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    • Eczema Care Online behavioural interventions to support self-care for children and young people: two independent, pragmatic, randomised controlled trials

      Santer, Miriam; Muller, Ingrid; Becque, Taeko; Stuart, Beth; Hooper, Julie; Steele, Mary; Wilczynska, Sylvia; Sach, Tracey H; Ridd, Matthew J; Roberts, Amanda; et al. (2022-12)
      Objective To determine the effectiveness of two online behavioural interventions, one for parents and carers and one for young people, to support eczema self-management. Design Two independent, pragmatic, parallel group, unmasked, randomised controlled trials. Setting 98 general practices in England. Participants Parents and carers of children (0-12 years) with eczema (trial 1) and young people (13-25 years) with eczema (trial 2), excluding people with inactive or very mild eczema (≤5 on POEM, the Patient-Oriented Eczema Measure). Interventions Participants were randomised (1:1) using online software to receive usual eczema care or an online ( behavioural intervention for eczema plus usual care. Main outcome measures Primary outcome was eczema symptoms rated using POEM (range 0-28, with 28 being very severe) every four weeks over 24 weeks. Outcomes were reported by parents or carers for children and by self-report for young people. Secondary outcomes included POEM score every four weeks over 52 weeks, quality of life, eczema control, itch intensity (young people only), patient enablement, treatment use, perceived barriers to treatment use, and intervention use. Analyses were carried out separately for the two trials and according to intention-to-treat principles. Results 340 parents or carers of children (169 usual care; 171 intervention) and 337 young people (169 usual care; 168 intervention) were randomised. The mean baseline POEM score was 12.8 (standard deviation 5.3) for parents and carers and 15.2 (5.4) for young people. Three young people withdrew from follow-up but did not withdraw their data. All randomised participants were included in the analyses. At 24 weeks, follow-up rates were 91.5% (311/340) for parents or carers and 90.2% (304/337) for young people. After controlling for baseline eczema severity and confounders, compared with usual care groups over 24 weeks, eczema severity improved in the intervention groups: mean difference in POEM score −1.5 (95% confidence interval −2.5 to −0.6; P=0.002) for parents or carers and −1.9 (−3.0 to −0.8; P<0.001) for young people. The number needed to treat to achieve a 2.5 difference in POEM score at 24 weeks was 6 in both trials. Improvements were sustained to 52 weeks in both trials. Enablement showed a statistically significant difference favouring the intervention group in both trials: adjusted mean difference at 24 weeks −0.7 (95% confidence interval −1.0 to −0.4) for parents or carers and −0.9 (−1.3 to −0.6) for young people. No harms were identified in either group. Conclusions Two online interventions for self-management of eczema aimed at parents or carers of children with eczema and at young people with eczema provide a useful, sustained benefit in managing eczema severity in children and young people when offered in addition to usual eczema care.
    • Medical treatment for heavy menstrual bleeding in primary care: 10-year data from the ECLIPSE trial

      Kai, Joe; Dutton, Brittany; Vinogradova, Yana; Hilken, Nicholas; Gupta, Janesh; Daniels, Jane (2022-12)
      Background: Heavy menstrual bleeding (HMB) is a common problem that can significantly affect women's lives. There is a lack of evidence on long-term outcomes after seeking treatment. Aim: To assess continuation rates of medical treatments and rates of surgery in women 10 years after initial management for HMB in primary care. Design and setting: This was a prospective observational cohort study. Method: Women with HMB who participated in the ECLIPSE primary care trial (ISRCTN86566246) completed questionnaires 10 years after randomisation to the levonorgestrel-releasing intrauterine system (LNG-IUS) or other usual medical treatments (oral tranexamic acid, mefenamic acid, combined oestrogen-progestogen; or progesterone alone). Outcomes were rates of surgery, medical treatments, and quality of life using the 36-item Short-Form Health Survey (SF-36) and EuroQoL EQ-5D. Results: The responding cohort of 206 women was demographically and clinically representative of the original trial population. Mean age at baseline was 41.9 years (SD 4.9) and 53.7 years (SD 5.1) at follow-up. Over the 10-year follow-up, 60 of 206 (29.1%) women had surgery (hysterectomy n = 34, 16.5%; endometrial ablation n = 26, 12.6%). Between 5 and 10 years, 89 women (43.2%) ceased all medical treatments and 88 (42.7%) used LNG-IUS alone or in combination with other treatments. Fifty-six women (27.2%) were using LNG-IUS at 10 years. There were improvements over time in quality-of-life scores, with no evidence of differences in these or other outcomes between the two groups. Conclusion: Medical treatments for women with HMB can be successfully initiated in primary care, with low rates of surgery and improvement in quality of life observed a decade later.
    • Scale, scope and impact of skill mix change in primary care in England: a mixed-methods study

