TP3-9 Assessment of seizures in over 75-year olds: a clinical audit

2019 ◽  
Vol 90 (3) ◽  
pp. e20.3-e21
Author(s):  
ZT Ahmed ◽  
A Rather
Keyword(s):  
Current Practice ◽  
Clinical Audit ◽  
Data Entry ◽  
Integrated Approach ◽  
Initial Assessment ◽  
National Audit ◽  
Retrospective Audit ◽  
Specialist Referral ◽  
Nice Guidance

ObjectivesThis audit evaluates the assessment of first seizures in over 75-year-olds within our centre using NICE guidance (CG137) as our standard. This is in response to the National Audit of Seizure management in Hospitals which revealed significant deficits in current practice.DesignA retrospective audit design was used.SubjectsWe reviewed patient records of 74 patients over the age of 75 who presented to A+E with their first seizure between 1 st January and 30th April 2017.MethodsData entry took place between 14th November and 22nd January when follow-up information should have been available. A proforma based on current NICE guidance was used to evaluate initial assessment, investigations and specialist review.Results38 females and 36 males were assessed with an average age of 83 years (range 76–95). NICE recommends that all patients are seen by a specialist within 2 weeks, however only 38% of our patients met this standard. Only 65% of patients indicated for an EEG had one and 34% waited longer than the recommended 4 weeks. Neuroimaging was optimal with 95% of patients receiving an MRI within 4 weeks. In contrast, blood glucose was only measured in 47% of patients and only 51% had a 12-lead ECG despite recommendations that these investigations should be performed routinely.ConclusionsThere is a lack of comprehensive A+E assessments and specialist referral for older people both within our centre and nationally. A more thorough and integrated approach is needed to improve outcomes and optimise care.

Current management of popliteal fossa incompetent superficial venous systems

2007 ◽  
Vol 22 (4) ◽  
pp. 179-185 ◽  
Author(s):  
A Kambal ◽  
C Bicknell ◽  
M Najem ◽  
S Renton ◽  
S T Hussain
Keyword(s):  
Current Practice ◽  
Varicose Veins ◽  
Postal Questionnaire ◽  
Popliteal Fossa ◽  
Duplex Scanning ◽  
Initial Assessment ◽  
Current Management ◽  
Skin Changes

Objectives: Controversy exists regarding the management of varicose veins at the level of the popliteal fossa. This questionnaire reviews the current practice of vascular surgeons. Methods: A postal questionnaire was sent to 440 consultant surgeon members of the Vascular Society of Great Britain and Ireland. Recipients were asked to indicate their current practice of investigation and management of small saphenous (SSV), gastrocnemius and Giacomini varicosities. Results: We have received 296 (67%) responses to the questionnaire. Duplex scanning is utilized by 275 (93%) for the initial assessment of patients. Preoperatively, 188 (64%) reuse duplex scanning to mark the saphenopopliteal junction (SPJ) site, 53 (18%) mark with handheld Doppler only and 24 (8%) do not mark the SPJ. At operation, 198 (67%) flush ligate the SPJ and 87 (29%) tie the SSV 2–3 cm from the junction. A total of 101 (34%) usually strip the SSV to various levels. In symptomatic patients, 158 (53%) ligate the SPJ when an incompetent segment of SSV with a competent SPJ exists. One hundred and sixty-nine (57%) disconnect incompetent gastrocnemius veins during SPJ surgery and 172 (58%) regularly look for the Giacomini vein. Routine follow-up after surgery is practised by 172 (58%), most commonly at six weeks. This is mostly (88%) by clinical examination, with 14 (8.1%) using duplex scanning and six (4.7%) using a nurse-run clinic for the follow-up. Conclusions: This review suggests marked variation in the management of popliteal fossa venous incompetence. There is a clear need for further research to clarify the role of ablation in the management of symptoms and skin changes.

