Felton M.,Felton S.,Kay N; Journal of the American Academy of Dermatology, May 2014

Bilateral superficial granulomatous pyoderma of the auricular and periauricular skin

Journal of the American Academy of Dermatology, May 2014
Author(s): Felton M.,Felton S.,Kay N.
Abstract:  A 36-year-old presented with a 3-month history of a nonhealing 5-mm diameter ulcer in the left conchal bowl. Swabs revealed no bacterial growth, and blood tests, including eosinophil count, were normal and antineutrophil cytoplasmic antibody negative. Histology from excisional biopsy, performed because of suspected malignancy, described extremely acanthotic squamous epithelium with ulcerated areas lined by palisading histiocytes. The dermis had a neutrophilic and in some areas eosinophilic infiltrate, again with palisading histiocytes. The cartilage was degenerate but not inflamed. There was no dysplasia. The key diagnosis proposed was superficial granulomatous pyoderma. The other histologic differentials, infection and systemic vasculitis, were excluded clinically. Unfortunately, he subsequently developed marked ulceration across the ipsilateral periauricular skin and within the contralateral conchal bowl. Some areas have healed with cribriform scarring. Treatment with high-dose oral prednisolone and azathioprine did not provide sustained improvement. Minocycline and dapsone had limited success, whilst more recently he has commenced anti-tumor necrosis factor therapy with infliximab after excluding underlying malignancy.

Van Der Ploeg, N; Hamer, D; European Journal of Surgical Oncology, May 2014

Breast care clinical nurse specialist led follpw up for patients who have undergone breast cancer surgery and have annual mammography

European Journal of Surgical Oncology, May 2014 vol/iss 40/5/(636), 0748-7983

Source: Embase

Abstract: Patients have annual mammograms for six years post diagnosis of breast cancer, they are seen within one hour of having their mammograms by a clinical nurse specialist, for clinical examination, results of mammography and follow up. The aim of the study was to evaluate whether patients were satisfied with the service or whether the process was more stressful than returning two weeks later for the results at a further appointment and whether they would prefer to see a doctor rather than a nurse. Method: The data was collected via questionnaire completed by the patient after they have attended for the follow up visit. All responses were anonymous. Results: Data was collected for one month in September 2013, 100 questionnaires were completed. This included patients who had undergone wide local excision, mastectomy +/- reconstruction of the breast. 100% of patients were very happy to be seen by a breast care specialist nurse. 100% of patients valued the service and found it less stressful having one visit to the hospital and receiving the results on the same day, 96% felt that any concerns were addressed at the consultation, 4% had no concerns.

Conclusion: Receiving mammogram results within one hour of having the mammogram significantly reduces level of anxiety in patients and seeing a breast care specialist nurse results in a very high level of patient satisfaction.

This article can be ordered through our inter-library loan scheme.


News from NHS Networks – Acute

NHS England will transfer £1,100 million from the mandate to local authorities.
The number of opiate and crack cocaine users in England has fallen again according to independent research published by Public Health England.
Action to tackle smoking, drinking, sedentary behaviour and poor diet could reduce the risk of dementia in later life alongside other conditions such as heart disease, stroke and many cancers, according to the UK Health Forum and Public Health England..
NHS England has issued guidance to trusts with inpatient beds on publishing staffing data on NHS Choices.
Many more news topics available from NHS Networks

News from NHS Networks

nhs networksFrom NHS Networks
NHS England is to launch a new pilot scheme that aims to help general practitioners assess the care and support needs of people with long-term conditions.
Updated immunisation schedule showing the introduction of the rotavirus vaccination at two and three months of age, the withdrawal of the second MenC vaccination at four months and the introduction of the MenC booster at 13 to 14 years.
A new paper from Community Links looks at the growing issue of an ageing society, noting that by 2025 13.5 million people will be over 65, up from 10.8 million today.
The National Institute for Health and Care Excellence (NICE) has produced a new quality standard aimed at helping all healthcare professionals, including GPs, pharmacists and school nurses, to improve the care of children and young people with idiopathic constipation.

BMJ: table of contents May 27 2014

Here is the table of contents for the BMJ (27 May). Use the links to access the articles and have your Athens account details to hand to read the full-text.

