27 results found
Markar SR, Zaninotto G, Castoro C, et al., 2020, Lasting Symptoms After Esophageal Resection (LASER): European Multicenter Cross-sectional Study., Ann Surg
OBJECTIVE: To identify the most prevalent symptoms and those with greatest impact upon health-related quality of life (HRQOL) among esophageal cancer survivors. BACKGROUND: Long-term symptom burden after esophagectomy, and associations with HRQOL, are poorly understood. PATIENTS AND METHODS: Between 2010 and 2016, patients from 20 European Centers who underwent esophageal cancer surgery, and were disease-free at least 1 year postoperatively were asked to complete LASER, EORTC-QLQ-C30, and QLQ-OG25 questionnaires. Specific symptom questionnaire items that were associated with poor HRQOL as identified by EORTC QLQ-C30 and QLQ-OG25 were identified by multivariable regression analysis and combined to form a tool. RESULTS: A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had symptoms associated with their esophagectomy. Ongoing weight loss was reported by 10.4% of patients, and only 13.8% returned to work with the same activities.Three LASER symptoms were correlated with poor HRQOL on multivariable analysis; pain on scars on chest (odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81 ± 0.02 and 0.82 ± 0.09 respectively. CONCLUSION: Two-thirds of patients experience significant symptoms more than 1 year after surgery. The 3 key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased support.
Stefanova I, Huddy JR, Richardson J, 2020, A rare case of acute congestive ischaemic colitis related to combined superior and inferior mesenteric arteriovenous malformations., J Surg Case Rep, Vol: 2020, ISSN: 2042-8812
Visceral arteriovenous malformations (AVMs) are extremely rare with only a few cases described within the literature. To date, no cases of ischaemic colitis related to arteriovenous malformations affecting both superior and inferior mesenteric arteries have been reported. We report the first case of acute ischaemic colitis caused by venous congestion and reduced arterial flow due to combined AVMs in the territory of superior and inferior mesenteric arteries in a 51-year-old patient. After a multidisciplinary meeting, interventional radiology embolization was considered to be of unlikely benefit due to extensive varicosities; therefore, surgical treatment in the form of open subtotal colectomy and end ileostomy was performed. This case report demonstrates the severity and the complexity in the management of AVM-related ischaemic colitis, together with a review of the literature.
Huddy JR, Ni M, Misra S, et al., 2019, Development of the Point-of-Care Key Evidence Tool (POCKET): a checklist for multi-dimensional evidence generation in point-of-care tests, Clinical Chemistry and Laboratory Medicine, Vol: 57, Pages: 845-855, ISSN: 1434-6621
BackgroundThis study aimed to develop the Point-of-Care Key Evidence Tool (POCKET); a multi-dimensional checklist to guide the evaluation of point-of-care tests (POCTs) incorporating validity, utility, usability, cost-effectiveness and patient experience. The motivation for this was to improve the efficiency of evidence generation in POCTs and reduce the lead-time for the adoption of novel POCTs.MethodsA mixed qualitative and quantitative approach was applied. Following a literature search, a three round Delphi process was undertaken incorporating a semi-structured interview study and two questionnaire rounds. Participants included clinicians, laboratory personnel, commissioners, regulators (including members of National Institute for Health and Care Excellence [NICE] committees), patients, industry representatives and methodologists. Qualitative data were analysed based on grounded theory. The final tool was revised at an expert stakeholder workshop.ResultsForty-three participants were interviewed within the semi-structured interview study, 32 participated in the questionnaire rounds and nine stakeholders attended the expert workshop. The final version of the POCKET checklist contains 65 different evidence requirements grouped into seven themes. Face validity, content validity and usability has been demonstrated. There exists a shortfall in the evidence that industry and research methodologists believe should be generated regarding POCTs and what is actually required by policy and decision makers to promote implementation into current healthcare pathways.ConclusionsThis study has led to the development of POCKET, a checklist for evidence generation and synthesis in POCTs. This aims to guide industry and researchers to the evidence that is required by decision makers to facilitate POCT adoption so that the benefits they can bring to patients can be effectively realised.
