Author: Jason Curtis

The Rise in Trauma & Orthopaedic Trainee-Led Research and Audit Collaborative Projects in the United Kingdom Since the Start of the COVID-19 Pandemic (2022)

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Type of publication:
Conference abstract

Author(s):
*Khaleeq T.; *Kabariti R.; *Ahmed U.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi35), 2022. Date of Publication: September 2022.

Abstract:
Introduction: There has been a rise in trainee-led trauma & orthopaedic multi-centre research collaborative projects globally. These increase trainee involvement in research with an opportunity to deliver highly generalisable results on a particular topic. Objective(s): To evaluate the number of trauma & orthopaedic trainee-led research collaborative projects that took part since the start of the COVID-19 pandemic in the UK and compare them to projects from 2019. Method(s): This was a retrospective study that evaluated trauma & orthopaedic trainee-led national collaborative projects within the UK since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021). Our exclusion criteria included any regional collaborative projects, pre Covid- 19 projects and projects of other surgical specialities. Result(s): In 2019, 0 trainee-led collaborative projects were commenced nationally in the UK. Since the COVID-19 pandemic, we identified 10 trainee-led collaborative trauma & orthopaedic projects with 6 being published so far. The level of evidence ranged between 3 and 4 and included 5 Audits and 5 cohort studies. The patients that were included in the studies ranged from 927 to 140,231 from a total of 2249 centres. Conclusion(s): Covid-19 has placed significant challenges across healthcare. However, one positive aspect is the increase in multi-centre trainee-led collaborative projects within the UK. Our study highlights the feasibility of a trainee-led high quality collaborative research projects in the UK and the availability of new tools such as social media and centralised confidential online databases such as Redcap facilitates such projects. Therefore, we recommend expanding this trainee-led collaborative platform in the field of trauma & orthopaedics worldwide.

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The Surgical Trainee Perception of the Operating Room Educational Environment (2022)

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Type of publication:
Conference abstract

Author(s):
Rupani N.; Evans A.; *Iqbal M.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi9-vi10), 2022. Date of Publication: September 2022

Abstract:
Aim: Limited hours and service provision are diminishing training opportunities for surgical trainees. It is therefore imperative to maximise each educational event in theatre. The Operating Room Educational Environment Measure (OREEM) evaluates each component of the theatre learning environment; however, it has not been validated in higher surgical trainees in England. We aim to validate the OREEM and evaluate surgical trainees' objective perspectives of the current operating room educational environment in one region. Method(s): Data was collected over one month from surgical trainees within Health Education Thames Valley using an online questionnaire consisting of: demographic data; the OREEM; a global satisfaction score. Result(s): 54 trainees participated. The OREEM had good internal consistency (alpha=0.906, variables=40) and unidimensionality. Mean OREEM score was 79.16%. Areas for improvement included better learning opportunities (72.9%) and pre/post-operative teaching (70.4%). Trainees were most satisfied with the level of supervision and workload (82.9%). No differences between gender (p=0.535) or hospital type (p=0.099) were demonstrated. The learning environment favoured senior trainees (p=0.017). There was a strong correlation between OREEM and the global satisfaction score (p<0.001). Conclusion(s): The OREEM was shown to be a reliable measure of the educational environment in theatre. It can be used to identify areas of improvement and as an audit tool. Suggested areas of improvement include facilitating pre- and post-operative teaching, reducing service provision, empowering trainees to plan lists, improving teamwork and using tools to optimise the educational value of each operation. There is a favourable attitude regarding the use of such improvement tools, especially for dissatisfied trainees.

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Exploring the Impact of Interhospital Transfers on Patients Who Are Managed Conservatively Following Traumatic Spinal Injury: A Scoping Review (2022)

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Type of publication:
Conference abstract

Author(s):
*Nedham M.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi132), 2022. Date of Publication: September 2022.

