Staff Publication

Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: A randomized controlled trial (2023)

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Type of publication:
Journal article

Author(s):
Norton, Christine; Bannister, Sybil; Booth, Lesley; Brown, Steve R; Cross, Samantha; Eldridge, Sandra; Emmett, Christopher; Grossi, Ugo; Jordan, Mary; *Lacy-Colson, Jon; Mason, James; McLaughlin, John; Moss-Morris, Rona; Scott, S Mark; Stevens, Natasha; Taheri, Shiva; Taylor, Stuart A; Yiannakou, Yan; Knowles, Charles H.

Citation:
Colorectal Disease. 25(11):2243-2256, 2023 Nov.

Abstract:
AIM: The aim was to determine whether specialist-led habit training using Habit Training with Biofeedback (HTBF) is more effective than specialist-led habit training alone (HT) for chronic constipation and whether outcomes of interventions are improved by stratification to HTBF or HT based on diagnosis (functional defaecation disorder vs. no functional defaecation disorder) by radio-physiological investigations (INVEST). METHOD: This was a parallel three-arm randomized single-blinded controlled trial, permitting two randomized comparisons: HTBF versus HT alone; INVEST- versus no-INVEST-guided intervention. The inclusion criteria were age 18-70 years; attending specialist hospitals in England; self-reported constipation for >6 months; refractory to basic treatment. The main exclusions were secondary constipation and previous experience of the trial interventions. The primary outcome was the mean change in Patient Assessment of Constipation Quality of Life score at 6 months on intention to treat. The secondary outcomes were validated disease-specific and psychological questionnaires and cost-effectiveness (based on EQ-5D-5L). RESULTS: In all, 182 patients were randomized 3:3:2 (target 384): HT n = 68; HTBF n = 68; INVEST-guided treatment n = 46. All interventions had similar reductions (improvement) in the primary outcome at 6 months (approximately -0.8 points of a 4-point scale) with no statistically significant difference between HT and HTBF (-0.03 points; 95% CI -0.33 to 0.27; P = 0.85) or INVEST versus no-INVEST (0.22; -0.11 to 0.55; P = 0.19). Secondary outcomes showed a benefit for all interventions with no evidence of greater cost-effectiveness of HTBF or INVEST compared with HT. CONCLUSION: The results of the study at 6 months were inconclusive. However, with the caveat of under-recruitment and further attrition at 6 months, a simple, cheaper approach to intervention may be as clinically effective and more cost-effective than more complex and invasive approaches.

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Identifying Cases Of Pernicious Anaemia For Offering Baseline/Surveillance Gastroscopies as per BSG Guidance - Service Development In Shropshire (2023)

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Type of publication:
Conference abstract

Author(s):
*Rafique H.; *Rugemintwaza J.; *Mostafa W.; *Smith M.;

Citation:
Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2023. Liverpool United Kingdom. 72(Supplement 2) (pp A178-A179), 2023. Date of Publication: June 2023.

