Revolution in UK General Practice Due to COVID-19 Pandemic: A Cross-Sectional Survey

Objectives To assess how UK General Practitioners (GPs) and Practice Managers (PMs) have coped with the challenges posed by the coronavirus disease-19 (COVID-19) pandemic and whether they felt adequately supported by the wider National Health Service (NHS). Methods This is a cross-sectional survey. All GPs and PMs (total 1,354) in Leicester, Leicestershire, and Rutland (LLR) were invited to participate in an online questionnaire. Results A total of 95 invitees completed the survey. Over a quarter had required time off work due to COVID symptoms or contact. All respondents described either introducing or increasing the use of remote patient consultations. Most striking was the rise in video consultations from just 3% to 95% during the pandemic. Almost half of the feedback on the usefulness of remote consultations were positive, 16% were negative and 17% were mixed. The most commonly cited benefit was time efficiency. Drawbacks of remote consultations included technical difficulties and poor patient communication. Practice premises, systems and processes also required significant modifications during the pandemic to ensure the provision of safe clinical care, including reception screens, one-way patient flow, greater infection prevention measures. However, despite their ability to introduce such widescale change virtually overnight, over 10% of respondents reported that the strain had placed their practice at risk of closure. Over half of respondents felt they were not provided with adequate personal protective equipment (PPE) for the safety of their staff. Perception of the support provided by NHS England and the Clinical Commissioning Groups (CCGs) was rather mixed, although additional guidelines were broadly welcomed. The most requested enduring changes related to remote patient consultations (59%) and remote triage (19%). However, in order to support such largescale permanent change, study respondents felt that a different funding and financial structure is required together with improved IT infrastructure, greater patient education and a more supportive regulatory environment. Conclusions COVID-19 has substantially accelerated the pace of change within NHS primary care. The long-term fear is that there may be insufficient financial and clinical backing from regulatory bodies to support such rapid and far-reaching changes.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

ChatGPT in Plastic and Reconstructive Surgery

Background  Chat Generative Pre-Trained Transformer (ChatGPT) is a versatile large language model-based generative artificial intelligence. It is proficient in a variety of tasks from drafting emails to coding to composing music to passing medical licensing exams. While the potential role of ChatGPT in plastic surgery is promising, evidence-based research is needed to guide its implementation in practice. Methods  This review aims to summarize the literature surrounding ChatGPT's use in plastic surgery. Results  A literature search revealed several applications for ChatGPT in the field of plastic surgery, including the ability to create academic literature and to aid the production of research. However, the ethical implications of using such chatbots in scientific writing requires careful consideration. ChatGPT can also generate high-quality patient discharge summaries and operation notes within seconds, freeing up busy junior doctors to complete other tasks. However, currently clinical information must still be manually inputted, and clinicians must consider data privacy implications. Its use in aiding patient communication and education and training is also widely documented in the literature. However, questions have been raised over the accuracy of answers generated given that current versions of ChatGPT cannot access the most up-to-date sources. Conclusions  While one must be aware of its shortcomings, ChatGPT is a useful tool for plastic surgeons to improve productivity for a range of tasks from manuscript preparation to healthcare communication generation to drafting teaching sessions to studying and learning. As access improves and technology becomes more refined, surely more uses for ChatGPT in plastic surgery will become apparent.

The Anatomy, Presentation and Management Options of Cubital Tunnel Syndrome

Cubital tunnel syndrome is the second most common nerve compression syndrome seen in the upper limb. Paresthesia and weakness are the two most common presentations in the hand. If left untreated, compression can lead to irreversible nerve damage, resulting in a loss of function of the forearm and hand. Therefore, recognizing the various clinical presentations of cubital tunnel syndrome can lead to early detection and prevention of nerve damage. Conservative management is usually tried first and involves supporting the elbow using a splint. If this fails and symptoms do not improve, surgical management is indicated. There are 3 main surgical techniques used to relieve compression of the nerve. These are simple decompression, anterior transposition and medial epicondylectomy. Studies comparing the techniques have demonstrated particular advantages to using one or another. However, the overall technique of choice is based on both the clinical scenario and the surgeon's digression. Following primary cubital tunnel surgery, recurrent symptoms can often occur due to a variety of pathological and non-pathological causes and revision surgery is usually warranted. This article provides a complete review of cubital tunnel syndrome.