Editor’s choice
Navjoyt Ladher
Mark D Huffman
James Raftery and Christopher Newdick
Karl Michaëlsson
Ruth Cairns, Matthew Hotopf, and Gareth S Owen
Mark Porter and David Richmond
Ingrid Torjesen

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Cost-effectiveness of histamine receptor-2 antagonist versus proton pump inhibitor for stress ulcer prophylaxis in critically ill patients*.

Citation: Critical Care Medicine, 01 April 2014, vol./is. 42/4(809-815), 00903493

Author(s): Maclaren, Robert; Campbell, Jon
Language: English

Abstract: OBJECTIVE: To examine the cost-effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis.

DESIGN: Decision analysis model examining costs and effectiveness of using histamine receptor-2 antagonist or proton pump inhibitor for stress ulcer prophylaxis. Costs were expressed in 2012 U.S. dollars from the perspective of the institution and included drug regimens and the following outcomes: clinically significant stress-related mucosal bleed, ventilator-associated pneumonia, and Clostridium difficile infection. Effectiveness was the mortality risk associated with these outcomes and represented by survival. Costs, occurrence rates, and mortality probabilities were extracted from published data.

SETTING: A simulation model.     PATIENTS: A mixed adult ICU population.

NTERVENTIONS: Histamine receptor-2 antagonist or proton pump inhibitor for 9 days of stress ulcer prophylaxis therapy.

MAIN MEASUREMENTS AND RESULTS: Output variables were expected costs, expected survival rates, incremental cost, and incremental survival rate. Univariate sensitivity analyses were conducted to determine the drivers of incremental cost and incremental survival. Probabilistic sensitivity analysis was conducted using second-order Monte Carlo simulation. For the base case analysis, the expected cost of providing stress ulcer prophylaxis was $6,707 with histamine receptor-2 antagonist and $7,802 with proton pump inhibitor, resulting in a cost saving of $1,095 with histamine receptor-2 antagonist. The associated mortality probabilities were 3.819% and 3.825%, respectively resulting in an absolute survival benefit of 0.006% with histamine receptor-2 antagonist. The primary drivers of incremental cost and survival were the assumptions surrounding ventilator-associated pneumonia and bleed. The probabilities that histamine receptor-2 antagonist was less costly and provided favourable survival were 89.4% and 55.7%, respectively. A secondary analysis assuming equal rates of C. difficile infection showed a cost saving of $908 with histamine receptor-2 antagonists, but the survival benefit of 0.0167% favoured proton pump inhibitors.

CONCLUSIONS: Histamine receptor-2 antagonist therapy appears to reduce costs with survival benefit comparable to proton pump inhibitor therapy for stress ulcer prophylaxis. Ventilator-associated pneumonia and bleed are the variables most affecting these outcomes. The uncertainty in the findings justifies a prospective trial.

Publication Type: journal article                         Source: CINAHL

Full Text: Available from Ovid in Critical Care Medicine – Athens required

Anjum G.A.; Skouras T.; Longley C.; Liu L.S.; Rathe S.; Khan U.A; International Journal of Surgery, 2013,

Day case laparoscopic cholecystectomy: A DGH experience, can a national average target be achieved?
International Journal of Surgery, 2013, vol./is. 11/8(648-649), 1743-9191
Author(s): Anjum G.A.; Skouras T.; Longley C.; Liu L.S.; Rathe S.; Khan U.A.
Language: English

Aim: To evaluate our current practice of Cholecystectomy in terms of number of Day Case Cholecystectomies (DCLC) and re-admissions as compared to National Average, to improve the outcome.

Methods: A retrospective audit from 01/09/2010 to 31/08/2011. All patients who underwent cholecystectomy at DGH Macclesfield, were included in the study. Data was extracted from case notes and electronic discharge summaries, entered to a Performa and was analysed using Microsoft Excel. No exclusion criteria.

Results:  Out of 194, 90.7% were operated laparoscopically, 36% as day case, 43% as 23 hour stay (total 79%)and 21% as inpatient. Average length of stay for all laparoscopic cholecystectomies was 1.21 days. Number of DCLCs varied from 14% to 55% among surgical teams. 10.3% of patients readmitted to the hospital within 29 days of index surgery with intra-abdominal collection, wound infection, pancreatitis and cholangitis in descending order. Conclusion: The high performing team (in number) had highest number of DCLCs (55%). Our readmission rates were comparable to the National Average.

