Staff Publication

Blood Cultures in Patients with Acute Covid-19 Pneumonitis: Contamination or Bacterial Co-Infection? (2021)

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Type of publication:Conference abstract

Author(s):*Nikhita Moudgil, *Afrah Riaz, *Annabel Makan *Emma-Jane Crawford, *Koottalai Srinivasan, *Nawaid Ahmad, *Harmesh Moudgil

Citation:Chest Infections, October 2021, Vol 160, Issue 4, Supplement, A546

Abstract:PURPOSE: INTRODUCTION: Research shows that 90% of blood cultures show no growth and a third of the remainder who test positive are identified as false positives [Garcia RA et al. Am J Infect Control 2015]. Although blood culture contamination rates of <1% are achievable, historical rates at <3% are industry accepted standards[Wayne PA. Clinical and laboratory Standards Institute (CLSI) document M47-A; 2007];contaminants from skin flora are the most common, but 20% are from microbes deep in the dermis layer which may be drawn into blood specimens. Evidence for early use of antibiotics managing patients with COVID19 pneumonitis is lacking but there are anecdotal concerns that more blood cultures than usual have identified organisms usually considered contaminants in sampling. Objectives were to quantify our local findings and relate these to outcome at discharge and during follow up.METHODS: Computer based retrospective review of 228 patients, mean age 71.8 (SD 8.7, range 29-87) years admitted at this hospital between March-May 2020 during the UK COVID-19 (SARS-Cov-2 RNA) peak and surge. Blood cultures reported here correspond to initial presentation with COVID-19 following a sepsis protocol. Comparative analysis by chi square (X2).RESULTS: 137/228 (60%) of patients had blood cultures at admission. 21/137 (15.3%) identified organisms from either one (n¼13) or both (n¼8) aerobic and anaerobic blood culture bottles. 12/21 (57.1%) (8 died) were identified as coagulase negative staphylococci (CoNS), traditionally considered contaminants at sampling; others included coagulase positive staph aureus (2), Klebsiella (2), E coli (2), and one each for Diptheroids, Proteus Miribalis and Aerococcus Viridans. The remaining 116 reported no growth from initial samples but 3 had positive results later in the admission (2 with CoNS, 1 with E Coli). 7/21 (33.3%) of those with any growth had died during the admission and this was proportionately similar to the 38/116 (32.8%) with no growth on blood cultures [X2 0.0027, p=.9588, not significant]. At 6 month follow up however, 15/21 (71.4%) of those who had positive findings on original cultures had died compared with 48/116 (41.4%) that had shown no growth [X2 6.4639, p=.0110, statistically significant].CONCLUSIONS: Although death rates during admission did not differ, comparing those with and without positive findings on initial blood cultures, a large percentage with positive initial findings then died during follow up. Despite several organisms traditionally considered contaminants, the higher (15.3%) reporting and potential false positive rates requires further study; this should address sampling errors but also revisit bacterial co-infection in COVID-19.CLINICAL IMPLICATIONS: Improving sampling for blood cultures, but research is also needed to make sure this is not a signal for underlying bacterial co-infection

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Interactive teaching environment for diagnostic radiography with real-time X-ray simulation and patient positioning (2022)

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Type of publication:Journal article

Author(s):Sujar, Aaron; *Kelly, Graham; García, Marcos; Vidal, Franck P

Citation:International Journal of Computer Assisted Radiology and Surgery; January 2022, 17(1), pages 85-95

Abstract:PURPOSE Traditional undergraduate radiographer training mixes academic lectures and clinical practice. Our goal is to bridge the current disconnection between theory and practice in a safe environment, avoiding the risk of radiation for both practitioners and patients. To this end, this research proposes a new software to teach diagnostic radiography using real-time interactive X-ray simulation and patient positioning. METHODS The proposed medical simulator is composed of three main modules. A fast and accurate character animation technique is in charge of simulating the patient positioning phase and adapts their internal anatomy accordingly. gVirtualXRay is an open-source X-ray simulation library and generates the corresponding radiographs in real time. Finally, the courseware allows going through all the diagnostic radiology steps from the patient positioning and the machine configuration to the final image enhancing. RESULTS A face and content validation study has been conducted; 18 radiology professionals were recruited to evaluate our software using a questionnaire. The results show that our tool is realistic in many ways (72% of the participants agreed that the simulations are visually realistic), useful (67%) and suitable (78%) for teaching X-ray radiography. CONCLUSIONS The proposed tool allows simulating the most relevant steps of the projectional radiography procedure. The virtual patient posing system and X-ray simulation module execute at interactive rates. These features enable the lectures to show their students the results of good and bad practices in a classroom environment, avoiding radiation risk.