Transient loss of consciousness--initial assessment, diagnosis, and specialist referral: summary of NICE guidance

BMJ ◽  
2010 ◽  
Vol 341 (sep02 1) ◽  
pp. c4457-c4457 ◽  
Author(s):  
M. Westby ◽  
I. Bullock ◽  
P. N. Cooper ◽  
S. Davis ◽  
Keyword(s):  
Initial Assessment ◽  
Loss Of Consciousness ◽  
Transient Loss Of Consciousness ◽  
Specialist Referral ◽  
Nice Guidance ◽  
Transient Loss

Clinical audit on nice guidance on anticholinesterases in a memory clinic

2011 ◽  
Vol 26 (S2) ◽  
pp. 829-829
Author(s):  
S. Bangar ◽  
R. Powell
Keyword(s):  
Mental Health ◽  
Clinical Audit ◽  
Mmse Score ◽  
Clinical Excellence ◽  
Memory Clinic ◽  
Baseline Mmse Score ◽  
Nice Guidance

IntroductionThe National Institute for Clinical Excellence (NICE) has laid down certain guidelines for prescribing Anti-cholinesterases in patients with dementia. Keeping in mind the NICE guidance, an audit was conducted to see whether these were followed.Aims and objectivesTo ascertain the level of compliance to the NICE guidance and ensure they are adhered to.MethodThe data was collected from patients attending the memory clinic at Park Royal Centre for Mental Health in Central London over a six month period. Sixteen patients were randomly selected for this audit. The baseline MMSE score was recorded and also the medication prescribed.ResultsThe baseline MMSE score in all the 16 (100%) patients was above the recommended score of 12.The MMSE score was done in 12(75%) patients during follow up at 4–6 months.Of the 12 available MMSE scores at follow up, none were below 12 and hence continued treatment.In 2 (12.5%) patients there was an improvement, in 6 (37.5%) patients there was a fall and in 4 (25%) patients there was no change in the MMSE score at follow up.ConclusionIt was found that the NICE guidance was followed in most (75%) patients.

SP1.1.4The Walking Thread – What happens to fistula-in-ano patients who are lost to follow up? A Service Improvement Study

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Ellen Murgitroyd ◽  
Blair Wilson ◽  
Darja Kremel ◽  
David Anderson
Keyword(s):  
Current Practice ◽  
Single Point ◽  
Perianal Abscess ◽  
Service Improvement ◽  
Fistula In Ano ◽  
Best Management ◽  
Retrospective Audit ◽  
Lost To Follow Up

Abstract Aims Management of perianal abscess and resultant fistula-in-ano remains controversial. Studies suggest that 1/3 of idiopathic cryptoglandular abscesses can result in fistula-in-ano. Our current practice is to incise and drain primary abscesses and for patients to return as necessary. Known fistula patients will be appointed for Examination Under Anaesthetic (EUA) at 6-12 weeks. Does this result in best management or do they become “elective emergencies”? Methods A retrospective audit of management of fistula-in-ano over 4 years was conducted, utilising precollected data of Cryptoglandular abscesses, excluding inflammatory, radiation or malignant causes. Patients lost to follow up were analysed including presentation, fistula diagnosed at first or subsequent attendance, number of operations, number of attendances and seton placement. Results 512 patients underwent operations for cryptoglandular abscess causing fistula-in-ano between 2013 and 2017. 10% (N = 50) were lost to follow up despite documented follow up plans for 32. Of these, 18 were elective attendances, 14 emergency. 24 of the 32 had a Seton sited prior to being lost to follow up. Conclusions The various presentations (emergency, elective, clinic) and waiting lists mean these patients are presenting as emergencies whilst awaiting follow-up. Many are simply lost to follow up, with Setons in-situ.   We propose a fortnightly hot-clinic system, run by second on-call registrars to assess and manage these patients. This would provide an elective clinic to allow single point of access to fistula-in-ano patients ensuring prompt follow-up and reduction in unnecessary EUA, as well as improving senior colorectal trainees exposure to perianal disease and its management.

