A decade of experience of thyroglossal cyst excision.

INTRODUCTION: We report our ten-year experience of thyroglossal cyst excision at Queen's Medical Centre, Nottingham, comparing outcomes, practice and technique. METHODS: Retrospective case note analysis was conducted alongside surgical histopathology review for all thyroglossal cyst excisions performed between 2000 and 2010. This yielded 108 patients with histopathology results confirming a thyroglossal cyst. RESULTS: The mean patient age was 21 years (range: 1 week - 76 years). Over half the patients (n=59, 55%) were less than 18 years of age. Fifty-five patients (51%) were male and fifty-three (49%) were female. Seventy cases (63%) were operated on by ear, nose and throat (ENT) surgeons. The rest were performed by paediatric surgeons (n=35, 32%), maxillofacial surgeons (n=2, 2%) and general surgeons (n=1, 1%). Paediatric surgeons undertook 35 (69%) of the 59 paediatric cases, with ENT surgeons operating on the rest (n=24, 41%). The primary surgeon was a consultant in 59 operations (55%) while in 49 cases (45%) it was a registrar. Thyroglossal cysts were ruptured in 21 operations (19%) during removal. The central portion of the hyoid bone was not excised in seven cases (6%). Twelve patients (11%) suffered postoperative complications, six of which were recurrences. CONCLUSIONS: There was a combined recurrence rate of 6% across all specialties for the Sistrunk procedure. This is in keeping with commonly reported recurrence rates. However, we found that central compartment neck dissection, as a modification of the original Sistrunk procedure, provides a highly effective method for permanently excising a thyroglossal cyst and, in our experience, it eliminates recurrence.

Outcome of laparoscopic duodenal switch for morbid obesity.

BACKGROUND: The aim of this study was to determine the safety and efficacy of laparoscopic duodenal switch (LDS) as a treatment option in a selected group of patients with morbid obesity. METHODS: This retrospective analysis of a prospective database assessed the frequency of all complications and alterations in weight, body mass index (BMI), co-morbidity and quality of life. RESULTS: One hundred and twenty-one patients underwent LDS between April 2003 and March 2009. Median preoperative weight was 160 kg and median BMI 55 kg/m(2). All procedures were performed laparoscopically. The in-hospital mortality rate was zero. No ileoduodenal anastomotic stenosis was encountered. There were four clinical leaks (3·3 per cent) managed by laparoscopic drainage and placement of a feeding jejunostomy. Median percentage excess weight loss was 75 per cent at 12 months and 90 per cent at 24 months. Thirty-six of 40 diabetic patients had complete resolution of diabetes within 1 year. There were significant improvements in other obesity-related co-morbidity. Only a few patients developed postoperative protein deficiency, and fat-soluble vitamin deficiencies were easily managed with oral supplementation. CONCLUSION: The LDS procedure is a safe and effective treatment for morbid obesity and its associated co-morbidity in selected patients.

Measuring the quality of urinary continence care in long-term care facilities: an analysis of outcome indicators.

BACKGROUND: the National Centre for Health Outcomes Development has produced outcome indicators for the assessment of quality of care in the management of urinary incontinence. Three measures relate to the management of older people in long-term care: the prevalence of incontinence, the use of indwelling catheters and clinical assessment rates. OBJECTIVE: to evaluate the recommended outcome measures in clinical practice. METHOD: participating centres included residential homes, nursing homes and long-stay wards. We sent a structured questionnaire to each centre for qualitative assessment of the acceptability of the outcome indicators. We analysed data collected by nurses and other staff who used the urinary incontinence section of the Royal College of Physicians Continuous Assessment Review and Evaluation scheme audit tool for long-term care. RESULTS: there were 1125 residents in 17 residential homes, 14 nursing homes and five long-stay wards. The overall prevalence of urinary incontinence was 34% in residential homes (range 2-86%), 70% in nursing homes (38-100%) and 71% in long-stay wards (4-97%). Catheterization rates were 5% in residential homes (0-20%), 10% in nursing homes (0-44%) and 6% in long-stay wards (0-20%). Rates of full clinical assessment were 48, 24 and 36% respectively. CONCLUSION: there is great variability in these outcome measures within and between settings. Interpretation of outcome results requires more precise details on case-mix and the definition of outcome measures. Individual units found the audit tool helpful, but we advise caution with interpretation of outcomes between units.

Laxatives and faecal incontinence in long-term care.

High levels of faecal incontinence and laxative use in long-term care settings for older people are revealed in this study. Further research, together with more considered prescribing policies are needed, the authors suggest.

Sequential audits of geriatric care: measuring change in structure and process and the contribution of clinical audit.

BACKGROUND: Sequential audits of care in geriatric practice can demonstrate improvement in its content and quality, and identify its strengths and weaknesses. However, there are problems in such sequential audit, particularly if it depends on data entry by lay staff rather than trained researchers. These include: changes in staff and patients from one audit to the next; having to take into account instances where the desired standards are already in place and therefore no further improvement can be shown, or where initial standards are so low that only improvement can take place. OBJECTIVES: To demonstrate methods of analysis of sequential audits in long-term care for elderly people and in geriatric day hospital practice designed to overcome these difficulties. DESIGN: Audit packages for long-term care and for care provided by geriatric day hospitals have been evaluated in each case by analysing two audit cycles carried out at eight and six month intervals respectively. METHODS: The Royal College of Physicians CARE scheme for audit of long-term care was carried out in 17 locations (nursing homes and geriatric long-stay wards) in two cycles at an interval of eight months. The Royal College of Physicians audit scheme for geriatric day hospitals was carried out in 27 day hospitals in two cycles at an interval of six months. A different method of analysis and presentation of results was devised for each of the two projects. RESULTS AND CONCLUSION: The two methods of analysis and presentation of data used to evaluate the effect of sequential audits reveal the ups and downs in the standards of care provided by the different institutions for the care of the elderly, and in the standards of care experienced by individuals resident in the same long-term institutions. Overall, sequential audits show that improvement outweighs deterioration in all domains of geriatric care, and suggest that audit contributes to this improvement.

