Staff Publication

The diabetic foot: Get your patient on the right antibiotics! (2019)

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Type of publication:
Conference abstract

Author(s):
*Lefroy R.; Summerour V.; *McMullen K.; Corfield L.

Citation:
British Journal of Surgery; Sep 2019; vol. 106, S5, p. 165

Abstract:
Aim: The National Institute for Clinical Excellence has established evidence-based guidelines for the
management of diabetic foot infection. These follow basic principles of treating infections with broad spectrum
antibiotics until cultures provide more accurate guidance for antibiotic treatment. This audit aimed to assess
the practice of a tertiary vascular centre against this guideline, to bring in measures to improve practice and
then to re-examine this practice.
Method(s): Data was collected retrospectively for all patients who underwent an emergency operative
intervention for a diabetic foot infection under the care of vascular surgery (n=122). Data collection focused on
microbiological samples sent and antibiotics prescribed. The results were shared with the surgical unit and the
guidelines reiterated. A proforma was trialled and one month of patients with diabetic foot infection admitted
as emergencies were prospectively reviewed.
Result(s): Initially, we showed that only 36% had microbiological samples sent at the time of their procedure. Of these, almost half were on antimicrobial therapy not tailored to sensitivities. Following education and
instigation of our proforma, we demonstrated that 77% of patients had samples and improving rates of
appropriate antibiotic prescriptions.
Conclusion(s): Our data demonstrates significant improvement in these patients management. Doctors must
check sensitivities of samples to ensure antibiotic stewardship.

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Intraoperative Infiltration of Local Anaesthetic with Adrenaline In Sliding Hip Screw Surgery: Does It Reduce the Need for Transfusion? A Comparison of Practice Over Two Hospital Sites (2019)

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Type of publication:
Conference abstract

Author(s):
*T. Banks, *P. Jayawardena, *D. Ford

Citation:
British Journal of Surgery, Sep 2019; vol. 106, S6, p. 108

Abstract:
Aim: Post-operative blood transfusion is frequently required in patients undergoing Sliding Hip Screw (SHS) surgery. This is associated with transfusion related complications, increased cost and length of stay in hospital. We compared practice between two hospitals; pre-incision infiltration of local anaesthetic with adrenaline (LAAd) versus LA without adrenaline prior to wound closure, to evaluate if there was a difference in postoperative haemoglobin drop and the need for postoperative transfusion following SHS surgery.
Method: A retrospective service evaluation was performed using National Hip Fracture Database (NHFD) data in a cohort of 248 patients who underwent SHS surgery between 2017 and 2018; 110 patients had LAAd. Pre and post-operative haemoglobin, postoperative transfusion and local infiltration was recorded from the trust online patient databases. Relationships between groups was determined using z-testing on Excel.
Results: There was no significant difference in postoperative haemoglobin drop between the two cohorts (p=0.119). 32.7% of patients who had LAAd received blood transfusion in contrast with 20.3% without adrenaline.
Conclusion: Whilst surgeons using LAAd may report less bleeding from skin edges and vastus lataralis intra-operatively, and optimised regional anaesthesia, there was no significant difference in haemoglobin drop between the two cohorts. A difference in threshold for transfusion was identified between the
two hospitals.

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A Rare Case of Cavernous Haemangioma of the Larynx Presenting as Dyspnoea – A Case Report (2019)

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Type of publication:
Conference abstract

Author(s):
Teo X.Y.; *Rafie A.; Thompson S.; Jolly K.; Darr A.