Huddy JR, Sodergren MH, Deguara J, et al., 2018, Pancreaticoduodenectomy for the Management of Pancreatic or Duodenal Metastases from Primary Sarcoma, ANTICANCER RESEARCH, Vol: 38, Pages: 4041-4046, ISSN: 0250-7005
Borsci S, Buckle P, Huddy J, et al., 2017, Usability study of pH strips for nasogastric tube placement, PLoS ONE, Vol: 12, Pages: 1-14, ISSN: 1932-6203
Aims(1) To model the process of use and usability of pH strips (2) to identify, through simulation studies, the likelihood of misreading pH strips, and to assess professional’s acceptance, trust and perceived usability of pH strips.MethodsThis study was undertaken in four phases and used a mixed method approach (an audit, a semi-structured interview, a survey and simulation study). The three months audit was of 24 patients, the semi-structured interview was performed with 19 health professionals and informed the process of use of pH strips. A survey of 134 professionals and novices explored the likelihood of misinterpreting pH strips. Standardised questionnaires were used to assess professionals perceived usability, trust and acceptance of pH strip use in a simulated study.ResultsThe audit found that in 45.7% of the cases aspiration could not be achieved, and that 54% of the NG-tube insertions required x-ray confirmation. None of those interviewed had received formal training on pH strips use. In the simulated study, participants made up to 11.15% errors in reading the strips with important implications for decision making regarding NG tube placement. No difference was identified between professionals and novices in their likelihood of misinterpreting the pH value of the strips. Whilst the overall experience of usage is poor (47.3%), health professionals gave a positive level of trust in both the interview (62.6%) and the survey (68.7%) and acceptance (interview group 65.1%, survey group 74.7%). They also reported anxiety in the use of strips (interview group 29.7%, survey group 49.7%).ConclusionsSignificant errors occur when using pH strips in a simulated study. Manufacturers should consider developing new pH strips, specifically designed for bedside use, that are more usable and less likely to be misread.
Ni MZ, Huddy JR, Priest OH, et al., 2017, Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: a decision analytical modelling approach., BMJ Open, Vol: 7, ISSN: 2044-6055
OBJECTIVES: The existing British National Patient Safety Agency (NPSA) safety guideline recommends testing the pH of nasogastric (NG) tube aspirates. Feeding is considered safe if a pH of 5.5 or lower has been observed; otherwise chest X-rays are recommended. Our previous research found that at 5.5, the pH test lacks sensitivity towards oesophageal placements, a major risk identified by feeding experts. The aim of this research is to use a decision analytic modelling approach to systematically assess the safety of the pH test under cut-offs 1-9. MATERIALS AND METHODS: We mapped out the care pathway according to the existing safety guideline where the pH test is used as a first-line test, followed by chest x-rays. Decision outcomes were scored on a 0-100 scale in terms of safety. Sensitivities and specificities of the pH test at each cut-off were extracted from our previous research. Aggregating outcome scores and probabilities resulted in weighted scores which enabled an analysis of the relative safety of the checking procedure under various pH cut-offs. RESULTS: The pH test was the safest under cut-off 5 when there was ≥30% of NG tube misplacements. Under cut-off 5, respiratory feeding was excluded; oesophageal feeding was kept to a minimum to balance the need of chest X-rays for patients with a pH higher than 5. Routine chest X-rays were less safe than the pH test while to feed all without safety checks was the most risky. DISCUSSION: The safety of the current checking procedure is sensitive to the choice of pH cut-offs, the impact of feeding delays, the accuracy of the pH in the oesophagus, as well as the extent of tube misplacements. CONCLUSIONS: The pH test with 5 as the cut-off was the safest overall. It is important to understand the local clinical environment so that appropriate choice of pH cut-offs can be made to maximise safety and to minimise the use of chest X-rays. TRIAL REGISTRATION NUMBER: ISRCTN11170249; Pre-results.