Abstract:
Introduction: Traumatic spinal injury (TSI) is a devastating event that could lead to serious permanent disability to patients. Therefore, a multidisciplinary team is needed to manage such cases. In the UK, patients with a TSI score a minimum of 16 on the Injury Severity Score (ISS) and are transported to a Major Trauma Centre (MTC). In cases where patients initially present to a none MTC, patients are stabilised and transferred to MTC prominently. Specialised Spinal Cord Units (SCIU) are centres specialised in the definitive management of TSI patients and it is advised that patients get referred to SCIU in a timely manner as studies demonstrate improved patient outcomes. Early transfers are recommended due to the positive impact of early surgical decompression of the injury, which relieves the pressure on the neural tissue. Nevertheless, is this impact still positive if patients are managed conservatively? Aim: To explore the impact of intermediate interhospital transfers on TSI patients when no surgical intervention is taking place. Method(s): A scoping review is utilised to explore the research question. CINAHL, MEDLINE, Pubmed, Cochrane library and ASSIA were the search engines utilised. Result(s): The search resulted in 4,595 papers. 15 met the inclusion and exclusion criteria and included in the review. Conclusion(s): There are no studies that directly explored the impact of transfer on conservatively managed patients, and most of the studies were of low-quality evidence. Age, length of stay, mechanism of injury and cost were all explored as factors related to patients transfer status.

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Outcomes for Paediatric Patients Awaiting Bilateral Myringotomy and Ventilation Tube Insertion for Otitis Media with Effusion Listed Prior to the COVID-19 Pandemic (2022)

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Type of publication:Conference abstract

Author(s):*Lovett A.; Walters B.; Kumar Bhimrao S.

Citation:British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi38), 2022. Date of Publication: September 2022

Abstract:Aim: The decline in the incidence of otitis media with effusion (OME) during the COVID-19 pandemic has become apparent. This review investigates the outcomes for children with OME awaiting bilateral myringotomy and ventilation tube (BMT) who were referred prior to the COVID-19 pandemic. Method(s): All patients were reviewed in otolaryngology clinics between 1st February and 30th April 2021. Patients included were referred due to hearing, vestibular or developmental disorders prior to the first COVID-19 lockdown on 23rd March 2020. Analysis of routine consultation and audiological assessment was completed from records. Result(s): There were a total of 48 patients awaiting BMT. The average age was 6.8 years, with a male to female ratio of 1.38:1. Most initial referrals (54.2%) were due to hearing loss, followed by recurrent ear infections (33.3%). Forty-four patients were diagnosed with OME. Of those, only 9% remained awaiting BMT. All others were removed from the waiting list. One patient remained listed for an adenotonsillectomy, 30 were discharged, and nine required follow-up appointments. Conclusion(s): Our review demonstrates a significant reduction of BMT for OME following COVID-19. Further research on public health measures and changes in clinical practice during the 2020 lockdown would clarify the impact on OME.

Response to Tofacitinib in British Asians with ulcerative colitis: a real-world tertiary centre experience (2022)

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Type of publication:Conference abstract

Author(s):Forsyth K.; *Bhandal H.; Macfarlane M.; Gray C.; Hannah G.; Parkes G.

Citation:Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2022. Birmingham United Kingdom. 71(Supplement 1) (pp A47), 2022. Date of Publication: June 2022

Abstract:Introduction We have previously shown UK South Asians (SA) with IBD are prescribed TNF antagonists earlier in disease course in comparison with white British (WB) patients, but are more likely to stop due to treatment failure (Gadhok 2020). However, it is currently unknown whether there is a similar variation in response to Tofacitinib, a non-selective JAK inhibitor. We aim to determine whether persistence to tofacitinib varies with ethnicity and evaluate real world efficacy in an inner-city tertiary referral centre. Methods Patients prescribed Tofacitinib since 2019 were identified from electronic prescribing records. The following data was collected: ethnicity (as per UK standard coding), disease history including Montreal classification of disease extent, prior advanced therapies, persistence on therapy, indication for cessation, side effects, and endoscopic and biochemical markers of disease activity. Results 30 adults with UC were prescribed tofacitinib, with a median duration of follow up of 833 days (n=31). 11 patients were female, and ethnicity was as follows: SA:11: Black:1:WB:12:Other/unstated:7. The median failure free survival was 447 days, with no significant variation associated with number of prior advanced therapies (1 prior biologic, 303.5 days (n=12) vs >1 prior biologic, 715 days (n=19) p=0.28). Comparison between characteristics and response to treatment of South Asian and White British patients, presented in table 1: There was no difference between median failure free survival of SA and WB patients (304 days vs 447 days, p=0.28). There was a trend towards lower primary non-response in SA patients, with fewer stopping treatment by 12 weeks, although this was not statistically significant (9.09% vs 33.33% p=0.17). No difference in disease duration at first prescription of tofacitinib between SA and WB patients was found (78.75 months vs 86.80 months p=0.78). 2 patients stopped treatment due to side effects, with 1 patient (SA) stopping due to MACE. Conclusion In contrast to our previous work on TNF antagonists, British SA patients prescribed tofacitinib for UC had failure free survival comparable with WB patients, with a trend towards fewer primary non responders. Although limited by sample size, these findings are reassuring given that SA patients are underrepresented in trials of novel therapies in IBD and warrants a larger study.