Nerve wrapping for recurrent compression neuropathy: A systematic review

BACKGROUND

The recurrence of symptoms following primary nerve compression surgery can occur in up to 25% of cases. Nerve wrapping can be utilised for revision surgery. An ideal barrier should minimise the chance of fibrosis, scarring and allow for adequate nerve gliding. This review evaluates the use of autologous or commercially available allograft and xenograft options as barriers against nerve scarring following revision surgery.

METHODS

PubMed, Ovid Embase and Cochrane databases were searched using the All Fields Index. Nine hundred titles underwent title screening with 11 studies being included in the final analysis. The risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. PRISMA guidelines were followed at all stages and the review was registered with PROSPERO (CRD 42020182818).

RESULTS

The 11 studies comprised of all case series. In total, 114 patients were included, with ages ranging from 28 to 90. Previously, the number of revision surgeries ranged from 0 to 5. Autologous veins were used in 6 studies, collagen in 3 studies and human amniotic membrane in 2 studies. Improvements in subjective and objective outcomes were seen with all wrap types. Pain was the most common residual symptom (46% of patients). The most common complication was pain at the donor site following vein harvest (19% of patients).

CONCLUSION

This is the first systematic review to summarise the outcomes of nerve wraps for revision compression neuropathy. While improvements in outcomes were reported, further comparative studies are needed to determine the best nerve wrap.

Is there a role for virtual reality in objective structured clinical examinations (OSCEs)?

This article was migrated. The article was marked as recommended. Virtual reality is an area with fascinating possibilities. It has already revolutionised the entertainment industry, and over the last ten years, it has advanced similarly within the medical field. We have already seen virtual reality make a difference in a variety of ways. This ranges from improving the way surgical training is delivered, having a role in the management of chronic pain and now, it is even being considered in the treatment of psychiatric diseases. Currently, the application of virtual reality towards the training of health care professionals and medical education are concepts that are being explored. Within medical education and more specifically medical student training, the benefits of virtual reality have so far been limited to studies assessing its role in teaching. Very few studies exist looking at the role of virtual reality in the assessment of medical students. Therefore, in this article, we discuss the idea of utilising virtual reality for objective structured clinical examinations (OSCEs) and analyse the potential benefits and pitfalls of implementing this technology.

Near-Peer-Teaching Revision Series During the COVID-19 Recovery Phase: An Experience From a UK Medical School

Background The COVID-19 pandemic led to a significant disruption in clinical attachments for final-year medical students which can result in gaps in clinical knowledge and lower confidence levels. We developed a targeted near-peer-teaching (NPT) revision series to bridge this gap. Method A one-week virtual revision series was developed by the postgraduate doctors (PD and AT) and supervised by the final year written paper lead (NS) as per curriculum requirements. The series focused on eight key common clinical presentations. It was delivered via Leicester Medical School's virtual platform by PD and AT a week before the finals. Multiple-choice surveys were sent out prior to the commencement of the series to gauge participation and baseline confidence. Surveys were also sent out before and after each session evaluating teaching, confidence levels, and improvement points. Results This NPT experience was the first comprehensive revision series during the COVID-19 recovery phase. Between 30 and 120 students attended each session. From the pre-series survey (n=63), almost all students indicated that their clinical attachments had been affected by the pandemic and that they (100%) would be interested in participating in the NPT series. From the post-session surveys, 93% of students reported that the session enhanced their confidence in recognizing and managing the clinical presentation, and 100% considered the quality of teaching to be good to excellent. From the post-series survey, a significant improvement was seen in confidence based on the Likert scale (from a combined 35% to 83%, pre, and post-series, respectively). Conclusion The series evaluation demonstrates that students found it a valuable experience and benefited from the social and cognitive congruence afforded by near-peer teachers. Furthermore, the results support the continued use and development of a virtual pre-exam revision series within the medical school curriculum as an adjunct to normal teaching.