Markar S, Mackenzie H, Ni Z, et al., 2017, The influence of procedural volume and proficiency gain on mortality from upper GI endoscopic mucosal resection, Gut, Vol: 67, Pages: 79-85, ISSN: 1468-3288
ObjectiveEndoscopic mucosal resection (EMR) is established for the management of benign and early malignant upper gastrointestinal disease. The aim of this observational study was to establish the effect of endoscopist procedural volume on mortality.DesignPatients undergoing upper gastrointestinal EMR between 1997 and 2012 were identified from the Hospital Episode Statistics database. The primary outcome was 30-day mortality and secondary outcomes were 90-day mortality, requirement for emergency intervention and elective cancer reintervention. Risk-adjusted Cumulative Sum (RA-CUSUM) analysis was used to assess patient mortality-risk during initial stage of endoscopist proficiency gain and the effect of endoscopist and hospital volume. Mortality was compared before and after the change point or threshold in RA-CUSUM curve.Results11,051 patients underwent upper gastrointestinal EMR. Endoscopist procedure volume was an independent predictor of 30-day mortality. Fifty-eight percent of EMR procedures were performed by endoscopists with annual volume of 2 cases or less, and had a higher 30- and 90-day mortality rate for cancer patients, 6.1% vs. 0.4%; P<0.001 and 12% vs. 2.1%; P<0.001 respectively. The requirement for emergency intervention after EMR for cancer was also greater with low-volume endoscopists (1.8%vs. 0.1%; P=0.002). In cancer patients, the RA-CUSUM curve change-point for 30-day mortality and elective re-intervention was 4 and 43 cases respectively.ConclusionEMR performed by high volume endoscopists is associated with reduced adverse outcomes. In order to reach proficiency, appropriate training and procedural volume accreditation training programmes are needed nationally.
Huddy JR, Huddy FMS, Markar SR, et al., 2017, Nutritional optimization during neoadjuvant therapy prior to surgical resection of esophageal cancer - A narrative review., Diseases of the Esophagus, Vol: 31, Pages: 1-11, ISSN: 1120-8694
This narrative review aims to evaluate the evidence for the different nutritional approaches employed during neoadjuvant therapy in patients with loco-regional esophageal cancer. Patients with esophageal cancer are often malnourished and difficult to optimise nutritionally. Whilst evidence suggests neoadjuvant therapy can offer a survival advantage, associated toxicity can exacerbate poor nutritional status. There is currently no accepted standard of care regarding optimal nutritional approach.A systematic literature search was undertaken. Studies describing the utilization of an additional nutritional intervention in patients with esophageal cancer receiving neoadjuvant therapy prior to esophagectomy were included. Primary outcome measure was 30-day postoperative mortality after esophagectomy. Secondary outcome measures were loss of weight during neoadjuvant therapy, completion rate of intended neoadjuvant therapy, complications from nutritional intervention, 30-day postoperative morbidity after esophagectomy and quality of life during neoadjuvant treatment. Given the heterogeneity of retrieved articles results were presented as a narrative review.Twenty-five studies were included of which 16 evaluated esophageal stenting, four feeding jejunostomy, three gastrostomy, one naso-gastric feeding, and one comparative study of esophageal stenting to feeding jejunostomy. 30-day postoperative mortality was only reported in two of the 26 included studies limiting comparison between nutritional strategies. All studies of esophageal stents reported improvements in dysphagia with reported weight change ranging from -5.4kg to + 6kg but none reported 30-day postoperative mortality. In patients undergoing oesophageal stenting for their neoadjuvant treatment overall migration rate was 29.9%. Studies of laparoscopically inserted jejunostomy were all retrospective reviews that demonstrated an increase in weight ranging from 0.4 to 11.8kg and similarly no study reported 30-
El-Osta A, Woringer M, Pizzo E, et al., 2017, Does use of point of care testing improve cost effectiveness of the NHS Health Checks programme in the primary care setting? A cost minimisation analysis, BMJ Open, Vol: 7, ISSN: 2044-6055
