Variation in patient information and rehabilitation regimens after flexor tendon repair in the United Kingdom

Introduction There is clinical uncertainty regarding the optimal method of rehabilitation following flexor tendon repair. Many splint designs and rehabilitation regimens are reported in the literature; however, there is insufficient evidence to support the use of any one regimen. The aim of this study was to describe rehabilitation guidelines used in the United Kingdom (UK) following zone I/II flexor tendon repair. Methods Using a cross-sectional design, hand units in the UK were invited to complete a short survey and to upload their flexor tendon rehabilitation guidelines and patient information material. Approval was granted by the British Association of Hand Therapists. Data were extracted in duplicate, using a pre-piloted form, and analysed using descriptive statistics. Results Thirty-five hand units responded (21%), providing 52 treatment guidelines. Three splinting regimens were described, and all involved early active mobilisation: (i) long dorsal-blocking splint (DBS); (ii) short DBS; and (iii) relative motion flexion splint. Duration of full-time splint wear ranged from 4 to 6 weeks. There were variations in splint design and composition of home exercise programmes, particularly for the long DBS. Where reported, recommended return to driving ranged from 8 to 12 weeks, and return to light work activities ranged from 5 to 10 weeks. Discussion Treatment guidelines varied across UK hand therapy departments, suggesting that patients receive differing advice about how to protect, move and use their hand after zone I/II flexor tendon repair. The disparity in splint wear duration, home exercise frequency and prescribed functional restrictions raises potential financial and social implications for patients. Future research should explore rehabilitation burden in addition to clinical outcomes

Australian Sphingidae – DNA Barcodes Challenge Current Species Boundaries and Distributions

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Epidemiology of common hand conditions

This thesis aims to appraise and analyse a variety of routine data sources to better understand their use in surgical epidemiology. The clinical focus of the thesis is to use real world data to generate a better understanding of the benefits and risks of surgery for carpal tunnel syndrome (CTS) and base of thumb osteoarthritis (BTOA) in routine clinical practice, and of the role of female hormones in the aetiology of these conditions. A bespoke extract of administrative secondary care data (HES APC) was used to evaluate the safety of CTS and BTOA surgery and BTOA injection in routine clinical practice in England. For CTS, an observed perimenopausal peak in incidence stimulated further analysis of aetiology in later chapters. 3.42% of CTS surgeries proceeded to revision, with very low rates of serious adverse events (SAE). For BTOA, only 50% had any form of intervention after their first intraarticular injection, with 22% proceeding to surgery. Trapeziectomy was the predominant BTOA surgical subtype with an increasing trend over the 19 years studied. BTOA surgery revision intervention rate was low (1.39%), but with 2.5 times relative risk for those undergoing BTOA arthroplasty or arthrodesis compared to trapeziectomy. Very low rates of SAEs were found after BTOA intervention and prior injection did not increase post-operative complications. An extract of the UK Hand Registry was used to assess patient reported outcome following trapeziectomy versus trapeziectomy with ligament reconstruction. A significant improvement following both types of surgery was found in both general and hand specific quality of life with no difference between procedures. In the second part of this thesis, two systematic reviews identified the role of risk factors in CTS and BTOA disease development and were used to design two studies of disease aetiology. The association of endogenous female hormones in disease aetiology was investigated using a prospective cohort (the Million Women Study) linked to HES APC. An increased risk of CTS and BTOA was associated with early menarche, an increased number of full-term pregnancies, and oophorectomy. Undergoing oophorectomy at an early age was associated with a 50% increased risk of CTS and twice the risk of incident BTOA. Finally, an international federated network analysis investigating the role of exogenous female hormonal blockade in disease development was undertaken, replicating a study designed in UK primary care data in seven datasets across four countries. This identified an increased risk of CTS and BTOA in an analysis of just under one million women who were new users of aromatase inhibitors compared to tamoxifen. A relative risk of 1.8 to two-fold for CTS in new users of AIs was seen at one year following treatment initiation, with a 40% increased risk of BTOA, revealing the same direction of effect as seen in early RCTs for AI use. This thesis provides evidence for informed consent and shared decision making for interventions for CTD and BTOA, and provides generalisable results for use in everyday practice. It demonstrates the benefits of repurposing of data to better understand surgical disease aetiology, and illustrates how with careful curation, clinically relevant conclusions can be drawn.</p

Complications of ear rings

In this paper the complications of ear piercing are considered and the treatment of resultant deformities is described

Complications of ear rings

In this paper the complications of ear piercing are considered and the treatment of resultant deformities is described

Requirement for post-operative radiological imaging in an enhanced recovery programme