      McDermott, Imelda; Spooner, Sharon; Goff, Mhorag; Gibson, Jon; Dalgarno, Elizabeth; Francetic, Igor; Hann, Mark; Hodgson, Damian; McBride, Anne; Checkland, Katherine; et al. (2022-05)
      Background: General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals. Objectives: Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs. Design: NHS Digital workforce data (2015–19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August–December 2019) explored factors motivating general practices’ employment decisions. An in-depth case study of five general practices in England (August–December 2019) examined how a broader range of practitioners is experienced by practice staff and patients. Results: We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients’ problems with practitioners’ competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners’ job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between skill mix and hospital activity were mixed. Our analysis of payments to practices and prescribing costs suggested that NHS expenditure may not decrease with increasing skill mix employment.
    • The onset, progress and factors influencing degenerative arthritis of the wrist following scaphoid fracture non-union

      Dias, Joseph; Kheiran, Amin; Adeleye, Emmanuel; Wildin, Clare; Ullah, Aamer; Bhowal, Bhaskar
      Background/aims: Scaphoid non-union causes osteoarthritis but factors associated are poorly understood. We investigated the rate of osteoarthritis after scaphoid fracture non-union, and if duration and fracture location influenced arthritis and its severity. Methods: This retrospective cross-sectional observational study of 278 consecutive cases with scaphoid fracture non-union retrieved data on demographics, non-union duration, fracture location, dorsal intercalated segment instability (DISI), severity and distribution of wrist arthritis. Patient Evaluation Measure (PEM) and Quality of Life assessed impact on patients. Regression models investigated prediction of osteoarthritis by different variables. Time-to-event analysis investigated osteoarthritis evolution. Missing (MAR) data for the PEM and QoL was imputed and analysed. Results: 278 patients, 246 males, aged 27.9 years (range 11 to 78 years), with a scaphoid fracture non-union confirmed on computed tomography (CT) scans (243) and plain radiographs (35) were reviewed. The interval between injury and imaging was 3.3 years (SD 5.9 years; range 0.1-45). The fracture was proximal to the ridge in 162, distal to the ridge in 83 and in the proximal 20% in 33. DISI (RLA ≥ 10°) occurred in 93.5% (260/278). Osteoarthritis was identified in 62.2% (173/278), and we classified a SNAC pattern in 93.6% (162/173). Of these, 100 (61.7%) had SNAC 1, 22 (13.6%) SNAC 2, 17 (10.5%) SNAC 3, and 23 (14.2%) SNAC 4. The mean duration in years for SNAC 1, 2, 3 and 4 were 2.5, 6.0, 8.2, and 11.3 years respectively. In fractures proximal to the ridge, 50% had arthritis in 2.2 years. Whereas in proximal pole, and distal to the ridge, 50% developed in 3.8 and 6.6 years, respectively. The PEM score was 42.8% (SD 18.9%) in those without arthritis and 48.8% (SD 21.5%) in those with arthritis. The mean QoL was 0.838 in patients without SNAC and 0.792 with SNAC. Conclusion: Scaphoid fracture non-union caused early carpal collapse, majority had osteoarthritis usually observed within a year following injury and occurred earliest in proximal waist fractures. Distribution of osteoarthritis (SNAC stage) may not always follow a distinctive pattern, as previously described.
    • FIT stratification in the COVID era - Is it safe for rectal bleeding?

