Author: Jason Curtis

Cost Analysis of Thoracic Endovascular Aortic Repair in Type B Aortic Dissection: How Much Does Quality Cost? (2023)

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Type of publication:Journal article

Author(s):Bashir M; Jubouri M; *Patel R; Geragotellis A; Tan SZ; Bailey DM; Mohammed I; Velayudhan B; Williams IM

Citation:
Annals of Vascular Surgery. 94 (pp 38-44), 2023. Date of Publication: August 2023.

Abstract:Introduction: Aortic dissection (AD) is a life-threatening medical emergency that affects an estimated 3-4 people per 100,000 annually, with 40% of cases classified as type B AD (TBAD). TBAD can be further classified as being complicated (co-TBAD) or uncomplicated (un-TBAD) based on the presence or absence of certain features such as malperfusion and rupture. TBAD can be managed conservatively with optimal medical therapy (OMT), or invasively with open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR), depending on several factors such as type of TBAD and its clinical acuity. The cost-effectiveness, or cost-benefit profile, of these strategies must be given equal consideration. However, TBAD studies featuring cost analyses are limited within the literature. Aims: This narrative review aims to address the gap in the literature on cost effectiveness of TBAD treatments by providing an overview of cost-analyses comparing OMT with TEVAR in un-TBAD and TEVAR with OSR in co-TBAD. Another aim is to provide a market analysis of the commercially available TEVAR devices. Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus and EMBASE to identify and extract relevant studies. Results: Several TEVAR devices are available commercially on the global market costing $12,000-19,495. Nevertheless, the Terumo Aortic RELAY® stent-graft seems to be the most cost-effective, yielding highly favourable clinical outcomes. Despite the higher initial cost of TEVAR, evidence in the literature strongly suggest that it is superior to OMT for un-TBAD on the long-term. In addition, TEVAR is well established in the literature as being gold-standard repair technique for co-TBAD, replacing OSR by offering a more optimal cost-benefit profile through lower costs and improved results. Conclusion: The introduction of TEVAR has revolutionised the field of aortovascular surgery by offering a highly efficacious and long-term cost effective treatment for TBAD.

Fate and Consequences of the False Lumen After Thoracic Endovascular Aortic Repair in Type B Aortic Dissection (2023)

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Type of publication:Journal article

Author(s):Jubouri M; *Patel R; Tan SZ; Al-Tawil M; Bashir M; Bailey DM; Williams IM

Citation:Annals of Vascular Surgery. 94:32-37, 2023 Aug.

Abstract:Background: Type B aortic dissection (TBAD) occurs due to an entry tear in the intimal layer of the aorta distal to the origin of the left subclavian artery where blood enters the newly formed false lumen (FL) and extends distally or proximally to form a dissection over an indeterminate length of the aorta which, over time, may eventually rupture. Thoracic endovascular aortic repair (TEVAR) aims to seal off the entry tear proximally with the stent-graft, occluding the origin of the dissection and excluding the FL. Nevertheless, in some cases, the perfusion to the FL is maintained, hindering the aortic remodelling process and increasing the risk of aneurysmal degeneration and rupture, particularly in the abdominal aorta where evidence suggest that remodelling is slower. This review examines the long-term effects of a patent or partially thrombosed FL on clinical outcomes following TEVAR in TBAD, also highlighting the pathological processes behind negative aortic remodelling. Another aim of this review is to provide an overview and appraisal of the currently available techniques for managing a patent or partially thrombosed FL to prevent long-term morbidity occurring. Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies. Results: Evidence in the literature show that a partially thrombosed FL is more dangerous than a patent FL due to the occlusion of the distal re-entry tears, impeding outflow and increasing mean arterial and diastolic pressures, whereas the latter is decompressed via distal re-entry sites. FL thrombosis and satisfactory remodelling is sometimes achieved in as few as 40% of patients after TEVAR due to the maintained perfusion of the FL either at the level of the thoracic or abdominal aorta. However, although the thoracic aorta is predominantly covered by the TEVAR stent-graft, poorer remodelling and more dilation is seen in the abdominal aorta. Several techniques are available to embolize the FL, including the Provisional Extension to Induce Complete Attachment, Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair, candy-plug, and Knickerbocker techniques. Conclusions: The management of TBAD is invariably TEVAR to seal off the proximal entry tear while extending the repair distally to completely exclude the FL. A risk of aortic wall dilatation distal to TEVAR stent-graft remains; hence, regular monitoring and accurate imaging are essential. At present, a patent FL can be treated using a range of different endovascular techniques.

