Staff Publication

Prevention of adrenal crisis: cortisol responses to major stress compared to stress dose hydrocortisone delivery (2020)

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Type of publication:
Journal article

Author(s):
Prete A.; Taylor A.E.; Bancos I.; Smith D.J.; O'Neil D.M.; Karavitaki N.; Arlt W.; Foster M.A.; Lord J.M.; Kohler S.; Fazal-Sanderson V.; Komninos J.; Wass J.A.H.; Vassiliadi D.A.; Mihai R.; *Mowatt C.J. ; Fallowfield J.L.; Annane D.; Keevil B.G.

Citation:
The Journal of Clinical Endocrinology and Metabolism; Volume 105, Issue 7, July 2020

Abstract:
CONTEXT: Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid life-threatening adrenal crisis. However, current treatment recommendations are not evidence-based. OBJECTIVE(S): To identify the most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency exposed to major stress. DESIGN AND PARTICIPANTS: Cross-sectional study: 122 unstressed healthy subjects and 288 subjects exposed to different stressors (major trauma [N=83], sepsis [N=100], and combat stress [N=105]). Longitudinal study: 22 patients with preserved adrenal function undergoing elective surgery. Pharmacokinetic study: 10 patients with primary adrenal insufficiency undergoing administration of 200mg hydrocortisone over 24 hours in four different delivery modes (continuous intravenous infusion; six-hourly oral, intramuscular or intravenous bolus administration). MAIN OUTCOME MEASURE: We measured total serum cortisol and cortisone, free serum cortisol and urinary glucocorticoid metabolite excretion by mass spectrometry. Linear pharmacokinetic modelling was used to determine the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress. RESULT(S): Serum cortisol was increased in all stress conditions, with the highest values observed in surgery and sepsis. Continuous intravenous hydrocortisone was the only administration mode persistently achieving median cortisol concentrations in the range observed during major stress. Linear pharmacokinetic modelling identified continuous intravenous infusion of 200mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range. CONCLUSION(S): Continuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress.

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Total knee arthroplasty reduces knee extension torque in-vitro and patellofemoral arthroplasty does not (2020)

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Type of publication:
Journal article

Author(s):
Joseph M.N.; Stephen J.M.; Amis A.A.; *Carmont M.R.; Tailor H.

Citation:
Journal of Biomechanics; 2020 May 7;104:109739

Abstract:
Patients often have difficulty recovering knee extension strength post total knee arthroplasty (TKA), and that may reflect alteration of the mechanics including geometry and rollback kinematics, so the purpose of this work was to explore this by comparing the knee extension torque (KET) of the native knee, TKA and patellofemoral arthroplasty (PFA) in response to quadriceps tension. Eight fresh-frozen knees were mounted in a knee extension rig with quadriceps loading and tibial extension torque measurement. Each knee was subject to four conditions: native knee, PFA, cruciate-retaining (CR) and posterior-stabilized (PS) TKA. The KET was measured from 120degree to 0degree knee flexion. Data were analyzed using one-way ANOVA and post-hoc paired t-tests. The native KET was lowest in terminal extension and 70-100degree flexion, and maximal at 20-30degree flexion. PFA produced the greatest KET (p < 0.008) compared with native, CR- and PS-TKA, at 30-40degree flexion. CR- and PS-TKA had lower KET across 0-50degree flexion (p < 0.001 across 0-30degree), falling to 25% of the native knee KET or the PFA at full extension. PFA had the highest KET in early flexion possibly due to increased trochlear offset and/or preservation of the cruciate mechanism, so PFA may be more beneficial during the functional range of motion. The claimed benefits of PS- over CR-TKA in deep flexion were not detected. Both CR- and PS-TKAs led to lower KET than the native and PFA knee states across 0-50degree flexion. This mechanical effect may help to explain clinical findings of knee extension weakness post-TKA.

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Perioperative management of women on oral anticoagulants and antiplatelet agents undergoing gynaecological procedures (2020)

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Type of publication:
Journal article

Author(s):
*Goh E.; Barker V.; Lee P.L.; *Eden D.; *Davies O.; *Sahu B.

Citation:
Obstetrician and Gynaecologist; 2020; Vol 22(2) p. 131-136

Abstract:
Key content: The number of women attending gynaecological services who are taking oral anticoagulants and antiplatelet agents is increasing. Direct oral anticoagulants are becoming increasingly popular and offer an alternative to warfarin. Knowledge of the use of anticoagulants in the perioperative period is imperative to provide optimal care and ensure patient safety. It is essential that health professionals practising gynaecology, at all levels, keep up to date to reduce unnecessary cancellations, delays in treatment and risks of thrombosis and bleeding. Learning objectives: To understand the management of women on oral anticoagulant and antiplatelet agents undergoing elective and emergency gynaecological procedures. To appreciate the importance of assessing patient- and procedural-related risks of thrombosis and bleeding. To review commonly used anticoagulant and antiplatelet agents.

