Sending NHS Patients for Operations Abroad: Is the Holiday Over?

INTRODUCTION

The UK Department of Health, in its attempt to help NHS trusts reduce long elective waiting lists, set up the overseas commissioning scheme in 2002. This allowed hospitals to send their patients abroad for their surgery. In theory, this was a win-win situation, where pressures upon surgeons were reduced, and trusts could reach UK Government targets and avoid breaches. At our hospital, a significant number of patients, who had undergone a total joint replacement abroad, were discharged after only one postoperative review and often had very little physiotherapy. A few presented to our clinic with more serious problems.

PATIENTS AND METHODS

This is a retrospective review of two matched groups of patients (22 each), all of whom underwent a total knee replacement in 2003. The first group (abroad, Belgium) included 10 males and 12 females with a mean age of 74.5 years and a mean follow-up of 37 months. The second group (local institution) included 10 males and 12 females with a mean age of 71.4 years and a mean follow-up of 34 months. All patients were evaluated using the Oxford Knee Score (OKS), Knee Society Score (KSS), and SF-12 systems.

RESULTS

OKS and KSS were similar in the two groups. However, SF-12 figures revealed a statistically significant difference in both the physical (PCS) and mental components (MCS). Belgium group – mean PCS 40, mean MCS 48: local group – mean PCS 47, mean MCS 57; P < 0.05.

CONCLUSIONS

The results demonstrate that, although the majority of patients operated upon abroad got comparable functional results to patients operated locally, they often felt dissatisfied with the overall experience of travelling for their operation. Furthermore, the issues of ‘patient ownership’ and long-term follow-up need to be fully addressed in order to safeguard the high standard of care we should offer our patients.     

Differences in emotional experience and emotion regulation as a function of age and psychiatric condition

In this study, self-reported experiences of negative affectivity and emotional regulation in a sample of older and younger adults with and without psychiatric co-morbidity were evaluated. Study participants were divided into four separate groups (younger nonpsychiatric = YN; younger psychiatric = YP; older non-psychiatric = ON; and older psychiatric = OP). Findings indicated that, as hypothesized, individuals in the OP and YP groups reported more negative affect intensity and reactivity and more maladaptive emotion regulation than individuals in the ON and YN groups. Contrary to hypotheses, when collapsed across psychiatric conditions, older adults did not report significantly less negative affect intensity and reactivity than younger adults. A significant age by psychiatric group interaction effect on negative affect intensity occurred such that individuals in YN and ON groups reported similar levels of negative affect intensity and individuals in the YP group reported more negative affect intensity than individuals in the OP group. The finding that older adults with Axis I and Axis II diagnoses differ in their symptom reports from younger adults with similar diagnoses suggests there may be important assessment and intervention issues related to the interaction of aging and psychopathology. Clinical implications and directions for future studies are discussed.     

Severe psychiatric problems in right hepatic lobe donors for living donor liver transplantation

BACKGROUND: The morbidity and mortality from donation of a right hepatic lobe for living donor liver transplantation (LDLT) is an important issue for this procedure. We report the prevalence of severe psychiatric postoperative complications from the Adult-to-Adult Living Donor Liver Transplantation Cohort study (A2ALL), which was established to define the risks and benefits of LDLT for donors and recipients. METHODS: Severe psychiatric complications were evaluated in all donors from the A2ALL study who were evaluated between 1998 and February 2003. RESULTS: Of the 392 donors, 16 (4.1%) had one or multiple psychiatric complications, including three severe psychiatric complications (suicide, accidental drug overdose, and suicide attempt). CONCLUSIONS: Despite extensive preoperative screening, some donors experience severe psychiatric complications, including suicide, after liver donation. Psychiatric assessment and monitoring of liver donors may help to understand and prevent such tragic events.     

Both heterozygous and homozygous alpha+ thalassemias protect against severe and fatal Plasmodium falciparum malaria on the coast of Kenya

Although the alpha+ thalassemias almost certainly confer protection against death from malaria, this has not been formally documented. We have conducted a study involving 655 case patients with rigorously defined severe malaria and 648 controls, frequency matched on area of residence and ethnic group. The prevalence of both heterozygous and homozygous alpha+ thalassemia was reduced in both case patients with severe malaria (adjusted odds ratios [ORs], 0.73 and 0.57; 95% confidence intervals [95% CIs], 0.57-0.94 and 0.40-0.81; P = .013 and P = .002, respectively, compared with controls) and among the subgroup of children who died after admission with severe malaria (OR, 0.60 and 0.37; 95% CI, 0.37-1.00 and 0.16-0.87; P = .05 and P = .02, respectively, compared with surviving case patients). The lowest ORs were seen for the forms of malaria associated with the highest mortality-coma and severe anemia complicated by deep, acidotic breathing. Our study supports the conclusion that both heterozygotes and homozygotes enjoy a selective advantage against death from Plasmodium falciparum malaria.     

Percutaneous radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation

Orthotopic liver transplantation (OLT) can be a definitive treatment for patients with hepatocellular carcinoma (HCC). Prolonged waiting times for cadaveric livers, however, may lead to dropout from the waiting list or worsened post-OLT prognosis as a result of interval tumor progression. Percutaneous radiofrequency ablation (RFA) is widely used for local control of small unresectable HCC, but its pretransplant role remains unclear. We studied the outcome of 52 consecutive patients accepted for OLT bearing 87 HCC nodules and treated with percutaneous RFA. On initial staging, the tumor burden exceeded the Milan criteria in 10 patients. Complete tumor coagulation was observed in 74 of 87 (85.1%) nodules based on postablation imaging. After a mean of 12.7 months (range: 0.3-43.5) on the waiting list, 3 of 52 patients (5.8%) had dropped out due to tumor progression. Forty-one patients had undergone transplantation, with 1- and 3-year post-OLT survival rates of 85% and 76%, respectively. No patient developed HCC recurrence. There were three major complications in 76 RFA procedures (hepatic arterial hemorrhage, small bowel perforation, and liver decompensation salvaged by OLT), without resultant death or dropout. In conclusion, percutaneous RFA is an effective bridge to OLT for patients with compensated liver function and safely accessible tumors. Tumor-related dropout rate and post-OLT outcome compared favorably with published controls of patients with early-stage disease. This can be attributed to the efficacy of RFA in producing local cure or curbing tumor progression during the waiting period.