      Seehra, Jaspreet; Bailey, James A; Chapman, Caroline J; Morling, Joanne R; Humes, David J; Banerjea, Ayan (Oxford University Press, 2021)
      Aims: Faecal Immunochemical Tests (FIT) are increasingly used for stratification of colorectal cancer risk in symptomatic patients. FIT is not currently recommended for use in patients with rectal bleeding, but recent studies have reported its safe use. We report our experiences of FIT in patients presenting with rectal bleeding during the COVID-19 pandemic. Method(s): Patients referred to NUH NHS Trust with rectal bleeding from 15/04/20-15/08/20 were invited to complete a postal-based FIT (OCSensor). Demographics, symptoms, investigations and results were recorded. Outcomes were retrospectively reviewed using an electronic hospital system. Result(s): 344 patients were invited to participate, with 301 (87.5%) returning FITs in accordance with testing protocol. 36 patients declined to be seen, 4 were considered not fit for investigation, and 4 had incomplete records. 257 patients were included in the final analysis with 10 CRC detected (3.9%). Rectal bleeding (257, 100%) was the most common presenting symptom followed by change in bowel habit (133, 51.8%). 10 CRC were diagnosed (3.9%). 2 CRC were detected with FIT 100 mug Hb / g faeces (8/45, 17.8%). FIT result was significantly associated with CRC diagnosis (p<0.0001). 4 with CRC had anaemia (4/53, 7.5%), 1 had thrombocytosis (1/12, 8.3%). Conclusion(s): FIT missed 20% of CRC in this patient group with the application of a very low threshold (<4 mug Hb / g faeces). Both cancers missed by FIT were detectable on digital rectal examination, emphasising the importance of this examination in primary care.
    • Quantitative FIT stratification is superior to NICE referral criteria NG12 in a high-risk colorectal cancer population

      Bailey, James A; Ibrahim, H; Bunce, J; Chapman, Caroline J; Morling, Joanne R; Simpson, J; Humes, David J; Banerjea, Ayan (Springer Nature, 2021)
      BACKGROUND: Guidelines for urgent investigation of colorectal cancer (CRC) are based on age and symptom-based criteria. This study aims to compare the diagnostic value of clinical features and faecal immunochemical test (FIT) results to identify those at a higher risk of CRC, thereby facilitating effective triage of patients., METHODS: We undertook a review of all patients referred for investigation of CRC at our centre between September 2016 and June 2018. Patients were identified using a prospectively recorded local database. We performed a logistic regression analysis of factors associated with a diagnosis of CRC., RESULTS: One-thousand-and-seven-hundred-eighty-four patients with FIT results were included in the study. Change in bowel habit (CIBH) was the most common referring clinical feature (38.3%). Patients diagnosed with CRC were significantly older than those without malignancy (74.0 years vs 68.9 years, p = 0.0007). Male patients were more likely to be diagnosed with CRC than females (6.5% vs 2.5%, Chi-squared 16.93, p = 100 microg Hb/g faeces group (55/181, 30.4%)., CONCLUSION: In a multivariate model, FIT outperforms age, sex and all symptoms prompting referral. FIT has greater stratification value than any referral symptoms. FIT does have value in patients with iron deficiency anaemia. Copyright © 2021. Springer Nature Switzerland AG.
    • Faecal immunochemical testing reduces demand and improves yield of Leicester's 2-week pathway for change in bowel habit

      Chapman, Caroline J
      Aim: We look at the effect of introducing the faecal immunochemical test (FIT) in the straight-to-test 2-week pathway for change in bowel habit (CIBH).; Method: The FIT in primary care triages 2-week wait (2WW) colorectal referrals for patients aged 60 years and above for straight-to-test CT colonography (CTC). We compare the impact of the FIT on numbers of 2WW CTCs, in the year before and after FIT, in both colorectal cancer (CRC) detection and cost-effectiveness at both 4 μg Hb/g faeces and 10 μg Hb/g faeces.; Results: At a threshold of 4 μg Hb/g faeces, the positive predictive value of the FIT for diagnosis of CRC is 5.0% with a negative predictive value of 99.8% and a polyp detection rate of 25.5%. The introduction of the FIT resulted in a reduction in the number of CTCs performed through the CIBH pathway from a mean of 143.9 per month prior to the FIT to 66.8 CTCs per month once the FIT was well established. Given a FIT threshold of 10 μg Hb/g the number of CTCs would be predicted to fall by 70.4% to 42.6 CTCs per month resulting in higher CRC and polyp detection rate, and an estimated annual cost saving of £238 258 in our institution.; Conclusion: The FIT use in primary care improves the yield of 2WW referrals for CIBH alone and reduces the burden and cost of investigations to exclude CRC. Improvements may be possible by increasing the cut-off employed, without adversely affecting the risk of missing a cancer.
    • Including a general practice endorsement letter with the testing kit in the Bowel Cancer Screening Programme: Results of a cluster randomised trial

