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  • An audit of the prescription and supply of medicines by podiatric surgery teams in the UK

    Maher, Anthony (2022)
    Aim: To gain a greater understanding of the methods used by podiatric surgeons to access medicines in the UK. Within that, it is also relevant to establish the range and quantity of medicines utilised to support patient care. With the advent of independent prescribing for podiatrists, the authors were keen to identify whether prescribing was being adopted by a sub-speciality of the podiatry profession and whether alternate means of accessing medicines, such as Patient Group Directions or exemptions remain relevant in clinical practice. Methods: The PASCOM 10 system was accessed to generate reports for the 2019 calendar year relating to podiatric surgery. The following reports were requested; procedures, fixations, anaesthesia, demographics, medications, post-treatment sequelae, patient satisfaction (PSQ-10), Manchester Oxford foot/ankle questionnaire (MOXFQ), providers and referrals. Results: In 2019 there were 11189 admissions for podiatric surgery in England recorded on the PASCOM 10 database. A total of 103 surgery centres contributed data resulting in 18497 procedures. Care was primarily offered in NHS settings accounting for 91% of activity, 94% of these procedures were performed under a local anaesthetic block. 18576 medicines were supplied, administered or prescribed from a list of 70 individual items. 29% of all medicines were prescribed by a podiatrist. Controlled drugs accounted for 28.7% of all recorded medicines. Conclusions: Through analysis of PASCOM 10 data, the range of medicines accessed by podiatric surgeons and their teams to support patient care perioperatively and the routes of accessing these medicines have been identified. Encouragingly, independent prescribing appears to be a frequent choice for accessing certain medicines. There is thorough evidence of a need for greater prescribing rights. Of note, it appears the management of postoperative pain could be improved with wider access to controlled drugs, namely opioid analgesics. PASCOM-10 has the capacity to provide revealing data on prescribing in podiatric clinical practice that is unique in the UK, though more work is required to ensure the validity of the dataset.
  • Correction of hallux abducto valgus by scarf osteotomy. A ten-year retrospective multicentre review of patient reported outcomes shows high satisfaction rates with podiatric surgery

    Clee, Sharon; Pavier, Julian (2022)
    BACKGROUNDCorrective surgery for hallux abducto valgus is one of the most performed elective procedures in foot and ankle practice. Numerous methods of surgical correction have been reported within the literature, with varying clinical and patient reported outcomes. This study reviews the patient experience and outcomes in five podiatric surgery centres using the scarf diaphyseal osteotomy.METHODPatient reported outcome measures (PROMs) were captured using the Patient Satisfaction Questionnaire 10 (PSQ-10), part of the PASCOM-10 podiatric surgery audit tool. PROMs were collated across five hospital sites over a 10-year period.RESULTSOf 1351 patients reported during the period, 1189 had complete retrospective data. The most common patient aim of surgery was 'no/less pain' reported in 70% of patients. 96.8% of patients reported their original foot complaint as 'better' or 'much better' after surgery. 92.8% of patients reported their expectations had been met with 96.6% reporting they would have surgery again under the same conditions. 98.5% of patients noted that the risks, complications, and expectations had been discussed prior to surgery. The most common complication was metatarsal fracture (4.6%).CONCLUSIONThe scarf osteotomy (with or without an Akin phalangeal osteotomy) consistently showed high patient satisfaction with low complication rates using PSQ-10 and this information can be used as part of the pre-operative consenting process. Patient expectations for surgery were often achieved, which may be attributed to the pre-operative work up of the patient. Further investigation into this correlation is suggested.LEVEL OF CLINICAL EVIDENCEIV (retrospective review).
  • Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study

    Drummond, Avril; Thomson, Louise (2020)
    Background: Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients’ needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively. Objectives: To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks. Design: An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process. Setting: Orthopaedic departments in NHS secondary care. Participants: Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers. Interventions: Occupational advice intervention. Main outcome measures: Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost. Results: A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff. Limitations: Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it. Conclusions: The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention. Future work: The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained.
  • Complete versus incomplete surgical resection in intramedullary ependymomas: A systematic review and meta-analysis

