Staff Publication

Urinary symptoms in pregnant women in their third trimester-a cross-sectional study (2021)

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Type of publication:
Journal article

Author(s):
Soundararajan K.; *Panikkar M.; Annappa M.

Citation:
International Urogynecology Journal; Jul 2021; vol. 32 (no. 7); p. 1867-1873

Abstract:
Introduction and hypothesis: Urinary symptoms are common in pregnancy. Our study aims to understand the extent of these symptoms in a cohort of pregnant women in the third trimester and their impact on quality of life (QOL) from the women's perspective. Method(s): A single-centre cross-sectional study of self-reported urinary symptoms of pregnant women in the third trimester conducted from August 2018 at the Diana Princess of Wales Hospital, Northern Lincolnshire, and Goole NHS Foundation Trust, Grimsby, UK. We used an international validated questionnaire (ICIQ-FLUTS questionnaire) (Brookes et al. Am J Obstet Gynecol. 191(1):73-82, 2004). Result(s): A total of 302 women were included in this study. Nocturia was the most common symptom, reported by 97%, affecting QOL in 80%. Urgency of micturition was the second most common, present in 83%, adversely affecting QOL in 75%. Our study showed a startling finding of bladder pain in 47% (95% CI 41.1%, 52.3%) of these women. There was a high prevalence of nocturnal enuresis in 9.9% (95% CI 7.05%, 13.8%). Straining during micturition is not a well-known symptom in pregnancy, however reported by 18.2% (95% CI 14.2%, 23.0%). Conclusion(s): The high prevalences of bladder pain, nocturnal enuresis and straining in the third trimester of pregnancy are novel findings. Our study also confirms that the prevalence of all voiding, filling and incontinence symptoms in pregnancy is significantly higher than in the non-pregnant population, having a negative impact on QOL, and yet is not discussed as part of routine antenatal care.

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Neonate with persisting respiratory distress after resolution of pneumothorax (2021)

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Type of publication:
Journal article

Author(s):
*Ray S.

Citation:
Archives of disease in childhood. Education and practice edition; Jun 2021; vol. 106 (no. 3); p. 152-154

Abstract:
A preterm baby boy was born in good condition at 31+5 weeks gestation with a birth weight of 1956 g, following a precipitous labour with no prolonged rupture of membranes and no opportunity for  dministration of antenatal steroids to mother. Following admission to the neonatal unit, he developed respiratory distress and was commenced on nasal continuous positive airway pressure (CPAP) of 6 cm of water. At 24 hours of age, he developed a left-sided tension pneumothorax (figure 1), requiring endotracheal intubation and insertion of a chest drain. He received two doses of surfactant and was extubated onto CPAP on day 3. There was reaccumulation of the pneumothorax on day 4, which was subsequently drained. He remained self-ventilating in air in the second week of life. From day 15 to day 30, he required humidified high flow nasal cannula oxygen (fractional inspired oxygen up to 0.4), in view of marked subcostal and intercostal recession, intolerance to handling and a compensated respiratory acidosis on capillary blood gases.Figure 2is the chest radiograph undertaken in the third week of life. Figure 1 Chest radiograph (supine anteroposterior) on day 1. Figure 2 Chest radiograph (supine  anteroposterior) in week 3. Questions: What is the most likely diagnosis in this case?
Congenital pulmonary airway malformation (CPAM) Respiratory distress syndrome Pulmonary interstitial
emphysema (PIE) Pneumatocoele Congenital diaphragmatic hernia Which of the following is not an effective option for treatment of this condition? Corticosteroid therapy Lateral decubitus with affected side down High frequency oscillatory ventilation (HFOV) Selective main bronchial intubation of contralateral lung (which is not affected) Chest physiotherapy Which of the following statements is false about this condition? Complications can include other air leak syndromes Most neonates presenting with this condition have been mechanically ventilated Diagnosis is usually made on a chest radiograph Surfactant therapy has been associated with an increase in this condition Air embolism can be a fatal complication Answers can be found on page 2.