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Thyrotoxic Periodic Paralysis: Case Presentation With Tetraparesis and Cardiac Dysrhythmia (2022)

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Type of publication:Journal article

Author(s):*Dosu A; *Gupta M; *Walsh O; *Makan J

Citation:Cureus, 2022 Sep 29; Vol. 14 (9), pp. e29759

Abstract:Thyrotoxic hypokalaemic periodic paralysis (THPP) is a rare complication of hyperthyroidism that is potentially life-threatening if not treated promptly. It is more common in Asian and Polynesian populations and very few cases have been reported to date in people of White ethnicity. We present a case report of a young male patient of White ethnicity, who was initially brought in as a stroke alert with tetraparesis which was ruled out on initial assessment, but then had a syncopal episode and was noted to be initially bradycardic and subsequently tachycardic. Blood tests showed hypokalaemia and hypophosphataemia and he was treated as a hypokalaemic periodic paralysis patient. Intravenous potassium replacement was commenced. Symptoms and ECG changes resolved with correction of potassium levels. Thyroid function tests requested later were suggestive of hyperthyroidism and the diagnosis of thyrotoxic hypokalaemic periodic paralysis was made. This is an interesting case given its rarity, and this case report highlights the importance of early diagnosis and prompt treatment.

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All sleep and no play? An audit and service evaluation of children undergoing radiological imaging (2022)

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Type of publication:
Conference abstract

Author(s):
*Muneer K.

Citation:
Archives of Disease in Childhood. Conference: Royal College of Paediatrics and Child Health Conference, RCPCH 2022. Liverpool United Kingdom. 107(Supplement 2) (pp A120-A121), 2022. Date of Publication: August 2022.

Abstract:
Aims The use of sedation in children for radiological imaging is common practice in Paediatrics. However, the risks need to be weighed against the benefits of imaging under sedation. Play therapy has been considered as an alternative to sedation in a cooperative child. This study explored the safety, efficacy and adherence of practice to local trust guidelines for sedation of children (derived from the NICE Sedation under 19s guidelines) and highlighted play therapy as a potential alternative for selected children requiring radiological imaging. Methods Data was gathered retrospectively from a 6 month period with the help of the Trust's medical records department. There were 36 children who underwent sedation for various imaging modalities and 19 children who had imaging done utilising play therapy over the same period. The information gathered from the resources used was collated in an excel database for the purpose of comparative analysis. Results 1. The assignment of patients was based on their clinical presentation, urgency and medical background 2. Children receiving sedation were predominantly below the age of 3 years while those in the play group were between 6-9 years 3. The youngest child to receive sedation was 3 months old and the youngest to have successful MRI using play therapy was 3 years 5 months 4. The success rate of Sedation was 92% vs. 86% for play therapy 5. 83% underwent MRI, 11% DMSA and 6% MAG3 under sedation. 95% had MRI and 5% CT in the play group 6. 14% required a repeat dose of medication for sedation 7. None had complications secondary to sedation 8. One had MRI Head done under sedation and later MRI Spine successfully under play therapy at 3 years 5 months 9. Where all documents were available for analysis, the adherence to local guidelines for sedation was 100% Conclusion 1. Sedation is a safe and effective option available in a DGH setting for young children needing relatively urgent radiological imaging to establish diagnosis where the benefits generally outweigh the risks. 2. Play therapy is a suitable alternative for cooperative children who can be adequately prepared. 3.Healthcare teams and parents need to be made more aware of these options in the future.

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Laparoscopic ventral mesh rectopexy for pelvic floor dysfunction is a safe procedure: a single centre experience (2022)

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Type of publication:
Conference abstract

Author(s):
*Chang J.; *Rajalingam V.; *Ebanks A.; *Lacy-Colson J.; *Farquharson A.

Citation:
Colorectal Disease. Conference: Association of Coloproctology of Great Britain and Ireland Annual Meeting. Edinburgh United Kingdom. 24(Supplement 2) (pp 65), 2022. Date of Publication: September 2022.