Aim Enhanced recovery (ERAS) produces benefits to patients by reducing length of stay and morbidity. Its effect on nursing and physiotherapy workload has been studied but the demand upon radiology is unclear. We aimed to determine radiology use to understand possible hidden expenditure not included in existing ERAS cost-effectiveness analyses. Method 265 patients from a prospective multidimensional ERAS database were retrospectively assessed for post-operative radiology use. All had undergone colorectal surgery within an established ERAS programme from 2008-2009 with all data prospectively recorded. Laparoscopy was offered for all primary colon and rectal resections. All adverse events including gut dysfunction, surgical site infection (SSI) and reoperation were assessed. All radiology within 30 days of surgery was recorded. Results Radiology data were absent in 12 patients leaving 253 for analysis. Post-operative radiology was used in 71 (28%) and 41(16%) patients had CT of the abdomen and pelvis(A/P) within 30 days. In thirty three (13%) patients this was required during the primary admission including 30% of patients with any post-op adverse event. Nine (27%; 3.6% of the whole cohort) of the 33 required reoperation. No patient required interventional radiology. The median time to CT (A/P) during primary admission was 5 days (IQR 3-8). Eight (3%) had CT (A/P) after readmission with one reoperation. Forty(16%) patients underwent plain radiology (chest or abdominal) and six (2%) had abdominal ultrasonography. Using general estimates of CT and plain radiology total costs, these data suggest an overall radiology cost of over £22, 000, amounting to a radiology cost of £90 per ERAS patient. Conclusion Post-operative radiology is required in a significant proportion of ERAS patients potentially reflecting a low threshold to investigate in the presence of an adverse event. Very few require subsequent intervention. Radiology costs incurred with ERAS should be considered into future economic analysis. </p

Requirement for post-operative radiological imaging in an enhanced recovery programme

Aim Enhanced recovery (ERAS) produces benefits to patients by reducing length of stay and morbidity. Its effect on nursing and physiotherapy workload has been studied but the demand upon radiology is unclear. We aimed to determine radiology use to understand possible hidden expenditure not included in existing ERAS cost-effectiveness analyses. Method 265 patients from a prospective multidimensional ERAS database were retrospectively assessed for post-operative radiology use. All had undergone colorectal surgery within an established ERAS programme from 2008-2009 with all data prospectively recorded. Laparoscopy was offered for all primary colon and rectal resections. All adverse events including gut dysfunction, surgical site infection (SSI) and reoperation were assessed. All radiology within 30 days of surgery was recorded. Results Radiology data were absent in 12 patients leaving 253 for analysis. Post-operative radiology was used in 71 (28%) and 41(16%) patients had CT of the abdomen and pelvis(A/P) within 30 days. In thirty three (13%) patients this was required during the primary admission including 30% of patients with any post-op adverse event. Nine (27%; 3.6% of the whole cohort) of the 33 required reoperation. No patient required interventional radiology. The median time to CT (A/P) during primary admission was 5 days (IQR 3-8). Eight (3%) had CT (A/P) after readmission with one reoperation. Forty(16%) patients underwent plain radiology (chest or abdominal) and six (2%) had abdominal ultrasonography. Using general estimates of CT and plain radiology total costs, these data suggest an overall radiology cost of over £22, 000, amounting to a radiology cost of £90 per ERAS patient. Conclusion Post-operative radiology is required in a significant proportion of ERAS patients potentially reflecting a low threshold to investigate in the presence of an adverse event. Very few require subsequent intervention. Radiology costs incurred with ERAS should be considered into future economic analysis. </p

A new acute scaphoid fracture assessment method: a reliability study of the 'long axis' measurement

Background The aim of this study was to assess the inter observer and intra observer reliability of acute scaphoid fracture classification methods including a novel ‘long axis’ measurement, a simple method which we have developed with the aim of improving agreement when describing acute fractures. Methods We identified sixty patients with acute scaphoid fractures at two centres who had been investigated with both plain radiographs and a CT (Computed Tomography) scan within 4 weeks of injury. The fractures were assessed by three observers at each centre using three commonly used classification systems and the ‘long axis’ method. Results Inter observer reliability: based on X-rays the ‘long axis’ measurement demonstrated substantial agreement (Intraclass Correlation Coefficient (ICC) =0.76) and was significantly more reliable than the Mayo (p and#60; 0.01), the most reliable of the established classification systems with moderate levels of agreement (kappa = 0.56). Intra observer reliability: the long axis measurement demonstrated almost perfect agreement whether based on X-ray (ICC = 0.905) or CT (ICC = 0.900). Conclusions This study describes a novel pragmatic ‘long axis’ method for the assessment of acute scaphoid fractures which demonstrates substantial inter and intra observer reliability. The ‘long axis’ measurement has clear potential benefits over traditional classification systems which should be explored in future clinical research