Citation:
British Journal of Surgery, 2019, Volume 106, Issue S6, p. 72

Abstract:
Introduction: Haemangiomas are a rare entity and seldom observed within the cavern e.g. larynx. The rarity and nature of these lesions can result in clinical unpredictability and mortality. According to literature, laryngeal cavernous haemangiomas often present as dysphonia. However, we have documented a rare case of cavernous haemangioma presenting as dyspnoea. Case presentation: A 71-year old gentleman presented to the A&E with progressive breathlessness and a history of un-investigated intermittent dysphonia. Medical therapy for suspected heart failure and COPD was ineffective, with worsening stridor identified. Assessment by the Otolaryngology team elicited a pedunculated lesion of the vocal cord. An awake fibre-optic intubation was undertaken, under sedation while spontaneously respiring. The patient subsequently underwent urgent microlaryngoscopy to have the lesion resected. Discussion: Cavernous haemangiomas are relatively rare findings with less than 10 cases being documented in the literature. However, in this case, breathlessness was the main presenting complaint. Histological examination of cavernous haemangiomas demonstrated polypoid tissue surfaced by reactive squamous epithelium and underlying stroma containing large dilated vascular channels.
Conclusion: Laryngeal cavernous haemangiomas in adults are uncommon and rarely seen on the vocal cords. Although benign, their course can be unpredictable and airway obstruction can occur rapidly, warranting urgent
excision.

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Thyrotoxicosis and the consumption of bovine thyroid tissue (2021)

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Type of publication:
Journal article

Author(s):
S Senthilkumaran, *F Benita, P Thirumalaikolundusubramanian, K Swaminathan

Citation:
QJM : monthly journal of the Association of Physicians; Jul 2021; vol. 114 (no. 4); p. 253-254

Abstract:
Thyrotoxicosis due to consumption of bovine thyroid tissue is called hamburger thyroiditis. Despite bovine meat consumption in India and Asia, it is surprising to note that very few thyrotoxicosis from food contamination has been reported from Asia. We report a case of exogenous thyrotoxicosis due to bovine thyroid tissue consumption probably for the first time from Asia, to create an awareness of this entity among physicians and practitioners and others to consider this entity while handling patients with features of thyrotoxicosis of recent onset.

DRESS syndrome: an important differential for eosinophilia with systemic organ dysfunction (2020)

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Type of publication:
Journal article

Author(s):
*Whoasif Mukit, *Richard Cooper, *Harmesh Moudgil, *Nawaid Ahmad

Citation:
BMJ Case Reports, 2020 Vol. 13(5)

Abstract:
Drug rash occurring with eosinophilia and systemic symptoms syndrome is a potentially fatal adverse drug reaction that requires immediate action in order to minimise patient harm. Initially implicated with the use of anticonvulsants, it has also been shown to be caused by many other medications but less frequently with vancomycin. Patients typically present with fever, lymphadenopathy, eosinophilia and systemic organ dysfunction. Diagnosis is aided using probability calculators such as RegiSCAR (Registry of Severe Cutaneous Adverse Reaction), as well as clinical response on removing the responsible medication. Here, we present a case without any systemic organ dysfunction that improved with withdrawal of the offending drug vancomycin.

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Lessons of the month 1: A case of rhombencephalitis as a rare complication of acute COVID-19 infection (2020)

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Type of publication:
Journal article

Author(s):
*Po Fung Wong, *Sam Craik, *Piers Newman, *Annabel Makan, *Koottalai Srinivasan, *Emma Crawford, *Devapriya Dev, *Harmesh Moudgil and *Nawaid Ahmad

Citation:
Clinical Medicine 2020 Vol 20, No 3, p. 293-294

Abstract:
A 40-year-old man developed acute brainstem dysfunction 3 days after hospital admission with symptoms of the novel SARS-CoV-2 infection (COVID-19). Magnetic resonance imaging showed changes in keeping with inflammation of the brainstem and the upper cervical cord, leading to a diagnosis of rhombencephalitis. No other cause explained the patient’s abnormal neurological findings. He was managed conservatively with rapid spontaneous improvement in some of his neurological signs and was discharged home with continued neurology follow up.

