scholarly journals P-BN55 Results of the ARROW survey of anti-reflux practice in the UK

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Keyword(s):  
Clinical Guidelines ◽  
Clinical Symptoms ◽  
Steering Committee ◽  
National Guidelines ◽  
Lifestyle Modifications ◽  
Online Tool ◽  
Surgical Trainees ◽  
Final Questionnaire ◽  
The Uk ◽  
Survey Responses

Abstract Background Gastro-oesophageal reflux disease (GORD)  affects 10-20% of the population. Lifestyle modifications and medications such as proton pump inhibitors are generally well tolerated, however a variety of surgical and endoscopic interventions may be more suitable for well selected patients. Despite national guidelines and evidence from trials there is lack of consensus regarding the best approach to antireflux surgery (ARS). We designed a national audit (ARROW) to describe variation in UK clinical practice of ARS and adherence to clinical guidelines. Our audit was designed in two phases. First, a survey of national practice; Second, a prospective audit of adherence to available guidelines. Methods Survey questions were iteratively developed by the ARROW steering committee and an online tool was developed to gather survey responses and contact details for the audit phase. The final questionnaire consisted of 90 fields per surgeon and 57 fields per institution. Participants were enlisted through AUGIS, social media, personal contacts and the ROUX group of upper GI surgical trainees. The online tool was piloted in three centres. The protocol for the study was peer reviewed and published in Diseases of The Esophagus in January 2021 Results Survey responses were received from 151 surgeons at 57 institutions with a median of 40 cases annually and 4 surgeons/institution. Surgeons perform a median of 12(range 0-75) NHS cases and 6(range 0-75) private cases. 150/151 NHS surgeons perform some form of fundoplication for ARS, 4 surgeons perform LINX™, 4 STRETTA™ and 49 roux-en-y bypass for GORD.  Fundoplication procedures performed in the UK include Nissen (111/151), Watson (39/151), Toupet (72/151) and Dor (61/151). 104 surgeons adjust the wrap performed according to clinical symptoms, manometry or both. 20/57 centres had no access to a benign MDT to discuss ARS. Conclusions ARS in the UK lacks standardised approaches that can be reliably compared and therefore improved most surgeons perform less than 20 cases a year. Our survey revealed differences in which investigations are considered mandatory, which procedures are available to whom and with what variations, and available resources to facilitate shared decision making for patients with GORD and ARS surgeons. Our audit phase (begun in April 2021) will establish current practice, compliance with clinical guidelines and inform improvement projects and randomised trials in the future.

scholarly journals P-BN56 Anti-Reflux Surgery in the end-stage of the pandemic: Early results of the ARROW audit

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Keyword(s):  
Recurrent Hernia ◽  
Steering Committee ◽  
Complication Rates ◽  
National Guidelines ◽  
Lifestyle Modifications ◽  
Online Tool ◽  
Early Results ◽  
Consensus Statements ◽  
The Uk ◽  
End Stage

Abstract Background Gastro-oesophageal reflux disease (GORD)  affects 10-20% of the population. Lifestyle modifications and medications such as proton pump inhibitors are generally well tolerated, however a variety of surgical and endoscopic interventions may be more suitable for well selected patients. Despite national guidelines and evidence from trials there is lack of consensus regarding the best approach to antireflux surgery (ARS). We designed a national audit (ARROW) to describe variation in UK clinical practice of ARS and adherence to clinical guidelines. Our audit was designed in two phases. First, a survey of national practice; Second, a prospective audit of compliance with available guidelines. Methods International guidelines and consensus statements were collated and reviewed by the ARROW steering committee. Sources included NICE, ICARUS and BSG guidelines and AUGIS commissioning guidelines. Definitions were adopted from the Montreal consensus statements and the Chicago Classification of Esophageal Motility Disorders.  Audit fields were then iteratively developed by the steering committee and an online tool was developed to prospectively collect pseudo-anonymised patient data. Participants were enlisted through AUGIS, social media, personal contacts and the ROUX group of upper GI trainees. The online tool was piloted in three centres. The protocol was published in Diseases of The Esophagus in January 2021. Results Of 240 registered patients on 25th August 2021, 171 had complete data. Median age was 57(range 19-83), 60.2% were females. 156 (91.2%) had OGD performed prior to surgery. 105 (61.4%) had manometry and 97 (56.7%) had 24-hour pH studies performed. 91 DeMeester scores were recorded, median score 38 (IQR 24-70). Median days from referral to surgery was 471, (range 1 to 1374). 167 patients (93.3%) underwent some variant of fundoplication. The most common wrap was a posterior 360° (44%) followed by a posterior 270°(27%) and anterior 180°(23%). 2 patients returned to theatre, 1 for recurrent hernia and 1 for ischaemia. Conclusions In keeping with all non-cancer elective work in the UK, ARS is recovering from the effects of the COVID pandemic, and this is reflected in long delays between referral and surgery. Compliance with established guidelines and consensus opinions has similarly been affected as access to diagnostic services has been impeded. Variation persists in the interventions offered to individuals and long-term outcomes monitoring to compare interventions is beyond the scope of this audit. Complication rates are very small with only 2 returns to theatre, 9 patients experiencing any short-term complication and only 24 delayed discharges.