Autonomy for elderly people in long-term care.

A cross-sectional view of the extent to which residents in long-term care exercise autonomy has been obtained from an audit using the Royal College of Physicians' CARE scheme (Continuous Assessment Review and Evaluation) in 17 long-term care facilities among 298 residents. Most centres have procedures in place to enable residents to exercise choice, on information or services provided and how to complain, but only half provide opportunities to comment on policy and procedures and planned changes. There was a high level of personal care plans but many of these were disappointing in their detailed content; less than half of the residents had a key worker; a series of indicators of choice scored reasonably high in nursing homes but lower in hospitals; independent advocates are in evidence where patients' mental competence is in question. The established use of care plans should provide a foundation for improvements in this aspect of the quality of care. Such audits could form the basis for a national quality system in long-term care.

Urinary incontinence in the community--analysis of a MORI poll.

OBJECTIVES: To investigate the prevalence of urinary incontinence among people living at home, their responses to it, and its emotional and social effects. DESIGN: Random sample of 4007 adults interviewed in their own homes. SETTING: Random sample of 178 constituency sampling points throughout Great Britain. SUBJECTS: 1883 men, 2124 women aged 30 and over. MAIN OUTCOME MEASURES: Responses to questionnaire. RESULTS: 6.6% (125) men and 14.0% (297) women had been incontinent of urine at some time--2.8% (52) men and 7.5% (159) women in the previous two months and 61% (124) of these for more than four years. 52% (108) had consulted their general practitioner at the onset of incontinence and a further 31% (65) later. Doctors commonly took a urine sample (163, 54%), referred the patient to a specialist (127, 42%), and prescribed tablets (109, 36%); only 22% (66) carried out an abdominal, rectal, or vaginal examination. Patients were not embarrassed in seeing their doctor and most thought they were treated sympathetically. 60% (265) of all those affected were concerned or worried about their incontinence, and in almost half incontinence limited their daily social activities. CONCLUSION: More people with incontinence seem to be consulting their doctors about it than has been found in previous studies, but the procedures carried out by general practitioners still seem to be suboptimal. Urinary incontinence has a profound effect on the day to day lives of most of those who suffer from it.

Assessment of the use of bladder washouts/instillations in patients with long-term indwelling catheters.

A randomised cross-over study of 3 bladder washout treatments--saline, Suby G and Solution R--was conducted on 25 elderly females with long-term catheters in order to examine crystal formation and catheter encrustation. With 2 exceptions, all patients produced crystals; only 14 completed the study. While a significant reduction in struvite crystals was found in the returned acidic washout fluid, there was no significant reduction of crystals in the neutral (saline) washout following any of the 3-week periods of treatment. Uric acid crystals appeared with Suby G and Solution R and these solutions were associated with higher red cell deposits in the urine. There was no significant difference in catheter encrustation between the various washouts.

Parallel access read/write memory using an optically addressed ferroelectric spatial light modulator.

The ability is demonstrated to use optically addressed ferroelectric spatial light modulators in designing digital optical computers involving data processing and storage athigh rates and contrast levels. Key words: Bistability, ferroelectric SLM, parallel access memory.

Bacteriuria in non-catheterized elderly patients in the first eight days of hospital stay.

One hundred and sixty-one non-catheterized consecutive acute geriatric admissions were screened for bacteriuria on the day following admission, both in the morning and in the afternoon and seven days later--morning and afternoon. The prevalence of bacteriuria was 29% on admission. A correlation between bacteriuria and leucocyturia was shown. The patients were admitted with a variety of medical illnesses but in no case was a diagnosis of urinary-tract infection made prior to admission. There was a significant relationship between incontinence and bacteriuria on admission; 12% of abacteriuric patients became bacteriuric between day 1 and day 7 following admission. Escherichia coli accounted for 51% of the isolates on admission to hospital. Bacteriuria was associated with increased mortality within 1 year following admission to hospital.

Rectal motility studies in faecally incontinent geriatric patients.

Rectal motility was assessed in three groups of geriatric patients (faecally incontinent, continent faecally impacted and control patients) to determine whether 'uninhibited' rectal contractions are a cause of faecal incontinence. The incidence of rectal contractions in response to rectal distension did not differ between the three study groups. Two-thirds of the incontinent patients were unable to retain a condom distended with water (soft-stool model) during a proctometrogram. Involuntary expulsion of this device was correlated with the presence of rectal contractions and low anal resting pressure. Involuntary expulsion of an airfilled balloon (firm-stool model) from the rectum occurred less frequently and was correlated with low resting pressure but not with rectal contractions. The contribution of 'uninhibited' rectal contractions to faecal incontinence is insignificant except for a minor role in the expulsion of liquid stool.

Predicting urodynamic dysfunction from clinical features in incontinent elderly women.

In a retrospective survey of 296 elderly women referred with urinary incontinence and in whom urodynamic studies were completed, multiple logistic regression was used to determine the optimal set of clinical features to predict the urodynamic dysfunction. Three formulae were obtained expressing the predicted probabilities (p) of the urodynamic dysfunctions as functions of the clinical variables. By choosing the cut-off values of p which gave equal weighting to sensitivity and specificity, we found that clinical features (symptoms, signs, residual volume) are helpful in diagnosing the presence of unstable detrusor and voiding dysfunction, but not incompetent urethra.