      Chapman, Caroline J (Sage, 2021)
      OBJECTIVES: To evaluate the effect of general practitioner endorsement accompanying the screening kit rather than with the invitation letter on participation in the NHS Bowel Cancer Screening Programme and on the socioeconomic gradient in participation in the Programme., METHODS: The NHS Bowel Cancer Screening Programme in England is delivered via five regional hubs. In early 2016, we carried out a cluster-randomised trial, with hub-day of invitation as the randomisation unit. We randomised 150 hub-days of invitation to the intervention group, GP endorsement on the letter accompanying the guaiac faecal occult blood testing kit (75 hub-days, 197,366 individuals) or control, usual letter (75 hub-days, 197,476 individuals). The endpoint was participation, defined as return of a valid kit within 18 weeks of initial invitation. Because of the cluster randomisation, data were analysed by a hierarchical logistic regression, allowing a random effect for date of invitation. Socioeconomic status was represented by the index of multiple deprivation., RESULTS: Participation was 59.4% in the intervention group and 58.7% in the control group, a significant difference (p = 0.04). There was no heterogeneity of the effect of intervention by index of multiple deprivation. We found that there was some confounding between date and screening episode order (first or subsequent screen). This in turn may have induced confounding with age and slightly diluted the result., CONCLUSIONS: General practitioner endorsement induces a modest increase in participation in bowel cancer screening, but does not affect the socioeconomic gradient. When considering cluster randomisation as a research method, careful scrutiny of potential confounding is indicated in advance if possible and in analysis otherwise.
    • Service evaluation of faecal immunochemical testing and anaemia for risk stratification in the 2-week-wait pathway for colorectal cancer

      Chapman, Caroline J; Bunce, J; Ng, O; Logan, Richard F; Humes, David J; Banerjea, Ayan (John Wiley & Sons Ltd, 2019)
      Background: New national guidance on urgent referral for investigation of colorectal cancer included faecal occult blood testing in 2015. A service evaluation of faecal immunochemical testing (FIT) and anaemia as risk stratification tools in symptomatic patients suspected of having CRC was undertaken., Methods: Postal FIT was incorporated into the colorectal cancer 2-week wait (2WW) pathway for all patients without rectal bleeding in 2016. Patients were investigated in the 2WW pathway as normal, and outcomes of investigations were recorded prospectively. Anaemia was defined as a haemoglobin level below 120 g/l in women and 130 g/l in men., Results: FIT kits were sent to 1106 patients, with an 80.9 per cent return rate; 810 patients completed investigations and 40 colorectal cancers were diagnosed (4.9 per cent). FIT results were significantly higher in patients with anaemia (median (i.q.r.) 4.8 (0.8-34.1) versus 1.2 (0-6.4) mug Hb/g faeces in those without anaemia; P < 0.001). Some 60.4 per cent of patients (538 of 891) had a result lower than 4 mug haemoglobin (Hb) per g faeces (limit of detectability), and 69.7 per cent (621 of 891) had less than 10 mug Hb/g faeces. Some 60 per cent of patients with colorectal cancer had a FIT reading of 150 mug Hb/g faeces or more. For five colorectal cancers diagnosed in patients with a FIT value below 10 mug Hb/g faeces, there was either a palpable rectal mass or the patient was anaemic. A FIT result of more than 4 mug Hb/g faeces had 97.5 per cent sensitivity and 64.5 per cent specificity for a diagnosis of colorectal cancer. A FIT result above 4 mug Hb/g faeces and/or anaemia had a 100 per cent sensitivity and 45.3 per cent specificity for colorectal cancer diagnosis., Conclusion: FIT is most useful at the extremes of detectability; strongly positive readings predict high rates of colorectal cancer and other significant pathology, whereas very low readings in the absence of anaemia or a palpable rectal mass identify a group with very low risk. High return rates for FIT within this 2WW pathway indicate its acceptability.
    • Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation

      Bailey, James A; Weller, J; Chapman, Caroline J; Ford, Abby; Hardy, Katie; Morling, Joanne R; Simpson, J; Humes, David J; Banerjea, Ayan (Oxford University Press, 2021)
      Background: A novel pathway incorporating faecal immunochemical testing (FIT) for rapid colorectal cancer diagnosis (RCCD) was introduced in 2017. This paper reports on the service evaluation after 2 years of pathway implementation.; Methods: The RCCD protocol was based on FIT, blood results and symptoms to stratify adult patients in primary care. Two-week-wait (2WW) investigation was indicated for patients with rectal bleeding, rectal mass and faecal haemoglobin (fHb) level of 10 µg Hb/g faeces or above or 4 µg Hb/g faeces or more in the presence of anaemia, low ferritin or thrombocytosis, in all other symptom groups. Patients with 100 µg Hb/g faeces or above had expedited investigation . A retrospective audit of colorectal cancer detected between 2017 and 2019 was conducted, fHb thresholds were reviewed and critically assessed for cancer diagnoses.; Results: In 2 years, 14788 FIT tests were dispatched with 13361 (90.4 per cent) completed returns. Overall, fHb was less than 4 µg Hb/g faeces in 9208 results (68.9 per cent), 4-9.9 µg Hb/g in 1583 (11.8 per cent), 10-99.9 µg Hb/g in 1850 (13.8 per cent) and 100 µg Hb/g faeces or above in 720 (5.4 per cent). During follow-up (median 10.4 months), 227 colorectal cancers were diagnosed. The cancer detection rate was 0.1 per cent in patients with fHb below 4 µg Hb/g faeces, 0.6 per cent in those with fHb 4-9.9 µg Hb/g faeces, 3.3 per cent for fHb 10-99.9 µg Hb/g faeces and 20.7 per cent for fHb 100 µg Hb/g faeces or above. The detection rate in the cohort with 10-19.9 µg Hb/g faeces was 1.4 per cent, below the National Institute for Health and Care Excellence threshold for urgent referral. The colorectal cancer rate in patients with fHb below 20 µg Hb/g faeces was less than 0.3 per cent.; Conclusion: Use of FIT to "rule out" urgent referral from primary care misses a small number of cases. The threshold for referral may be adjusted with blood results to improve stratification .
    • GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

      Bailey, James A; Khawaja, A; Andrews, Helen; Weller, J; Chapman, Caroline J (Elsevier Ltd, 2021)
      OBJECTIVE: Service evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for "rule out", "rule in" and "first test selection"., DESIGN: Retrospective audit of FIT results, CRC outcomes and resource utilisation before and after introduction of FIT in Primary Care in November 2017. Data from the new pathway up to December 2018 was compared with previous experience., RESULTS: Between November 2017 and December 2018, 6747 GP FIT test requests yielded 5733 FIT results, of which 4082 (71.2%) were =150.0 mug Hb/g faeces. The proportion of "rule out" results =150.0 mug Hb/g faeces. The proportion of "rule out" results =150.0 mug Hb/g faeces was significantly lower (4.1% vs 8.1%, Chi squared 27.3,P < 0.0001). There was a 33% rise in urgent referrals across Nottingham overall during the evaluation period. 2 CRC diagnoses were made in 4082 patients who had FIT<4.0 mug Hb/g faeces. 58.4% of new CRC diagnoses associated with a positive FIT were early stage cancers (Stage I and II). The proportion of all CRC diagnoses that follow an urgent referral s rose after introduction of FIT., CONCLUSIONS: FIT allows GP's to select a more appropriate cohort for urgent investigation without a large number of missed diagnoses. FIT appears to promise a "stage migration" effect which may ultimately improve CRC outcomes.
    • Choice of faecal immunochemical test matters: comparison of OC-Sensor and HM-JACKarc, in the assessment of patients at high risk of colorectal cancer

      Chapman, Caroline J; Banerjea, Ayan; Humes, David J; Ford, Abby; Hardy, Katie; Djedovic, Natasha; Logan, Richard F; Morling, Joanne R (De Gruyter, 2021)
      OBJECTIVES: Currently, NICE recommends the use of faecal immunochemical test (FIT) at faecal haemoglobin concentrations (f-Hb) of 10 mug Hb/g faeces to stratify for colorectal cancer (CRC) risk in symptomatic populations. This f-Hb cut-off is advised across all analysers, despite the fact that a direct comparison of analyser performance, in a clinical setting, has not been performed., METHODS: Two specimen collection devices (OC-Sensor, OC-S; HM-JACKarc, HM-J) were sent to 914 consecutive individuals referred for follow up due to their increased risk of CRC. Agreement of f-Hb around cut-offs of 4, 10 and 150 microg Hb/g faeces and CRC detection rates were assessed. Two OC-S devices were sent to a further 114 individuals, for within test comparisons., RESULTS: A total of 732 (80.1%) individuals correctly completed and returned two different FIT devices, with 38 (5.2%) CRCs detected. Median f-Hb for individuals diagnosed with and without CRC were 258.5 and 1.8 microg Hb/g faeces for OC-S and 318.1 and 1.0 microg Hb/g faeces for HM-J respectively. Correlation of f-Hb results between OC-S/HM-J over the full range was rho=0.74, p<0.001. Using a f-Hb of 4 microg Hb/g faeces for both tests found an agreement of 88.1%, at 10 microg Hb/g faeces 91.7% and at 150 microg Hb/g faeces 96.3%. A total of 114 individuals completed and returned two OC-S devices; correlation across the full range was rho=0.98, p<0.001., CONCLUSIONS: We found large variations in f-Hb when different FIT devices were used, but a smaller variation when the same FIT device was used. Our data suggest that analyser-specific f-Hb cut-offs are applied with regard to clinical decision making, especially at lower f-Hb. Copyright © 2020 Walter de Gruyter GmbH, Berlin/Boston.
    • Early clinical outcomes of a rapid colorectal cancer diagnosis pathway using faecal immunochemical testing in Nottingham