Abstract:
Introduction Pernicious anaemia (PA) is associated with a higher risk of gastrointestinal malignancies. BSG guidance suggests baseline gastroscopies for individuals aged >=50 years with laboratory evidence of PA, with surveillance offered to those with high-risk chronic atrophic gastritis.1 Shrewsbury and Telford NHS Trust is not currently offering gastroscopies to patients with PA. Our aim was to identify cases of PA suitable for gastroscopies in line with BSG guidance, followed by implementation of pathways for prospective detection of similar future cases. Methods A list of patients who tested positive for intrinsic factor antibodies (IF Ab) or gastric parietal cell (GPC Ab) between 2017-2022 was obtained from the laboratory. Patients aged 50-70y were stratified into groups as follows: Positive IF Ab considered confirmed PA; positive GPC Ab with low B12 levels considered probable PA; positive GPC with historically normal B12 and no anaemia considered unlikely to be PA. Patients who had gastroscopy for any indication in the last 5 years were excluded. Results 50 cases that met the criteria for confirmed or probable PA were deemed suitable for baseline gastroscopy. Pathway for these patients will be agreed with the hospital governance and GP liaison teams and standard letters and information leaflets will be devised. Confirmed cases will be offered gastroscopy, while probable cases will be offered further testing with IF Ab. If diagnosis is confirmed, gastroscopy will be offered, whereas if IF Ab is negative, no further action taken if the B12 deficiency responds to oral supplementation. For prospective detection of future cases, clinical text will be added in all biochemistry reports with low B12 levels prompting clinicians to consider IF Ab testing if PA is possible in clinical context, with referral to gastroenterology for confirmed cases. Cases tested before 2017 who fit the above criteria will be identified. Conclusions The number of confirmed or probable cases of PA in Shropshire is relatively small and sets a realistic target for offering gastroscopies in line with BSG guidance. Similar initiatives across other trusts could identify cases of PA in the respective regions that could be suitable for baseline or surveillance gastroscopies, with prospective detection of future cases leading to better overall management of PA.

The Advanced Colonoscopy Skills Training Required For NHS Bowel Cancer Screening Accreditation: The Outcomes Of An Integrative Literature Review (2023)

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Type of publication:
Conference abstract

Author(s):
*Brayford P.

Citation:
Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2023. Liverpool United Kingdom. 72(Supplement 2) (pp A169), 2023. Date of Publication: June 2023.

Abstract:
Introduction NHS Bowel cancer screening colonoscopists are required to undertake accreditation for which there are well defined standards, but training to achieve these skills has not been clearly determined. An Integrative Review aimed to identify the training required for independent colonoscopists to develop the advanced skills necessary to achieve Bowel Cancer Screening Accreditation (BCSA). The findings were utilised to develop a training plan which could support independent colonoscopists achieve BCSA. Methods The Integrative Review (IR) utilised the secondary research process described by Whittemore and Knafl (2005) to synthesise and analyse a range of methodologically diverse studies. Key stages of this process included problem identification, literature search, data evaluation, data analysis, conclusion drawing and presentation. Electronic databases including CINHAL, MEDLINE and PubMed were searched in September 2020. The inclusion criteria were English language literature focused on training in the advanced colonoscopy skills from 2012 onwards, excluding beginner colonoscopy training. Results In total this generated 3548 papers of which 3476 were excluded. The full text of seventy-seven papers were screened, identifying twenty-three methodologically diverse papers, meeting the inclusion/exclusion criteria for critical evaluation and analysis within the IR. Five broad themes were found to contribute to the development of the advanced colonoscopy skills required for BCSA-See figure 1. Conclusions It was clear from the IR that training in polyp related skills and knowledge was vital for successful BCSA. In addition, selecting motivated, meticulous colonoscopists and focusing on individual learning needs along with utilisation of audit and feedback all contribute to skill development for BCSA. The IR findings were utilised to develop evidence based individual, local, regional and national recommendations to assist with the advanced colonoscopy skill development necessary for BCSA.

A case of disseminated herpes zoster in an immunocompetent child (2023)

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Type of publication:
Conference abstract

Author(s):
*Jacob M.A.; *Kelly S.

Citation:
British Journal of Dermatology. Conference: 103rd Annual Meeting of the British Association of Dermatologists. Liverpool United Kingdom. 188(Supplement 4) (pp iv156-iv157), 2023. Date of Publication: June 2023