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Point-of-care lung ultrasound in patients with COVID-19 - a narrative review (2020)

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Type of publication:
Journal article

Author(s):
Smith, M J; Hayward, S A; Innes, S M; *Miller, A S C

Citation:
Anaesthesia; Aug 2020, vol. 75 (no. 8); p. 1096-1104

Abstract:
Ultrasound imaging of the lung and associated tissues may play an important role in the management of patients with COVID-19-associated lung injury. Compared with other monitoring modalities, such as auscultation or radiographic imaging, we argue lung ultrasound has high diagnostic accuracy, is ergonomically favourable and has fewer infection control implications. By informing the initiation, escalation, titration and weaning of respiratory support, lung ultrasound can be integrated into COVID-19 care pathways for patients with respiratory failure. Given the unprecedented pressure on healthcare services currently, supporting and educating clinicians is a key enabler of the wider implementation of lung ultrasound. This narrative review provides a summary of evidence and clinical guidance for the use and interpretation of lung ultrasound for patients with moderate, severe and critical COVID-19-associated lung injury. Mechanisms by which the potential lung ultrasound workforce can be deployed are explored, including a pragmatic approach to training, governance, imaging, interpretation of images and implementation of lung ultrasound into routine clinical practice.

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Adult cavernous haemangioma of the vocal cords with a unique presentation of acute respiratory distress: a case report (2020)

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Type of publication:
Journal article

Author(s):
*Rafie, A; Jolly, K; Darr, A; *Thompson, S

Citation:
Annals of the Royal College of Surgeons of England; Sep 2020; vol. 102 (no. 7); p. e152

Abstract:
Laryngeal haemangiomas can commonly be seen in children, and first-line treatment is usually propranolol. However, in adults, cavernous haemangioma of the vocal cord(s) is an extremely rare condition – with this being the only published adult case presenting with acute respiratory distress – the mainstay of treatment is surgical excision under microlaryngoscopy. Presentation in adults can be unpredictable, but primarily consists of hoarseness which can be associated with, dyspnoea, dysphagia, and haemoptysis – and in one documented case stenosis of the aero-digestive tract led to death. Due to these airway difficulties, surgery can often prove challenging. In this study, we explore the unusual case of a previously well 71-year-old gentleman presenting to the Emergency Department, with worsening shortness of breath as his primary complaint. Uniquely, in this case, an awake fibre-optic intubation was undertaken to manage the difficult airway and a microlaryngoscopy was performed. A 20x10x15 mm lesion was excised, which had characteristics in keeping with a cavernous haemangioma on microscopic examination.

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Comprehensive geriatric assessment in the emergency department (2020)

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Type of publication:
Journal article

Author(s):
*Harding, Siobhan

Citation:
Age & Ageing; Nov 2020; vol. 49 (no. 6); p. 936-938

Abstract:
Completing comprehensive geriatric assessments (CGA) for frail patients admitted to acute hospitals has well-established benefits and is advocated by national guidelines. There is high-quality evidence demonstrating an association between inpatient CGAs and the patient being alive and community-dwelling at 12-month follow-up. However, less well-known is the effectiveness of CGAs conducted within the emergency department (ED), with the primary purpose of facilitating admission avoidance, on reducing 30-day reattendance or readmission. This commentary provides an overview of five studies that measure the impact of conducting an ED-CGA on subsequent secondary care attendance. Two randomised-controlled trials, one case-matched cohort study and two quasi-experimental pre- and post-intervention studies were reviewed. The studies reported variable success in preventing subsequent secondary care use. No studies meeting the criteria had been conducted within the UK, affecting generalisability of the findings. There is no clear evidence that conducting a CGA within ED reduced reattendances or admissions 30 days post-discharge. The existing evidence base is methodologically and clinically heterogeneous and is vulnerable to multiple sources of bias. Further research is needed to understand whether screening to identify target populations or whether increased intensity of interventions delivered improves outcomes. ED-CGA may not have a beneficial effect on cost improvement or service delivery metrics, but it may have positive outcomes that are of high importance to the patients. This warrants further study.