Immunoglobulin for Kawasaki disease: a 3-year retrospective audit

AIM

To evaluate whether intravenous immunoglobulin (IVIG) use in children with suspected Kawasaki disease (KD) was given according to local trust and the newly revised American Heart Association (AHA) guidelines.

METHODS

In our tertiary hospital, any child with suspected KD given IVIG, over the past 3 years, was identified. Their electronic notes were then reviewed.

RESULTS

Ten patients were identified. Nine patients had a fever lasting 5 days or more. Four patients had either 5/5 or 4/5 of the diagnostic criteria for KD and were diagnosed with complete KD. The remaining six patients were suspected to have incomplete KD. 7/10 patients received IVIG within 10 days of onset of illness. Patients suspected to have incomplete KD experienced a mean delay in administration of IVIG of 5.3 days compared with those with complete KD. In four patients, an alternative diagnosis was established. Three patients had coronary artery abnormalities on first echocardiogram. From these patients, only one had a follow-up echocardiogram recorded in their notes. No patient had more than one follow-up echocardiogram (at both 2 and 6 weeks).

CONCLUSION

Identifying patients with incomplete KD is more difficult than identifying those with complete KD and any delay in giving IVIG could be due to this reason. This audit suggests that increasing awareness of incomplete KD and a clear guideline will aid prompter diagnosis and administration of IVIG. This audit also suggests that all patients with KD should receive more than one follow-up echocardiogram.

Intramedullary Headless Screw Fixation of Distal Metacarpal Fractures - the Birmingham Experience

Background: Surgical fixation using intramedullary headless screws (IHS) is a relatively new technique for metacarpal fracture repair. However, there are very few studies investigating the outcomes of this procedure. We present the surgical and functional outcomes of a consecutive series of 30 metacarpal fractures treated by a single surgeon over a 2.5-year period using IHS. Methods: We retrospectively reviewed the records of 30 metacarpal fractures in 27 patients who underwent IHS fixation from March 2016 to October 2018. There were 29 fractures of the metacarpal neck and 1 was to the metacarpal head. All fractures underwent the procedure by a single operating surgeon. Individual joint movements along with total active movement (TAM) was measured at postoperative follow-up appointments 4-8 weeks after surgery. Fracture healing was confirmed with plain radio-graphs. Patients were also recalled in March 2019 for their latest functional measurements. A QuickDASH (disabilities of the arm, shoulder and hand) questionnaire was used to assess for any residual functional disability. Results: All fractures healed within acceptable radiological parameters with no mal-unions or rotational deformities. The average TAM at initial follow-up was 245°, which improved to 264° at the March 2019 review. All patients returned to work in an average of 6 weeks. The final functional QuickDASH score was an average of 2.9/100 (range 0-18.2). 2/27 patients required further surgery for stiffness before regaining excellent TAM. No patient required metalwork removal. There were no other complications. Conclusions: Our findings suggest that IHS fixation is an effective alternative technique for the treatment of metacarpal fractures. It is a relatively simple procedure, which provides good stable fixation, allowing for early mobilisation. It has few complications and does not routinely require removal of the implant.

Factors influencing surgical treatment of De Quervain's tendinopathy: A retrospective cross-sectional observational study

Background

The literature surrounding how different patient, sociodemographic, and anatomical factors influence surgical treatment of De Quervain's tendinopathy (DQT) is limited.

Purpose

We hypothesised that different patient, anatomical, or sociodemographic factors influence the management of DQT with regard to non-operative vs. surgical management.