scholarly journals Asthma diagnosis: into the fourth dimension

Thorax ◽  
2021 ◽  
pp. thoraxjnl-2020-216421
Author(s):  
Ran Wang ◽  
Clare S Murray ◽  
Stephen J Fowler ◽  
Angela Simpson ◽  
Hannah Jane Durrington
Keyword(s):  
Clinical Symptoms ◽  
Home Monitoring ◽  
Chronic Respiratory Disease ◽  
Diagnostic Tools ◽  
Fourth Dimension ◽  
Asthma Diagnosis ◽  
National Guidelines ◽  
Diurnal Variability ◽  
The Uk ◽  
Almost All

Asthma is the most common chronic respiratory disease in the UK; however, the misdiagnosis rate is substantial. The lack of consistency in national guidelines and the paucity of data on the performance of diagnostic algorithms compound the challenges in asthma diagnosis. Asthma is a highly rhythmic disease, characterised by diurnal variability in clinical symptoms and pathogenesis. Asthma also varies day to day, seasonally and from year to year. As much as it is a hallmark for asthma, this variability also poses significant challenges to asthma diagnosis. Almost all established asthma diagnostic tools demonstrate diurnal variation, yet few are performed with standardised timing of measurements. The dichotomous interpretation of diagnostic outcomes using fixed cut-off values may further limit the accuracy of the tests, particularly when diurnal variability straddles cut-off values within a day, and careful interpretation beyond the ‘positive’ and ‘negative’ outcome is needed. The day-to-day and more long-term variations are less predictable and it is unclear whether performing asthma diagnostic tests during asymptomatic periods may influence diagnostic sensitivities. With the evolution of asthma diagnostic tools, home monitoring and digital apps, novel strategies are needed to bridge these gaps in knowledge, and circadian variability should be considered during the standardisation process. This review summarises the biological mechanisms of circadian rhythms in asthma and highlights novel data on the significance of time (the fourth dimension) in asthma diagnosis.

Evaluation of Nationwide Referral Pathways, Investigation and Treatment of Suspected Cauda Equina Syndrome in the United Kingdom (ENTICE)

Neurosurgery ◽  
2019 ◽  
Vol 84 (5) ◽  
pp. E271-E271 ◽  
Author(s):  
Dillon Vyas ◽  
Keyword(s):  
United Kingdom ◽  
Cauda Equina Syndrome ◽  
Clinical Symptoms ◽  
Cauda Equina ◽  
National Guidelines ◽  
Time Intervals ◽  
Mri Scan ◽  
Out Of Hours ◽  
The United Kingdom ◽  
The Uk

