Author: Jason Curtis

First impressions of the foundation interim year 1 postings: positives, pitfalls, and perils (2020)

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Type of publication:
Journal article

Author(s):
Youssef S.; Zaidi S.; Varghese C.; Rajagopalan S.; *Shrestha S.

Citation:
Medical Education Online; Dec 2020; vol. 25 (no. 1)

Abstract:
COVID-19 has placed an increased burden on the NHS. Changes were made to expand patient capacity including hospital restructuring, cancellation of most elective surgeries and early graduation of final year medical students. 1 The UK foundation programme (UKFP) curated a new training position for graduates as foundation interim year 1 (FiY1) doctors, where they voluntarily work in paid positions prior to entering formal foundation year 1 (FY1) roles. 2 Expediting the process of fulfilling these positions, the General Medical Council facilitated early provisional registration of doctors. We discuss the positives, pitfalls, and perils of the new roles and the first impressions of three newly qualified FiY1 s in medical, obstetrics and gynaecology and surgical posts, a surgical FY1 doctor and a clinical supervisor in surgery.

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Randomized Trial of Ciprofloxacin Doxycycline and Hydroxychloroquine Versus Budesonide in Active Crohn's Disease (2021)

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Type of publication:
Randomised controlled trial

Author(s):
Rhodes J.M.; Subramanian S.; Martin K.; Probert C.; Flanagan P.K.; Horgan G.W.; Mansfield J.; Parkes M.; Hart A.; Dallal H.; Iqbal T.; *Butterworth J.; Culshaw K.

Citation:
Digestive Diseases and Sciences; Aug 2021; vol. 66 (no. 8); p. 2700-2711

Abstract:
Background: Increased mucosa-associated E. coli are present in Crohn's disease, but their role in pathogenesis is uncertain. Aim(s): To assess efficacy and safety of an antibiotic/hydroxychloroquine combination effective against E. coli inside macrophages. Method(s): Adults with moderately active disease (CDAI > 220-450 plus C reactive protein >= 5 mg/l and/or fecal calprotectin > 250 mug/g) were randomized to receive (open-label) oral budesonide (Entocort CR 9 mg/day 8 weeks, 6 mg/day 2 weeks, 3 mg/day 2 weeks) or oral ciprofloxacin 500 mg bd, doxycycline 100 mg bd, hydroxychloroquine 200 mg tds for 4 weeks, followed by doxycycline 100 mg bd and hydroxychloroquine 200 mg tds for 20 weeks. Primary endpoints were remission (CDAI <= 150) at 10 weeks, remission maintained to 24 weeks, and remission maintained to 52 weeks. Patients not responding (CDAI fall by > 70) by 10 weeks were invited to crossover onto the alternative therapy. Result(s): Fifty-nine patients were recruited across 8 sites. Including crossover, 39 patients received antibiotics/hydroxychloroquine and 39 received budesonide. At 10 weeks, 24 weeks, and 52 weeks on initial therapy, only 2/27, 2/27, and 1/27 were in remission on antibiotics/hydroxychloroquine compared with 8/32, 1/32, and 1/32 on budesonide (P = 0.092 at 10 weeks). Withdrawals by 10 weeks due to adverse events were seen in 15 receiving antibiotics/hydroxychloroquine and 6 budesonide. Results including crossover were more promising with 9/24 patients receiving antibiotics/hydroxychloroquine per protocol in remission by 24 weeks. No correlation was seen between response to antibiotics/hydroxychloroquine and ASCA/OmpC antibody status or disease location. Conclusion(s): Overall results with this antibiotic/hydroxychloroquine combination were unimpressive, but long-term remission is seen in some patients and justifies further study.