Abstract:
Herpes zoster (HZ) caused by the reactivation of varicella-zoster virus (VZV) affects mainly the adult population. The incidence is low in children (0.45 cases per 1000 individuals annually), especially in the immunocompetent. It is said to be disseminated when there are >20 lesions outside the primary and adjacent affected dermatome. We present this case to highlight a rare complication of cutaneous dissemination in a previously healthy child with HZ, following in utero exposure to varicella at 28 weeks' gestation. A 15-year-old boy presented with painful blisters in the T2 dermatome of 1 week's duration, which later spread to trunk, extremities and face. This was associated with fever and neuralgia. There was no previous history of varicella and no recent contact history. He had no significant past medical history and was not on any medications. Antenatal history revealed that his mother had varicella at 28 weeks' gestation and was treated with aciclovir. He was febrile on admission (39degreeC). There were coalesced vesiculopustules and crusted lesions with marked perilesional erythema in the T2 dermatome. In addition, disseminated vesicular lesions were seen on the trunk, extremities and face. Remaining systemic examination was unremarkable. C-reactive protein was elevated. Complete blood count and renal function tests were normal. Liver function tests, namely alanine transaminase and 7gamma;-glutamyl transferase were elevated. Blood culture showed no growth. Varicella-zoster IgG was positive. Viral swab (polymerase chain reaction) from the skin lesions was positive for varicella-zoster DNA. Infectious serology for HIV, hepatitis B and hepatitis C was negative. Antinuclear antibody and antineutrophil cytoplasmic antibodies were negative. A clinical diagnosis of HZ with cutaneous dissemination was made, and he was treated with intravenous aciclovir. Intravenous antibiotics were added for suspected secondary bacterial infection. Disseminated zoster is less common in children and mainly occurs in patients with underlying immunodeficiency like HIV, immunosuppressive drug use or malignancy. In immunocompetent children, this can happen when primary infection (varicella) has occurred in utero or the first year of life due to the low response in specific varicella-zoster virus immunity. Complications like cutaneous dissemination due to viraemia are rare in healthy children, but can affect 2-10% of immunocompromised patients. It occurs 3-4 days after the onset of dermatomal lesions. It is important to look for other complications, especially in the immunocompromised, as viraemia can affect the brain, kidneys, lung and liver. Sequelae like postherpetic neuralgia is rare, but it is important to follow-up these children to look for its development.

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Supracondylar elbow fracture management (Supra Man) a national trainee collaborative evaluation of practice (2023)

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Type of publication:
Journal article

Author(s):
Barrie A.; Kent B.; Jones R.; Hutton C.; Jones M.; Berry A.; Marusza C.; Reynolds P.; A'Court J.; Lum J.; Flannery O.; Knapper T.; Dela Cruz N.; Flaherty D.; Raza M.; Godavitarne C.; Ho S.; Brunt A.; Hardie J.; Taha A.; Kazzaz S.; Sri A.; Logishetty K.; Shah G.; Woods S.; Barwell J.; Marhoon Z.; Qaiyum T.; Punwar S.; Liew I.; Rooney A.; Watts D.; Kabwama S.; Townson A.; Baskaran D.; Vernon O.; Bryson D.; Stringfellow T.; Buddhdev P.; Gacaferi H.; Bretherton C.; Jordan S.; Thiruchandran G.; Mustafa Q.; Morcos Z.; Peters K.; Wilson C.; Dupley L.; Thomas A.; *Kabariti R.; Khaleeq T.; Davoudi K.; Cox I.; Cuthbert R.; Berber O.; Javed O.; Hafez A.; Garg V.; Kumar S.; O'Calloghan J.; Stanier P.; Bhalerao B.; Lokanathan S.; Sinnerton R.; Davies P.; John A.; Sreenivasan S.; Ferns J.; Bawa A.; Mattar A.; Gulihar A.; Yates J.; Al-Faqih M.; Kennedy J.; Baxter I.; Gilmore C.; Crone A.; McAlinden G.; Al-Sukaini A.; Syed S.; Tiwari I.R.; Black P.; Kang H.W.; Napier R.; Ferguson D.; Lim R.; Dott C.;

Citation:
Bone and Joint Journal. 105 B(1) (pp 82-87), 2023. Date of Publication: January 2023.