Abstract INTRODUCTION Cauda equina syndrome (CES) is a spinal emergency with clinical symptoms and signs that have low diagnostic accuracy. National guidelines in the United Kingdom (UK) state that all patients should undergo an MRI prior to referral to specialist spinal units and surgery, if required, should be performed at the earliest opportunity. We aimed to evaluate the current practice of investigating and treating suspected CES in the UK. METHODS A retrospective, multicentre observational study of the investigation and management of patients with suspected CES was conducted across the UK, including all patients referred to a spinal unit over 6 mo between 1st October 2016 and 31st March 2017. RESULTS A total of 28 UK spinal units submitted data on 4441 referrals. Over half of the referrals were made without any previous imaging (n = 2572, 57.9%). The majority of referrals were made out-of-hours (n = 2229/3517, 63.4%), of which 2.9% (n = 45/1529) underwent surgical decompression. Patient location and prereferral imaging were not significantly associated with time intervals from symptom onset or presentation to decompression. Patients investigated outside of the spinal unit experienced significantly longer time intervals from presentation and from referral to undergoing the MRI scan. CONCLUSION This is the largest known study of the investigation and management of suspected CES. We found that the majority of referrals were made without adequate investigations. Most patients were referred out-of-hours and many were transferred for an MRI without subsequently requiring surgery. Cases not transferred experienced delays if undergoing an MRI scan outside of the spinal unit.

scholarly journals The Tailoring Of National Guidelines For Upper Extremity Post-Stroke Rehabilitation: A Concept In Use.

2019 ◽  
Author(s):  
Salem Alatawi
Keyword(s):  
Upper Extremity ◽  
Clinical Guidelines ◽  
Stroke Rehabilitation ◽  
Research Evidence ◽  
Nominal Group ◽  
National Guidelines ◽  
Post Stroke ◽  
Time Gap ◽  
The Uk

Background: In Saudi Arabia, national evidence-based clinical guidelines (NCG) were created based for healthcare interventions. However, clinicians appear to be slow to incorporate the evidence into practice. As a result, there exists a time-gap between the gathering and presentation of evidence for best practice and the use of that evidence by clinicians. It becomes, therefore, imperative to investigate the gap between the research evidence and clinical practice. The knowledge to action (KTA) framework is available to facilitate the implementation of research evidence. This framework incorporates the theory of tailoring, a concept that is intended to create a fit between the evidence for the intervention and its use by the clinician. Unfortunately, the process of tailoring stills awaits clear guidelines on how it should be implemented. Consequently, this study presents hitherto unknown strategies for using novel methods, which reflect the particular role of the KTA framework in tailoring recommendations. Aim: The purpose of this study is to examine the use of the UK National Clinical Guidelines for Stroke as a clinical tool for tailoring evidence around upper extremity (UE) rehabilitation after a stroke. Methods: This study used a mixed methods (consensus approach), which includes a survey (n = 26) and nominal group meeting (NGM) with physiotherapists (n=15). Result: The first part of this study (survey) showed that 59 items (recommendations) from the UK National Clinical Guidelines for Stroke around UE post-stroke rehabilitation were accepted as consensus. Of these fifty-nine items, only 5 were rated as “no consensus.” In addition, of all the items that had been included, not a single one was rejected. The results led to three groups of recommendations based on the agreed median scores. These are as follow: lack of agreement (no consensus), highest consensus with tightest range of scores, or lowest consensus with widest range of scores. The second part of this study (NGM) explores four themes, which appeared to significantly influence the concept of “tailoring” and the participants’ ways of thinking. Conclusion: This study illustrates the role of tailoring in bridging the time-gap between the evidence and its implementation in the clinical setting. The study also provides more clarification about the role of tailoring and outlines the steps required to effectively investigate it.

scholarly journals Widespread gaps in the quality of care for primary biliary cholangitis in UK

2021 ◽  
pp. flgastro-2020-101713
Author(s):  
Mathuri Sivakumar ◽  
Akash Gandhi ◽  
Eathar Shakweh ◽  
Yu Meng Li ◽  
Niloufar Safinia ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Medical Records ◽  
Clinical Symptoms ◽  
Primary Biliary Cholangitis ◽  
Cholestatic Liver Disease ◽  
Patient Demographics ◽  
Risk Patients ◽  
Wide Scale ◽  
The Uk