Objective: To determine if use of Point of Care Testing (POCT) is less costly than laboratory testing to the NHS in delivering the NHS Heath Check (NHSHC) programme in the primary care setting Design: Observational study and theoretical mathematical model with micro-costing approachSetting: We collected data on NHSHC delivered at 9 general practices (7 using POCT; 2 not using POCT). Participants: We recruited 9 general practices offering NHSHC, and a Pathology Services Laboratory in the same area. Methods: We conducted mathematical modelling with permutations in the following fields: provider type (HCA or nurse), type of test performed (total cholesterol with either lab fasting glucose or HbA1c), consumables costs and variable uptake rates including rate of non-response to invite letter and rate of missed (DNA) appointments. We calculated Total Expected Cost (TEC) per 100 invites, number of NHSHC conducted per 100 invites and costs for completed NHSHC for laboratory and POCT-based pathways. A univariate and probabilistic sensitivity analysis was conducted to account for uncertainty in the input parameters. Main outcome measures: We collected data on cost, volume and type of pathology services performed at seven general practices using POCT and a Pathology Services Laboratory. We collected data on response to the NHSHC invitation letter and DNA rates from two general practices. Results: TEC of using POCT to deliver a routine NHSHC is lower than the laboratory-led pathway with savings of £29 per 100 invited patients up the point of CVD risk-score presentation. Use of POCT can deliver NHSHC in one sitting, whereas the laboratory pathway offers patients several opportunities to DNA appointment. Conclusions: TEC of using POCT to deliver an NHSHC in the primary care setting is lower than the laboratory-led pat
Misra S, Huddy J, Hanna G, et al., 2017, Validation and regulation of point of care devices for medical applications, Medical Biosensors for Point of Care (POC) Applications, Pages: 27-44, ISBN: 9780081000724
Point of care test (POCT) devices for medical applications require validation and regulation before they can be implemented into clinical practice. Undertaking method validation of devices ensures that their performance meets pre-specified analytical criteria and is a requirement assessed by accreditation bodies. Verifying these criteria also assesses real-world performance of analysers by end users and uncovers potential bias or variability in performance. Clinical validation of POCT devices defines the clinical need and assesses the effect of introducing the device into clinical pathways as well as demonstrating performance in a specific clinical context. Taken together these two stages of evaluation ensure that devices perform to an acceptable quality standard and, if undertaken appropriately, further provide evidence of clinical effectiveness. In this chapter, we review the features of method validation, which involves an analytical and clinical component and the regulation of POCT devices whilst also discussing the key considerations when implementing these devices for medical applications.
Boshier PR, Huddy JR, Zaninotto G, et al., 2016, Dumping syndrome after esophagectomy: a systematic review of the literature, DISEASES OF THE ESOPHAGUS, Vol: 30, ISSN: 1120-8694
Bouras G, Markar SR, Burns EM, et 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.
Markar SR, Mackenzie H, Ni M, et al., 2016, The influence of procedural volume and proficiency gain on mortality from upper GI endoscopic mucosal resection, Gut, ISSN: 0017-5749
© 2016 BMJ Publishing Group Ltd & British Society of Gastroenterology. Objective Endoscopic mucosal resection (EMR) is established for the management of benign and early malignant upper GI disease. The aim of this observational study was to establish the effect of endoscopist procedural volume on mortality. Design Patients undergoing upper GI EMR between 1997 and 2012 were identified from the Hospital Episode Statistics database. The primary outcome was 30-day mortality and secondary outcomes were 90-day mortality, requirement for emergency intervention and elective cancer re-intervention. Risk-adjusted cumulative sum (RACUSUM) analysis was used to assess patient mortality risk during initial stage of endoscopist proficiency gain and the effect of endoscopist and hospital volume. Mortality was compared before and after the change point or threshold in the RA-CUSUM curve. Results 11 051 patients underwent upper GI EMR. Endoscopist procedure volume was an independent predictor of 30-day mortality. Fifty-eight per cent of EMR procedures were performed by endoscopists with annual volume of 2 cases or less, and had a higher 30-day and 90-day mortality rate for patients with cancer, 6.1% vs 0.4% (p<0.001) and 12% vs 2.1% (p<0.001), respectively. The requirement for emergency intervention after EMR for cancer was also greater with low volume endoscopists (1.8% vs 0.1%, p=0.002). In patients with cancer, the RA-CUSUM curve change points for 30-day mortality and elective re-intervention were 4 cases and 43 cases, respectively. Conclusions EMR performed by high volume endoscopists is associated with reduced adverse outcomes. In order to reach proficiency, appropriate training and procedural volume accreditation training programmes are needed nationally.