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Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study (2020)

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Type of publication:
Journal article

Author(s):
Corcoran J.P.; Psallidas I.; Hassan M.; Hallifax R.J.; Rahman N.M.; Dobson M.; Shaw R.; Hedley E.L.; Sabia A.; Robinson B.; Gerry S.; Collins G.S.; Piccolo F.; Popowicz N.D.; Koegelenberg C.F.; Saba T.; Saba J.; Daneshvar C.; Ward N.R.; Fairbairn I.; *Heinink R.; West A.; Stanton A.E.; Holme J.; Kastelik J.A.; Steer H.; Downer N.J.; Haris M.; Baker E.H.; Everett C.F.; Pepperell J.; Bewick T.; Yarmus L.; Maldonado F.; Khan B.; Hart-Thomas A.; Hands G.; Warwick G.; De Fonseka D.; Maskell N.A.; Munavvar M.; Guhan A.; Shahidi M.; Pogson Z.; Dowson L.; Davies H.E.; Yu L.-M.; Miller R.F.

Citation:
The European respiratory journal; 2020 Nov;56(5)

Abstract:
BACKGROUND: Over 30% of adult patients with pleural infection either die and/or require surgery. There is no robust means of predicting at baseline presentation which patients will suffer a poor clinical outcome. A validated risk prediction score would allow early identification of high-risk patients, potentially directing more aggressive treatment thereafter. OBJECTIVE(S): To prospectively assess a previously described risk score (RAPID – Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)) in adults with pleural infection. METHOD(S): Prospective observational cohort study recruiting patients undergoing treatment for pleural infection. RAPID score and risk category were calculated at baseline presentation. The primary outcome was mortality at 3 months; secondary outcomes were mortality at 12 months, length of hospital stay, need for thoracic surgery, failure of medical treatment, and lung function at 3 months. RESULT(S): Mortality data were available in 542 of 546 (99.3%) patients recruited. Overall mortality was 10% (54/542) at 3 months and 19% (102/542) at 12 months. The RAPID risk category predicted mortality at 3 months; low-risk (RAPID score 0-2) mortality 5/222 (2.3%, 95%CI 0.9 to 5.7), medium-risk (RAPID score 3-4) mortality 21/228 (9.2%, 95%CI 6.0 to 13.7), and high-risk (RAPID score 5-7) mortality 27/92 (29.3%, 95%CI 21.0 to 39.2). C-statistics for the score at 3 and 12 months were 0.78 (95%CI 0.71 to 0.83) and 0.77 (95%CI 0.72 to 0.82) respectively. CONCLUSION(S): The RAPID score stratifies adults with pleural infection according to increasing risk of mortality and should inform future research directed at improving outcomes in this patient population.

The importance of skin biopsies: Sweet syndrome as a differential for 'acute painful red rash' in a patient with normal neutrophils and polymyalgia rheumatica on glucocorticoids (2020)

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Type of publication:
Journal article

Author(s):
Rajakulenthiran T.G.; Amarasena R.; Silva S.S.C.; *Singh R.; *Kelly S.

Citation:
Clinical Medicine, Journal of the Royal College of Physicians of London; Mar 2020; vol. 20, p. S25

Abstract:

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Stepped-wedge randomised trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation: A randomised controlled trial (2020)

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Type of publication:
Conference abstract

Author(s):
Grossi U.; McAlees E.; Knowles C.H.; Stevens N.; Di Tanna G.L.; Marlin N.; *Lacy-Colson J.; Brown S.; Scott S.M.; Norton C.; Mason J.

