Staff Publication

No difference in strength and clinical outcome between early and late repair after Achilles tendon rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R; Zellers, Jennifer A; Brorsson, Annelie; Silbernagel, Karin Grävare; Karlsson, Jón; Nilsson-Helander, Katarina

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : Official Journal of the ESSKA; May 2020; vol. 28 (no. 5); p. 1587-1594

Abstract:
PURPOSE This retrospective study aimed to determine the patient-reported and functional outcome of patients with delayed presentation, who had received no treatment until 14 days following injury of Achilles tendon rupture repaired with minimally invasive surgery and were compared with a group of sex- and age-matched patients presenting acutely. Based on the outcomes following delayed presentation reported in the literature, it was hypothesized that outcomes would be inferior for self-reported outcome, tendon elongation, heel-rise performance, ability to return to play, and complication rates than for acutely managed patients.
METHODS Repair was performed through an incision large enough to permit mobilisation of the tendon ends, core suture repair consisting of a modified Bunnell suture proximally and a Kessler suture distally and circumferential running suture augmentation.
RESULTS Nine patients presented 21.8 (14.9) days (range 14-42 days) after rupture. The rate of delayed presentation was estimated to be 1 in 10. At 12 months following repair, patients with delayed treatment had median (range) ATRS score of 90 (69-99) compared with 94 (75-100) in patients treated acutely presenting 0.66 (1.7) (0-5) days. There were no significant differences between groups: ATRA [mean (SD) delayed: – 6.9° (5.5), acute: – 6° (4.7)], heel-rise height index [delayed: 79% (20), acute: 74% (14)], or heel-rise repetition index [delayed: 77% (20), acute: 71% (20)]. In the delayed presentation group, two patients had wound infection and one iatrogenic sural nerve injury.
CONCLUSIONS Patients presenting more than 2 weeks after Achilles tendon rupture may be successfully treated with minimally invasive repair. LEVEL OF EVIDENCE III.

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'You have got a foreign body in there': Renal transplantation, unexpected mild-to-moderate distress and patients' support needs: A qualitative study (2020)

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Type of publication:
Journal article

Author(s):
Jones J.; Damery S.; Combes G.; Allen K.; *Nicholas J. ; Baharani J.

Citation:
BMJ Open; Mar 2020; vol. 10 (no. 3)

Abstract:
Objective: To explore why transplant patients experience unexpected mild-to-moderate distress and what support they may need.
Design: Qualitative study using individual in-depth interviews. Setting Four National Health Service (NHS) Trusts in the Midlands, UK. Participants Fifteen renal transplant patients meeting the criteria for mild-to-moderate distress from their responses to emotion thermometers. Main outcome measures Identification of the reasons for distress and support options acceptable to renal transplant patients.
Results: Three themes were interpreted from the data: I am living with a "foreign body" inside me', why am I distressed?' and different patients want different support'. Following their transplant, participants felt that they should be happy and content, but this was often not the case. They described a range of feelings about their transplant, such as uncertainty about the lifespan of their new kidney, fear of transplant failure or fear of the donor having health conditions that may transfer to them. A few experienced survivors' guilt when others they had met at the dialysis unit had not received a transplant or because someone had died to enable them to receive the transplant. No longer having regular contact with the renal unit made participants feel isolated. Some participants did not initially attribute the source of their distress to their transplant. Participants' preferred support for their distress and their preferences about who should deliver it varied from peer support to seeing a psychologist.
Conclusions: Raising the issue of post-transplant mild-to-moderate distress with patients and encouraging them to think about and plan coping strategies pretransplant may prove beneficial for the patient and healthcare provider. Patients should be able to choose from a variety of support options.

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Improving our departmental reporting of thyroid cytology specimens against national guidelines: a two-cycle retrospective audit (2020)

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Type of publication:
Journal article

Author(s):
*Halliday E.; *Ahsan S.F.; *Harrison E.; *Harrison K.; *Sansom H.