Methods

This retrospective cross-sectional study reviewed 155 cases of patients with DQT seen over a 10 year period. Patient-specific factors included age, gender, hand affected, dominant hand, steroid injection given and mean number of injections. Sociodemographic factors included ethnicity, employment, and deprivation, were measured using deprivation quintiles through The Index of Multiple Deprivation. Anatomical factors included the presence of subcompartmentalization, number of APL and EPB tendon slips, tendon thickening, exudative tenosynovitis, hypervascularization, and the presence of a sheath ganglion Patients were categorized into either non-operative or surgical cohort. Bivariate analysis was used to compare factors between the cohorts, and significant factors (p < 0.05) were included in the logistic regression model, used to predict factors influencing surgical management.

Results

Bivariate analysis detected a significant difference in the mean number of steroids given between the non-operative and surgical cohort (p = 0.001) patient factors. For sociodemographic factors, a significant difference was found between deprivation quintiles (p = 0.02). From the anatomical factors, the surgical cohort had more patients with multiple APL tendon slips (p = 0.02) and the presence of a tendon ganglion sheath ganglion (p = 0.02). For patient and sociodemographic factors, logistic regression identified that the number of steroids (per patient) and being in deprivation quintile 4 were associated with surgical treatment. For anatomical factors, multiple APL tendon slips and the presence of a tendon sheath ganglion were associated with the surgical treatment.

Conclusion

This study suggests that several factors are associated with the need for surgical treatment of DQT, including the number of steroid injections received, social deprivation, and anatomical factors, such as the presence of multiple tendon slips and a tendon sheath ganglion. Our findings add to the growing body of literature exploring factors that may influence treatment pathways for patients with DQT.

How, what and from where to learn? Questions arising from early clinical exposure

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Comparison between intra-articular injections of corticosteroids, hyaluronic acid, PRP and placebo for thumb base osteoarthritis: A frequentist network meta-analysis

Background and aims

Current evidence for the use of intra-articular injections for thumb base osteoarthritis (TBOA) is equivocal. This study aims to investigate the efficacy of intra-articular corticosteroids, hyaluronic acid and platelet-rich plasma.

Methods

A Frequentist network meta-analysis was conducted comparing outcomes at short (≤3 months) and medium-term (>3-12 months) time points.

Results

Data from 7 RCTs and 1 non-RCT (446 patients) were collected, consisting of corticosteroids (n = 7), hyaluronic acid (n = 7), platelet-rich plasma (n = 2) and placebo (n = 2). At the short-term time point, no intra-articular injection demonstrated superiority over placebo at reducing pain. At the medium-term time point, superiority of platelet-rich plasma at reducing pain over placebo and corticosteroids was seen following sensitivity analysis (RCTs only) (SMD -1.48 95 % CI -2.71; -0.25). No injection proved superior at improving function at short or medium-term time points.

Conclusions

Overall, despite the promising result for platelet-rich plasma, the evidence quality was limited to two studies only justifying the need for further and larger methodologically robust trials investigating corticosteroids, hyaluronic acid and platelet-rich plasma vs each other and placebo.

What Are the Most Clinically Effective Nonoperative Interventions for Thumb Carpometacarpal Osteoarthritis? An Up-to-date Systematic Review and Network Meta-analysis

BACKGROUND

Thumb carpometacarpal osteoarthritis (CMC-1 OA) is a common and debilitating condition, particularly among older adults and women. With the aging population, the prevalence of CMC-1 OA is expected to rise, emphasizing the need to find effective nonoperative strategies. So far, for determining the most effective nonoperative interventions in CMC-1 OA, two network meta-analyses (NMAs) have been published. However, these NMAs were limited to specific intervention types: one comparing multiple splints and the other comparing different intraarticular injections. Therefore, an NMA that compared all nonoperative intervention types is urgently needed.