Acharya A, Markar SR, Wiggins H, et al., 2016, Is surgical preadmission an underused opportunity in HIV?, LANCET HIV, Vol: 3, Pages: E459-E460, ISSN: 2352-3018
Huddy JR, Weldon SM, Ralhan S, et al., 2016, Sequential simulation (SqS) of clinical pathways: a tool for public and patient engagement in point-of-care diagnostics., BMJ Open, Vol: 6, Pages: e011043-e011043, ISSN: 2044-6055
OBJECTIVES: Public and patient engagement (PPE) is fundamental to healthcare research. To facilitate effective engagement in novel point-of-care tests (POCTs), the test and downstream consequences of the result need to be considered. Sequential simulation (SqS) is a tool to represent patient journeys and the effects of intervention at each and subsequent stages. This case study presents a process evaluation of SqS as a tool for PPE in the development of a volatile organic compound-based breath test POCT for the diagnosis of oesophagogastric (OG) cancer. SETTING: Three 3-hour workshops in central London. PARTICIPANTS: 38 members of public attended a workshop, 26 (68%) had no prior experience of the OG cancer diagnostic pathway. INTERVENTIONS: Clinical pathway SqS was developed from a storyboard of a patient, played by an actor, noticing symptoms of oesophageal cancer and following a typical diagnostic pathway. The proposed breath testing strategy was then introduced and incorporated into a second SqS to demonstrate pathway impact. Facilitated group discussions followed each SqS. PRIMARY AND SECONDARY OUTCOME MEASURES: Evaluation was conducted through pre-event and postevent questionnaires, field notes and analysis of audiovisual recordings. RESULTS: 38 participants attended a workshop. All participants agreed they were able to contribute to discussions and like the idea of an OG cancer breath test. Five themes emerged related to the proposed new breath test including awareness of OG cancer, barriers to testing and diagnosis, design of new test device, new clinical pathway and placement of test device. 3 themes emerged related to the use of SqS: participatory engagement, simulation and empathetic engagement, and why participants attended. CONCLUSIONS: SqS facilitated a shared immersive experience for participants and researchers that led to the coconstruction of knowledge that will guide future research activities and be of value to stakeholders concerned with the inv
Markar SR, Mackenzie H, Huddy JR, et al., 2016, Practice Patterns and Outcomes After Hospital Admission With Acute Para-esophageal Hernia in England., Annals of Surgery, ISSN: 1528-1140
OBJECTIVE: (i) To establish at a national level clinical outcomes from patients presenting with acute para-esophageal hernia (PEH); and (ii) to determine if a hospital volume-outcome relationship exists for the management of acute PEH. BACKGROUND: Currently, no clear guidelines exist regarding the management of acute PEH, and practice patterns are based upon relatively small case series. METHODS: Patients admitted as an emergency for the treatment of acute PEH between 1997 and 2012 were included from the Hospital Episode Statistics database. The influence of hospital volume upon clinical outcomes was analyzed in unmatched and matched comparisons to control for patient age, medical comorbidities, and incidence of PEH hernia gangrene. RESULTS: Over the 16-year study period, 12,441 patients were admitted as an emergency with a PEH causing obstruction or gangrene. Of these, 90.8% patients were admitted with PEH with obstruction in the absence of gangrene and 9.2% with PEH with gangrene. The incidences of 30 and 90-day mortality were 7% and 11.5%, respectively, which did not decrease during the study period. Unmatched and matched comparisons showed, in high-volume centers, there were significant reductions in utilization of emergency surgery (8.8% vs 14.9%; P < 0.0001), 30-day (5.3% vs 7.8%; P < 0.0001), and 90-day mortality (9.3% vs 12.7%; P < 0.0001). Multivariate analysis also confirmed high hospital volume was independently associated with reduced 30 and 90-day mortality from acute PEH. CONCLUSIONS: Acute PEH represents a highly morbid condition, and treatment in high-volume centers provides the appropriate multidisciplinary infrastructure to manage these complex patients reducing associated mortality.