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Working Collaboratively: Outcomes of Geriatrician Input in Older Patients Undergoing Emergency Laparotomy in a District General Hospital (2020)

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Type of publication:
Journal article

Author(s):
*Khan, Kashuf A; Subramanian, Thejasvi; Richters, Megan; Mubarik, Ayesha; Saad Abdalla Al-Zawi, Abdalla; Thorn, Christopher C; Chalstrey, Susan; Gunasekera, Savithri

Citation:
Cureus; Feb 2020; vol. 12 (no. 2); p. e7069

Abstract:
With the increasing median age of survival in the UK, there is an increased burden on the provision of medical and surgical care to the population. The 2010 National Confidential Enquiry into Patient Outcome and Death report, "An Age Old Problem," emphasizes the early involvement of surgical and geriatric consultant input to improve perioperative care in older patients. This study describes the development of a Geriatric Surgical Liaison Service aimed at providing consultant-led geriatrician support to improve the outcomes of older patients undergoing Emergency Laparotomy (EL). The primary outcome is the reduction in length of stay (LOS) compared to baseline data prior to geriatrician involvement. The service was designed to include one clinical session involving a consultant geriatrician and two and a half days with a junior doctor in a week. Data was collected prospectively from February 2018 till July 2018 for surgical patients aged ≥ 70 years, who underwent EL, had an inpatient stay of more than seven days, and who were diagnosed with delirium or incurred inpatient falls (intervention group). Baseline data, prior to geriatrician involvement, were collected retrospectively for EL patients aged ≥ 70 years from December 2015 until May 2016. Length of stay and 30-day mortality were also compared between the two cohorts undergoing EL. A total of 69 patients were included in the intervention group; 45 patients underwent EL and their mean LOS was 17.5 days, which was reduced from 22.5 days prior to geriatrician involvement (n=57). There was no difference in median length of stay and 30-day mortality between the retrospective baseline group and the intervention groups. In the intervention group, 8.5% of patients had a new medical diagnosis and 26.8% of patients were offered follow-ups. Although statistically not significant (p=0.40), a shorter stay in hospital by five days can potentially have a positive impact on patient outcomes by reducing psychosocial, cognitive, and functional deconditioning. This would also improve patient flow, release capacity, and waiting times and would be of benefit to the financially strained National Health Service (NHS). Overall, our study suggests that a collaborative, consultant-led geriatric service can improve the management of older surgical patients by potentially reducing length of stay, identifying high-risk patients, and facilitating early and appropriate specialty input alongside adequate and required outpatient follow-up.

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Bronchiectasis in primary care (2020)

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Type of publication:
Journal article

Author(s):
*Pickstock, Shirley

Citation:
Journal of Community Nursing; Feb 2020; vol. 34 (no. 1); p. 51-54

Abstract:
Non-cystic fibrosis (CF) (bronchiectasis) is a common chronic lung condition, which occurs due to damage to the airways leading to persistent cough, sputum production and recurrent chest infections (Hill et al, 2018). This article focuses on the adult patient and describes the pathophysiology, aetiology, investigation, and management of bronchiectasis in the primary care setting. The aim is to raise awareness of this disease, which is increasing in prevalence and to empower community nurses with information to support patients through the bronchiectasis disease trajectory.

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Magseed for Localisation of Impalpable Breast Cancer is associated with High Patient Satisfaction and Lower Re-excision Rates (2019)

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Type of publication:
Poster presentation

Author(s):
*L.Deane, *B.Lake, *M.Wilson, *S.Williams, *M.Metelko, *G.Thomas, *S.Lewis, *L.Norwood, *T.Usman

Citation:
Poster presented at the International Cambridge Conference on Breast Cancer Imaging, July 2019

Link to poster [PDF]

Elevated BMI Significantly increases recurrence rate of Breast Cancer; a district general hospital experience (2019)

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Type of publication:
Poster presentation

Author(s):
*Blossom Lake, *Albert Mansoor, *Donna Appleton

Citation:
British Journal Surgery; September 2019; Vol 106(S5), p.20 (Poster presentation at Association of Surgeons of Great Britain May 2019)