    Shokraneh, Farhad (2020)
    STUDY DESIGNSystematic review.OBJECTIVETo compare outcomes of complete versus incomplete resection in primary intramedullary spinal cord ependymoma.METHODSA comprehensive search of the MEDLINE, CENTRAL, and Embase databases was conducted by 2 independent investigators. Random-effect meta-analysis and meta-regression with seven covariates were performed to evaluate the reason for the heterogeneity among studies. We also used individual patient data in the integrative analysis to compare complete and incomplete resection based on 4 outcomes: progression-free survival (PFS), overall survival (OS), postoperative neurological improvement (PNI), and follow-up neurological improvement (FNI).RESULTSA total of 23 studies were identified, including 407 cases. Significant heterogeneity among included studies was observed in risk estimates (I2 for PFS, FNI, and PNI were 49.5%, 78.3%, and 87.2%, respectively). The mean follow-up time across cases was 48.6 ± 2.35 months. Cox proportional multivariable analysis revealed that the complete resection can prolong PFS (model, hazard ratio = 0.18, CI 0.05-0.54, P = .004,) and improve the FNI (binary logistic regression, adjusted odds ratio = 16.5, CI 1.6-171, P = .019). However, PNI and OS were similar in patients with incomplete resected spinal cord ependymoma compared with complete resection (binary logistic regression respectively and Cox multivariable analysis, P > .5).CONCLUSIONThe data presented in this study showed that OS was not significantly affected by the degree of surgery. However, complete resection of intramedullary ependymomas provides the optimal outcomes with longer PFS and better long-term neurological outcomes than incomplete resection.
  • Does laparoscopic colorectal surgery result in short and long term post-operative cognitive decline (POCD)?

    Guo, Boliang (2020)
    Postoperative cognitive decline (POCD) is defined as a new cognitive impairment arising after surgical intervention. There is some concern that prolonged Trendelenburg positioning during laparoscopic colorectal surgery may cause POCD. Patients with POCD may experience prolonged hospitalisation and take longer returning to their normal level of functioning. Cognitive function can be assessed using validated tests including: N Back, Stroop; and Lexical Decision Making Task. Aim: To assess percentage of short and long-term POCD following laparoscopic colorectal surgery. Assess the effect of time spent in Trendelenburg position on developing POCD. Methods: Patients undergoing laparoscopic colorectal surgery were recruited. Cognitive tests including: 1, 2 and 3 back, lexical decision making task and stroop task were carried out pre-operatively and repeated Day 1, and minimum 3 months post-operatively. For assessment of POCD Day 1, the baseline was subtracted from Day 1 results for each test. This result was then divided by the standard deviation of the control group to give a Z score. A large positive Z score (>1.96) showed a deterioration in cognitive function from baseline for accuracy, and a large negative Z score (> -1.96) for response time. An individual Z score of 1.96 or more was defined as cognitive dysfunction. Results: Forty-six patients were recruited (26 males, 24 female), mean age 66 years (SD± 5.18). Of which 55% had POCD on Day 1; and 37 patients completed long-term follow up of which 32% had POCD. Conclusion: Our study does show a significant number of patients develop both long and short term POCD following laparoscopic colorectal surgery. © 2020 Elsevier Inc.
  • Bunion hallux valgus behind the scenes

    Maher, Anthony (2019)
    This is a book review of "Bunion Hallux Valgus: Behind the Scenes A New Foot Pain Series" by David R. Tollafield
  • What is podiatric surgery, and can it help to improve outcomes for chronic diabetic foot disease?

