal motor latency to squeeze pressure in patients with idiopathic fecal incontinence. Dis Colon Rectum 2001; 44:666-71. [PMID: 11357026 DOI: 10.1007/bf02234563] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE With the advent of transanal ultrasonography it has been possible to identify those incontinent patients without sphincter defects. The majority of these patients are now thought to have neurogenic fecal incontinence secondary to pudendal neuropathy. They have been found to have reduced anal sphincter pressures and increased pudendal nerve terminal motor latencies. The aim of this study was to determine whether in those incontinent patients who do not have a sphincter defect, prolonged pudendal nerve terminal motor latency correlates with anal manometry, in particular maximum squeeze pressure. METHODS Sixty-six incontinent patients were studied with transanal ultrasonography, anorectal manometry, and pudendal nerve terminal motor latency. Twenty-seven continent controls had anorectal manometry and pudendal nerve terminal motor latency measured. RESULTS Maximum resting pressure and maximum squeeze pressure were significantly lower in the group of incontinent patients with bilateral prolonged pudendal nerve terminal motor latency (median maximum resting pressure = 26.5 mmHg; median maximum squeeze pressure = 60 mmHg) when compared with incontinent patients with normal bilateral pudendal nerve terminal motor latencies (median maximum resting pressure = 46 mmHg; median maximum squeeze pressure = 79 mmHg; maximum resting pressure P = 0.004; and maximum squeeze pressure P = 0.04). In incontinent patients with no sphincter defects no correlation between pudendal nerve terminal motor latency and maximum squeeze pressure was found (r = -0.109, P = 0.48) and maximum squeeze pressure did not correlate with bilateral or unilateral prolonged pudendal nerve terminal motor latency (r = -0.148, P = 0.56 and r = 0.355, P = 0.19 respectively). CONCLUSIONS In patients with idiopathic fecal incontinence damage to the pelvic floor is more complex than damage to the pudendal nerve alone. Although increased pudendal nerve terminal motor latency may indicate that neuropathy is present, in patients with neuropathic fecal incontinence, pudendal nerve terminal motor latency does not correlate with maximum squeeze pressure. Normal pudendal nerve terminal motor latency does not exclude weakness of the pelvic floor.
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Affiliation(s)
- C B Súilleabháin
- Departments of Coloproctology and Radiology, Glasgow Royal Infirmary, Glasgow, United Kingdom
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46
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Wilson MJ, Williams DW, Forbes MD, Finlay IG, Lewis MA. A molecular epidemiological study of sequential oral isolates of Candida albicans from terminally ill patients. J Oral Pathol Med 2001; 30:206-12. [PMID: 11302239 DOI: 10.1034/j.1600-0714.2001.300403.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The pattern of candidal colonisation was studied in a group of terminally ill patients receiving antifungal treatment for oral candidosis. A total of 43 isolates of C. albicans was collected pre- and post-antifungal treatment from patients up to a maximum period of 4 weeks. Isolates were analysed by electrophoretic karyotyping (EK) and by inter-repeat polymerase chain reaction (IR-PCR). Fifteen electrophoretic karyotypes and 17 IR-PCR profiles were identified. Sequential isolates from 10 patients yielded identical profiles in both EKs and IR-PCR analyses. In the case of four patients, minor differences in the profiles were obtained by either EK or IR-PCR. The findings suggest that antifungal treatment in this patient group fails to eradicate the original C. albicans strain, thereby allowing recolonisation of the oral cavity. The present study has also shown that either EK or IR-PCR is a useful typing approach in such epidemiological investigations.
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Affiliation(s)
- M J Wilson
- Department of Oral Surgery, Medicine and Pathology, Dental School, University of Wales College of Medicine, Cardiff, UK
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Abstract
BACKGROUND AND AIMS It is well established that exposure to 1,25-dihydroxyvitamin D3 (1,25(OH)2D3) inhibits the proliferation of human colorectal cancer and hepatoma cell lines, both in vitro and in vivo. However, clinical trials of the administration of 1,25(OH)2D3 and analogs for the treatment of malignancy have been limited by the development of hypercalcemia. 1,25-dihydroxyvitamin D3 is principally excreted in bile following hepatic catabolism. This suggested the hypothesis that hepatic regional administration may allow high doses of 1,25(OH)2D3 to be administered for the treatment of liver cancers without producing hypercalcemia, caused by a clinically significant first pass effect. This phase one study investigates the effect of hepatic regional administration of 1,25(OH)2D3 on serum calcium levels, together with other markers of renal and liver function. METHODS Six subjects with hepatic colorectal cancer metastases and one with primary hepatocellular cancer were given continuous hepatic arterial infusions of 1,25(OH)2D3, for periods of 1-4 weeks. Blood samples were taken regularly and assayed for calcium levels, liver function tests and urea and electrolyte levels. RESULTS Patients remained normocalcemic at dosages of up to 10 mcg/day. No patient experienced any side-effects from the treatment. CONCLUSIONS Administration of 1,25(OH)2D3 as a continuous hepatic arterial infusion allows a high dosage to be administered without inducing hypercalcemia. This route of administration may allow the potential of 1,25(OH)2D3 in the treatment of hepatic cancers to be realized.
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Affiliation(s)
- I G Finlay
- University of New South Wales, Department of Surgery, St George Hospital, Sydney, Australia
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Affiliation(s)
- IG Finlay
- Department of General Surgery; The Freeman Hospital; High Heaton; Newcastle upon Tyne NE7 7DN; UK
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Abstract
INTRODUCTION Gastric emptying is delayed in patients with idiopathic slow-transit constipation (ISTC). Gastric emptying was measured before and after colectomy and ileorectal anastomosis in patients with ISTC to determine whether the abnormality persists after operation. METHODS Twelve patients undergoing colectomy for severe ISTC had solid-phase gastric emptying measured after an overnight fast. All 12 had an uncomplicated subtotal colectomy and ileorectal anastomosis; 11 had an excellent functional outcome. In ten of these patients gastric emptying was repeated within 3 months of operation. Seven patients (including the remaining two) had the study performed at 1 year. RESULTS All 12 patients had severely delayed gastric emptying before operation. Gastric emptying remained delayed in the ten patients who underwent an early postoperative gastric emptying study. Six of seven patients assessed at 1 year had improved gastric emptying, of whom four had returned to normal. Functional outcome did not relate to gastric emptying. CONCLUSION Patients with ISTC have delayed gastric emptying. In some patients this returns to normal after colectomy, but is persistent in others. This may have implications for our understanding of ISTC.
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Affiliation(s)
- D M Hemingway
- Department of Coloproctology, Glasgow Royal Infirmary, Glasgow, UK
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Abstract
A workload study of consultants in palliative medicine was carried out, in which a task inventory questionnaire was sent to the consultant members of the Association for Palliative Medicine of Great Britain and Ireland. The median number of hours per week worked by a palliative medicine consultant was 49.5 (mean 51.3), excluding time on-call and breaks. The median consultant first on-call roat is 1:3. Palliative medicine consultants work a median of 22.5 direct clinical and 4.5 indirect clinical hours per week. This is very similar to the hours worked by consultants in other specialties who work an average 51.3 h per week, but with a median on-call rota of 1:6. Further studies are planned to monitor the patterns of consultant activity and workload in this specialty.
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Affiliation(s)
- W Makin
- Department of Clinical Oncology, Christie Hospital, Manchester, UK
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