Huddy JR, Markar SR, Ni MZ, et al., 2016, Laparoscopic repair of hiatus hernia: does mesh type influence outcome? A meta-analysis and European survey study, Surgical Endoscopy and Other Interventional Techniques, ISSN: 1432-2218
BACKGROUND: Synthetic mesh (SM) has been used in the laparoscopic repair of hiatus hernia but remains controversial due to reports of complications, most notably esophageal erosion. Biological mesh (BM) has been proposed as an alternative to mitigate this risk. The aim of this study is to establish the incidence of complications, recurrence and revision surgery in patients following suture (SR), SM or BM repair and undertake a survey of surgeons to establish a perspective of current practice. METHODS: An electronic search of EMBASE, MEDLINE and Cochrane database was performed. Pooled odds ratios (PORs) were calculated for discrete variables. To survey current practice an online questionnaire was sent to emails registered to the European Association for Endoscopic Surgery. RESULTS: Nine studies were included, comprising 676 patients (310 with SR, 214 with SM and 152 with BM). There was no significant difference in the incidence of complications with mesh compared to SR (P = 0.993). Mesh significantly reduced overall recurrence rates compared to SR [14.5 vs. 24.5 %; POR = 0.36 (95 % CI 0.17-0.77); P = 0.009]. Overall recurrence rates were reduced in the SM compared to BM groups (12.6 vs. 17.1 %), and similarly compared to the SR group, the POR for recurrence was lower in the SM group than the BM group [0.30 (95 % CI 0.12-0.73); P = 0.008 vs. 0.69 (95 % CI 0.26-1.83); P = 0.457]. Regarding surgical technique 503 survey responses were included. Mesh reinforcement of the crura was undertaken by 67 % of surgeons in all or selected cases with 67 % of these preferring synthetic mesh to absorbable mesh. One-fifth of the respondents had encountered mesh erosion in their career. CONCLUSIONS: Both SM and BM reduce rates of recurrence compared to SR, with SM proving most effective. Surgical practice is varied, and there remains insufficient evidence regarding the optimum technique for the repair
Johnston MJ, Arora S, Pucher PH, et al., 2016, Improving Escalation of Care Development and Validation of the Quality of Information Transfer Tool, ANNALS OF SURGERY, Vol: 263, Pages: 477-486, ISSN: 0003-4932
Objective: To develop and provide validity and feasibility evidence for the QUality of Information Transfer (QUIT) tool.Background: Prompt escalation of care in the setting of patient deterioration can prevent further harm. Escalation and information transfer skills are not currently measured in surgery.Methods: This study comprised 3 phases: the development (phase 1), validation (phase 2), and feasibility analysis (phase 3) of the QUIT tool. Phase 1 involved identification of core skills needed for successful escalation of care through literature review and 33 semistructured interviews with stakeholders. Phase 2 involved the generation of validity evidence for the tool using a simulated setting. Thirty surgeons assessed a deteriorating postoperative patient in a simulated ward and escalated their care to a senior colleague. The face and content validity were assessed using a survey. Construct and concurrent validity of the tool were determined by comparing performance scores using the QUIT tool with those measured using the Situation-Background-Assessment-Recommendation (SBAR) tool. Phase 3 was conducted using direct observation of escalation scenarios on surgical wards in 2 hospitals.Results: A 7-category assessment tool was developed from phase 1 consisting of 24 items. Twenty-one of 24 items had excellent content validity (content validity index >0.8). All 7 categories and 18 of 24 (P < 0.05) items demonstrated construct validity. The correlation between the QUIT and SBAR tools used was strong indicating concurrent validity (r = 0.694, P < 0.001). Real-time scoring of escalation referrals was feasible and indicated that doctors currently have better information transfer skills than nurses when faced with a deteriorating patient.Conclusions: A validated tool to assess information transfer for deteriorating surgical patients was developed and tested using simulation and real-time clinical scenarios. It may improve the quality and safety of patient care on
Huddy JR, Ni MZ, Barlow J, et al., 2016, Point-of-care C reactive protein for the diagnosis of lower respiratory tract infection in NHS primary care: a qualitative study of barriers and facilitators to adoption, BMJ Open, Vol: 6, ISSN: 2044-6055
Huddy JR, Ni M, Mavroveli S, et al., 2015, A research protocol for developing a Point-Of-Care Key Evidence Tool 'POCKET': a checklist for multidimensional evidence reporting on point-of-care in vitro diagnostics., BMJ Open, Vol: 5, Pages: e007840-e007840, ISSN: 2044-6055
