Staff Publication

Recurrence of a second trimester fundal uterine rupture at the old scar site: A case report (2022)

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Type of publication:Journal article

Author(s):*Panesar H.; *Patel R.; Dhaliwal H.

Citation:Radiology Case Reports. 17(11) (pp 4445-4448), 2022. Date of Publication: November 2022.

Abstract:Uterine rupture is a rare life-threatening complication. It can occur in all 3 trimesters with the first and the second being a rarity. It mainly occurs in the third trimester or during labor in a previously scarred uterus. It is rare in an unscarred uterus. The risk fold is further enhanced by the induction and augmentation with prostaglandins and oxytocin. The clinical diagnosis at this early gestation can be a dilemma to the attending physician as in this case. (1) The patient was a holidaymaker with no documented evidence of a dating scan to suggest any evidence of an ovarian/placental pathology at that stage. (2) The ultrasound findings in our department did suggest a viable intrauterine pregnancy with free fluid within both the adnexa. A 6 cm solid homogenous mass in the midline/right adnexa suggested an ovarian torsion or bowel pathology. The differentials in this particular case were that of a ruptured hemorrhagic cyst, ovarian torsion and even a heterotrophic pregnancy as there had been a few documented cases in the department. Ultrasound diagnosis of an intrauterine pregnancy together with a fluid collection does not suggest by any means that the uterus is intact or there is no ectopic pregnancy.

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Airway management, intensive care requirement, and corticosteroid use in cervicofacial infection. A Maxillofacial Trainee Research Collaborative (MTReC) study (2022)

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Type of publication:Journal article

Author(s):Exley R.; Logan G.; Kent S.; McDonald C.; Hennedige A.; Henry A.; Dawoud B.; Kulkarni R.; Kyzas P.; Morrison R.; McCaul J.; Brandsma D.S.; Cashman H.; Swain A.; Java K.; Vithlani G.; Watson M.; Christopher M.; Murray S.; Baniulyte G.; Grant J.; Wareing S.; Kawalec A.; Ng T.; Reedy N.; Tavakoli M.; Underwood C.; Gowrishankar S.; Collins T.; Davies R.; Uppal S.; Elledge R.; Shaheen S.; O'Connor R.; King H.; Tudor-Green B.; Garg M.; Wareing J.; Wicks C.; Mitchell O.; Maarouf M.; Chohan P.; *Otukoya R.; Wu E.; Farooq S.; Brewer E.; King S.; Nandra B.; Stevenson S.; Stiles E.; Davies L.; Madattigowda R.; Mohindra A.; Gilbert K.; Young D.

Citation:British Journal of Oral and Maxillofacial Surgery, 2022 Nov; Vol. 60 (9), pp. 1228-1233.

Abstract:Cervicofacial infection (CFI) is a frequently encountered presentation to Oral and Maxillofacial Departments (OMFS). The United Kingdom has recently seen cessation of all routine community dental treatment due to the Coronavirus (COVID-19) pandemic and consequently an initial modification of treatment received in secondary care. Subsequent airway difficulties and the need for level 2 High Dependency Unit (HDU) or level 3 Intensive Care Unit (ICU) is a concern to surgeons and anaesthetists alike. The availability of skilled staff and appropriate facilities can be variable. It is imperative to understand the resource implications of CFI with respect to airway management and critical care utilisation. Adequate provision is fundamental for optimal care. A national, multicentre, trainee-led audit was carried out across 17 hospitals in the UK from May to September 2017. Information recorded included demographic features, presentation, airway management, medical and surgical treatment, and steroid administration. One thousand and two presentations (1002) were recorded. Forty-five percent were female, with a mean (range) age of 37.5 years (0-94). Regarding surgical airway management, 63.4% had a standard intubation (oral 42%, nasal 21.4%). Awake fibreoptic intubation (AFOI) was performed in 28% and surgical airway required in 0.9%. Impending airway compromise at the time of presentation was 1.7%. Following surgical incision and drainage, 96.1% of patients returned to a general ward, 2.7% to Level 3, and 1.1% to Level 2 care. The return to theatre was 2.8%, and 0.7% required reintubation. There was an association between corticosteroid administration and duration of intubation. Those who received steroids were more likely to remain intubated postoperatively (p = 0.006), require a higher level of postoperative care (p < 0.001), and require a return to theatre (p = 0.019). Postoperatively, patients who received steroids were less likely to be extubated at the close of the procedure. Intubated patients who received multiple steroid doses postoperatively were extubated with less frequency those that received a single dose. To our knowledge, this dataset is the largest ever recorded for CFI. Our results showed a high requirement for advanced airway management in this cohort. The requirement for surgical airway was low, but the significance of this situation should not be underestimated. The relatively frequent need for care at levels 2 or 3 within this cohort also placed a significant demand on already overburdened resources. Knowledge of care requirements for these patients will inform resource planning.