    Maher, Anthony; Metcalf, Lisa (2019)
    The relentless demand for diabetic foot care and the drive to reduce amputation rates is placing an untenable strain on an already financially stretched English national health service. As a consequence, commissioners and providers alike are having to come together to consider novel ways of working. This article argues that integrating podiatric surgery into the acute diabetes multidisciplinary team (MDT) may be part of the solution to easing pressure on hospital services. The authors share their experience of utilising podiatric surgery in the management of diabetic foot disease. Podiatric surgeons in England currently work in a variety of acute and community settings but increasingly have a role to play in the acute MDT. Podiatric surgeons can offer the MDT advice or treatment where the usual conservative podiatric or medical treatments have failed to heal ulceration or infection.
  • Evaluating the variation of intraocular pressure with positional change during colorectal laparoscopic surgery: Observational study

    Guo, Boliang (2018)
    Background: The incidence of perioperative visual loss following colorectal surgery in the US is quoted as 1.24 per 10,000. Raised intraocular pressure (IOP) during extreme Trendelenburg position leading to reduced optic nerve perfusion is thought to be a cause. Objective: To assess the effect of the degree of Trendelenburg tilt and time spent in Trendelenburg on IOP during laparoscopic colorectal surgery. Methods: Fifty patients undergoing laparoscopic colorectal surgery were recruited. A Tonopen XL applanation tonometer was used to take IOP measurements hourly during surgery, and each time the operating table was tilted. A correlation coefficient for the degree of Trendelenburg tilt and IOP was calculated for each patient. Group 1 included patients undergoing a right-sided colonic procedure, and Group 2 included all left-sided colonic operations. Results: The mean age of Group 1 participants (n=25) was 69 years (SD 14), and Group 2 (n=25) was 63 years (SD 16; P>.05). The average length of surgery for Group 1 was 142 minutes (SD 48), and Group 2 was 268 minutes (SD 99; P≤.05). The mean maximum degree of Trendelenburg tilt in Group 1 was 10 (SD 7) and Group 2 was 19 (SD 6; P≤.05). The mean IOP increase was 9 mm Hg (SD 5) for Group 1 and 15 mm Hg (SD 5) in Group 2 (P≤.05). An overall correlation coefficient for the degree of Trendelenburg tilt and IOP change (n=48) was .78. Conclusions: There is a strong correlation between IOP elevation during laparoscopic colorectal surgery and the degree of Trendelenburg tilt. This may be significant for patients undergoing prolonged surgery and especially those with glaucoma.
  • Patient expectations of podiatric surgery in the United Kingdom

    Maher, Anthony (2011)
    Patient expectations can be difficult to conceptualise and are liable to change with time, health and environmental factors. Patient expectation is known to influence satisfaction, however little is known about the expectations of patients attending for podiatric surgery. This paper will explore the expectations of a large cohort of patients undergoing elective foot surgery.
  • PASCOM-10 how to report your podiatric activity and outcomes

    Maher, Anthony (2018)
    PASCOM has its origins as a paper-based audit of podiatric surgery dating back to the late 1990s. Since the early 2000s, PASCOM has been under the direction of the College of Podiatry. Following a major investment in the system, an online version was launched in May 2010, and made available to all members. The website is able to capture activity and patient-reported outcome measures (PROMS) for all elements of podiatry.
  • An analysis of Euroqol EQ-5D and Manchester Oxford Foot Questionnaire scores six months following podiatric surgery

    Maher, Anthony (2012)
    In the United Kingdom patient-reported outcome measures (PROMS) have been adopted as a key measure of foot surgery outcomes. The intention of this study was to evaluate the responsiveness of a regional outcome measure; the Manchester Oxford Foot Questionnaire (MOXFQ) and a generic measure; the EuroQol EQ-5D, in the context of day care Podiatric Surgery.
  • A midterm review of lesser toe arthrodesis with an intramedullary implant