Citation:
Techniques in Coloproctology; 2020; vol. 24 (no. 4); p. 373-374

Abstract:
Background: Laparoscopic ventral mesh rectopexy (LVMR) is an established treatment for external full-thickness rectal prolapse. However, its clinical efficacy in patients with internal prolapse is uncertain due to the lack of high-quality evidence.
Methods: An individual level, stepped-wedge randomised trial has been designed to allow observer blinded data comparisons between patients awaiting LVMR with those who have undergone surgery. Adults with symptomatic internal rectal prolapse, unresponsive to prior conservative management, will be eligible to participate. They will be randomised to three arms with different delays before surgery (0, 12 and 24 weeks). Efficacy outcome data will be collected at equally stepped time points (12, 24, 36 and 48 weeks). The primary objective is to determine clinical efficacy of LVMR compared to controls with reduction in the Patient Assessment of Constipation Quality of Life (PAC-QOL) at 24 weeks serving as the primary outcome. Secondary objectives are to determine: (1) the clinical effectiveness of LVMR to 48 weeks to a maximum of 72 weeks; (2) preoperative determinants of outcome; (3) relevant health economics for LVMR; (4) qualitative evaluation of patient and health professional experience of LVMR and (5) 30-day morbidity and mortality rates.
Results: An individual-level, stepped-wedge, randomised trial serves the purpose of providing an untreated comparison for the active treatment group, while at the same time allowing the waiting-listed participants an opportunity to obtain the intervention at a later date. Conclusions: In keeping with the basic ethical tenets of this design, the average waiting time for LVMR (12 weeks) will be shorter than that for routine services (24 weeks).

Metabolic stone screening - can education improve adherence to national guidelines? (2020)

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Type of publication:
Journal article

Author(s):
Ravindraanandan M.; *Jayawardena P.

Citation:
Journal of Endoluminal Endourology; Jan 2020; vol. 3 (no. 1)

Abstract:
Nephrolithiasis is a common urological disease affecting approximately 13% of the global population. Identifying a preventable cause during follow-up for stone formation is a necessary factor in reducing recurrence. The majority of kidney stones are comprised of calcium, with oxalate and phosphate compounds accounting for approximately 80% of stone formers. Serum analysis can be used to identify the levels of calcium in the blood, excluding metabolic causes for stones. Current NICE guidelines recommend performing a metabolic screen during an acute admission. Adherence to these guidelines from clinicians can be poor. We aim to see whether education can improve serum metabolic requests from clinicians in the UK. Method A case-control study was performed in a single rural district general hospital in the UK. Patients who presented with renal colic were analyzed retrospectively for four months, looking at serum metabolic screen requests. Two months of education was then delivered to acute departments, with a further prospective study performed following this for six months. Outcomes were then compared between both groups to see if there was an improvement in serum requests following the delivery of local education. Results A total of 124 patients were included in our study. 50 patients were analyzed in cohort A over a 4-month period. Complete serum analysis was performed on 22% (n=11) of patients. Incomplete serum analysis was performed on 58% (n-29) of patients with uric acid being missed on all of them. 10 patients had no metabolic serum analysis performed at all, with 1 patient having a previous history of stones. A total of 74 patients were analyzed in cohort B over a 6-month period. This was following the 2 months of departmental education given by urologists. Complete serum analysis was performed on 24% (n=18) of patients. Incomplete serum analysis was performed on 55% (n=41) of patients with uric acid being missed from all of them. The remaining 21% of patients (n=15) had no metabolic serum screen performed at all. There was no significant difference seen between both cohorts after comparing metabolic serum requests before and after department education for 2 months (p=0.7287). Conclusion Improving adherence to clinical guidelines for metabolic screening has proved difficult with departmental teaching alone, with very little improvement achieved. Nevertheless, formal face-to-face education is advocated to reinforce knowledge in junior doctors managing renal stones.

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Providing a safe and effective intravitreal treatment service: strategies for service delivery (2020)

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Type of publication:
Journal article

Author(s):
Amoaku W.; Bailey C.; Downey L.; Gale R.P.; Ghanchi F.; Hamilton R.; Mahmood S.; Menon G.; *Nosek J. ; Pearce I.; Yang Y

Citation:
Clinical Ophthalmology; 2020; vol. 14 ; p. 1315-1328

Abstract:
An aging population leads to increasing demand for medical retina services with chronic diseases being managed in long-term care pathways. Many hospital services struggle to deliver efficient and effective MR care due, at least in part, to infrastructure that does not expand responsively enough to meet the increased demand. A steering committee of retinal specialists from a variety of UK NHS hospital ophthalmology departments with experience of leading and managing NHS retinal services in the intravitreal era came together for the generation of this document to review and compile key aspects that should be considered when optimising intravitreal treatment capacity within MR services. This article aims to provide a useful collation and signposting of key published evidence, consensus and insights on aspects of delivering an intravitreal service, including treatment regimens, virtual clinics, staff training and governance, telemedicine and information technology, and data collection and key performance indicators. The objective is to equip ophthalmologic healthcare professionals with the necessary tools to develop and adapt their local service in the face of current and projected increased demand.