Abstract:
Purpose: Laparoscopic Ventral Mesh Rectopexy (LVMR) is an established treatment option in the management of internal and external rectal prolapse. However, there is some concern regarding the safety and long-term outcomes of the use of mesh in the pelvis. The Pelvic Floor Society (TPFS) has suggested a move towards delivering this surgery in accredited units in the UK. We present our experience and outcomes for LVMR where a standardised technique is performed. Method(s): All patients who underwent LVMR between 2012 and 2020 at a single centre were included. Clinical indications for surgery, preoperative proctogram, endoanal ultrasound, anorectal physiology, pre and postoperative symptom severity scoring (Longo and Wexner) and outcome data were collected and analysed. Result(s): 146 patients underwent LVMR during the study period. Indications included; faecal incontinence (FI) (5), obstructive defecation syndrome (ODS) (74), mixed ODS/FI (34), and external rectal prolapse (32). One patient required re-operation for vaginal erosion of mesh suture (4 years post-LVMR). No other mesh complications were identified. 100 patients had resolution of symptoms, 46 had symptomatic improvement but required ongoing therapies (rectal irrigation, laxatives or biofeedback therapy). Ten patients underwent subsequent sutured transanal mucosal repair or haemorrhoidectomy for ongoing symptoms of ODS. Two patients developed recurrence of external prolapse which required operation: Delorme's (1), repeat LVMR (1). Conclusion(s): LVMR is a safe and effective procedure for pelvic floor dysfunction and the treatment of internal and external rectal prolapse in selected patients. Undertaking a standardised procedure in high volume units ensures optimal patient outcomes.

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Comparative analysis of gene mutations present in rectal mucus sampled using the OricolTM and DNA retrieved from the Paired Formalin-Fixed Tumour Blocks. Early Data from the OricolTM EGI-02 Study (2022)

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Type of publication:
Conference abstract

Author(s):
*Lacy-Colson J.

Citation:
Colorectal Disease. Conference: Association of Coloproctology of Great Britain and Ireland Annual Meeting. Edinburgh United Kingdom. 24(Supplement 2) (pp 15), 2022. Date of Publication: September 2022.

Abstract:
Background: The Colorectal 2-week wait (2WW) pathway is overwhelmed. qFiT has been added to the pathway, however cancer detection rate remains low ~5%. Using a novel rectal mucus sampling device (OricolTM) we hypothesized that shed genetic material could be retrieved from rectal mucus using OricolTM, potentially forming an accurate triage tool for colonoscopy or other investigation (Oricol EGI-02 Study). Method(s): The OricolTM device was used in symptomatic patients recruited from 4 NHS Trusts. DNA from FFPE-histology blocks was compared to the pre-operative OricolTM rectal mucus specimen. Using targeted next generation sequencing (NGS) incorporating error suppression technology, including unique molecular indexes (UMI's) and dual indexes (UDI's) for removal of PCR/sequencing errors/index hopping events, we assessed the single nucleotide polymorphisms (SNPs) present in 50 known CRC genes across both samples. Current recruitment to the Oricol-EGI- 02 Study is 586/600. 35 paired samples and 35 Oricol samples from normal 2WW colonoscopies were evaluated. Result(s): There were no statistical differences between tumour associated SNP burden in the FFPE-blocks and the rectal mucus sample from CRC patients. Tumour associated SNP burden in the paired cancer samples was significantly higher compared to the normal group (p < 0.001). Identical SNPs were identified in both tumour and paired Oricol samples. Conclusion(s): This result confirms the hypothesis that shedding of DNA from colorectal cancers (caecum to rectum) can be detected in rectal mucus using OricolTM. Sampling rectal mucus could be used to accurately detect CRC in unprepared patients, dramatically reducing the number of normal colonoscopies which currently overwhelm the 2WW pathway.

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A Retrospective Audit Of The Management of Patients on a General Paediatric Ward With Anorexia Nervosa Against Marsipan Guidelines (2022)

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Type of publication:
Conference abstract

Author(s):
Franklin L.; *Cowley A.; *Bennett R.

Citation:
BMJ Paediatrics Open. Conference: Royal College of Paediatrics and Child Health, RCPCH and the Young Person's Health Special Interest Group, YPHSIG 2022. Birmingham United Kingdom. 6(Supplement 1) (pp A22-A23), 2022. Date of Publication: 2022.