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Treatment with bile acid sequestrants improves quality-of-life in specific patients with bile acid diarrhoea (2022)

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Type of publication:Conference abstract

Author(s):Kumar A.; Galbraith N.; Al-Hassi H.; Jain M.; *Butterworth J.; Steed H.; McLaughlin J.; Brookes M.

Citation:Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2022. Birmingham United Kingdom. 71(Supplement 1) (pp A156), 2022. Date of Publication: June 2022

Abstract:Background Bile acid diarrhoea (BAD) is a common cause of chronic diarrhoea and up to 30% of patients can be misdiagnosed as irritable bowel syndrome. Type 1 BAD is secondary to ileal resection or inflammation; type 2 is idiopathic; and type 3 is secondary to other intestinal conditions such as cholecystectomy. BAD can be severely debilitating and negatively affect patients' quality of life (QoL). We carried out a multicentre prospective study exploring QoL outcomes in patients with BAD before and after treatment with colesevelam. Methods Patients with or without BAD (defined by a 23- seleno-25-homotaurocholic acid (SeHCAT) retention < 19%) were recruited into four groups: 1) SeHCAT normal control group (CG), 2) idiopathic (BAD), BAD secondary to 3) postcholecystectomy (PC) and 4) post-terminal ileal resection for Crohn's disease (CD). Patients in groups 2-4 were treated with colesevelam and dosing was titrated to symptomatic response. Patients were reviewed at 4- and 8-weekly intervals and QoL evaluated by EQ-5D-3L, SF-36, IBDQ-32 (where relevant). Clinical response was defined as patients who had improved bowel frequency by >50% or <3 bowel movements per day. Results 47 patients (BAD=24, PC=12, CD=11) completed QoL questionnaires before and after treatment and 30 CG patients completed a baseline questionnaire. The CD cohort had improved IBDQ-32 mean scores after treatment (134.6 vs 158.4, p=0.007). The BAD and CD cohort showed improved mean scores with treatment in all components of the SF-36 and EQ-5D-3L, whilst the PC cohort showed a general decline in mean scores after treatment. The CG cohort generally had higher baseline scores than the other three groups. 55% of patients clinically responded to treatment (41.7% BAD, 58.3% PC, 81.8% CD). Correlations between those deemed as responders with improvements on the IBDQ-32, SF-36 and EQ-5D-3L dimensions were not statistically significant. Conclusion Our results demonstrate improved QoL in the BAD and CD cohort with treatment. Further larger studies are recommended specifically investigating the PC cohort and whether patients may improve with newer treatments such as FXR agonists.

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The use of a faecal bile acid test for diagnosing patients with bile acid diarrhoea (2022)

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Type of publication:Conference abstract

Author(s):Kumar A.; Al-Hassi H.; Jain M.; Ford C.; Gama R.; Steed H.; *Butterworth J.; McLaughlin J.; Galbraith N.; Brookes M.; Hughes L.;

Citation:Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2022. Birmingham United Kingdom. 71(Supplement 1) (pp A157), 2022. Date of Publication: June 2022.

Abstract:Introduction BAD is a common cause of chronic diarrhoea, affecting 1% of the general population. Type 1 is secondary to ileal resection or inflammation; type 2 is idiopathic; and type 3 is a result of other intestinal conditions such as cholecystectomy. Although the UK gold standard diagnostic test for BAD is the 75selenium-homotaurocholic acid (SeHCAT) scan, this is not widely available. This study examines the validity of measuring faecal bile acids (FBA) in a single stool sample as a diagnostic tool for bile acid diarrhoea (BAD) by direct comparison to the SeHCAT. Methods Patients with chronic diarrhoea investigated for BAD with a SeHCAT scan were prospectively recruited to the study. Patients provided random stool samples to measure FBA, using an enzyme-linked immunosorbent assay. Patients were characterised into four groups: SeHCAT negative control group (CG), post-cholecystectomy (PC), idiopathic BAD and post-terminal ileal resection Crohn's disease (CD). SeHCAT retention of <5%, 5-10%, 10-15% and >15% were considered to be severe BAD, moderate, mild and normal, respectively. Results 108 patients had a stool with a comparative SeHCAT result. FBA concentrations (umol/g) and interquartile ranges in patients in CG (2.6; 1.6-4.1), PC (4.0; 2.4-6.6) and BAD (3.6; 1.9-7.2) were similar, but all were significantly lower (p<0.001) compared to patients with CD (12.5; 10.2-16.1). FBA concentrations in patients with SeHCAT retention of <5% (8.6; 4.3-15.4) were significantly higher (p<0.005) than those with a SeHCAT retention >15% (2.6; 1.5-4.2). Using <=15% SeHCAT retention as diagnostic for BAD, the sensitivity and specificity with FBA cut-off of 1.6umol/g were 89% and 26% respectively. Conclusion This pilot study demonstrated that a single random stool sample may have potential use in diagnosing severe BAD or BAD in CD patients. Larger studies are needed to confirm the potential efficacy of a single, random FBA test to accurately diagnose BAD in the absence of SeHCAT testing.

