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  • Journal article
    Balinskaite V, Bottle R, Sodhi V, Angus R, Brett S, Bennett P, Aylin Pet al., 2017,

    The risk of adverse pregnancy outcomes following non-obstetric surgery during pregnancy. Estimates from a retrospective cohort study of 6.5 million pregnancies

    , Annals of Surgery, Vol: 266, Pages: 260-266, ISSN: 1528-1140

    Objective. To estimate the risk of adverse birth outcomes for women who underwent non-obstetric surgery during pregnancy compared with those who did not. Background. Previous research suggests that non-obstetric surgery occurs during 1%-2% of pregnancies. However, there is limited evidence quantifying risks to the mother or pregnancy of such surgery. Methods. We examined maternity admissions using hospital administrative data collected between 1st April 2002 and 31st March 2012 and identified pregnancies where non-obstetric surgery occurred. We used logistic regression models to determine the adjusted relative risk, attributable risk and number needed to harm of non-obstetric surgical procedures for adverse birth outcomes.Results. We identified 6,486,280 pregnancies. In 47,628 of these pregnancies, non-obstetric surgery had occurred. We found that non-obstetric surgery during pregnancy was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that every 287 surgical operations were associated with one additional stillbirth, every 31 operations associated with one additional preterm delivery, every 39 operations associated with one additional low birth weight baby, every 25 operations associated with one additional caesarean section, and every 50 operations associated with one additional long inpatient stay.Conclusions. Although we have no means of disentangling the effect of the surgery from the effect of the underlying condition, we found that the risk associated with non-obstetric surgery was relatively low, confirming that surgical procedures during pregnancy are generally safe. We believe that our findings improve upon previous research, and are useful reference points for any discussion of risk with prospective patients.

  • Journal article
    Bouras G, Burns EM, Howell AM, Bottle A, Athanasiou T, Darzi Aet al., 2017,

    Linked hospital and primary care database analysis of the impact of short-term complications on recurrence in laparoscopic inguinal hernia repair

    , HERNIA, Vol: 21, Pages: 191-198, ISSN: 1265-4906

    Objective:To study the effects of short-term complications on recurrence following laparoscopic inguinal hernia repair using routine data.Background:Linked primary and secondary care databases can evaluate the quality of inguinal hernia surgery by quantifying short- and long-term outcome together.Methods:Longitudinal analysis of linked primary care (Clinical Practice Research Datalink) and hospital administrative (Hospital Episodes Statistics) databases quantified 30-day complications (wound infection and bleeding) and surgery for recurrence after primary repair performed between 1st April 1997 and 31st March 2012.Results:Out of 41,545 primary inguinal hernia repairs, 10.3% (4296/41,545) were laparoscopic. Complications were less frequent following laparoscopic (1.8%, 78/4296) compared with open (3.5%, 1288/37,249) inguinal hernia repair (p < 0.05). Recurrence was more frequent following laparoscopic (3.5%, 84/2541) compared with open (1.2%, 366/31,859) repair (p < 0.05). Time to recurrence was shorter for laparoscopic (26.4 months SD 28.5) compared with open (46.7 months SD 37.6) repair (p < 0.05). Overall, complications were associated with recurrence (3.2%, 44/1366 with complications; 1.7%, 700/40,179 without complications; p < 0.05). Complications did not significantly increase the risk of recurrence in open hernia repair (OR = 1.49; 95% CI 0.97−2.30, p = 0.069). Complications following laparoscopic repair was significantly associated with increased risk of recurrence (OR = 7.86; 95% CI 3.46−17.85, p < 0.05).Conclusions:Complications recorded in linked routine data predicted recurrence following laparoscopic inguinal hernia repair. Focus must, therefore, be placed on achieving good short-term outcome, which is likely to translate to better longer term results using the laparoscopic approach.

  • Journal article
    Bouras G, Markar SR, Burns EM, Huddy JR, Bottle A, Athanasiou T, Darzi A, Hanna GBet al., 2016,

    The psychological impact of symptoms related to esophagogastric cancer resection presenting in primary care: A national linked database study

    , European Journal of Surgical Oncology, Vol: 43, Pages: 454-460, ISSN: 1532-2157

    BackgroundThe objective was to evaluate incidence, risk factors and impact of postoperative symptoms following esophagogastric cancer resection in primary care.MethodsPatients undergoing esophagogastrectomy for cancer from 1998 to 2010 with linked records in Clinical Practice Research Datalink, Hospital Episodes Statistics and Office of National Statistics databases were studied. The recording of codes for reflux, dysphagia, dyspepsia, nausea, vomiting, dumping, diarrhea, steatorrhea, appetite loss, weight loss, pain and fatigue were identified up to 12 months postoperatively. Psychiatric morbidity was also examined and its risk evaluated by logistic regression analysis.ResultsOverall, 58.6% (1029/1755) of patients were alive 2 years after surgery. Of these, 41.1% had recorded postoperative symptoms. Reflux, dysphagia, dyspepsia and pain were more frequent following esophagectomy compared with gastrectomy (p < 0.05). Complications (OR = 1.40 95%CI 1.00–1.95) and surgical procedure predicted postoperative symptoms (p < 0.05). When compared with partial gastrectomy, esophagectomy (OR = 2.03 95%CI 1.26–3.27), total gastrectomy (OR = 2.44 95%CI 1.57–3.79) and esophagogastrectomy (OR = 2.66 95%CI 1.85–2.86) were associated with postoperative symptoms (p < 0.05). The majority of patients with postoperative psychiatric morbidity had depression or anxiety (98%). Predictors of postoperative depression/anxiety included younger age (OR = 0.97 95%CI 0.96–0.99), complications (OR = 2.40 95%CI 1.51–3.83), psychiatric history (OR = 6.73 95%CI 4.25–10.64) and postoperative symptoms (OR = 1.78 95%CI 1.17–2.71).ConclusionsOver 40% of patients had symptoms related to esophagogastric cancer resection recorded in primary care, and were associated with an increase in postoperative depression and anxiety.