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Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial (2021)

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Type of publication:
Journal article

Author(s):
Okeke Ogwulu, C B; Williams, E V; Chu, J J; Devall, A J; Beeson, L E; Hardy, P; Cheed, V; Yongzhong, S; Jones, L L; La Fontaine Papadopoulos, J H; Bender-Atik, R; Brewin, J; Hinshaw, K; Choudhary, M; Ahmed, A; Naftalin, J; Nunes, N; Oliver, A; Izzat, F; Bhatia, K; Hassan, I; Jeve, Y; Hamilton, J; Deb, S; Bottomley, C; Ross, J; Watkins, L; *Underwood, M; Cheong, Y; Kumar, C S; Gupta, P; Small, R; Pringle, S; Hodge, F S; Shahid, A; Horne, A W; Quenby, S; Gallos, I D; Coomarasamy, A; Roberts, T E

Citation:
BJOG : an international journal of obstetrics and gynaecology; May 2021 [epub ahead of print]

Abstract:
OBJECTIVE To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using non-parametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the NHS perspective.SETTING28 UK NHS early pregnancy units.PARTICIPANTS711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. INTERVENTIONS Mifepristone and misoprostol or matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES Cost per additional successfully managed miscarriage and QALYs. RESULTS For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI: 0.7% to 12.5%) per successfully managed miscarriage and QALYs difference of 0.04% (95% CI: -0.01% to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost-saving of £182 (95% CI: £26 to £338). Hence, MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that MifeMiso intervention is dominant compared to expectant management and the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS The within-trial analysis found that based on cost-effectiveness grounds, MifeMiso intervention is likely to be recommended by decision-makers for the medical management of women presenting with a missed miscarriage.

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COVID-19 and the multidisciplinary care of patients with lung cancer: an evidence-based review and commentary (2021)

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Type of publication:
Journal article

Author(s):
Round, Thomas; L'Esperance, Veline; Bayly, Joanne; Brain, Kate; Dallas, Lorraine; Edwards, John G; Haswell, Thomas; Hiley, Crispin; Lovell, Natasha; *McAdam, Julia; McCutchan, Grace; Nair, Arjun; Newsom-Davis, Thomas; Sage, Elizabeth K; Navani, Neal

Citation:
British Journal of Cancer; Aug 2021; vol. 125 (no. 5); p. 629-640

Abstract:
Delivering lung cancer care during the COVID-19 pandemic has posed significant and ongoing challenges. There is a lack of published COVID-19 and lung cancer evidence-based reviews, including for the whole patient pathway. We searched for COVID-19 and lung cancer publications and brought together a multidisciplinary group of stakeholders to review and comment on the evidence and challenges. A rapid review of the literature was undertaken up to 28 October 2020, producing 144 papers, with 113 full texts screened. We focused on new primary data collection (qualitative or quantitative evidence) and excluded case reports, editorials and commentaries. Following exclusions, 15 published papers were included in the review and are summarised. They included one qualitative paper and 14 quantitative studies (surveys or cohort studies), with a total of 2295 lung cancer patients data included (mean study size 153 patients; range 7-803). Review of current evidence and commentary included awareness and help-seeking; lung cancer screening; primary care assessment and referral; diagnosis and treatment in secondary care, including oncology and surgery; patient experience and palliative care. Cross-cutting themes and challenges were identified using qualitative methods for patients, healthcare professionals and service delivery, with a clear need for continued studies to guide evidence-based decision-making.