National Average targets for DCLC can be achieved at relatively smaller organizations like DG Hospitals provided that Cholecystectomy is considered as a Day Case procedure by default and clear criteria for patient selection are established and implemented.

Publication Type: Journal: Conference Abstract
Source: EMBASE

Embedding the 6 Cs into clinical research practice and management

Br J Nurs. 2014 Apr 10;23(7):365-7.   Author: Hardicre J.
Compassion in Practice was launched by the Chief Nursing Officer (CNO), Jane Cummings, at the CNO’s Conference in December 2012 (Cummings and Bennett, 2012). The values and behaviours of this 3-year plan have been embraced. It has driven the NHS action and change agenda with calls for every nurse, midwife and member of the care team to implement the 6 Cs into practice (NHS Commissioning Board, 2013) and, furthermore, into all areas of health, public health and social care services. This was almost palpable around NHS Change Day in March 2014 and the rapid recruitment of caremakers acting as ambassadors for change and the implantation of the 6 Cs into practice.
The values and behaviours of the 6 Cs are:
■ Care
■ Compassion
■ Competence
■ Communication
■ Courage
■ Commitment.

Read the full article via EBSCO (Athens credentials required)

NEW Medicine Safety app from CPPE

Our thanks to Ciaran Friel of Liverpool Community Health NHS Trust for this news.

The Centre for Pharmacy Postgraduate Education (CPPmedsafetyE) has launched the Medicines Safety app. This is free and funded by Health Education North West. It offers short quizzes for any healthcare professional to test their knowledge on high-risk areas for medicines safety incidents. The topics so far include: Insulin, Allergies, Opioids, Anticoagulation and Medicines safety.

It stimulates further learning so it can be used to generate ideas for CPD portfolios and to improve practice. You can also use it in group learning situations as a starting point for discussion on key safety issues.

Download the app free of charge from the App Store for iPhone/iPad users and from Google Play Store for Android devices.  More topics will be released soon. 

You can also keep up to date with developments at CPPE and get in touch via the following media:  www.cppe.ac.uk/blog or via Twitter at twitter.com/cppeengland

Productive Ward article: International Journal of Nursing Studies

The impact of a large-scale Quality Improvement Programme on Work Engagement; Preliminary Results from a national cross-sectional-survey of the ‘Productive Ward …

M White, JSG Wells, T Butterworth – International Journal of Nursing Studies, May 2014

Quality improvement (QI) Programmes, like the Productive Ward: Releasing-time-to-care initiative, aim to ‘engage’ and ‘empower’ ward teams to actively participate, innovate and lead quality improvement at the front line. However, little is known about the relationship and impact that QI work has on the ‘engagement’ of the clinical teams who participate and vice-versa.

This paper explores and examines the impact of a large-scale QI programme, the Productive Ward, on the ‘work engagement’ of the nurses and ward teams involved.

Using the Utrecht Work Engagement Scale (UWES), we surveyed, measured and analysed work engagement in a representative test group of hospital-based ward teams who had recently commenced the latest phase of the national ‘Productive Ward’ initiative in Ireland and compared them to a control group of similar size and matched (as far as is possible) on variables such as ward size, employment grade and clinical specialty area.

Szatmary, P, et al; Annals of Surgery, May 2014,

Safety of short, in-hospital delays before surgery for acute appendicitis: Multicentre cohort study, systematic review, and meta-analysis

Citation: Annals of Surgery, May 2014, vol./is. 259/5(894-903), 0003-4932;1528-1140 (May 2014)

Author(s): Bhangu A.; Panagiotopoulou I.G.; Chatzizacharias N.; Rana M.; Rollins K.; Ejtehadi F.; Jha B.; Tan Y.W.; Fanous N.; Markides G.; Tan A.; Marshal C.; Akhtar S.; Mullassery D.;  P. Szatmary (East Cheshire NHS Trust, Macclesfield);

OBJECTIVE:  To determine safety of short in-hospital delays before appendicectomy.   BACKGROUND:   Short organizational delays before appendicectomy may safely improve provision of acute surgical services.