ObjectivePrimary biliary cholangitis (PBC) is a progressive, autoimmune, cholestatic liver disease affecting approximately 15 000 individuals in the UK. Updated guidelines for the management of PBC were published by The European Association for the Study of the Liver (EASL) in 2017. We report on the first national, pilot audit that assesses the quality of care and adherence to guidelines.DesignData were collected from 11 National Health Service hospitals in England, Wales and Scotland between 2017 and 2020. Data on patient demographics, ursodeoxycholic acid (UDCA) dosing and key guideline recommendations were captured from medical records. Results from each hospital were evaluated for target achievement and underwent χ2 analysis for variation in performance between trusts.Results790 patients’ medical records were reviewed. The data demonstrated that the majority of hospitals did not meet all of the recommended EASL standards. Standards with the lowest likelihood of being met were identified as optimal UDCA dosing, assessment of bone density and assessment of clinical symptoms (pruritus and fatigue). Significant variations in meeting these three standards were observed across UK, in addition to assessment of biochemical response to UDCA (all p<0.0001) and assessment of transplant eligibility in high-risk patients (p=0.0297).ConclusionOur findings identify a broad-based deficiency in ‘real-world’ PBC care, suggesting the need for an intervention to improve guideline adherence, ultimately improving patient outcomes. We developed the PBC Review tool and recommend its incorporation into clinical practice. As the first audit of its kind, it will be used to inform a future wide-scale reaudit.

scholarly journals Common hand and wrist conditions: creation of UK research priorities defined by a James Lind Alliance Priority Setting Partnership

BMJ Open ◽  
2021 ◽  
Vol 11 (3) ◽  
pp. e044207
Author(s):  
Alexia Karantana ◽  
Tim Davis ◽  
Donna Kennedy ◽  
Debbie Larson ◽  
Dominic Furniss ◽  
...  
Keyword(s):  
Priority Setting ◽  
Research Priorities ◽  
Treatment Modalities ◽  
Grant Applications ◽  
Charitable Organisation ◽  
James Lind Alliance ◽  
Treatment Uncertainties ◽  
The Uk ◽  
Survey Responses ◽  
Priority Setting Partnership

ObjectivePrioritisation of important treatment uncertainties for ‘Common Conditions Affecting the Hand and Wrist’ via a UK-based James Lind Alliance Priority Setting Partnership.SettingThis process was funded by a national charitable organisation and based in the UK.ParticipantsAnyone with experience of common conditions affecting the adult hand and wrist, including patients, carers and healthcare professionals. All treatment modalities delivered by a hand specialist, including therapists, surgeons or other allied professionals, were considered.InterventionsEstablished James Lind Alliance Priority Setting Partnership methods were employed.Electronic and paper questionnaires identified potential uncertainties. These were subsequently confirmed using relevant, up-to-date systematic reviews. A final list of top 10 research uncertainties was developed via a face-to-face workshop with representation from patients and clinicians. Impact of research was sought by surveying hand clinicians electronically.Outcome measuresThe survey responses and prioritisation—both survey and workshop based.ResultsThere were 889 individually submitted questions from the initial survey, refined to 59 uncertainties across 32 themes. Eight additional uncertainties were added from published literature before prioritisation by 261 participants and the workshop allowed the final top 10 list to be finalised. The top 10 has so far contributed to the award of over £3.8 million of competitively awarded funding.ConclusionsThe Common Conditions in the Hand and Wrist Priority Setting Partnership identified important research questions and has allowed research funders to identify grant applications which are important to both patients and clinicians

scholarly journals Experts’ opinion on the detection and management of prediabetes in Lebanon

2021 ◽  
Vol 104 (3) ◽  
pp. 003685042110294
Author(s):  
Emile Andari ◽  
Paola Atallah ◽  
Sami Azar ◽  
Akram Echtay ◽  
Selim Jambart ◽  
...  
Keyword(s):  
Risk Factors ◽  
Preliminary Report ◽  
Early Stage ◽  
National Guidelines ◽  
Lifestyle Modifications ◽  
Multiple Tests ◽  
Lebanese Population ◽  
To Come ◽  
Near Future