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Efficacy of Reduced-Intensity Chemotherapy With Oxaliplatin and Capecitabine on Quality of Life and Cancer Control Among Older and Frail Patients With Advanced Gastroesophageal Cancer: The GO2 Phase 3 Randomized Clinical Trial (2021)

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Type of publication:
Randomised controlled trial

Author(s):
Hall, Peter S; Swinson, Daniel; Cairns, David A; Waters, Justin S; Petty, Russell; Allmark, Christine; Ruddock, Sharon; Falk, Stephen; Wadsley, Jonathan; Roy, Rajarshi; Tillett, Tania; Nicoll, Jonathan; Cummins, Sebastian; Mano, Joseph; Grumett, Simon; Stokes, Zuzana; Konstantinos-Velios, Kamposioras; *Chatterjee, Anirban; Garcia, Angel; Waddell, Tom; Guptal, Kamalnayan; Maisey, Nick; Khan, Mohammed; Dent, Jo; Lord, Simon; Crossley, Ann; Katona, Eszter; Marshall, Helen; Grabsch, Heike I; Velikova, Galina; Ow, Pei Loo; Handforth, Catherine; Howard, Helen; Seymour, Matthew T; GO2 Trial Investigators

Citation:
JAMA oncology; May 2021; 7(6):869-877

Abstract:
Importance Older and/or frail patients are underrepresented in landmark cancer trials. Tailored research is needed to address this evidence gap. ObjectiveThe GO2 randomized clinical trial sought to optimize chemotherapy dosing in older and/or frail patients with advanced gastroesophageal cancer, and explored baseline geriatric assessment (GA) as a tool for treatment decision-making.Design, Setting, and Participants This multicenter, noninferiority, open-label randomized trial took place at oncology clinics in the United Kingdom with nurse-led geriatric health assessment. Patients were recruited for whom full-dose combination chemotherapy was considered unsuitable because of advanced age and/or frailty.InterventionsThere were 2 randomizations that were performed: CHEMO-INTENSITY compared oxaliplatin/capecitabine at Level A (oxaliplatin 130 mg/m2 on day 1, capecitabine 625 mg/m2 twice daily on days 1-21, on a 21-day cycle), Level B (doses 0.8 times A), or Level C (doses 0.6 times A). Alternatively, if the patient and clinician agreed the indication for chemotherapy was uncertain, the patient could instead enter CHEMO-BSC, comparing Level C vs best supportive care.Main Outcomes and MeasuresFirst, broad noninferiority of the lower doses vs reference (Level A) was assessed using a permissive boundary of 34 days reduction in progression-free survival (PFS) (hazard ratio, HR = 1.34), selected as acceptable by a forum of patients and clinicians. Then, the patient experience was compared using Overall Treatment Utility (OTU), which combines efficacy, toxic effects, quality of life, and patient value/acceptability. For CHEMO-BSC, the main outcome measure was overall survival. Results A total of 514 patients entered CHEMO-INTENSITY, of whom 385 (75%) were men and 299 (58%) were severely frail, with median age 76 years. Noninferior PFS was confirmed for Levels B vs A (HR = 1.09 [95% CI, 0.89-1.32]) and C vs A (HR = 1.10 [95% CI, 0.90-1.33]). Level C produced less toxic effects and better OTU than A or B. No subgroup benefited from higher doses: Level C produced better OTU even in younger or less frail patients. A total of 45 patients entered the CHEMO-BSC randomization: overall survival was nonsignificantly longer with chemotherapy: median 6.1 vs 3.0 months (HR = 0.69 [95% CI, 0.32-1.48], P = .34). In multivariate analysis in 522 patients with all variables available, baseline frailty, quality of life, and neutrophil to lymphocyte ratio were independently associated with OTU, and can be combined in a model to estimate the probability of different outcomes. Conclusions and Relevance This phase 3 randomized clinical trial found that reduced-intensity chemotherapy provided a better patient experience without significantly compromising cancer control and should be considered for older and/or frail patients. Baseline geriatric assessment can help predict the utility of chemotherapy but did not identify a group benefiting from higher-dose treatment. Trial Registrationisrctn.org Identifier: ISRCTN44687907.