An internal pilot study of a novel rectal mucocellular sampling device to allow next-generation sequencing for colorectal disease (2023)

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Type of publication:
Journal article

Author(s):
Humphrey H.N.; Diodato A.; Isner J.-C.; Walker E.; *Lacy-Colson J.; Nedjai B.; Daniels I.R.; McDermott F.D.; Walker E.T.; Battersby N.J.; Sisodia H.; Rottenburg H.; Cunningham C.; Bird S.; Jones G.A.R.; Wise D.; Spencer S.J.;

Citation:
Techniques in Coloproctology. 27(3):227-235, 2023 Mar.

Abstract:
Background: The ORI-EGI-02 study was designed to test the hypothesis that rectal mucus collected using a novel rectal sampling device (OriColTM), contains sufficient human deoxyribonucleic acid (DNA) of the required quality for Next Generation Sequencing (NGS), for colorectal disease genetic signature discovery. Method(s): Using National Institute for Health and Care Research methodology, an internal pilot study was performed in January 2020-May 2021, at four sites in the United Kingdom, to assess the process of recruitment, consent, specimen acquisition and viability for analysis. Following an OriColTM test, the sample was stabilized with a buffer solution to preserve the material, which was posted to the laboratory. Samples were processed using QIAamp DNA Blood Midi kit to extract DNA and Quant-iTTM PicoGreen dsDNA Reagent to quantify the retrieved DNA. DNA integrity was measured by Agilent TapeStation system. 25 ng of human amplifiable DNA was prepared for Next Generation Sequencing (NGS), which was performed on an Illumina NextSeq550 sequencer using the 300-cycle high output kit v2.5.
Result(s): This study assessed the first 300 patients enrolled to the ORI-EGI-02 Study (n = 800). 290/300 (96.67%) were eligible to undergo OriColTM sampling procedure and 285/290 (98.27%) had a successful OriColTM sample taken. After transportation, extraction and quantification of DNA, 96.20% (279/290) of the samples had NGS successfully performed for bioinformatic analysis. Conclusion(s): Our internal pilot study demonstrated that the OriColTM sampling device can capture rectal mucus from unprepared bowel in subjects who could undergo a digital rectal examination. The technique could be applied irrespective of age, frailty, or co-morbidity. Completion of the study to 800 patients and analysis of NGS data for colorectal cancer mutations will now proceed.

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Thrombolysis for pulmonary embolism in palliative care: a case report (2017)

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Type of publication:Conference abstract

Author(s):Macfarlane M.; Gilhooley L.; *Griffiths T.; Frost S.; Willis D.

Citation:BMJ Supportive and Palliative Care. Conference: APM ASP Conference. Belfast United Kingdom. 7(Supplement 1) (pp A31-A32), 2017. Date of Publication: March 2017.