METHODS: The primary endpoint was the rate of complex appendicitis (perforation, gangrene, and/or abscess). The main explanatory variable was timing of surgery, using less than 12 hours from admission as the reference. The first part of this study analyzed primary data from a multicentre study on appendicectomy from 95 centers. The second part combined this data with a systematic review and meta-analysis of published data.

RESULTS: The cohort study included 2510 patients with acute appendicitis, of whom 812 (32.4%) had complex findings. Adjusted multivariable binary regression modelling showed that timing of operation was not related to risk of complex appendicitis [12-24 hours odds ratio (OR) 0.98 (P = 0.869); 24-48 hours OR 0.88 (P = 0.329); 48+ hours OR 0.82 (P = 0.317)]. However, after 48 hours, the risk of surgical site infection and 30-day adverse events both increased [adjusted ORs 2.24 (P = 0.039) and 1.71 (P = 0.024), respectively]. Meta-analysis of 11 nonrandomized studies (8858 patients) revealed that delay of 12 to 24 hours after admission did not increase the risk of complex appendicitis (OR 0.97, P = 0.750).

CONCLUSIONS: Short delays of less than 24 hours before appendicectomy were not associated with increased rates of complex pathology in selected patients. These organizational delays may aid service provision, but planned delay beyond this should be avoided. However, where optimal surgical systems allow for expeditious surgery, prompt appendicectomy will still aid fastest resolution of pain for the individual patient.

Copyright 2014 by Lippincott Williams & Wilkins.
Publication Type: Journal: Article
Source: EMBASE
Full Text: Available from Ovid in Annals of Surgery

EC Trust – 4 times a winner in CHKS Top 40 Hospitals

CHKS logoIt’s getting to be a habit – East Cheshire Trust is listed for the 4th time since 2011 in CHKS ‘Top 40 Hospitals.

“The award is based on the evaluation of 22 key performance indicators covering safety, clinical effectiveness, health outcomes, efficiency, patient experience and quality of care.”

CHKS 40Top Winners 2014

  • Airedale NHS Foundation Trust
  • Ashford and St Peter’s Hospitals NHS Foundation Trust
  • Barking, Havering and Redbridge University Hospitals NHS Trust
  • Barnsley Hospital NHS Foundation Trust
  • Bedford Hospital NHS Trust
  • Blackpool Teaching Hospitals NHS Foundation Trust
  • NHS Borders
  • Cambridge University Hospitals NHS Foundation Trust
  • Chelsea and Westminster Hospital NHS Foundation Trust
  • Countess of Chester Hospital NHS Foundation Trust
  • Derby Hospitals NHS Foundation Trust
  • Dorset County Hospital NHS Foundation Trust
  • East Cheshire NHS Trust
  • East Kent Hospitals University NHS Foundation Trust
  • Kingston Hospital NHS Trust
  • Lewisham Healthcare NHS Trust
  • Mid Cheshire Hospitals NHS Foundation Trust
  • Mid Essex Hospital Services NHS Trust
  • North Tees and Hartlepool NHS Foundation Trust
  • Northern Health and Social Care Trust (Northern Ireland)
  • Northumbria Healthcare NHS Foundation Trust
  • Portsmouth Hospitals NHS Trust
  • Royal Berkshire NHS Foundation Trust
  • Royal Cornwall Hospitals NHS Trust
  • Royal Surrey County Hospital NHS Foundation Trust
  • Sandwell and West Birmingham Hospitals NHS Trust
  • Sheffield Teaching Hospitals NHS Foundation Trust
  • Shrewsbury and Telford Hospital NHS Trust
  • South Eastern Health and Social Care Trust (Northern Ireland)
  • South Warwickshire NHS Foundation Trust
  • Southern Trust Health and Social Care Trust (Northern Ireland)
  • The Dudley Group NHS Foundation Trust
  • The Newcastle Upon Tyne Hospitals NHS Foundation Trust
  • The Rotherham NHS Foundation Trust
  • University College London Hospitals NHS Foundation Trust
  • University Hospitals Bristol NHS Foundation Trust
  • West Suffolk NHS Foundation Trust
  • Weston Area Health NHS Trust
  • Wye Valley NHS Trust
  • York Teaching Hospital NHS Foundation Trust

Read the report in The Middlewich Guardian or more information at CHKS

Eyes on Evidence: Issue 61; May 2014

Here are the latest topics for this month from NICE – Eyes on Evidence.