Abstract:
Objectives The Junior MARSIPAN guidelines were created to improve the medical care of paediatric patients with severe anorexia nervosa. This audit aims to evaluate the care provided by a general paediatric ward compared to the recommendations outlined in the MARSIPAN guidelines and the completion of risk assessments. Methods Retrospective analysis of patient notes was conducted on the most recent admission to the general paediatric ward of 10 patients with anorexia nervosa within the last 24 months. The documentation of their care was audited against a pre-made proforma based on the MARSIPAN guidelines and the MARSIPAN risk assessment. Medical notes and a nursing care pathway document were reviewed. The initial blood tests, refeeding blood and nursing care was also assessed. The inclusion criteria for this audit was any patient under the age of 18-years-old admitted in the last 24 months to the general paediatric ward. Any patients currently admitted or without a complete set of admission and inpatient medical notes were excluded. Results 10 patients were included and a total of 434 bed days were assessed. Our results show variability in compliance with the MARSIPAN guidelines, in terms of the initial admission and the care received. On admission, 70% of the patients were reviewed by a consultant, 30% had a full MARSIPAN risk assessment and 40% had a percentage median BMI calculated. Important investigations were inconsistently completed, such as an ECG with a recorded QTc length (70%), sitting and standing blood pressure (20%), dehydration assessment (30%), and SUSS stand-squat and sit-up test (20%). Common initial blood tests such as Full Blood Count, Bone Profile and Liver Function Tests were completed for all patients, however many of the other important investigations were incomplete; for example Folate and B12 (40%), amylase (20%) and creatinine kinase (0%). 80% of the patients received daily biochemical blood tests to screen for refeeding syndrome in their first week in hospital; 100% of the refeeding blood tests included U&Es, magnesium, and phosphate levels. During their stay, 80% of patients had input from a dietitian and 100% had input from either CAMHS or a specialist eating disorder service. 20% of patients had daily consultant reviews and 30% of patients had a MARSIPAN risk assessment done during their admission, with only 10% having regular risk assessments. All patients received thiamine and vitamin supplementation. Nursing care was adherent to guidelines with 4-hourly vitals, enforced bed-rest, and supervised mealtimes for 100% of patients. 70% of patients had 4-hourly blood glucose measurements. Conclusions The medical care documentation assessed in this audit was not compliant with MARSIPAN guidelines but nursing care was. The findings in this audit, along with national audits, suggest sub-optimal care for inpatient admissions with anorexia nervosa. The excellent nursing results demonstrates the introduction of the nursing pathway document makes a significant difference. We recommend a joint medical and nursing pathway document for admission including weekly medical reviews should be implemented and re-audited to reassess the documentation and adherence to guidelines, especially in light of the new MEED (Medical emergencies in eating disorders -CR233) guidelines.

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Reduction in rates of reversal of temporary stoma after anterior resection, another building crisis post COVID-19? (2022)

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Type of publication:
Conference abstract

Author(s):
*Chang J.; *Rajalingam V.; *Dowdeswell M.; *Ball W.

Citation:
Colorectal Disease. Conference: Association of Coloproctology of Great Britain and Ireland Annual Meeting. Edinburgh United Kingdom. 24(Supplement 2) (pp 77), 2022. Date of Publication: September 2022.

Abstract:
Purpose: Diverting loop-ostomies are sometimes formed in patients undergoing resection for rectal cancer with primary anastomosis. Timing to reversal is commonly reported between 3-6 months of original surgery, with longstanding issues of delays secondary to low-surgical prioritisation. Our retrospective study over a 5-year period aims to understand the effect on timing to reversal of the COVID-19 pandemic. Method(s): All patients undergoing resection for rectal cancer were identified from the Hospital Episode Statistics data between 01.01.2018 and 01.07.2021. Data was then cross-referenced with patients undergoing reversal surgery. Demographics, time to surgery, length of stay and post-operative morbidity data were collected. <br/>Result(s): There were 262 anterior resections performed. 192 patients had resection with primary anastomosis (PA): 85 had formation of loop ileostomy, 23 formation of loop colostomy. Results before March 2020: 65 resections with PA and ileostomy. 34 (52.3%) reversed with median time to reversal of 266 days, (range 98-1015). 16 resections with PA and colostomy. 7 reversed (44%), median time to reversal 476 days (range 104-768). Results after March 2020: 20 resections with PA and loop-ileostomy. 3 have been reversed (15%), with median time to reversal of 211 days, (range 103-449). 7 resections with PA and colostomy, none reversed. Showing reduction in overall stoma-reversal in the post pandemic period (p = 0.000297). Conclusion(s): We will experience ongoing conflicts with prioritisation of caseloads as the ongoing effects of COVID continue. This is the time for novel solutions to a building crisis, such as ring-fenced lists or same-day surgery with ambulatory follow-up.

Link to full-text [p. 34, NHS OpenAthens account required]