    Harmer, James; Maher, Anthony (2017)
    Lesser toe deformities are one of the most common conditions encountered by podiatric surgeons. When conservative treatments fail surgical correction is indicated. Many surgical options have been described to address the complex nature of these deformities but no perfect solution has been reported to date. However, with the continued advancement of internal fixation technology, interphalangeal joint (IPJ) arthrodesis with an intramedullary implant may be a good option. This retrospective study presents patient reported outcomes and complications at 6 months and 3 years following lesser toe proximal interphalangeal joint (PIPJ) arthrodesis with a polyketone intrameduallary implant (Toe Grip, Orthosolutions, UK). Between September 2011 and November 2012, a total of 38 patients attended for second toe PIPJ arthrodesis by means of the Toe Grip device. At 6 months postoperation, 94.7% of patients and at 3 years postoperation, 92.8% of patients felt that their original complaint was better or much better. Health-related quality of life scores continued to improve overtime as measured by the Manchester Oxford Foot Questionnaire. Complications were generally observational and asymptomatic. The most common complications were floating toes (17.8%), mallet deformities (14.2%), metatarsalgia (17.8%), and transverse plane deformity of the toe (10.7%). This study demonstrates excellent patient-eported outcomes with minimal symptomatic complications making the ?Toe Grip? implant a safe and effective alternative fixation device for IPJ arthrodesis when dealing with painful digital deformities.Levels of Evidence: Therapeutic, Level IV: Case series
  • Can the SENSIMED Triggerfish lens data be used as an accurate measure of intraocular pressure?

    Guo, Boliang (2018)
    Purpose: The SENSIMED Triggerfish<sup></sup> contact lens sensor (CLS) has an embedded micro-sensor that captures spontaneous circumferential changes at the corneoscleral junction and transmits them via an antenna to a device where these measurements are stored. During laparoscopic colorectal surgery, patients are placed in Trendelenburg position which has been shown to increase intraocular pressure (IOP). Laparoscopic colorectal surgery requires both pneumoperitoneum and Trendelenburg positioning; therefore, IOP can vary significantly. We aimed to assess whether circumferential changes in the corneoscleral area can be correlated to IOP changes measured using Tono-pen<sup></sup> XL applanation tonometer during laparoscopic colorectal surgery. Method: Patients undergoing laparoscopic colorectal resections were included. On the day of surgery, baseline IOP was taken and the SENSIMED Triggerfish<sup></sup> CLS was then set up in one eye of the patient. During surgery (whilst under general anaesthetic), IOP measurements were taken in the contralateral eye using a Tono-pen<sup></sup> XL applanation tonometer every hour and any time the table was moved to record the fluctuations of IOP during surgery and any association with position change. The timings of these readings were documented. Results: Twenty patients were included in this study (six males, 14 females). Average age was 64.6 years (SD = 16.3). The fluctuation in IOP measured in the reference eye ranged between 6.3 and 46.7 mmHg. The mean correlation coefficient between CLS output measurements and these IOP measurements was r = 0.291 (95% CI). Conclusion: Our results showed a weak correlation between the SENSIMED Triggerfish<sup></sup> CLS data output and IOP measurements taken using the Tono-pen<sup></sup> XL applanation tonometer.<br/>Copyright &#xa9; 2017 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd
  • A retrospective audit of lesion excision and rotation skin flap for the treatment of intractable plantar keratosis

    Saipoor, Amir; Maher, Anthony; Hogg, Lance (2017)
    AIMThe purpose of this study was to evaluate the treatment of plantar skin lesions by excision and rotation skin flap closure with reference to patient satisfaction; patient reported outcomes and complication rates.METHODA retrospective audit of 54 consecutive patients who had undergone plantar lesion excision with rotation skin flap between May 2011 and November 2015 under the care of experienced consultant podiatric surgeons. A total of 36 patients were included in this study, 16 were lost to follow up, 2 patients were excluded due to non-related pathology. Outcomes were reviewed retrospectively via data extracted from PASCOM-10. This included the MOXFQ and also the PSQ-10 patient satisfaction questionnaire. Data extracted was analysed.RESULTSThe mean MOXFQ scores improved across the three domains. Walking/standing improved from 68.75 (SD: 17.62) pre-operative to 41.38 (SD: 32.94) post-operative. Pain improved from 63.47 (SD: 19.41) pre-operative to 36.53 (SD: 25.51) post-operative and social interaction improved from 53.88 (SD: 20.33) pre-operative to 29.13 (SD: 26.56) post-operative. Similarly, the PSQ-10 scores have shown positive outcomes where 88.9% out of the cohort felt that their aims of surgery had been met.CONCLUSIONThis audit has demonstrated that the Schrudde flap is an effective and alternative safe surgical procedure for the treatment of intractable plantar keratosis and viral warts.

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