Adenotonsillectomy in children with obstructive sleep apnoea
A randomised controlled trial in the USA finds that adenotonsillectomy does not improve cognitive function in children with obstructive sleep apnoea syndrome, although it does have a beneficial effect on symptoms of sleep apnoea.

Ibuprofen compared with indometacin for patent ductus arteriosus
A Cochrane review reports that ibuprofen is as effective as indometacin for closure of patent ductus arteriosus in preterm or low-birthweight babies, and is associated with a lower risk of necrotising enterocolitis, reduced time on assisted ventilation and a lower risk of negative effects on renal function.

Gallbladder removal with or without bile duct imaging
A retrospective cohort study of US data raises caution about interpreting the benefits of using bile duct imaging during gallbladder removal.

Collaborative care for depression
A cluster randomised controlled trial in English general practices suggests that collaborative care delivered by mental health workers acting as care managers is more effective at reducing depression than usual care.

End-of-life preferences of people with terminal illness who live alone
An Australian cohort study finds that around half of people with terminal illness who live alone would prefer to die at home, but only a small proportion manage to do so.

Evidence Updatesnice_logo
NICE has recently published Evidence Updates on:

  • Venous thromboembolic diseases -Interventions to reduce substance misuse among vulnerable young people

Eyes on Evidence helps contextualise important new evidence, highlighting areas that could signal a change in clinical practice. It does not constitute formal NICE guidance. The commentaries
included are the opinions of contributors and do not necessarily reflect the views of NICE.


Jeff A; Taylor, C; Gastrointestinal Nursing, 2014

Ward nurses’ experience of enhanced recovery after surgery: a grounded theory approach

Ward nurses’ experience of enhanced recovery after surgery: a grounded theory approach.

at East Cheshire NHS Trust, Cheshire, England.

Congratulations to Angela Jeff our Colorectal Macmillan Nurse Specialist and Claire Taylor, Macmillan Team Leader in Colorectal Cancer at St Mark’s Hospital, London, England on publication of this article in Gastrointestinal Nursing.

Many studies looking at enhanced recovery after surgery (ERAS) examine the clinical outcomes and patient satisfaction of the programme. This article reports on the findings of a qualitative study employing a grounded theory approach to explore the experiences of ward nurses involved in the postoperative stage of the ERAS programme with colorectal patients. Data were collected in 2012 using semistructured interviews. The basic social process that emerged from the analysis describes how ward nurses adapted their delivery of care in order to meet patient need. This process also explains why variance in individual patient recovery, lack of resources, and an inconsistent adherence to protocols necessitated the adapting of the ERAS nursing-care protocol. ERAS can provide a framework for nurses to deliver care but protocol-led care can have limitations. This study also developed the theory of adaptation, which describes how ward nurses adapt in certain situations to deliver care.

BMJ Learning: Gastroenterology modules

Here are the latest modules in gastroenterology from BMJ Learning

Royal College of Physicians: National care of the dying audit of hospitals

National care of the dying audit of hospitals

Holding Hands with Elderly PatientThis report has found significant variations in care across hospitals in England.  The audit shows that major improvements need to be made to ensure better care for dying people, and better support for their families, carers, friends and those important to them. While previous audits had been based on the goals of care within the Liverpool Care Pathway for the Dying Patient (LCP), the new audit sampled the care of dying people in hospital, regardless of whether they were supported by the LCP or other care pathways or frameworks, and included more hospitals than the previous audits.

