Influence of a Nurse Practitioner on Non-Attendance Rate for Barium Enema

Non-attendance for barium enema investigation wastes resources, prolongs waiting times and delays diagnosis of colorectal carcinoma. In an inner-city hospital with a previous non-attendance rate of over 20% for barium enema we investigated the value of systematic personal contact with a nurse practitioner at the time of booking. We compared two groups of patients, all of whom received an explanation of the procedure from the referring clinician. Patients referred from the colorectal clinic were accompanied by the colorectal nurse practitioner to the radiology department for booking, an appointment being sent later by mail. The nurse practitioner reiterated the details of the procedure, provided supplementary information, confirmed the patient's contact details and provided a telephone number in case further information or assistance was needed. Patients referred from the gastroenterology clinic were managed as previously, making their own way to the radiology department and receiving supplementary information only on request.

The patients referred from the two clinics were closely similar; however, the non-attendance rate for the intervention (colorectal) clinic was 4/157 (2.5%) compared with 17/110 (15.5%) for the comparison clinic (P < 0.001). A year previously the non-attendance rates in these clinics had been 23% and 20%, respectively.

These results indicate that personal contact, with supplementary information, can substantially reduce the non-attendance rate for barium enema.

Quality and impact of appraisal for revalidation: the perceptions of London's responsible officers and their appraisers

BACKGROUND

To evaluate NHS England London region's approach to the revalidation appraisal of responsible officers in London, exploring perceptions of the quality and impact of the appraisal process. Revalidation is the process which aims to ensure doctors in the UK are up-to-date and fit to practice medicine thus improving the quality of patient care. Revalidation recommendations are largely premised on the documentation included in annual appraisals, which includes the professional development a doctor has undertaken and supporting information about their practice.

METHODS

A pan-London qualitative study exploring the views of responsible officers and their appraisers about the revalidation appraisal process. The study aimed to gain an in-depth understanding of the experiences and perceptions of the participants. Responsible officers were purposefully sampled to represent the broadest range of designated bodies. Data analysis generated themes pertaining to quality and impact of appraisal for revalidation with the potential to feed into and shape the evolving system under investigation.

RESULTS

The central importance of highly skilled appraisers was highlighted. Both groups reported educational opportunities embedded within the appraisal process. Independent appraisers, not matched by clinical speciality or place of work, were considered to take a more objective view of a responsible officer's practice by providing an 'outsider perspective'. However, covering the breadth of roles, in sufficient depth, was challenging. Participants reported a bias favouring the appraisal of the responsible officer role above others including clinical work. Appraisal and revalidation was perceived to have the potential to improve the healthcare standards and support both personal development and institutional quality improvement.

CONCLUSIONS

Responsible officers play a central role in the revalidation process. Getting responsible officer appraisal right is central to supporting those individuals to in turn support doctors and healthcare organisations in continuous quality improvement. The complexity and importance of the role of responsible officer may make achieving an appraisal of all roles of such individuals problematic. This evaluation suggests responsible officer appraisal was perceived as educational and effective.

What proportion of patients referred to secondary care with iron deficiency anemia have colon cancer?

PURPOSE

Iron deficiency anemia can be the first presentation of right-sided colon cancer. There is an impression that because this presentation is nonspecific it may be associated with a longer delay from referral to diagnosis compared with those patients with symptoms of change in bowel habit and/or rectal bleeding caused by more distal colorectal cancer. This study was designed to determine the incidence of colon cancers in patients referred to the hospital with iron deficiency anemia and to determine what proportion of these patients were referred and diagnosed urgently in line with cancer waiting time targets.

METHODS

A retrospective study was performed, including all patients referred to one district general hospital in 2003 whose blood indices met the criteria for significant iron deficiency anemia as defined by the Referral Guidelines for Suspected Cancer issued by the Department of Health in 1999, which defined iron deficiency anemia in the "target wait" criterion as a low hemoglobin (<11 g/dl in males and < 10 g/dl in postmenopausal females) with a mean corpuscular volume < 78 fl and/or a serum ferritin < 12 ng/ml. Patients with hemoglobinopathy were excluded. The underlying diagnosis reached for each patient was determined by using ICD10 C18-21. Case note review confirmed the diagnoses and yielded information on urgency of referral and time to diagnosis.