QUESTIONS/PURPOSES

This study aimed to assess and compare the effectiveness of available nonoperative interventions (both nonpharmacologic and pharmacologic) for CMC-1 OA to establish which nonoperative options are more effective than control in terms of (1) pain, (2) function, and (3) grip strength.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) NMA guidelines (PROSPERO: CRD2021272247) and conducted a comprehensive search across Medline, Embase, CENTRAL, and CINAHL up to March 2023. We included randomized controlled trials (RCTs) and quasi-RCTs evaluating nonoperative interventions for symptomatic CMC-1 OA, excluding inflammatory or posttraumatic arthritis. Studies comparing ≥ 2 interventions or against a control, focusing on pain reduction, functional improvement, and grip strength, were selected. We assessed methodologic quality using the modified Coleman Methodology Score, including only studies scoring > 70. Risk of bias was evaluated with the Risk of Bias 2.0 tool, and evidence quality with Confidence in Network Meta-Analysis (CINeMA). Of 29 screened studies, 22 (21 RCTs and one quasi-RCT) were included, involving 1631 women and 331 men. We analyzed eight different nonoperative interventions, including splints, hand exercises, injections, and multimodal treatment (≥ 2 nonpharmacologic interventions or nonpharmacologic with a pharmacologic intervention). Six studies had a low risk of bias, eight had a high risk, and the remainder were moderate. We extracted mean and SD scores, and NMA and pairwise analyses were performed at short- (≤ 3 months) and medium-term (> 3 to ≤ 12 months) time points. Standardized mean differences were re-expressed into common units for interpretation, which were the VAS (range 0 to 10) for pain, the DASH test (range to 100) for function, and pounds for grip strength. Clinical recommendations were considered strong if the mean differences exceeded the minimum clinically important difference-1.4 points for VAS, 10 points for DASH, and 14 pounds for grip strength-and were supported by moderate or high confidence in the evidence, as assessed using CINeMA methodology.

RESULTS

Our NMA (based on moderate or high confidence) showed a clinically important reduction in pain at the short-term time point for multimodal treatment and hand exercises versus control (mean difference VAS score -5.3 [95% confidence interval (CI) -7.6 to -3.0] and -5.0 [95% CI -8.5 to -1.5]). At the medium-term time point, only the rigid carpometacarpal-metacarpophalangeal (CMC-MCP) splint was superior to control (mean difference VAS score -1.9 [95% CI -3.1 to -0.6]) and demonstrated clinical importance. For function, only the rigid CMC-MCP splint demonstrated a clinically important improvement at the medium-term time point versus control (mean difference DASH score -11 [95% CI -21 to -1]). Hand exercises resulted in a clinically important improvement in short-term grip strength versus control (mean difference 21 pounds [95% CI 11 to 31]).

CONCLUSION

This systematic review and NMA show that multimodal treatment and hand exercises reduce short-term pain and improve grip strength, while a rigid CMC-MCP splint enhances medium-term function. Future research should evaluate long-term efficacy.

LEVEL OF EVIDENCE

Level I, therapeutic study.

The research process and naivety-a student's perspective

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Time to Reconsider Occupation Induced De Quervain's Tenosynovitis: An Updated Review of Risk Factors

De Quervain's tenosynovitis (DQT) is described to be an attritional and degenerative process, triggered by stenosing inflammation of the tendon sheath in the first dorsal compartment of the wrist. Understanding and targeting the risk factors associated with DQT will help clinicians and patients to reduce its prevalence. This review aims to evaluate the current literature surrounding the risk factors which were divided into the anatomical, patient, and occupational factors associated with the condition. The two main anatomical variations associated with DQT are subcomparmentalization and multiple tendon slips of the abductor pollicus longus (APL) and extensor pollicus brevis (EPB) tendons. DQT is more common in females and is often noted in pregnancy and the postpartum period. When considering occupational factors, work-related activity has not been shown to be a direct cause of DQT, despite leading organisations supporting the converse.