Given that the complications of type 2 diabetes can start at an early stage, early detection and appropriate management of prediabetes are essential. We aimed to develop an expert opinion on prediabetes in Lebanon to pave the way for national guidelines tailored for the Lebanese population in the near future. A panel of seven diabetes experts conducted a thorough literature review and discussed their opinions and experiences before coming up with a set of preliminary recommendations for the detection and management of prediabetes in Lebanon. Lebanese physicians employ multiple tests for the diagnosis of prediabetes and no national cut-off values exist. The panel agreed that prediabetes screening should be focused on patients exceeding 45 years of age with otherwise no risk factors and on adults with risk factors. The panel reached that fasting plasma glucose (FPG) and HbA1c should be used for prediabetes diagnosis in Lebanon. FPG values of 100–125 mg/dL or HbA1c values of 5.7%–6.4% were agreed upon as indicative of prediabetes. For the management of prediabetes, a three-step approach constituting lifestyle modifications, pharmacological treatment and bariatric surgery is recommended. There should be more focus on research on prediabetes in Lebanon. This preliminary report will be further discussed with the Lebanese Society of Endocrinology, Diabetes and Lipids in 2021 in order to come up with the first Lebanese national guidelines for the detection and management of prediabetes in Lebanon.

scholarly journals Development of clinical guidelines for service provision of functional electrical stimulation to support walking: mixed method exploration of stakeholder views

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
C Bulley ◽  
C Meagher ◽  
T Street ◽  
A Adonis ◽  
C Peace ◽  
...  
Keyword(s):  
Electrical Stimulation ◽  
Functional Electrical Stimulation ◽  
Clinical Guidelines ◽  
Service Provision ◽  
Clinical Guideline ◽  
Service Providers ◽  
Delphi Consensus ◽  
Stakeholder Views ◽  
Key Stakeholders ◽  
The Uk

Abstract Background Over the past 20 years Functional Electrical Stimulation (FES) has grown in clinical use to support walking in people with lower limb weakness or paralysis due to upper motor neuron lesions. Despite growing consensus regarding its benefits, provision across the UK and internationally is variable. This study aimed to explore stakeholder views relating to the value of a clinical guideline focusing on service provision of FES to support walking, how people might use it and what should be included. Methods A mixed methods exploration sought the views of key stakeholders. A pragmatic online survey (n = 223) focusing on the study aim was developed and distributed to the email distribution list of the UK Association for Chartered Physiotherapists Interested in Neurology (ACPIN). In parallel, a qualitative service evaluation and patient public involvement consultation was conducted. Two group, and seven individual interviews were conducted with: FES-users (n = 6), their family and carers (n = 3), physiotherapists (n = 4), service providers/developers (n = 2), researchers (n = 1) and distributors of FES (n = 1). Descriptive analysis of quantitative data and framework analysis of qualitative data were conducted. Results Support for clinical guideline development was clear in the qualitative interviews and the survey results. Survey respondents most strongly endorsed possible uses of the clinical guideline as ensuring best practice and supporting people seeking access to a FES service. Data analysis and synthesis provided clear areas for inclusion in the clinical guidelines, including current research evidence and consensus relating to who is most likely to benefit and optimal service provision as well as pathways to access this. Specific areas for further investigation were summarised for inclusion in the first stage of a Delphi consensus study. Conclusions Key stakeholders believe in the value of a clinical guideline that focuses on the different stages of service provision for FES to support walking. A Delphi consensus study is being planned based on the findings.

scholarly journals Orthogeriatrics and Hip Fracture Care in the UK: Factors Driving Change to More Integrated Models of Care

Geriatrics ◽  
2018 ◽  
Vol 3 (3) ◽  
pp. 55 ◽  
Author(s):  
Mark Middleton
Keyword(s):  
Hip Fracture ◽  
Financial Incentives ◽  
Models Of Care ◽  
Social Needs ◽  
Medical Rehabilitation ◽  
Integrated Models ◽  
National Guidelines ◽  
Fracture Care ◽  
The Uk ◽  
The Impact

In the United Kingdom (UK), approximately 80,000 hip fractures each year result in an estimated annual cost of two billion pounds in direct healthcare costs alone. Various models of care exist for collaboration between orthopaedic surgeons and geriatricians in response to the complex medical, rehabilitation, and social needs of this patient group. Mounting evidence suggests that more integrated models of orthogeriatric care result in superior quality of care indicators and clinical outcomes. Clinical governance through national guidelines, audit through the National Hip Fracture Database (NHFD), and financial incentives through the Best Practice Tariff (providing a £1335 bonus for each patient) have driven hip fracture care in the UK forward. The demanded improvement in quality indicators has increased the popularity of collaborative care models and particularly integrated orthogeriatric services. A significant fall in 30-day mortality has resulted nationally. Ongoing data collection by the NHFD will lead to greater understanding of the impact of all elements of hip fracture care including models of orthogeriatrics.