RESULTS

Of 513 patients referred with iron deficiency anemia in 2003, 142 (28 percent) met the eligibility criteria. Nine (6.3 percent) of these had colon cancer, including one (1.2 percent) female and eight (14 percent) males. Eight of nine cancers were in the right colon. Other patients with iron deficiency anemia were found to have benign upper or lower gastrointestinal disease (n = 125) or upper gastrointestinal cancer (n = 1). In seven patients, no cause was found. Of the nine patients with iron deficiency anemia who were found to have colon cancer, five had been referred urgently and four as routine. The mean delay from referral to diagnosis for these was 31 days for those referred urgently but 60 days for those referred routinely.

CONCLUSIONS

Males referred with iron deficiency anemia have a significant risk of having colon cancer. The risk seems lower in females; this gender difference has been observed in other studies and further evidence should be sought before advising any change in referral practice.

A small rise in CEA is sensitive for recurrence after surgery for colorectal cancer

OBJECTIVE

Rise in carcinoembryonic antigen (CEA) above normal limits can indicate recurrent colorectal cancer. The aim of this study was to evaluate whether a small rise in CEA, even within normal limits was a sensitive indicator of recurrence.

METHOD

150 patients aged 22-87 years were followed up for a mean of 27 months after colorectal surgery with CEA 3 and 6 monthly computerized tomography. We analysed whether a rise in CEA > 1 ng/ml correlated with recurrence of metastases.

RESULTS

Forty-six of 139 patients in final analysis had recurrent disease. A rise in CEA > 1 had a predictive value of 74% for recurrence or metastases (sensitivity 80%, specificity 86%). These findings were similar whether or not the CEA was normal preoperatively.

CONCLUSION

If CEA is measured after surgery for colorectal cancer, a rise of >1 in the patient's postoperative value is predictive for recurrence or metastases with an overall sensitivity of 80% and specificity of 86%. Previous studies have recognized the role of large rises in CEA in predicting recurrence but this study shows that small changes in CEA may be significant even if these levels would be traditionally within 'normal' limits.

An effective electronic surgical referral system

INTRODUCTION

Electronic booking of out-patient appointments is being rolled out in England under the 'Choose and Book' programme. We set up and ran a local electronic surgical referral service before this. This paper assesses the effect of the electronic surgical referral service on patient waiting times and attendance rates.

PATIENTS AND METHODS

The study included 54 patients referred electronically and 189 referred on paper to a single colorectal surgical service over the same period.

RESULTS

The appointment booking was achieved on the same day as the referral was made for the majority of electronic referrals whereas it took an average of 7 days for paper referrals. There was no significant difference in the time from referral to being seen in clinic between the two groups. Patients referred electronically were much more likely to attend for their appointment.

CONCLUSIONS

This study shows that an electronic surgical referral system can improve efficiency. This may be because this system allows enhanced patient choice of appointment date and time.

Which patients would prefer to walk to theatre?

INTRODUCTION

Increasing patient autonomy in the pre-operative period may help to lessen the anxiety associated with under-going a surgical procedure, and may enhance patient satisfaction. This study seeks to explore patients' preferences for mode of travel to the operating theatre.

PATIENTS AND METHODS

A questionnaire survey was undertaken with all patients having an in-patient or day-case surgical procedure over a 4-week period at one hospital. Results were analysed with respect to the patients' age, gender and surgical specialty.

RESULTS

In all, 171 patients completed the questionnaire, 118 day-cases and 53 in-patients. In both sexes and in all age groups, the majority of patients expressed a preference to walk to theatre. The only sub-group which demonstrated an equal preference for a trolley transfer compared with walking were gynaecology patients.

CONCLUSIONS

These results suggest that a high proportion of patients would prefer to walk to theatre for their operation if given the choice. If the policy of offering choice were adopted, it would enhance patient autonomy and may reduce delays in transferring patients to theatre. It may also release portering resources for other purposes.

Time management

There is never enough time for a doctor to do everything that he/she wants to do. Time management is a challenge for every grade of doctor. However, it is often hardest for the most junior doctors, since they have the least control over their work.