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Quality of life and two-year results of a randomized phase III study of dysphagiaoptimized intensity modulated radiotherapy (DO-IMRT) versus standard IMRT (SIMRT) in head and neck cancer (2022)

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Type of publication:Conference abstract

Author(s):Nutting C.; Rooney K.; Foran B.; *Pettit L.; Beasley M.; Finneran L.; Roe J.; Tyler J.; Roques T.; Cook A.; Petkar I.; Bhide S.; Srinivasan D.; Boon C.; De Winton E.; Frogley R.; Sydenham M.A.; Emson M.; Hall E.

Citation:Journal of Clinical Oncology. Conference: Annual Meeting of the American Society of Clinical Oncology, ASCO 2022. Online. 40(16 Supplement 1) (no pagination), 2022. Date of Publication: June 2022

Abstract:Background: Most newly diagnosed oro- & hypopharngeal cancers (OPC, HPC) are treated with (chemo) RT with curative intent but at the consequence of adverse effects on quality of life. We investigated if using DO-IMRT to reduce RT dose to the dysphagia/aspiration related structures (DARS) improved swallowing function compared to S-IMRT. Method(s): Patients with T1-4, N0-3, M0 OPC/HPC were randomised 1:1 to S-IMRT (65 Gray (Gy)/30 fractions (f) to primary & nodal tumour; 54Gy/30f to remaining pharyngeal subsite & nodal areas at risk of microscopic disease) or DO-IMRT. The volume of the superior & middle pharyngeal constrictor muscle (PCM) (OPC) or inferior PCM (HPC) lying outside the high-dose target volume was set a mandatory mean dose constraint in DO-IMRT. Treatment allocation was by minimisation balanced by centre, use of induction/concomitant chemotherapy, tumour site & AJCC stage. Primary endpoint was mean MD Anderson Dysphagia Inventory (MDADI) composite score 12 months after RT. Secondary endpoints included University of Washington (UW)-Qol, Performance Status Scale Head & Neck (PSS-HN) domain scores (range: 0-100), swallow volume, swallow capacity and local control. Result(s): 112 patients (56 S-IMRT, 56 DO-IMRT) were randomised from 22 UK & Ireland centres from 06/2016 – 04/2018. 111/112 had RT doses as prescribed (1 patient died before RT). Outcome measures at 12 and 24 months are summarised below. DO-IMRT had higher MDADI scores at 12 (p = 0.04) and 24 (p = 0.07) months. Clinically important improvements in swallowing function were seen in patients receiving DO-IMRT using PSS-HN domains and the UW-QoL tool. Conclusion(s): DO-IMRT improved patient reported swallowing function compared with S-IMRT. Improvements were seen in overall MDADI as well as functional scores in both PSS-HN and UW-QoL.

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Implications for sequencing of biologic therapy and choice of second anti-TNF in patients with inflammatory bowel disease: Results from the IMmunogenicity to Second Anti-TNF therapy (IMSAT) therapeutic drug monitoring study (2022)

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Type of publication:Journal article