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Postpartum haemorrhage and risk of long-term hypertension and cardiovascular disease: an English population-based longitudinal study using linked primary and secondary care databases (2021)

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Type of publication:
Journal article

Author(s):
*Parry-Smith, William; Šumilo, Dana; Subramanian, Anuradhaa; Gokhale, Krishna; Okoth, Kelvin; Gallos, Ioannis; Coomarasamy, Arri; Nirantharakumar, Krishnarajah

Citation:
BMJ Open; May 2021; vol. 11 (no. 5); p. e041566

Abstract:
OBJECTIVE To investigate the long-term risk of developing hypertension and cardiovascular disease (CVD) among those women who suffered a postpartum haemorrhage (PPH) compared with those women who did not. DESIGN Population-based longitudinal open cohort study. SETTING English primary care (The Health Improvement Network (THIN)) and secondary care (Hospital Episode Statistics (HES)) databases. POPULATION Women exposed to PPH during the study period matched for age and date of delivery, and unexposed. METHODS We conducted an open cohort study using linked primary care THIN and HES Databases, from 1 January 1997 to 31 January 2018. A total of 42 327 women were included: 14 109 of them exposed to PPH during the study period and 28 218 matched for age and date of delivery, and unexposed to PPH. HRs for cardiovascular outcomes among women who had and did not have PPH were estimated after controlling for covariates using multivariate Cox regression models. OUTCOME MEASURES Risk of hypertensive disease, ischaemic heart disease, heart failure, stroke or transient ischaemic attack. RESULTS During a median follow-up of over 4 years, there was no significant difference in the risk of hypertensive disease after adjustment for covariates (adjusted HR (aHR): 1.03 (95% CI: 0.87 to 1.22); p=0.71). We also did not observe a statistically significant difference in the risk of composite CVD (ischaemic heart disease, heart failure, stroke or transient ischaemic attack) between the exposed and the unexposed cohort (aHR: 0.86 (95% CI: 0.52 to 1.43; p=0.57). CONCLUSION Over a median follow-up of 4 years, we did not observe an association between PPH and hypertension or CVD.

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Modification of hospital discharge summary software to improve Covid-19 documentation and safeguard community infection prevention (2021)

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Type of publication:
Conference abstract

Author(s):
*Lo N.

Citation:
European Journal of Case Reports in Internal Medicine. Conference: 19th European Congress in Internal Medicine Internal Medicine, ECIM 2021. Virtual. 8(Supplement 1) (pp 108), 2021. Date of Publication: 2021.

Abstract:
Background and Aims: Initial review of 50 discharge summaries at Royal Shrewsbury Hospital in April 2020 revealed only 27% included the patient's COVID-19 test result and 2% outlined any recommended self-isolation advice. This had potential adverse implications for infection control as well as medicolegal sequalae for the Trust if exposed patients were discharged without self-isolation advice and subsequently spread COVID-19 in the community. The medical team worked with hospital IT to amend the existing discharge summary software, such that two tabs were added to make COVID-19 test result and self isolation documentation mandatory prior to sign off, in an early pilot version. We aimed to evaluate the impact of this software modification on COVID-19 discharge summary documentation. Method(s): Following the implementation of the modified software, 50 consecutive discharge summaries were retrospectively reviewed for: Documentation of COVID-19 result. Documentation of self-isolation advice for patient. Result(s): Following the software amendment, 91% of discharge summaries included COVID-19 test result (up from 27%) and 100% included documented self-isolation advice for the patient (up from 2%). Conclusion(s): Simple modification of the existing IT system greatly improved compliance with COVID-19 test result and self-isolation advice documentation on discharge summaries. A further software update since the study has added a tab awaiting results, to cater for patients discharged prior to COVID-19 test result becoming available. We propose all hospitals consider adopting similar measures in the interest of infection prevention, public safety and potential medico-legal sequalae.

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A different perspective: using interactive virtual reality (IVR) for psychiatry training (2021)

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Type of publication:
Conference abstract

Author(s):
Evans H.; Young S.; Whitehurst J.; *Madadi A.; Barton J.

Citation:
BJPsych Open. Conference: Royal College of Psychiatrists International Congress, RCPsych 2021. Virtual. 7(Supplement 1) (pp S22-S23), 2021. Date of Publication: June 2021.