Citation:
Cytopathology : official journal of the British Society for Clinical Cytology; November 2020, Volume31, Issue6, Pages 514-524

Abstract:
OBJECTIVE: In the United Kingdom, guidelines from the Royal College of Pathologists (RCPath) facilitate consistent and reproducible reporting and classification of fine needle aspiration cytology (FNAC) thyroid specimens. The aim was to audit our department against RCPath guidelines to refine and improve our reporting process.
METHOD(S): Two-cycle retrospective observational audit of all patients undergoing thyroid FNAC over a two-year period (one year for each cycle). Final histology was correlated. The positive predictive value (PPV) for malignant neoplastic lesions was calculated; for Thy1, Thy1c, Thy2 and Thy2c all cases without final histology were assumed to be benign, while for Thy3a, Thy3f, Thy4 and Thy5 samples the PPV calculation was based only on those cytology samples with corresponding histology. 'False positive' and 'false negative' cases were reviewed.
RESULT(S): 288 cytology samples were included in the first cycle; 96 (33.3%) had corresponding histology. 287 samples were included in the second cycle; 119 (41.5%) had follow-up histology. The rate of non-diagnostic samples (Thy1/1c) decreased from 39.6% to 30.0%. The PPV for malignant neoplastic lesions was Thy1/1c 2.6%, Thy2/2c 0.0%, Thy3a 40.0%, Thy3f 19.4%, Thy4 75.0%, Thy5 100.0% (first cycle); Thy1/1c 4.7%, Thy2/2c 0.7%, Thy3a 13.3%, Thy3f, 7.7%, Thy4, 50.0%, Thy5 100.0% (second cycle).
CONCLUSION(S): Our department was able to reduce the rate of non-diagnostic FNAC samples and improve the diagnostic accuracy of FNAC. Auditing local outcomes helps refine and improve the reporting process. Review of 'false positive' and 'false negative' cases helps examine potential pitfalls of cytology.

Developing an intervention around referral and admissions to intensive care: a mixed-methods study (2019)

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Type of publication:
Journal article

Author(s):
Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C & Slowther A.

Study involved patients at Shrewsbury and Telford Hospital NHS Trust

Citation:
Health Services and Delivery Research 2019, Vol 7, Issue 39

Abstract:
Background: Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.
Objectives: To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.
Methods: A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.
Results: Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.
Limitations: Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.
Conclusions: Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.
Future work: Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.
Study registration: The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.
Funding: The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

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Age and Tightness of Repair Are Predictors of Heel-Rise Height After Achilles Tendon Rupture (2020)

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Type of publication:
Journal article

Author(s):
*Carmont, Michael R.; Zellers, Jennifer A.; Brorsson, Annelie; Nilsson-Helander, Katarina; Karlsson, Jón; Grävare Silbernagel, Karin

Citation:
Orthopaedic Journal of Sports Medicine; Mar 2020; vol. 8 (no. 3); p. 1-8

Abstract:
Background: Achilles tendon rupture leads to weakness of ankle plantarflexion. Treatment of Achilles tendon rupture should aim to restore function while minimizing weakness and complications of management. Purpose: To determine the influence of factors (age, sex, body mass index [BMI], weight, time from injury to operative repair, and tightness of repair) in the initial surgical management of patients after an acute Achilles tendon rupture on 12-month functional outcome assessment after percutaneous and minimally invasive repair. Study Design: Cohort study; Level of evidence, 3. Methods: From May 2012 to January 2018, patients sustaining an Achilles tendon rupture receiving operative repair were prospectively evaluated. Tightness of repair was quantified using the intraoperative Achilles tendon resting angle (ATRA). Heel-rise height index (HRHI) was used as the primary 12-month outcome variable. Secondary outcome measures included Achilles tendon total rupture score (ATRS) and Tegner score. Stepwise multiple regression was used to create a model to predict 12-month HRHI. Results: A total of 122 patients met the inclusion criteria for data analysis (mean ± SD age, 44.1 ± 10.8 years; 78% male; mean ± SD BMI, 28.1 ± 4.3 kg/m2). The elapsed time to surgery was 6.5 ± 4.0 days. At 12-month follow-up, patients had an HRHI of 82% ± 16% and performed 82% ± 17% of repetitions compared with the noninjured side. Participants had a mean ATRS of 87 ± 15 and a median Tegner score of 5 (range, 1-9), with a reduction in Tegner score of 2 from preinjury levels. The relative ATRA at 12 months was –4.8° ± 3.9°. Multiple regression identified younger age (B = ±0.006; P <.001) and greater intraoperative ATRA (B = 0.005; P =.053) as predictors of more symmetrical 12-month HRHI (R 2 = 0.19; P <.001; n = 120). Conclusion: Age was found to be the strongest predictor of outcome after Achilles tendon rupture. The most important modifiable risk factor was the tightness of repair. It is recommended that repair be performed as tight as possible to optimize heel-rise height 1 year after Achilles tendon rupture and possibly to reduce tendon elongation.