Profiles of Psychosocial and Clinical Functioning in Adolescence and Risk for Later Depression

2019 ◽  
Author(s):  
Thomas M Olino ◽  
Daniel Klein ◽  
John Seeley
Keyword(s):  
Psychosocial Functioning ◽  
Adolescent Depression ◽  
Depressive Disorders ◽  
Self Report ◽  
Initial Assessment ◽  
Predictive Utility ◽  
Regression Methods ◽  
History Of ◽  
History Of Depression

Background: Most studies examining predictors of onset of depression focus on variable centered regression methods that focus on effects of multiple predictors. In contrast, person-centered approaches develop profiles of factors and these profiles can be examined as predictors of onset. Here, we developed profiles of adolescent psychosocial and clinical functioning among adolescents without a history of major depression. Methods: Data come from a subsample of participants from the Oregon Adolescent Depression Project who completed self-report measures of functioning in adolescence and completed diagnostic and self-report measures at follow-up assessments up to approximately 15 years after baseline. Results: We identified four profiles of psychosocial and clinical functioning: Thriving; Average Functioning; Externalizing Vulnerability and Family Stress; and Internalizing Vulnerability at the baseline assessment of participants without a history of depression at the initial assessment in mid- adolescence. Classes differed in the likelihood of onset and course of depressive disorders, experience of later anxiety and substance use disorders, and psychosocial functioning in adulthood. Moreover, the predictive utility of these classes was maintained when controlling for multiple other established risk factors for depressive disorders. Conclusions: This work highlights the utility of examining multiple factors simultaneously to understand risk for depression.

Gestational diabetes mellitus: are mothers being followed-up? A retrospective study

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X697469
Author(s):  
Rebecca Ward ◽  
Fahmy W Hanna ◽  
Ann Shelley-Hitchen ◽  
Ellen Hodgson ◽  
Adrian Heald ◽  
...  
Keyword(s):  
Gestational Diabetes ◽  
Median Time ◽  
Post Partum ◽  
Tolerance Test ◽  
Oral Glucose ◽  
Tertiary Referral Centre ◽  
Alternative Approach ◽  
Nice Guidance ◽  
History Of

BackgroundWomen with gestational diabetes (GDM) have an elevated risk of developing type 2 diabetes (T2DM). NICE Guidance recommends women who develop GDM are screened 6 weeks post-partum and annually thereafter.AimTo evaluate conformity to guidance of screening in women with GDM by 6-week post-partum fasting plasma glucose (FPG) and annual FPG and determine time between delivery and development of T2DM.MethodRecords at a tertiary referral centre were used to identify women (n = 54) diagnosed with GDM by antenatal oral glucose tolerance test between July 1999 and January 2007. Data from laboratory records were used to collect investigations of glycaemic status during the follow-up period (median follow-up 12.4 years, range 9.5–17.1 years).ResultsOf 252 women, 102 (40.2%) did not have a FPG at 6 weeks (+/−2 weeks). Of these, median time to first test was 1.2 years (range 0.04–10.8 years), with only 43.1% followed-up within 1 year. In those who had a 6-week FPG, 17 (11.3%) women had no further tests. A total of 84 (33% of those with gestational diabetes in the index pregnancy) women were diagnosed with T2DM; median time from delivery to diagnosis was 5.2 years (range 0.35–15.95). We found the only significant factor for a follow-up test at 1-year post-partum was the use of insulin.ConclusionOur data suggest an alternative approach is needed for monitoring women with a history of GDM. This needs to be appropriate for a generally healthy group in which traditional screening mechanisms may not be adequate or sufficient.

scholarly journals MTX optimization or adding bDMARD equally improve disease activity in rheumatoid arthritis: results from the prospective study STRATEGE

Rheumatology ◽  
2021 ◽  
Author(s):  
Cécile Gaujoux-Viala ◽  
Christophe Hudry ◽  
Elena Zinovieva ◽  
Hélène Herman-Demars ◽  
René-Marc Flipo
Keyword(s):  
Disease Activity ◽  
Biological Treatment ◽  
Current Practice ◽  
Treatment Strategies ◽  
Route Optimization ◽  
Treat To Target ◽  
Inadequate Response ◽  
Inclusion Criteria ◽  
Treatment Optimization