INTRODUCTION: Point-of-care in vitro diagnostics (POC-IVD) are increasingly becoming widespread as an acceptable means of providing rapid diagnostic results to facilitate decision-making in many clinical pathways. Evidence in utility, usability and cost-effectiveness is currently provided in a fragmented and detached manner that is fraught with methodological challenges given the disruptive nature these tests have on the clinical pathway. The Point-of-care Key Evidence Tool (POCKET) checklist aims to provide an integrated evidence-based framework that incorporates all required evidence to guide the evaluation of POC-IVD to meet the needs of policy and decisionmakers in the National Health Service (NHS). METHODS AND ANALYSIS: A multimethod approach will be applied in order to develop the POCKET. A thorough literature review has formed the basis of a robust Delphi process and validation study. Semistructured interviews are being undertaken with POC-IVD stakeholders, including industry, regulators, commissioners, clinicians and patients to understand what evidence is required to facilitate decision-making. Emergent themes will be translated into a series of statements to form a survey questionnaire that aims to reach a consensus in each stakeholder group to what needs to be included in the tool. Results will be presented to a workshop to discuss the statements brought forward and the optimal format for the tool. Once assembled, the tool will be field-tested through case studies to ensure validity and usability and inform refinement, if required. The final version will be published online with a call for comments. Limitations include unpredictable sample representation, development of compromise position rather than consensus, and absence of blinding in validation exercise. ETHICS AND DISSEMINATION: The Imperial College Joint Research Compliance Office and the Imperial College Hospitals NHS Trust R&D department have approved the protocol. The checklist tool will be
Huddy JR, Thomas RL, Worthington TR, et al., 2015, Liver metastases from esophageal carcinoma: is there a role for surgical resection?, Dis Esophagus, Vol: 28, Pages: 483-487
Esophageal cancer recurrence rates after esophagectomy are high, and locally recurrent or distant metastatic disease has poor prognosis. Management is limited to palliative chemotherapy and symptomatic interventions. We report our experience of four patients who have undergone successful liver resection for metastases from esophageal cancer. All underwent esophagectomy and were referred to our unit with metastatic recurrent liver disease, two with solitary metastases and two with multi-focal disease. The patients underwent multidisciplinary assessment and proceeded to a course of neoadjuvant chemotherapy followed by open or laparoscopic liver resection. Three patients were male, and the mean age was 57.5 (range 44-71) years. Response to chemotherapy ranged from partial to complete response. Following liver resection, two patients developed recurrent disease at 5 and 15 months, and both had disease-specific mortality at 10 and 21 months, respectively. The other two patients remain disease free at 22 and 92 months. Recurrent metastatic esophageal cancer continues to have a poor prognosis, and the majority of patients with liver involvement will not be candidates for hepatic resection. However, this series suggests that in selected patients, liver resection of metastases from esophageal cancer combined with neoadjuvant and adjuvant chemotherapy is feasible, but further research is required to determine whether this can offer a survival advantage.
Huddy JR, Ni MZ, Markar SR, et al., 2015, Point-of-care testing in the diagnosis of gastrointestinal cancers: Current technology and future directions, WORLD JOURNAL OF GASTROENTEROLOGY, Vol: 21, Pages: 4111-4120, ISSN: 1007-9327
Johnston MJ, Muirhead LJ, Huddy JR, et al., 2015, Chlorhexidine-Induced Anaphylaxis During Surgery - Two Cases and Systematic Literature Review, International Surgical Congress of the Association-of-Surgeons-of-Great-Britain-and-Ireland (ASGBI), Publisher: WILEY-BLACKWELL, Pages: 281-281, ISSN: 0007-1323
Huddy JR, Macharg FMS, Lawn AM, et al., 2013, Exocrine pancreatic insufficiency following esophagectomy., Dis Esophagus, Vol: 26, Pages: 594-597
Weight loss following esophagectomy is a management challenge for all patients. It is multifactorial with contributing factors including loss of gastric reservoir, rapid small bowel transit, malabsorption, and adjuvant chemotherapy. The development of a postoperative malabsorption syndrome, as a result of exocrine pancreatic insufficiency (EPI), is recognized in a subgroup of patients following gastrectomy. This has not previously been documented following esophageal resection. EPI can result in symptoms of flatulence, diarrhea, steatorrhea, vitamin deficiencies, and weight loss. It therefore has the potential to pose a significant level of morbidity in postoperative patients. There is some evidence that patients with proven EPI (fecal elastase-1 < 200 μg/g) may benefit from a trial of pancreatic enzyme replacement therapy (PERT). We observed symptoms compatible with EPI in a subgroup of patients following esophagectomy. We hypothesized that this was contributing to malabsorption and malnutrition in these patients. To investigate this, fecal elastase-1 was measured in postoperative patients, and in those with proven EPI, a trial of PERT was commenced in combination with specialist dietary education. At routine postoperative follow-up, which included assessment by a specialist dietitian, those patients with symptoms suggestive of malabsorption were given the opportunity to have their fecal elastase-1 measured. PERT was then offered to patients with fecal elastase-1 less than 200 μg/g (EPI) as well as those in the 200-500 μg/g range (mild EPI) with more severe symptoms. Fecal elastase-1 was measured in 63 patients between June 2009 and January 2011 at a median of 4 months (range 1-42) following surgery. Ten patients had fecal elastase-1 less than 200 μg/g, and all had failed to maintain preoperative weight. All accepted a trial of PERT. Nine (90%) had symptomatic improvement, and seven (70%) increased their weight. Thirty-nine patients had a fecal elast