Abstract:
Aims. To evaluate the potential of interactive virtual reality in teaching and training Postgraduate Psychiatry Trainees in the Keele Cluster Background. Face to face supervised clinical experience will always be the best way to train and learn, followed by using simulated patients in practice scenarios allowing a safe environment in which to practice and train without risk. However, the practicalities of a busy NHS often mean that the expense and time required for both of these are not possible and often PowerPoints and handouts in induction are used to prepare new starters in Psychiatry, which is clearly suboptimal. Interactive Virtual Reality (IVR) allows trainees to not only be immersed in a simulation but take control, choosing the direction of questioning for example. It also allows the training to be easily repeated and scaled to any number of students, anytime and anywhere there is an internet connection. Method. Following successful funding from the RCPsych General Adult Faculty we chose three common scenarios that a new started in Psychiatry would face. These included acute agitation/ rapid tranquilisation, a patient wishing to leave/section 5(2) and a patient with tachycardia following clozapine initiation. Using established guidelines and literature, in conjunction with feedback from subject matter experts and practicing clinicians, scenarios were written. We then researched the best hardware and software to make this possible, ensuring that the resources required were realistic to allow accessibility to as many trainees as possible. Result. Creating IVR is challenging but an engaging medium. Achieving consensus on the training material is time consuming yet paramount to a good training session. Producing high quality videos is extremely resource intensive requiring large amounts of computing power and storage. However, the outcome is an engaging and practical alternative to face to face training. Conclusion. The possibilities for IVR for are vast. For example, trainees can practice different methods of asking questions (e.g. open vs closed) and how this affects the outcome. Training could be produced centrally and then shared, allowing best practice to be disseminated. It could improve and standardise induction, especially considering the expanding workforce. It could also improve recruitment, allowing an immersive experience of Psychiatry to those who would otherwise be unable to obtain shadowing. It also has a role in patient safety – demonstrating common scenarios that the trainee may face allowing them to practice in a safe environment.

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MRI of the Achilles tendon - a comprehensive pictorial review. Part two (2021)

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Type of publication:
Journal article

Author(s):
Szaro P.; Nilsson-Helander K.; *Carmont M.

Citation:
European Journal of Radiology Open; Jan 2021; vol. 8

Abstract:
The most common disorder affecting the Achilles tendon is midportion tendinopathy. A focal fluid signal indicates microtears, which may progress to partial and complete rupture. Assessment of Achilles tendon healing should be based on tendon morphology and tension rather than structural signal. After nonoperative management or surgical repair of the Achilles tendon, areas of fluid signal is pathologic because it indicates re-rupture. A higher signal in the postoperative Achilles tendon is a common finding and is present for a prolonged period following surgical intervention and needs to be interpreted alongside the clinical appearance.

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Randomised controlled trial of antibiotic/ hydroxychloroquine combination versus standard budesonide in active Crohn's disease (Apricot) (2021)

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Type of publication:
Conference abstract

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

Citation:
Gut; Jan 2021; vol. 70

Abstract:
Introduction Mucosal E. coli are increased in Crohn's disease (CD). They replicate within macrophages and are then inaccessible to penicillins and gentamicin. Hydroxychloroquine is used with doxycycline to treat Whipple's disease. It raises macrophage intra-vesicular pH and inhibits replication of bacteria that require acidic pH. Ciprofloxacin and doxycycline are also effective against E. coli within macrophages. Methods Adult patients with active CD (CDAI>220 plus CRP>=5 mg/l and/or faecal calprotectin >250 ugram/g) were randomised to receive (open label) either oral budesonide (Entocort CR 9 mg/day 8 weeks, then 6 mg/day 2 weeks and 3 mg/day 2 weeks) or antibiotics/hydroxychloroquine (AB/ HCQ) – oral ciprofloxacin 500 mg bd, doxycycline 100 mg bd, hydroxychloroquine 200 mgs tds for 4 weeks, followed by doxycycline 100 mg bd and hydroxychloroquine 200 mgs tds for 20 weeks. Use of anti-TNF in the previous 3 months was an exclusion. Primary endpoints were remission (CDAI

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