Abstract Objectives The STRATEGE study aimed to describe treatment strategies in current practice in RA bDMARD-naive patients with an inadequate response to MTX therapy, and to compare clinical efficacy of the different therapeutic strategies on disease activity after six months. Methods Main inclusion criteria of this prospective, observational, multicentre study were confirmed RA diagnosis, treatment by MTX monotherapy, and need for therapeutic management modification. Results The 722 patients included had a mean (S.D.) RA duration of 5.3 (6.7) years, a mean DAS28 of 4.0 (±1.1); they were all receiving MTX monotherapy, 68% oral, at a mean dose of 15.0 (4.1) mg/wk. Two major strategies were identified: (i) MTX monotherapy dose and/or route optimization (72%) and (ii) bDMARD initiation ± MTX (16%). MTX dosing was modified for 70% of patients, maintained (dose and route) for 28% of patients, and interrupted for 2%. bDMARDs were started when the MTX mean dose was 17.4 mg/wk, 56% parenterally; MTX was maintained concomitantly for 96% of patients. Six-month follow-up results adjusted by propensity score showed that both options were equally successful in improving disease activity and physical function, with 63% and 68% of good-to-moderate EULAR responses, respectively. Conclusion The STRATEGE study shows the importance of initial MTX treatment optimization before initiation of a biological treatment and emphasizes the importance of treat-to-target strategy.

scholarly journals POS1189 THE IMPACT OF TELEMEDICINE AND COVID-19 ON A TERTIARY RHEUMATOLOGY SERVICE: A RETROSPECTIVE AUDIT

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 876-877
Author(s):  
W. Zhu ◽  
T. De Silva ◽  
L. Eades ◽  
S. Morton ◽  
S. Ayoub ◽  
...  
Keyword(s):  
Immunosuppressive Therapy ◽  
Univariate Analysis ◽  
Diagnostic Delay ◽  
Cohort Differences ◽  
Phone Calls ◽  
Retrospective Audit ◽  
Common Diagnosis ◽  
Significant Difference ◽  
The Impact

Background:Telemedicine was widely utilised to complement face-to-face (F2F) care in 2020 during the COVID-19 pandemic, but the impact of this on patient care is poorly understood.Objectives:To investigate the impact of telemedicine during COVID-19 on outpatient rheumatology services.Methods:We retrospectively audited patient electronic medical records from rheumatology outpatient clinics in an urban tertiary rheumatology centre between April-May 2020 (telemedicine cohort) and April-May 2019 (comparator cohort). Differences in age, sex, primary diagnosis, medications, and proportion of new/review appointments were assessed using Mann-Whitney U and Chi-square tests. Univariate analysis was used to estimate associations between telemedicine usage and the ability to assign a diagnosis in patients without a prior rheumatological diagnosis, the frequency of changes to immunosuppression, subsequent F2F review, planned admissions or procedures, follow-up phone calls, and time to next appointment.Results:3,040 outpatient appointments were audited: 1,443 from 2019 and 1,597 from 2020. There was no statistically significant difference in the age, sex, proportion of new/review appointments, or frequency of immunosuppression use between the cohorts. Inflammatory arthritis (IA) was a more common diagnosis in the 2020 cohort (35.1% vs 31%, p=0.024). 96.7% (n=1,444) of patients seen in the 2020 cohort were reviewed via telemedicine. In patients without an existing rheumatological diagnosis, the odds of making a diagnosis at the appointment were significantly lower in 2020 (28.6% vs 57.4%; OR 0.30 [95% CI 0.16-0.53]; p<0.001). Clinicians were also less likely to change immunosuppressive therapy in 2020 (22.6% vs 27.4%; OR 0.78 [95% CI 0.65-0.92]; p=0.004). This was mostly driven by less de-escalation in therapy (10% vs 12.6%; OR 0.75 [95% CI 0.59-0.95]; p=0.019) as there was no statistically significant difference in the escalation or switching of immunosuppressive therapies. There was no significant difference in frequency of follow-up phone calls, however, patients seen in 2020 required earlier follow-up appointments (p<0.001). There was also no difference in unplanned rheumatological presentations but significantly fewer planned admissions and procedures in 2020 (1% vs 2.6%, p=0.002). Appointment non-attendance reduced in 2020 to 6.5% from 10.9% in 2019 (OR 0.57 [95% CI 0.44-0.74]; p<0.001), however the odds of discharging a patient from care were significantly lower in 2020 (3.9% vs 6%; OR 0.64 [95% CI 0.46-0.89]; p=0.008), although there was no significance when patients who failed to attend were excluded. Amongst patients seen via telemedicine in 2020, a subsequent F2F appointment was required in 9.4%. The predictors of needing a F2F review were being a new patient (OR 6.28 [95% CI 4.10-9.64]; p<0.001), not having a prior rheumatological diagnosis (OR 18.43 [95% CI: 2.35-144.63]; p=0.006), or having a diagnosis of IA (OR 2.85 [95% CI: 1.40-5.80]; p=0.004) or connective tissue disease (OR 3.22 [95% CI: 1.11-9.32]; p=0.031).Conclusion:Most patients in the 2020 cohort were seen via telemedicine. Telemedicine use during the COVID-19 pandemic was associated with reduced clinic non-attendance, but with diagnostic delay, reduced likelihood of changing existing immunosuppressive therapy, earlier requirement for review, and lower likelihood of discharge. While the effects of telemedicine cannot be differentiated from changes in practice related to other aspects of the pandemic, they suggest that telemedicine may have a negative impact on the timeliness of management of rheumatology patients.Disclosure of Interests:None declared.