      Chapman, Caroline J; Thomas, C; Morling, Joanne R; Simpson, J; Humes, David J; Banerjea, Ayan; Clark, S. K (John Wiley & Sons Ltd, 2020)
      AIM: We introduced primary care access to faecal immunochemical testing (FIT) as a stratification tool for symptomatic patients considered to be at risk of colorectal cancer (CRC) prior to urgent referral. We aimed to evaluate clinical and pathway outcomes during the first 6 months of this novel approach., METHOD: FIT was recommended for all patients who consulted their general practitioner with lower gastrointestinal symptoms other than rectal bleeding and rectal mass. We undertook a retrospective audit of the results of FIT, related clinical outcomes and resource utilization on prospectively logged cases between November 2017 and May 2018., RESULTS: Of the 1862 FIT kits dispatched by post 91.4% were returned, with a median return time of 7 days (range 2-110 days); however, 1.3% of returned kits could not be analysed. FIT results >= 150.0 mug haemoglobin (Hb)/g faeces identified patients with a significantly higher risk of CRC (30.9% vs 1.4%, chi-square 167.1, P = 10.0 mug Hb/g faeces identified patients with significantly higher risk of significant noncancer bowel pathology (24.1% vs 4.9%, chi-square 73.6, P < 0.0001) and FIT results < 4.0 mug Hb/g faeces identified a group more likely to have non-CRC pathology (5.1% vs 2.4%, chi-square 3.9, P < 0.05). The CRC detection rate in 531 patients investigated after a FIT result of < 4.0 mug Hb/g faeces was 0.2%. In 899 investigated patients, a FIT result with a threshold of 4.0 mug Hb/g faeces had sensitivity 97.2% (85.5-99.9% CI), specificity 61.4% (58.1-64.7% CI), negative predictive value 99.8% (98.7-100.0% CI) and positive predictive value 9.5% (8.7-10.4% CI)., CONCLUSION: A symptomatic pathway incorporating FIT is feasible and appears more clinically effective than pathways based on age and symptoms alone. Copyright Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.
    • Atraumatic Isolated Peroneal Compartment Syndrome

      Ashwood, Neil
      26-year-old male presented with leg lateral aspect pain with numbness over foot dorsum lateral aspect for 6 hours after rugby training with no trauma. Slight peroneal compartment tightness with negative stretch test. Creatine kinase 4659U/L. Peroneal compartment discomfort was worsening, fasciotomy of all leg compartments was done with only lateral peroneal compartment affected. Sensory changes in presentation highlights the importance of having a high index of suspicion. One could use biochemical mark ers aiding decision making on borderline situations, however we advise decompression in these cases. Although the patient had uneventful postoperative recovery, having ICP monitoring equipment or MRI would prevent overzealous opening of posterior compartment.
    • A Rare Presentation of Myositis Ossificans in a Diabetic Individual

      Hind, Jamie; Prabodhinee, Dhiren Jogiya; Sidhu, Gur Aziz; Suryawanshi, Suraj; Amara, Veda; Ashwood, Neil
      Introduction: Myositis ossificans (MO) is a disease with self-limiting, benign ossifying lesions. MO traumatica is most common cause and occurs after blunt trauma to muscle tissue and the most common site of occurrence is the anterior thigh often developing after an intramuscular hematoma. The pathophysiology of MO is not well understood. The association of myositis and diabetes is quite rare.Case Report: A 57-year-old male presented with a discharging ulcer on the right lateral lower leg. A radiograph was carried out to ascertain the degree of bone involvement. However, the X-ray showed calcifications. Ultrasound, magnetic resonance imaging (MRI) and X-ray imaging were used to exclude malignant disorders such as osteomyelitis or osteosarcoma. The diagnosis of myositis ossificans was confirmed with MRI. As the patient had a background of diabetes, this could have led to MO as a result of the macrovascular complication of a discharging ulcer; hence, diabetes could be considered a risk factor for the disease. Conclusion:The reader may appreciate that diabetic patients may present with MO and that repeated discharging ulcers may imitate the effects of physical trauma on calcifications. The specific take home message is that regardless of the apparent rarity of a disease and subversion to typical clinical presentation, it should still be considered. Furthermore, the exclusion of severe and malignant diseases which benign diseases may mimic is of utmost importance to correctly manage patients.
    • Correlation of IVF outcomes and number of oocytes retrieved: a UK retrospective longitudinal observational study of 172 341 non-donor cycles.