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The triple effect of the magseed for localisation of impalpable breast cancer: Significant reduction in re-excision rate, cost saving by reducing further surgery and high patient satisfaction (2020)

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Type of publication:
Conference abstract

Author(s):
*Lake B.; *Wilson M.; *Thomas G.; *Williams S.; *Usman T.

Citation:
European Journal of Surgical Oncology; Jun 2020; vol. 46 (no. 6); e12

Abstract:
Introduction: Traditionally impalpable breast cancers have been localised with image guided techniques of wire guidance or ultrasound marking. Magseed is a small magnetic seed which is changing practice of localisation of these cancers. The aim of this study was to see if the change of practice of localisation to Magseed affected patient outcome evaluated by re-excision rate, specimen weight and patient satisfaction. Method(s): A change of practice service evaluation was conducted at the Shrewsbury and Telford Hospital of all patients who had imaged guided wide local excision for impalpable breast cancer from July 2017 to August 2019. Data recorded included tumour demographics, localisation method, size of tumour and specimen weight. Evaluation of localisation methods included re-excision rates, type of further surgery, cost saving in reduction in re-excision, and patient satisfaction. Result(s): 2017/2018 226 Traditional guided WLE were performed. 2018/2019 90 traditional guided WLE, and 106 Magseed WLE were performed. Tumour demographics, size of tumour were similar for localisation methods. The introduction of Magseed in our practice has resulted in a significant reduction in overall re-excision rates from 22.4 to 12%, (z =2.6616 p.00782), and average specimen weight from 40 to 27g (t= -3.2364, P.000716). Cost saving analysis of further surgery showed a saving of 34,457 with 48% less further operations following change of practice. 98% of patients had a very good/excellent experience of Magseed. Conclusion(s): Magseed demonstrates a triple effect on patient outcome with significant reduction in re-excision rate, cost saving by reducing further surgery and high patient satisfaction.

The histopathological correlation of magnetic resonance imaging-identified additional lesions detected in 2nd read breast MRIS (2020)

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Type of publication:
Conference abstract

Author(s):
*Aksoy U.; *Barlow E.; *Williams S.; *Lake B.; *Metelko M

Citation:
European Journal of Surgical Oncology; Jun 2020; vol. 46 (no. 6), p. e19

Abstract:
Introduction: Magnetic resonance imaging-identified additional lesions (MRALs) in breast cancer have always been a diagnostic dilemma as they may result in significant delay in management plans and sometimes cause overtreatment. Clinical guidelines for the management of breast cancer in the UK recommend second read MRIs in at least 50% of patients. In this audit project, our aim is to correlate the MRALs reported in 2nd read breast MRIs (2bMRI) with the histopathological outcomes.
Method(s): The patients who were referred to 2bMRIs between July 2018 and August 2019 were retrieved from the archives. 86 consecutive patients (mean age: 54) were included in the audit. First read MRIs were correlated with 2bMRI results and noted as; agreed, a larger lesion (>1cm) or additional foci reported, a smaller lesion or fewer number of additional foci reported. According to histopathology reports MRALs were classified as; proved malignant, benign or not applicable.
Result(s): In 80% (69/86) of the patients the 2bMRI reports agreed with the first and the management did not change. In 20% there was disagreement. Five true positive cases benefited from more extensive surgery. Eight false positive cases ended up with more extensive surgery.
Conclusion(s): Referral indications were in accordance with the guidelines and 5.8% of the patients benefited from the 2bMRIs. However, a significant number of the patients did not benefit from the 2bMRIs. Larger studies are needed to see the true benefit of 2bMRIs as they have the potential to delay the patient pathway and increase anxiety levels of breast cancer patients.