Huddy JR, Jamal K, Soon Y, 2013, Single port Billroth I gastrectomy., J Minim Access Surg, Vol: 9, Pages: 87-90, ISSN: 0972-9941
INTRODUCTION: Experience has allowed increasingly complex procedures to be undertaken by single port surgery. We describe a technique for single port Billroth I gastrectomy with a hand-sewn intracorporeal anastomosis in the resection of a benign tumour diagnosed incidentally on a background of cholelithiasis. MATERIALS AND METHODS: Single port Billroth I gastrectomy and cholecystectomy was performed using a transumbilical quadport. Flexible tipped camera and straight conventional instruments were used throughout the procedure. The stomach was mobilised including a limited lymph node dissection and resection margins in the proximal antrum and duodenum were divided with a flexible tipped laparoscopic stapler. The lesser curve was reconstructed and an intracorporal hand sewn two layer end-to-end anastomosis was performed using unidirectional barbed sutures. Intraoperative endoscopy confirmed the anastomosis to be patent without leak. RESULTS: Enteral feed was started on the day of surgery, increasing to a full diet by day 6. Analgesic requirements were a patient-controlled analgesia morphine pump for 4 postoperative days and paracetamol for 6 days. There were no postoperative complications and the patient was discharged on the eighth day. Histology confirmed gastric submucosal lipoma. DISCUSSION: As technology improves more complex procedures are possible by single port laparoscopic surgery. In this case, flexible tipped cameras and unidirectional barbed sutures have facilitated an intracorporal hand-sewn two layer end-to-end anastomosis. Experience will allow such techniques to become mainstream.
Qureshi YA, Huddy JR, Miller JD, et al., 2012, Unplanned excision of soft tissue sarcoma results in increased rates of local recurrence despite full further oncological treatment., Ann Surg Oncol, Vol: 19, Pages: 871-877
BACKGROUND: Unplanned excision of soft tissue sarcoma (STS) accounts for up to 40% of all initial operations for STS and is undertaken when the mass is presumed to be benign. The effect this has on outcome has never been fully established. METHODS: Patients with extremity or trunk STS between 2001 and 2005 who were treated by an initial inadvertent operation and then referred immediately to our unit were identified. Outcomes were compared with a control group of patients with STS who were stage-matched and had been treated conventionally by core biopsy and definitive surgery. Endpoints were local recurrence, distant metastases and sarcoma-specific survival. RESULTS: 134 patients who had undergone unplanned excision of STS were identified. One hundred twenty-one underwent further re-excision, and 51 (48%) of these patients had residual tumour identified after surgical re-excision. Two hundred nine stage-matched controls were identified who were treated conventionally. Median follow-up was 51.6 months. Local recurrence rates were considerably higher in the study group (23.8 vs. 11%, p = 0.0016), despite the control group having more stage 3 tumours. When the tumours were matched by stage, an increase in local recurrence was seen across all stages but was most pronounced for stage 3 tumours (37.5 vs. 14.2%, p = 0.005). Metastasis-free and sarcoma-specific survival were also significantly increased for stage 3 tumours. CONCLUSION: Unplanned initial excision of extremity soft tissue sarcoma may compromise long-term local control of extremity STS despite full further oncological management.
Huddy J, Wadhwani SS, Soon Y, 2008, Enterocutaneous Fistula as a complication of Laparoscopic Cholecystectomy: A Case Report., J Minim Access Surg, Vol: 4, Pages: 51-53, ISSN: 0972-9941
Laparoscopic cholecystectomy is the gold standard method for treating gallstone related disease. Despite its widespread and well established application, clear consensus is not arrived at regarding the comparative risks and benefits of acute versus interval cholecystectomy. The complications of this technique are well known, with respect to both the operative intervention and the technique used. This case describes a case of cholecystitis in a 76-year-old man, who underwent acute laparoscopic cholecystectomy for cholecystitis refractory to antibiotic therapy. Postoperative complications included subhepatic collections bilaterally, eventually leading to the formation of an enterocutaneous fistula to the left chest wall - a previously undocumented phenomenon. The protracted course of the disease is discussed, with reference to investigations performed and the eventual successful outcome.
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