Author(s):Chanchlani N.; Lin S.; Auth M.K.; Lee C.L.; Robbins H.; Looi S.; Murugesan S.V.; Riley T.; Preston C.; Stephenson S.; Cardozo W.; Sonwalkar S.A.; Allah-Ditta M.; Mansfield L.; Durai D.; Baker M.; London I.; London E.; Gupta S.; Di Mambro A.; Murphy A.; Gaynor E.; Jones K.D.J.; Claridge A.; Sebastian S.; Ramachandran S.; Selinger C.P.; Borg-Bartolo S.P.; Knight P.; Sprakes M.B.; Burton J.; Kane P.; Lupton S.; Fletcher A.; Gaya D.R.; Colbert R.; Seenan J.P.; MacDonald J.; Lynch L.; McLachlan I.; Shields S.; Hansen R.; Gervais L.; Jere M.; Akhtar M.; Black K.; Henderson P.; Russell R.K.; Lees C.W.; Derikx L.A.A.P.; Lockett M.; Betteridge F.; De Silva A.; Hussenbux A.; Beckly J.; Bendall O.; Hart J.W.; Thomas A.; Hamilton B.; Gordon C.; Chee D.; McDonald T.J.; Nice R.; Parkinson M.; Gardner-Thorpe H.; *Butterworth J.R.; *Javed A.; *Al-Shakhshir S.; *Yadagiri R.; *Maher S.; Pollok R.C.G.; Ng T.; Appiahene P.; Donovan F.; Lok J.; Chandy R.; Jagdish R.; Baig D.; Mahmood Z.; Marsh L.; Moss A.; Abdulgader A.; Kitchin A.; Walker G.J.; George B.; Lim Y.-H.; Gulliver J.; Bloom S.; Theaker H.; Carlson S.; Cummings J.R.F.; Livingstone R.; Beale A.; Carter J.O.; Bell A.; Coulter A.; Snook J.; Stone H.; Kennedy N.A.; Goodhand J.R.; Ahmad T.

Citation:Alimentary Pharmacology and Therapeutics, 2022 Oct; Vol. 56 (8), pp. 1250-1263. Date of Publication: October 2022

Abstract:Background: Anti-drug antibodies are associated with treatment failure to anti-TNF agents in patients with inflammatory bowel disease (IBD). <Aim(s): To assess whether immunogenicity to a patient's first anti-TNF agent would be associated with immunogenicity to their second, irrespective of drug sequence. <br/>Method(s): We conducted a UK-wide, multicentre, retrospective cohort study to report rates of immunogenicity and treatment failure of second anti-TNF therapies in 1058 patients with IBD who underwent therapeutic drug monitoring for both infliximab and adalimumab. The primary outcome was immunogenicity to the second anti-TNF drug, defined at any timepoint as an anti-TNF antibody concentration >=9 AU/ml for infliximab and >=6 AU/ml for adalimumab. Result(s): In patients treated with infliximab and then adalimumab, those who developed antibodies to infliximab were more likely to develop antibodies to adalimumab, than patients who did not develop antibodies to infliximab (OR 1.99, 95%CI 1.27-3.20, p = 0.002). Similarly, in patients treated with adalimumab and then infliximab, immunogenicity to adalimumab was associated with subsequent immunogenicity to infliximab (OR 2.63, 95%CI 1.46-4.80, p < 0.001). For each 10-fold increase in anti-infliximab and anti-adalimumab antibody concentration, the odds of subsequently developing antibodies to adalimumab and infliximab increased by 1.73 (95% CI 1.38-2.17, p < 0.001) and 1.99 (95%CI 1.34-2.99, p < 0.001), respectively. Patients who developed immunogenicity with undetectable drug levels to infliximab were more likely to develop immunogenicity with undetectable drug levels to adalimumab (OR 2.37, 95% CI 1.39-4.19, p < 0.001). Commencing an immunomodulator at the time of switching to the second anti-TNF was associated with improved drug persistence in patients with immunogenic, but not pharmacodynamic failure. Conclusion(s): Irrespective of drug sequence, immunogenicity to the first anti-TNF agent was associated with immunogenicity to the second anti-TNF, which was mitigated by the introduction of an immunomodulator in patients with immunogenic, but not pharmacodynamic treatment failure.

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Deposition keratopathy (2022)

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Type of publication:Journal article

Author(s):
Panthagani J.; MacDonald T.; *Bruynseels A.; Madathilethu S.C.; Jenyon T.

Citation:British Journal of Hospital Medicine. 83(7) (pp 1-13), 2022. Date of Publication: 02 Jul 2022.

Abstract:Material can be deposited in the cornea as a result of a wide range of systemic and ophthalmic diseases, as well as local and systemic therapies. Causes include local infection or trauma, systemic malignancy, a wide range of medications and a host of genetic and metabolic diseases. Some of these can be acutely life threatening, so generalists caring for both children and adults should have a basic awareness of the pattern and distribution of corneal deposits to facilitate timely diagnosis, investigation, management or onward referral to avoid significant morbidity or mortality. This article outlines causes of corneal deposits found in patients presenting to primary care, ophthalmic clinics or encountered on the wards to help generalists avoid missing serious pathology. It also provides insight into the natural history of underlying causative conditions and their possible treatments.