Abstract:
Aims: Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. this national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. Methods: this study was led by the south West Orthopaedic research division (sWOrd) and performed by the supra Man Collaborative. displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (redCap). Results: A total of 972 patients were identified across 41 hospitals. Mean age at injury was 6.3 years (1 to 15), 504 were male (52%), 583 involved the left side (60%), and 538 were Gartland type 3 fractures (55%). Median time from injury to theatre was 16 hours (interquartile range (IQR) 6.6 to 22), 300 patients (31%) underwent surgery on the day of injury, and 91 (9%) underwent surgery between 10:00 pm and 8:00 am. Overall, 910 patients (94%) had Kirschner (K)-wire) fixation and these were left percutaneous in 869 (95%), while 62 patients (6%) had manipulation under anaesthetic (MUA) and casting. Crossed K-wire configuration was used as fixation in 544 cases (59.5%). Overall, 208 of the fixation cases (61%) performed or supervised by a paediatric orthopaedic consultant underwent lateral-only fixation, whereas 153 (27%) of the fixation cases performed or supervised by a non-paediatric orthopaedic consultant used lateral-only fixation. In total, 129 percutaneous wires (16%) were removed in theatre. Of the 341 percutaneous wire fixations performed or supervised by a paediatric orthopaedic consultant, 11 (3%) underwent wire removal in theatre, whereas 118 (22%) of the 528 percutaneous wire fixation cases performed or supervised by a non-paediatric orthopaedic consultant underwent wire removal in theatre. Four MUA patients (6%) and seven K-wire fixation patients (0.8%) required revision surgery within 30 days for displacement. Conclusion: the treatment of supracondylar elbow fractures in children varies across the UK. patient cases where a paediatric orthopaedic consultant was involved had an increased tendency for lateral only K-wire fixation and for wire removal in clinic. Low rates of displacement requiring revision surgery were identified in all fixation configurations.

The purple line and its association with cervical dilatation in labour: A systematic review and meta-analysis (2023)

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Type of publication:
Systematic Review

Author(s):
*Papoutsis, Dimitrios; Antonakou, Angeliki; *Gornall, Adam; Tzavara, Chara

Citation:
European Journal of Obstetrics, Gynecology, & Reproductive Biology. 289:91-99, 2023 Aug 25.

Abstract:
BACKGROUND: There is a growing body of evidence that the presence and length of the purple line could represent a non-invasive method of estimating and determining labour progress. OBJECTIVES: The primary outcome was to provide a systematic review and meta-analysis on the association between the purple line length and cervical dilatation in active labour. The secondary outcome was to determine the association between the purple line length and the fetal head descent, and to calculate the pooled mean length of the purple line at a cervical dilatation of 3-4 cm and at a cervical dilatation of 9-10 cm. SEARCH STRATEGY: We searched the Medline, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Clinical Trials.gov and Cochrane Pregnancy and Childbirth's Trials Register databases from inception till March 25, 2023. SELECTION CRITERIA: We included observational studies of pregnant women in active first stage of labour who had their labour progress assessed with the use of regular vaginal examinations and who had the occurrence recorded and length of the purple line measured at the same time. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated study eligibility. We used the random effects and fixed effects model for meta-analysis. MAIN RESULTS: There were six eligible studies included in the systematic review that reported on 982 women in total with the purple line appearing in 760 (77.3%) of cases. We found a moderate positive pooled correlation between the purple line length with cervical dilatation (r = +0.64; 95%CI: 0.41-0.87) and fetal head descent (r = +0.50; 95%CI: 0.32-0.68). For women either in spontaneous or induced labour, the pooled mean length of the purple line was more than 9.4 cm when the cervical dilatation was 9-10 cm, whereas it was more than 7.3 cm when the cervical dilatation was 3-4 cm. CONCLUSIONS: The purple line is a non-invasive method that may potentially be used as an adjunct in labour progress assessment.