  • Journal article
    D'Lima D, Bottle A, Benn J, 2016,


  • Journal article
    Balinskaite V, Bottle A, Aylin P, 2016,


  • Journal article
    Bottle A, Chase H, Aylin P, Loeffler Met al., 2016,


  • Report
    Balinskaite V, Aylin P, Bennett P, Bottle R, Brett S, Sodhi V, Rivers Aet al., 2016,

    Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study

    , Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study, Publisher: NIHR Journals Library

    Background:Previous research suggests that non-obstetric surgery is carried out in 1–2% of allpregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of theevidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelinesregarding non-obstetric surgery in pregnant women.Objectives:To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgerywas or was not carried out. To further analyse common procedure groups.Data Source:Hospital Episode Statistics (HES) maternity data collected between 2002–3 and 2011–12.Main outcomes:Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, longinpatient stay, stillbirth and low birthweight.Methods:We utilised HES, an administrative database that includes records of all patient admissions andday cases in all English NHS hospitals. We analysed HES maternity data collected between 2002–3 and2011–12, and identified pregnancies in which non-obstetric surgery was carried out. We used logisticregression models to determine the adjusted relative risk and attributable risk of non-obstetric surgicalprocedures for adverse birth outcomes and the number needed to harm.Results:We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out.In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgerywas associated with a higher risk of adverse birth outcomes, although the attributable risk was generallylow. We estimated that for every 287 pregnancies in which a surgical operation was carried out there wasone additional stillbirth; for every 31 operations there was one additional preterm delivery; for every25 operations there was one additional caesarean section; for every 50 operations there was oneadditional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby.Limitations:We

  • Journal article
    Tudor Car L, Papachristou N, Bull A, Majeed A, Gallagher J, El-Khatib M, Aylin P, Rudan I, Atun R, Car J, Vincent C, Tudor Car Let al., 2016,

    Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study

    , BMC Family Practice, Vol: 17, ISSN: 1471-2296

    Background: Delayed diagnosis in primary care is a common, harmful and costly patient safety incident. Its measurement and monitoring are underdeveloped and underutilised. We created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. Methods: We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were thematically grouped and synthesized into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians’ scores was presented using the Average Expert Agreement.Results: The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients’ medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts.Conclusions: The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their vie

  • Journal article
    Pinder EM, Bottle A, Aylin P, Loeffler MDet al., 2016,

    Does laminar flow ventilation reduce the rate of infection? an observational study of trauma in England.

    , Bone and Joint Journal, Vol: 98-B, Pages: 1262-1269, ISSN: 2049-4408

    AIMS: To determine whether there is any difference in infection rate at 90 days between trauma operations performed in laminar flow and plenum ventilation, and whether infection risk is altered following the installation of laminar flow (LF). PATIENTS AND METHODS: We assessed the impact of plenum ventilation (PV) and LF on the rate of infection for patients undergoing orthopaedic trauma operations. All NHS hospitals in England with a trauma theatre(s) were contacted to identify the ventilation system which was used between April 2008 and March 2013 in the following categories: always LF, never LF, installed LF during study period (subdivided: before, during and after installation) and unknown. For each operation, age, gender, comorbidity, socio-economic deprivation, number of previous trauma operations and surgical site infection within 90 days (SSI90) were extracted from England's national hospital administrative Hospital Episode Statistics database. Crude and adjusted odds ratios (OR) were used to compare ventilation groups using hierarchical logistic regression. Subanalysis was performed for hip hemiarthroplasties. RESULTS: A total of 803 065 trauma operations were performed during this time; 19 hospitals installed LF, 124 already had LF, 13 had PV and the type of ventilation was unknown in 28. Patient characteristics were similar between the groups. The rate of SSI90 was similar for always LF and PV (2.7% and 2.4%). For hemiarthroplasties of the hip, the rates of SSI90 were significantly higher for LF compared with PV (3.8% and 2.6%, OR 1.45, p = 0·001). Hospitals installing LF did not see any statistically significant change in the rate of SSI90. CONCLUSION: The results of this observational study imply that infection rate is similar when orthopaedic trauma surgery is performed in LF and PV, and is unchanged by installing LF in a previously PV theatre. Cite this article: Bone Joint J 2016;98-B:1262-9.

  • Journal article
    Bouras G, Markar SR, Burns EM, Mackenzie HA, Bottle A, Athanasiou T, Hanna GB, Darzi Aet al., 2016,

    Linked Hospital and Primary Care Database Analysis of the Incidence and Impact of Psychiatric Morbidity Following Gastrointestinal Cancer Surgery in England

    , Annals of Surgery, Vol: 264, Pages: 93-99, ISSN: 1528-1140

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