Miller C.A.; Naish J.H; Egdell, R; Journal of Cardiovascular Magnetic Resonance, January 2014

Voxel-wise quantification of myocardial blood flow with cardiovascular magnetic resonance: Effect of variations in
methodology and validation with positron emission tomography
Journal of Cardiovascular Magnetic Resonance, January 2014, vol./is. 16/1, 1097-6647;1532-429X (24 Jan 2014)
Author(s): Miller C.A.; Naish J.H.; Ainslie M.P.; Tonge C.; Tout D.; Arumugam P.; Banerji A.; Egdell R.M.; Clark D.; Weale P.; Steadman C.D.; McCann G.P.; Ray S.G.; Parker G.J.; Schmitt M.

Abstract:  Quantitative assessment of myocardial blood flow (MBF) from cardiovascular magnetic resonance (CMR) perfusion images appears to offer advantages over qualitative assessment. Currently however, clinical translation is lacking, at least in part due to considerable disparity in quantification methodology. The aim of this study was to evaluate the effect of common methodological differences in CMR voxel-wise measurement of MBF, using position emission tomography (PET) as external validation.

Methods. Eighteen subjects, including 9 with significant coronary artery disease (CAD) and 9 healthy volunteers prospectively underwent perfusion CMR. Comparison was made between MBF quantified using: 1. Calculated contrast agent concentration curves (to correct for signal saturation) versus raw signal intensity curves; 2. Mid-ventricular versus basal-ventricular short-axis arterial input function (AIF) extraction; 3. Three different deconvolution approaches; Fermi function parameterization, truncated singular value decomposition (TSVD) and first-order Tikhonov regularization with b-splines. CAD patients also prospectively underwent rubidium-82 PET (median interval 7 days).

Results: MBF was significantly higher when calculated using signal intensity compared to contrast agent concentration curves, and when the AIF was extracted from mid- compared to basal-ventricular images. MBF did not differ significantly between Fermi and Tikhonov, or between Fermi and TVSD deconvolution methods although there was a small difference between TSVD and Tikhonov (0.06 mL/min/g). Agreement between all
deconvolution methods was high. MBF derived using each CMR deconvolution method showed a significant linear relationship (p < 0.001) with PET-derived MBF however each method underestimated MBF compared to PET (by 0.19 to 0.35 mL/min/g).

Variations in more complex methodological factors such as deconvolution method have no greater effect on estimated MBF than simple factors such as AIF location and observer variability. Standardization of the quantification process will aid comparison between studies and may help CMR MBF quantification enter clinical use. 2014 Miller et al.; licensee BioMed Central Ltd.
Publication Type: Journal: Article
Source: EMBASE
Full Text: Available from EBSCOhost in Journal of Cardiovascular Magnetic Resonance (BioMed Central)

Losa, I; BMJ Case Reports 2013

Beau’s lines in postpartum period and hyperparathyroidism
BMJ Case Reports 2013; doi:10.1136/bcr-2013-201220
Dr Ignatius Losa, ignatius.losa@nhs.net
Department of Paediatrics, Macclesfield District Hospital, Macclesfield, UK
Apologies for the late posting of this published article by Dr Losa.

Description: A woman brought her baby for review 3 months after delivery. The patient reported that she developed transverse nail ridges-Beau’s lines (figure 1). During pregnancy, she was incidentally found to have a raised serum calcium of 3.89 mmol/L (adjusted 4.13). Her parathormone …

Read the full article at BMJ Case Reports  (Athens account login required)

Alsaffar H.; Whitby T.; Chandrasekaran S. Hormone Research in Paediatrics, October 2013

The effect of automated bolus calculators on HbA1c in children with type 1 diabetes in Macclesfield

Hormone Research in Paediatrics, October 2013, vol./is. 80/(413), 1663-2818

diabetesBackground: Previous studies have shown that using Automated bolus calculators (ABC) in type1 diabetic children showed noticeable reduction in HbA1C(1). Furthermore, it showed reduction in post prandial blood glucose level(2) and glucose variability(3) for those children treated with insulin pumps. Data from adults has already shown improvement in HbA1C following usage of ABC(4).

Objective: To confirm the effect of ABC on HbA1C in children with type1 diabetes who are on multiple daily insulin injection regimes in our unit.

Methods: This is a cross-sectional study. We have collected the data via Accu-check software and by reviewing the case notes. HbA1C was measured
before and after ABC use. Some of the patients were started immediately on ABC following their diagnosis with diabetes and others were started later after they showed poor glycaemic control.

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