Abstract:Background Thrombolysis for pulmonary embolism (PE) in a patient with advanced cancer has never been reported in the literature. Whilst not an absolute contraindication, most clinicians would be wary of thrombolysing a patient with a limited life expectancy. A case is presented of a patient with advanced mesothelioma who received thrombolysis treatment with a resultant significant improvement in pleuritic chest pain and dyspnoea. History The patient was a 69 year old man who was diagnosed with epithelioid mesothelioma and received radiotherapy to his right chest followed by palliative chemotherapy. Subsequent CT scanning showed disease progression and the patient declined further chemotherapy. Thrombolysis The patient was admitted to hospital with sudden- onset shortness of breath and right sided chest discomfort which was felt to be due to disease progression. Three days later the patient developed new, severe left sided pleuritic chest pain and acute breathlessness. The patient was thrombolysed with alteplase (50 mg IV over 1 hour) on clinical suspicion of a PE. The pleuritic chest pain resolved completely and the acute severe dyspnoea improved significantly within two hours of treatment and a CTPA later confirmed acute-onchronic pulmonary thromboembolism as well as progressive mesothelioma. The patient was transferred to the hospice four days later for ongoing management and end-of-life care. Effect of Thrombolysis on Symptom Control On admission to the hospice, the patient continued to complain of mild to moderate dyspnoea but had no pain. He was commenced on regular immediate-release morphine (10 mg QDS) for breathlessness but only required one breakthrough dose of analgesia before his condition deteriorated. The patient died comfortably nine days after thrombolysis treatment. Conclusion Thrombolysis was very effective in controlling pleuritic chest pain and acute severe dyspnoea in this patient with PE and advanced cancer with a limited life expectancy.

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Quality improvement project: improving junior doctors' confidence in prescribing at end of life for acute inpatients (2022)

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Type of publication:Conference abstract

Author(s):*Dewhirst L.; *Hudson H.

Citation:BMJ Supportive and Palliative Care. Conference: Palliative Care Congress 1 Specialty: 3 Settings – Home, Hospice, Hospital. Telford United Kingdom. 10(Supplement 1) (pp A14), 2020. Date of Publication: March 2020

Abstract:Background Junior doctors are often at the forefront of prescribing for acute inpatients. It is imperative that they are equipped with the knowledge and confidence to prescribe appropriately for patients at the end of their life. We felt that there was reduced awareness of the need for individualised prescribing for patients with relatively common chronic diseases such as Parkinson's disease and epilepsy. Recognising that prescribing end of life medications for patients with such diseases can differ, we looked to improve symptom management by focussing on improving end of life prescribing. Methods A pre-intervention questionnaire was used to assess subjective confidence levels in prescribing anticipatory medications, syringe drivers, and individualised prescribing for patients with Parkinson's disease, end-stage renal disease, epilepsy, end-stage heart failure, and diabetes mellitus. Based on these findings a prescribing handbook was produced, incorporating consultant advice from relevant specialities. Teaching sessions were carried out using case-based discussions alongside the handbook content. A local press release facilitated dissemination of the handbook. A post-intervention questionnaire was then distributed to reassess prescribers' confidence levels. Results Twenty-five allied health professionals (mainly foundation doctors) completed the questionnaires. The preintervention questionnaire found that the majority were confident in prescribing anticipatory medication but were significantly less confident in prescribing syringe drivers and in individualised prescribing. Following formal education and release of the prescribing handbook, higher confidence levels were reported throughout all themes of the questionnaire. Conclusions This quality improvement project has significantly increased prescribers' confidence levels in end of life prescribing. It has also increased awareness of the need for alternative approaches to prescribing for certain individuals and diseases at the end of life. It was stressed that the handbook is to be used as a guide and should not replace the need to escalate concerns to the relevant specialities and the in-house palliative care team.

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Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms (2022)

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Type of publication:
Journal article

Author(s):
arsson E.; Helander K.N.; Falkheden Henning L.; Heiskanen M.; *Carmont M.R.; Gravare Silbernagel K.; Brorsson A.

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : official journal of the ESSKA. 2022 Dec; Vol. 30 (12), pp. 4250-4257

Abstract:
PURPOSE: The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12 months after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability and patient-reported outcome measurements (PROMs). METHOD(S): Patients were included following acute Achilles tendon rupture (ATR). Achilles tendon length, ATRA, heel-rise height (HRH), drop countermovement jump (Drop CMJ) and PROMs (Achilles tendon total rupture score (ATRS) and physical activity scale (PAS)) were evaluated 6 and 12 months after injury. Achilles tendon length was evaluated using US, while the ATRA was measured with a goniometer. RESULT(S): Sixty patients (13 women, 47 men), mean (SD) age 43 (9) years, with an acute ATR undergoing either surgical (35%) or non-surgical (65%) treatment were evaluated. A negative correlation (r=- 0.356, p=0.010) between relative ATRA and tendon elongation was seen at 12 months after ATR. There were also significant positive correlations at 6 and 12 months between relative ATRA and HRH (r=0.330, p=0.011 and r=0.379, p=0.004). There were no correlations between ATRA and ATRS or ATRA and Drop CMJ, at either 6 or 12 months after the injury. CONCLUSION(S): In combination with other clinical evaluations such as HRH and US, ATRA could be a clinical tool for indirect measurements of tendon elongation. However, ATRA cannot be recommended as a direct surrogate for US for determining Achilles tendon length.