      Jayaprakasan, Kanna
      OBJECTIVE: How do numbers of oocytes retrieved per In vitro fertilisation (IVF) cycle impact on the live birth rate (LBR) and multiple gestation pregnancy (MGP) rates? DESIGN: Retrospective observational longitudinal study. SETTING: UK IVF clinics. POPULATION: Non-donor IVF patients. MAIN OUTCOME MEASURES: LBR per IVF cycle and MGP levels against number of oocytes retrieved into subgroups: 0, 1-5, 6-15, 16-25, 26-49 oocytes and 50+ oocytes. Relative risk (RR) and 95% CIs were calculated for each group against the intermediate responder with '6-15 oocytes collected'. RESULTS: From 172 341 attempted fresh oocyte retrieval cycles, the oocyte retrieved was: 0 in 10 148 (5.9%) cycles from 9439 patients; 1-5 oocytes in 42 574 cycles (24.7%); 6-15 oocytes in 91 797 cycles (53.3%); 16-25 oocytes in 23 794 cycles (13.8%); 26-49 oocytes in 3970 cycles (2.3%); ≥50 oocytes in 58 cycles (0.033%). The LBRs for the 1-5, 6-15, 16-25 and 26-49 subgroups of oocytes retrieved were 17.2%, 32.4%, 35.3% and 18.7%, respectively. The RR (95% CI) of live birth in comparison to the intermediate group (6-15) for 1-5, 16-25 and 26-49 groups was 0.53 (0.52 to 0.54), 1.09 (1.07 to 1.11) and 0.58 (0.54 to 0.62), respectively. The corresponding MGP rates and RR were 9.2%, 11.0%, 11.4% and 11.3%, respectively and 0.83 (0.77 to 0.90), 1.04 (0.97 to 1.11) and 1.03 (0.84 to 1.26), respectively. CONCLUSION: There was only limited benefit in LBR beyond the 6-15 oocyte group going to the 16-25 oocytes group, after which there was significant decline in LBR. The MGP risk was lower in 1-5 group.
    • Chronic ectopic pregnancy presenting as a suspected tubo-ovarian abscess: a diagnostic dilemma.

      Alao, A; Dasgupta, J; Biswas, Bivas
      Though there is no definite agreement on diagnostic criteria or definition of chronic ectopic pregnancy (CEP), it could be deemed to be a variant of pregnancy of unknown location with non-specific clinical signs and symptoms. This was a case of a para 2+2 who presented with lower abdominal pain and bleeding per vaginum, and initial ultrasound was suggestive of a tubo-ovarian abscess/mass. With a further MRI scan and a diagnostic laparoscopy, she was found to have a CEP and had a laparoscopic salpingectomy for management. The diagnosis of CEP could be quite challenging as a result of the protracted symptoms, often negative/low serum B-HCG and ultrasound features mimicking a pelvic mass. A high index of suspicion is needed, and an MRI scan and diagnostic laparoscopy often aid in diagnosis and management.
    • Redefining WILD syndrome: a primary lymphatic dysplasia with congenital multisegmental lymphoedema, cutaneous lymphovascular malformation, CD4 lymphopaenia and warts.