Improving understanding, care and management of tracheostomy and laryngectomy patients amongst Foundation Year (FY) doctors -A Quality Improvement Project (QIP) at a district general hospital (2021)

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Type of publication:
Poster presentation

Author(s):
*Samsul Islam, *Elaine France, *Nawaid Ahmad

Citation:
International Tracheostomy Symposium, September 2021

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'There's a frog in my throat': bilateral prolapsing lung apices presenting as a neck lump (2021)

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Type of publication:Journal article

Author(s):*Ahmed R.A.; *Yang D.; *Nedham M.; *Osborne M.S.; *Ahsan S.F.

Citation:Annals of the Royal College of Surgeons of England; Sep 2021; vol. 103 (no. 8)

Abstract:This case report discusses an unusual presentation of a voluntarily produced neck mass, caused by the rare case of lung herniation. Lung herniation is associated with increased intrathoracic pressure that can be caused by chronic chough, straining and continuous positive airway pressure ventilation. An association with Ehlers-Danlos syndrome 1 also exists. We present a case of lung herniation that was multifactorial in nature and was identified at a head and neck clinic. The female patient presented with a voluntarily expandable anterior neck mass on Valsalva manoeuvre. Computed tomography imaging with and without Valsalva manoeuvre demonstrated bilateral anterior lung herniation and findings of spinal spondylosis.

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Machine learning risk prediction of mortality for patients undergoing surgery with perioperative SARS-CoV-2: The COVIDSurg mortality score (2021)

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Type of publication:Journal article

Author(s):COVIDSurg Collaborative (includes Blair, J of Shrewsbury and Telford Hospital NHS Trust)

Citation:British Journal of Surgery; 2021; vol. 19 (no. 4) p.1-19

Abstract:Since the beginning of the COVID-19 pandemic tens of millions of operations have been cancelled as a result of excessive postoperative pulmonary complications (51.2 per cent) and mortality rates (23.8 per cent) in patients with perioperative SARS-CoV-2 infection. There is an urgent need to restart surgery safely in order to minimize the impact of untreated non-communicable disease. As rates of SARS-CoV-2 infection in elective surgery patients range from 1–9 per cent, vaccination is expected to take years to implement globally9 and preoperative screening is likely to lead to increasing numbers of SARS-CoV-2-positive patients, perioperative SARS-CoV-2 infection will remain a challenge for theforeseeable future. In order to inform consent and shared decision making, a robust, globally applicable score is needed to predict individualized mortality risk for patients with perioperative SARS-CoV-2 infection. The authors aimed to develop and validate a machine learning-based risk score to predict postoperative mortality risk in patients with perioperative SARS-CoV-2 infection.

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Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study (2021)

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Type of publication:
Journal article

Author(s):
COVIDSurg Collaborative (includes *Blair J, *Lakhiani A, *Parry-Smith W, *Sahu B of Shrewsbury and Telford Hospital NHS Trust)

Citation:
The Lancet Oncology;  November 2021, Volume 22, Issue 22, Pages 1507-1517

Abstract:
Background: Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.
Methods; This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index <20), moderate lockdowns (20–60), and full lockdowns (>60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.
Findings; Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.
Interpretation: Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.

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Optimising frontline learning and engagement between consultant-led neonatal teams in the West Midlands: a survey on the utility of an augmented simulation training technique (2021)

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Type of publication:
Journal article

Author(s):
Pillay, Thillagavathie; Clarke, Lynsey; Abbott, Lee; Surana, Pinki; Shenvi, Asha; *Deshpande, Sanjeev; Cookson, Joanne; Nash, Matthew; Fawke, Joe; Rasiah, Vishna; Cusack, Jonathan