Influence of a nurse practitioner on non-attendance rate for barium enema

Non-attendance for barium enema investigation wastes resources, prolongs waiting times and delays diagnosis of colorectal carcinoma. In an inner-city hospital with a previous non-attendance rate of over 20% for barium enema we investigated the value of systematic personal contact with a nurse practitioner at the time of booking. We compared two groups of patients, all of whom received an explanation of the procedure from the referring clinician. Patients referred from the colorectal clinic were accompanied by the colorectal nurse practitioner to the radiology department for booking, an appointment being sent later by mail. The nurse practitioner reiterated the details of the procedure, provided supplementary information, confirmed the patient's contact details and provided a telephone number in case further information or assistance was needed. Patients referred from the gastroenterology clinic were managed as previously, making their own way to the radiology department and receiving supplementary information only on request. The patients referred from the two clinics were closely similar; however, the non-attendance rate for the intervention (colorectal) clinic was 4/157 (2.5%) compared with 17/110 (15.5%) for the comparison clinic (P<0.001). A year previously the non-attendance rates in these clinics had been 23% and 20%, respectively. These results indicate that personal contact, with supplementary information, can substantially reduce the non-attendance rate for barium enema.

Nucleophilic Substitution Induced by Electron Transfer at the Bridgehead of Polycyclic Alkanes: Competition between Polar and Radical Pathways

A series of 2,5(or 1,4)-dihaloadamantanes (4 and 5, X = Y = halogens) and 9,10-dihalotriptycenes (7, X = Y = halogens) as well as two 5-halo (X) adamantan-2-ones (6, Y = O, X = Br and I) have been treated with Me(3)SnLi in THF in the absence and presence of tert-butylamine (TBA) and dicyclohexylphosphine (DCHP). The product distributions of these reactions have been established by (13)C and (119)Sn NMR spectroscopy, vapor-phase chromatographic analyses, and GC/MS. The former compounds (4 and 5) appear to react exclusively by a free-radical chain process (S(RN)1 mechanism) to yield tin substitution products. By contrast, the triptycenes react predominantly by a polar mechanism initiated by the formation of a carbanion. In the case of the halo ketones (6, Y = O, X = Br and I), a mechanistic divergence of the reaction was unexpectedly encountered. Whereas the bromo ketone provides the substitution product (6, Y = O, X = SnMe(3)) in good yield (ca. 75%), apparently by a radical pathway, the iodo ketone yields a fragmentation product (ca. 95% yield) by a polar mechanism. This mechanistic switch highlights the importance of the electronegativity of the leaving group as well as substituent-induced electron delocalization as molecular factors governing the competition between radical and polar pathways.

Small peptides Do not inhibit human non-pancreatic secretory phospholipase-A(2) (Type IIA)

Seven small peptides, that are among the most potent reported inhibitors of secreted mammalian phospholipases A(2), were found not to inhibit processing of a small phospholipid substrate by human non-pancreatic secretory phospholipase A(2) (type IIa), under conditions where certain non-peptides are potent inhibitors at nanomolar concentrations.

Objectives of basic surgical training

There are a range of skills to be learned in basic surgical training. These include communication and patient management, operating and other technical skills, and audit. Surgical tutors might use such a framework to facilitate education and assessment of their trainees.

Donor cell infiltration of recipient tissue as an indicator of small bowel allograft rejection in the rat

This study assessed whether screening of host tissues for graft cells could be used as an effective monitor of rejection following small bowel transplantation. Allogeneic rat small bowel transplantation was performed with or without cyclosporin (CyA) immunosuppression and cellular infiltration of host tissues assessed by immunohistological staining. Without immunosuppression, grafts were completely rejected within 1 week. CyA treatment for 7 days preserved the graft for 28 days although there was histological evidence of mild rejection in some of the animals studied. Continuous CyA treatment preserved the graft for up to 56 days. The peripheral lymph nodes and spleens of untreated animals were transiently infiltrated by low numbers of donor cells that disappeared by day 6. There was a marked donor cell infiltration of the lymph nodes and spleens of 7-day. CyA-treated animals that was maintained during the administration of immunosuppressive therapy but that declined thereafter. Continuous CyA treatment sustained donor cell infiltration up to day 56. These findings suggest the presence of donor cells in recipient lymph nodes and spleen to be indicative of effective control of rejection and their disappearance to be predictive of developing rejection responses. Examination of recipient peripheral tissues for donor cells may provide an improved technique for monitoring clinical small bowel transplantation.