Health assessments for Indigenous Australians at Orange Aboriginal Medical Service: health problems identified and subsequent follow up

2016 ◽  
Vol 22 (3) ◽  
pp. 233 ◽  
Author(s):  
Tegan Dutton ◽  
Wendy Stevens ◽  
Jamie Newman
Keyword(s):  
Medical Service ◽  
Pap Smear ◽  
Aboriginal Health ◽  
Indigenous Australians ◽  
Adult Women ◽  
Health Issues ◽  
Retrospective Audit ◽  
Health Assessments ◽  
Clinical Records

This study aimed to document the types, management and follow up of health issues identified by all Aboriginal Health Assessments (AHA) performed at Orange Aboriginal Medical Service from 1 January 2011 to 31 December 2012. This was done with a retrospective audit of clinical records. In total, 1169 AHAs were performed: 41% child, 53% adult and 6% older person AHAs. Newly identified health issues were documented in 85% (984). Being overweight (41%; 476) and smoking (26%; 301) were the common risk factors identified. As a result of the AHA, most children who were not up-to-date with their vaccinations received catch-up immunisations; 11% (36) of adult women (n=314) received a Pap smear, although Pap smear status was unknown or not up-to-date for 61% (192); 27% (311) of cases were prescribed new medication; and 1239 referrals were made but only 40% were attended. At 6 months following the AHA, 26% (240) of cases with newly identified health issues were completely managed and followed up, whereas 25% (226) received no follow up. The AHAs are useful for identifying new health issues; however, follow up of the identified health issues should be improved. If AHAs are to improve health outcomes, appropriate management and follow up of the identified health issues are essential.

Effectiveness of Treatment for Dissociative Identity Disorder

1998 ◽  
Vol 83 (2) ◽  
pp. 483-490 ◽  
Author(s):  
Russell A. Powell ◽  
Andrew J. Howell
Keyword(s):  
Dissociative Identity Disorder ◽  
Initial Assessment ◽  
Systematic Research ◽  
Millon Clinical Multiaxial Inventory ◽  
Effect Of Treatment ◽  
Severe Pathology ◽  
Differential Responsiveness ◽  
Rule Out ◽  
Statistical Criteria

In a recent study by Ellason and Ross, patients with Dissociative Identity Disorder reported a decrease in symptoms on the Millon Clinical Multiaxial Inventory–II over a 2-yr. follow-up period. Patients judged to have achieved integration of their personalities rated themselves as more substantially improved on the Millon–II than did patients judged not to have achieved integration. Ellason and Ross suggested that this improvement reflected the influence of treatment; however, for several reasons, their findings are open to alternative interpretations. First, in the absence of proper control conditions, one cannot rule out the contribution of other factors to the over-all improvement of patients such as regression of symptoms toward the mean following the initial assessment. Second, patients' self-reported improvement was less substantial when data were reanalyzed using more appropriate statistical criteria. Third, the greater improvement observed among integrated patients relative to nonintegrated patients may reflect influences other than differential responsiveness to treatment, such as less severe pathology prior to treatment. More systematic research is needed to clarify the effect of treatment on Dissociative Identity Disorder.

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