scholarly journals The healthiness and sustainability of national and global food based dietary guidelines: modelling study

BMJ ◽  
2020 ◽  
pp. m2322 ◽  
Author(s):  
Marco Springmann ◽  
Luke Spajic ◽  
Michael A Clark ◽  
Joseph Poore ◽  
Anna Herforth ◽  
...  
Keyword(s):  
Global Health ◽  
Greenhouse Gas Emissions ◽  
Greenhouse Gas ◽  
National Level ◽  
Premature Mortality ◽  
Dietary Guidelines ◽  
National Guidelines ◽  
Gas Emissions ◽  
Paris Climate Agreement ◽  
The Uk

AbstractObjectiveTo analyse the health and environmental implications of adopting national food based dietary guidelines (FBDGs) at a national level and compared with global health and environmental targets.DesignModelling study.Setting85 countries.ParticipantsPopulation of 85 countries.Main outcome measuresA graded coding method was developed and used to extract quantitative recommendations from 85 FBDGs. The health and environmental impacts of these guidelines were assessed by using a comparative risk assessment of deaths from chronic diseases and a set of country specific environmental footprints for greenhouse gas emissions, freshwater use, cropland use, and fertiliser application. For comparison, the impacts of adopting the global dietary recommendations of the World Health Organization and the EAT-Lancet Commission on Healthy Diets from Sustainable Food Systems were also analysed. Each guideline’s health and sustainability implications were assessed by modelling its adoption at both the national level and globally, and comparing the impacts to global health and environmental targets, including the Action Agenda on Non-Communicable Diseases, the Paris Climate Agreement, the Aichi biodiversity targets related to land use, and the sustainable development goals and planetary boundaries related to freshwater use and fertiliser application.ResultsAdoption of national FBDGs was associated with reductions in premature mortality of 15% on average (95% uncertainty interval 13% to 16%) and mixed changes in environmental resource demand, including a reduction in greenhouse gas emissions of 13% on average (regional range −34% to 35%). When universally adopted globally, most of the national guidelines (83, 98%) were not compatible with at least one of the global health and environmental targets. About a third of the FBDGs (29, 34%) were incompatible with the agenda on non-communicable diseases, and most (57 to 74, 67% to 87%) were incompatible with the Paris Climate Agreement and other environmental targets. In comparison, adoption of the WHO recommendations was associated with similar health and environmental changes, whereas adoption of the EAT-Lancet recommendations was associated with 34% greater reductions in premature mortality, more than three times greater reductions in greenhouse gas emissions, and general attainment of the global health and environmental targets. As an example, the FBDGs of the UK, US, and China were incompatible with the climate change, land use, freshwater, and nitrogen targets, and adopting guidelines in line with the EAT-Lancet recommendation could increase the number of avoided deaths from 78 000 (74 000 to 81 000) to 104 000 (96 000 to 112 000) in the UK, from 480 000 (445 000 to 516 000) to 585 000 (523 000 to 646 000) in the USA, and from 1 149 000 (1 095 000 to 1 204 000) to 1 802 000 (1 664 000 to 1 941 000) in China.ConclusionsThis analysis suggests that national guidelines could be both healthier and more sustainable. Providing clearer advice on limiting in most contexts the consumption of animal source foods, in particular beef and dairy, was found to have the greatest potential for increasing the environmental sustainability of dietary guidelines, whereas increasing the intake of whole grains, fruits and vegetables, nuts and seeds, and legumes, reducing the intake of red and processed meat, and highlighting the importance of attaining balanced energy intake and weight levels were associated with most of the additional health benefits. The health results were based on observational data and assuming a causal relation between dietary risk factors and health outcomes. The certainty of evidence for these relations is mostly graded as moderate in existing meta-analyses.

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