Citation:
Advances in Simulation; Aug 2021; vol. 6 (no. 1); p. 29

Abstract:
BACKGROUND In England, neonatal care is delivered in operational delivery networks, comprising a combination of the Neonatal Intensive Care (NICU), Local-Neonatal (LNU) or Special-Care Units (SCU), based on their ability to care for babies with different degrees of illness or prematurity. With the development of network care pathways, the most premature and sickest are mostly triaged for delivery in services linked to NICU. This has created anxiety for teams in LNU and SCU. Less exposure to sicker babies has resulted in limited opportunities to maintain expertise for when these babies unexpectedly deliver at their centre and thereafter require transfer for care, to NICU. Simultaneously, LNU and SCU teams develop skills in the care of the less ill and premature baby which would also be of benefit to NICU teams. A need for mutual learning through inter-unit multidirectional collaborative learning and engagement (hereafter also called neonatal networking) between teams of different designations emerged. Here, neonatal networking is defined as collaboration, shared clinical learning and developing an understanding of local systems strengths and challenges between units of different and similar designations. We describe the responses to the development of a clinical and systems focussed platform for this engagement between different teams within our neonatal ODN. METHOD An interactive 1-day programme was developed in the West Midlands, focussing on a non-hierarchical, equal partnership between neonatal teams from different unit designations. It utilised simulation around clinical scenarios, with a slant towards consultant engagement. Four groups rotating through four clinical simulation scenarios were developed. Each group participated in a clinical simulation scenario, led by a consultant and supported by nurses and doctors in training together with facilitators, with a further ~two consultants, as observers within the group. All were considered learners. Consultant candidates took turns to be participants and observers in the simulation scenarios so that at the end of the day all had led a scenario. Each simulation-clinical debrief session was lengthened by a further ~ 20 min, during which freestyle discussion with all learners occurred. This was to promote further bonding, through multidirectional sharing, and with a systems focus on understanding the strengths and challenges of practices in different units. A consultant focus was adopted to promote a long-term engagement between units around shared care. There were four time points for this neonatal networking during the course of the day. Qualitative assessment and a Likert scale were used to assess this initiative over 4 years. RESULTS One hundred fifty-five individuals involved in frontline neonatal care participated. Seventy-seven were consultants, supported by neonatal trainees, staff grade doctors, clinical fellows, advanced neonatal nurse practitioners and nurses in training. All were invited to participate in the survey. The survey response rate was 80.6%. Seventy-nine percent felt that this learning strategy was highly relevant; 96% agreed that for consultants this was appropriate adult learning. Ninety-eight percent agreed that consultant training encompassed more than bedside clinical management, including forging communication links between teams. Thematic responses suggested that this was a highly useful method for multi-directional learning around shared care between neonatal units. CONCLUSION Simulation, enhanced with systems focussed debrief, appeared to be an acceptable method of promoting multidirectional learning within neonatal teams of differing designations within the WMNODN.

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Adult North Star Network (ANSN): Consensus Guideline For The Standard Of Care Of Adults With Duchenne Muscular Dystrophy (2021)

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Type of publication:
Journal article

Author(s):
Quinlivan, R; Messer, B; Murphy, P; Astin, R; Mukherjee, R; Khan, J; Emmanuel, A; Wong, S C; Kulshresha, R; Willis, T; Pattni, J; *Willis, D; Morgan, A; Savvatis, K; Keen, R; Bourke, J; Marini Bettolo, C; Hewamadduma, C; ANSN

Citation:
Journal of Neuromuscular Diseases; Sep 2021 [epub ahead of print]

Abstract:
There are growing numbers of adults with Duchenne Muscular Dystrophy living well into their fourth decade. These patients have complex medical needs that to date have not been addressed in the International standards of care. We sought to create a consensus based standard of care through a series of multi-disciplinary workshops with specialists from a wide range of clinical areas: Neurology, Cardiology, Respiratory Medicine, Gastroenterology, Endocrinology, Palliative Care Medicine, Rehabilitation, Renal, Anaesthetics and Clinical Psychology. Detailed reports of evidence reviewed and the consensus building process were produced following each workshop and condensed into this final document which was approved by all members of the Adult North Star Network including service users. The aim of this document is to provide a framework to improve clinical services and multi-disciplinary care for adults living with Duchenne Muscular Dystrophy.

Primary acinic cell carcinoma in a young female patient: a case report (2021)

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Type of publication:
Journal article

Author(s):
*Venkatasami, M ; *Harrison, K

Citation:
Oral Surgery, Oral Medicine, Oral Pathology & Oral Radiology; Jul 2021; vol. 132 (no. 1)

Abstract:
Background: Acinic cell carcinoma (ACC) is a rare, low-grade tumor, accounting for about 5% of all primary salivary gland malignancies. ACCs predominate in the parotid gland, are seen in the fifth and sixth decades of life, and have a female predilection. Well-differentiated and low-grade tumors are associated with a favorable prognosis.
Description: We report a case of a 16-year-old female patient presenting with a right parotid lump that had been slowly increasing over the past year. Clinical examination revealed a 1.5-cm right parotid nodule with no facial nerve involvement and presence of cervical lymphadenopathy. Her past medical history was unremarkable.
Findings: Radiological investigations revealed a well-circumscribed, lobulated lesion in the anterior right parotid gland with presence of reactive lymph nodes bilaterally. Fine-needle aspiration showed granular cells with a differential diagnosis of oncocytoma, Warthin's tumor, or acinic cell carcinoma. Histologic examination showed a multinodular appearance with some marked granular cytoplasm with oncolytic and lymphoid infiltrate. The results of immunohistochemistry were negative for S100 and positive with DOG-1. There were widespread periodic acid-Schiff diastase-resistant granules throughout the tumor cells, with a Ki67 proliferation index of approximately 5%.
Outcome: The tumor was completely excised, and the patient made a full recovery and was considered to have a good long-term prognosis.
Conclusions: This is an unusual case of ACC seen in this age group and gender, where less than 4% of cases of ACC have been reported in patients younger than 20. It is important to consider differential diagnoses of salivary gland pathology, such as ACC, in the young female patient.