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Early Cholecystectomy in the Ageing Population (2022)

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Type of publication:
Conference abstract

Author(s):
*Sturges P.; *Gupta A.; *Rashid U.; *Rupasinghe S.N.; *Adjepong S.; *Parampalli U.; *Kirby G.C.; *Jain R.K.; *Rink J.; *Riera-Portell M.; *Pattar J.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi67), 2022. Date of Publication: September 2022.

Abstract:
Background: The age group of patients presenting acutely with biliary pathology is rising and gallstone disease can no longer be said to be a disease of the young. The World Health Organisation classifies those aged 65 and over as elderly. Early cholecystectomy is accepted as a safe and effective method of managing acute biliary pathology, reducing further admissions, and reducing in-hospital stays. Our unit does not use age as barrier but uses performance status and co-morbidity to identify potential candidates for cholecystectomy. Method(s): Patients over the age of 65 who underwent acute cholecystectomy (AC) via the emergency cholecystectomy lists, were audited from 31st December 2019 to 31st June 2021. Patient demographics, co-morbidities and surgical factors were recorded. The primary outcome measures were in-hospital stay and re-admission, secondary outcomes were complications and perioperative mortality. Result(s): 41 elderly patients underwent AC during the audit period, (Female 56%, Male 44%). 30 patients had acute cholecystitis (73%). The median inpatient stay following surgery was 2 days (range 2-5 days) and the median admission to surgery time was 6 days (range 5-12 days). Three patients had a subtotal cholecystectomy. There were 3 complications from surgery which were all between a Clavien-Dindo score of 2 and 3. There were 3 immediate post-operative readmissions, with one 30-day mortality from ERCP pancreatitis and not from the operation. Conclusion(s): Early cholecystectomy appears to be a safe and effective treatment for this group of patients and based on this evidence we should continue to offer this treatment to patients irrespective of age.

Intussusception of the Appendix in a Young Adult with Cystic Fibrosis: An Important Differential Diagnosis of Abdominal Pain in Cystic Fibrosis Patients? (2022)

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Type of publication:
Conference abstract

Author(s):
*Venkatasami M.; *Cobby E.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi57), 2022. Date of Publication: September 2022.

Abstract:
Background: Cystic fibrosis (CF) is commonly associated with gastrointestinal manifestations from infancy to adulthood. Intussusception in the paediatric CF population is widely reported, whereas in the adult, distal intestinal obstruction syndrome (DIOS) is common affecting 20%, of which, intussusception is rare and appendiceal intussusception is rarer, affecting 1%. Case-Description: A 20-year-old male with CF presented with 3 days of right iliac fossa pain and diarrhoea. On admission, he was hypotensive and afebrile. Clinical examination revealed tenderness of the right flank with a palpable mass in the right iliac fossa. Serum investigations showed mildly raised inflammatory markers. Contrast CT of the abdomen-pelvis confirmed intussusception of the appendix into the ascending colon. Histological analysis of the appendix further demonstrated intussusception, with intraluminal mucinous material. Fascinatingly, no transmural inflammation was present. The patient underwent a laparotomy-open appendicectomy. Interestingly, intraoperative findings showed the intussusception resolved, no longer requiring surgical reduction. Patient postoperative recovery was complicated by pneumonia for which he was transferred for specialist CF respiratory care and thereafter, discharged. Discussion(s): Literature review highlighted a paucity of data, with 10 reported cases of appendiceal intussusception in adult CF patients. Interestingly, we report the intussusception had reduced by the time of operation. This is in-keeping with previous case reports of transient intussusception which spontaneously resolved. Conclusion(s): From this rare case presentation, we have learnt it is imperative to carry a high index of suspicion for gastrointestinal manifestations in CF patients where acute appendicitis is seen less often and differential diagnoses like DIOS and intussusception should be considered.

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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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