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Managing diabetes in primary care during Ramadan (2020)

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Type of publication:
Journal article

Author(s):
*Morris, David

Citation:
Practice Nursing; Apr 2020; vol. 31 (no. 4); p. 148-154

Abstract:
Individuals with diabetes may wish to fast during the holy month of Ramadan. David Morris provides an overview of the key considerations for practice nurses helping people with diabetes to manage their condition Ramadan is the holiest month of the Islamic calendar, during which healthy adult Muslims fast. Vulnerable people with diabetes can be exempted from fasting during Ramadan; however, many Muslims with diabetes feel strongly committed to observing Ramadan. The adoption of fasting together with alteration of mealtimes, sleeping arrangements and exercise, places physiological demands on the individual that are likely to be greater in those with diabetes. Health professionals involved in the care of these patients need to offer timely advice on the risks associated with fasting in those with diabetes and, where fasting is planned, support and empower these individuals.

Does perioperative use of tranexamic acid in hip fracture patients increase the risk of venous thromboembolism and reduce the need for postoperative transfusions? (2020)

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Type of publication:
Journal article

Author(s):
Geddes J.; *McConaghie G.

Citation:
Journal of Perioperative Practice; 2020 Dec;30(12):378-382

Abstract:
Perioperative tranexamic acid use is a popular choice among many surgeons for reducing surgical blood loss and its sequelae. While there is evidence in the literature that tranexamic acid use is effective in reducing blood loss in surgery for patients with hip fractures, there is less information on whether it leads to thromboembolic complications. We undertook a retrospective study in patients with hip fractures at two local hospitals to investigate if there was an increased risk of venous thromboembolism in patients who received tranexamic acid, and whether it reduced perioperative blood loss and the need for transfusion. We found that tranexamic acid used in patients undergoing hip fracture surgery reduced the drop in postoperative haemoglobin and the need for postoperative blood transfusion but was not associated with an increased risk of venous thromboembolism.

Severe anaemia complicating HIV in Malawi; Multiple co-existing aetiologies are associated with high mortality (2020)

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Type of publication:
Journal article

Author(s):
Huibers M.H.W.; van Hensbroek M.B.; Calis J.C.; Bates I.; *McKew S.; Allain T.J.; Phiri C.; Coupland S.E.; Phiri K.S.

Citation:
PLoS ONE; 2020; vol. 15 (no. 2)

Abstract:
Background Severe anaemia is a major cause of morbidity and mortality in HIV-infected adults living in resource-limited countries. Comprehensive data on the aetiology are lacking but are needed to improve outcomes. Methods HIV-infected adults with severe (haemoglobin <=70g/l) or very severe anaemia (haemoglobin <= 50 g/l) were recruited at Queen Elizabeth Central Hospital, Blantyre, Malawi. Fifteen potential causes and associations with anaemia severity and mortality were explored. Results 199 patients were enrolled: 42.2% had very severe anaemia and 45.7% were on ART. More than two potential causes for anaemia were present in 94% of the patients including iron deficiency (55.3%), underweight (BMI<20: 49.7%), TB infection (41.2%) and unsuppressed HIV infection (viral load >1000 copies/ml) (73.9%). EBV/CMV co-infection (16.5%) was associated with very severe anaemia (OR 2.8 95% CI 1.1-6.9). Overall mortality was high (53%; 100/199) with a median time to death of 17.5 days (IQR 6-55) days. Death was associated with folate deficiency (HR 2.2; 95% CI 1.2-3.8) and end stage renal disease (HR 3.2; 95% CI 1.6-6.2). Conclusion Mortality among severely anaemic HIV-infected adults is strikingly high. Clinicians should be aware of the urgent need for a multifactorial approach including starting or optimising HIV treatment, considering TB treatment, nutritional support and optimising renal management.

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