      Keeley, Vaughan;
      BACKGROUND: Primary lymphoedema (PL) syndromes are increasingly recognised as presentations of complex genetic disease, with at least 20 identified causative genes. Recognition of clinical patterns is key to diagnosis, research and therapeutics. The defining criteria for one such clinical syndrome, 'WILD syndrome' (Warts, Immunodeficiency, Lymphoedema and anogenital Dysplasia), have previously depended on a single case report. METHODS AND RESULTS: We present 21 patients (including the first described case) with similar clinical and immunological phenotypes. All had PL affecting multiple segments, with systemic involvement (intestinal lymphangiectasia/pleural or pericardial effusions) in 70% (n=14/20). Most (n=20, 95%) had a distinctive cutaneous lymphovascular malformation on the upper anterior chest wall. Some (n=10, 48%) also had hyperpigmented lesions resembling epidermal naevi (but probably lymphatic in origin). Warts were common (n=17, 81%) and often refractory. In contrast to the previous case report, anogenital dysplasia was uncommon-only found in two further cases (total n=3, 14%). Low CD4 counts and CD4:CD8 ratios typified the syndrome (17 of 19, 89%), but monocyte counts were universally normal, unlike GATA2 deficiency. CONCLUSION: WILD syndrome is a previously unrecognised, underdiagnosed generalised PL syndrome. Based on this case series, we redefine WILD as 'Warts, Immunodeficiency, andLymphatic Dysplasia' and suggest specific diagnostic criteria. The essential criterion is congenital multisegmental PL in a 'mosaic' distribution. The major diagnostic features are recurrent warts, cutaneous lymphovascular malformations, systemic involvement (lymphatic dysplasia), genital swelling and CD4 lymphopaenia with normal monocyte counts. The absence of family history suggests a sporadic condition, and the random distribution of swelling implicates mosaic postzygotic mutation as the cause.
    • Rupture of the Tibialis Posterior Tendon With Associated Bimalleolar Ankle Fracture.

      Clarke, D
      The acute traumatic rupture of the tibialis posterior tendon in association with closed ankle fractures is rare and often under-recognised. If recognised early, outcomes can be excellent. There are 28 known cases in the literature, and we report two further cases associated with bimalleolar ankle fracture dislocation. A 49-year-old presented with valgus deformity at the ankle joint and global tenderness following a work injury as a mechanic. A plain radiograph showed a displaced oblique comminuted fracture of the lateral malleolus with valgus angulation at a syndesmosis, with significant talar shift. The patient underwent open reduction and internal fixation with a seven-hole, one-third tubular plate and screws. A 35-year-old involved in a motorcycle collision with a car presented with swollen left ankle and valgus deformity. Plain radiographs revealed bimalleolar fracture subluxation. Closed reduction was unsuccessful and hence direct medial approach demonstrated a complete rupture of the posterior tendon. The medial malleolus was fixed using lag screws and washers. The tendon was repaired using the modified Kessler technique in both cases. The tibialis posterior plays a significant role in foot and ankle biomechanics due to its broad tendinous insertion. Acute traumatic rupture is rare, as it is protected due to its deep-seated anatomic location within the deep posterior compartment of the leg. Preoperative diagnosis of this injury is challenging and hence this diagnosis is often made intraoperatively. In both cases, there was a retraction of the proximal end beyond incision margins, and this can make tendon rupture difficult to identify intraoperatively as well. Upon identification, assessment of the tendon for degenerative changes was key to deciding upon suitability for primary repair. Despite its rarity, a high index of suspicion should be maintained in fracture dislocation of the ankle joint, especially when the mechanism is known to be pronation-external rotation.
    • Impact of malnutrition on health-related quality of life in persons receiving dialysis: a prospective study.

      Pittman, Zoe; Selby, Nicholas; Taal, Maarten
      Health-related quality of life (HRQoL) is severely impaired in persons receiving dialysis. Malnutrition has been associated with some measures of poor HRQoL in cross-sectional analyses in dialysis populations, but no studies have assessed the impact of malnutrition and dietary intake on change in multiple measures of HRQoL over time. We investigated the most important determinants of poor HRQoL and the predictors of change in HRQoL over time using several measures of HRQoL. We enrolled 119 haemodialysis and thirty-one peritoneal dialysis patients in this prospective study. Nutritional assessments (Subjective Global Assessment (SGA), anthropometry and 24-h dietary recalls) and HRQoL questionnaires (Short Form-36 (SF-36) mental (MCS) and physical component scores (PCS) and European QoL-5 Dimensions (EQ5D) health state (HSS) and visual analogue scores (VAS)) were performed at baseline, 6 and 12 months. Mean age was 64 (14) years. Malnutrition was present in 37 % of the population. At baseline, malnutrition assessed by SGA was the only factor independently (and negatively) associated with all four measures of HRQoL. No single factor was independently associated with decrease in all measures of HRQoL over 1 year. However, prevalence/development of malnutrition over 1 year was an independent predictor of 1-year decrease in EQ5D HSS, and 1-year decrease in fat intake independently predicted the 1-year decline in SF-36 MCS and PCS, and EQ5D VAS. These findings strengthen the importance of monitoring for malnutrition and providing nutritional advice to all persons on dialysis. Future studies are needed to evaluate the impact of nutritional interventions on HRQoL and other long-term outcomes.