Abstract:
Aims: Excess body weight has been shown to be a risk factor for breast cancer recurrence. The aim of this study was to evaluate the effect of BMI on recurrence rate of Breast cancer in Shropshire.
Methods: Retrospective analysis of Somerset Database of all new breast cancers diagnosed from January 2012 to December 2012 at the Shrewsbury & Telford NHS Trust. Clinical portal and pre-op database were used to obtain patient demographics including BMI and recurrence rate. Excluded patients from analysis: no surgery performed, or operated at another hospital. Overall recurrence rate, local recurrence, distant metastasis rate and 5 year disease free survival (DFS) were compared for 3 groups: BMI< 25, overweight; 25.1-29.9,and obese; >30.
Results: 498 new breast cancers were diagnosed in 2012, of these 132 were excluded as per criteria. 366 records were analysed; 40 patients had recurrent breast cancer 10.9%. 97.5% of recurrent patients had one or more prognostic factor, size> 3cm, node positive or Grade 3, with no significant difference between BMI groups for adverse prognostic factors. Overall Recurrence rate for BMI <25 was 5.9%, this was significantly higher in BMI> 25, 13.3% p<0.05.BMI Overall Recurrence rate Local recurrence Distant Metastasis rate 5 year DFS<25 5.9% 0.8% 5.9% 94.1% Overweight 14.4% 4.2% 10.2% 85.6% Obese 12.3% 2.3% 11.5% 87.7%
Conclusion: Our experience suggests a significant increase in Breast Cancer recurrence with increasing BMI. Further studies are needed to clarify this and whether methods of reducing BMI may improve disease free survival

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Mortality of in-patient medical admissions to a DGH Critical Care Unit (2019)

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Type of publication:
Conference abstract

Author(s):
*Sunil Tailor, *Ade Adiamou, *Omu Davies, *Roger Slater

Citation:
State of the Art 2019. Intensive Care Society Conference. Birmingham December 9-12.

Abstract:
Increasing clinical demand and reorganisation of hospital services may result in “stable” medical in-patients being “cohorted” into hospital locations without ready access to critical care services on site. The NEWS tool is recognised to provide warning of deterioration and a trigger for escalation of care [1]. Current EWS tools perform well for predicting death and cardiac arrest within 48 hours, although the impact on in-hospital health outcomes and utilization of resources remains uncertain [2]. In a retrospective case review, we examined the outcome of medical patients who had been hospital in-patients for more than 48 hours, whose condition deteriorated, requiring admission to our critical care unit (Princess Royal Hospital). The aim was to identify “red flag” observations for their deterioration and to measure mortality (overall: hospital + 30-day) in this patient group. During 2016-17 we identified 51 patients, of whom 39 patients were analysed because of a complete data set. We classified 48% (19 patients )as hot: defined as having a NEWS of 5 or more on one or more occasions in the 48-hours prior to ITU admission.
52% (21 patients) were classified as warm; defined as having a NEWS no greater than 4 on one or more occasions in the 48hr prior to ITU admission.
Red flag parameters (individual score of 3) were: Respiratory rate <8 or >25; SpO2 < 91%; temperature < 35C; SBP < 90 or > 220 mmHg; HR < 40 or > 131; AVPU: VPU.
Results:

  • The most common predictive red flag indicator for ITU admission was a raised respiratory rate.
  • 11 of the 39 patients did not score any red flag indicators. The mortality of this group was 33%.
  • The mortality rate of the 39 patients was 66%. The mortality for hot and warm classifications was 71% and 46% respectively.
  • The majority (>80%) of patients were aged 51-80 years .
  • The mean duration of ITU stay was 7.4 days (warm) vs 9.5 days (hot).
  • Over the same time period, ICNARC data demonstrated that 80% of all admissions to the ITU were non-surgical; overall ITU and hospital mortality was 15.7% and 22.5% respectively.

Conclusions

  • Medical inpatients with a persistently high NEWS of 5 or more during 48 hrs prior to ITU admission had a very high 30-day mortality despite ITU care.
  • 11 patients had no red flag indicators in the 48 hours prior to ITU admission despite their subsequent deterioration.
  • There are significant resource implications in managing such patients.
  • Care must be taken in defining stability in respect of medical in-patients in order to avoid later deterioration.

Limitations: Not all patients could be analysed because of incomplete data.

References:

  1. Thompson R. National Early Warning Score (NEWS). Report of a Working Party, Royal College of Physicians,UK, July 2012.
  2. Beth Smith M, Chiovaro J, O'Neil M, et al. Early Warning System Scores for Clinical Deterioration in Hospitalized Patients: A Systemic Review. Ann Am Thorac Soc 2014; 11:1454-1465.

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Severe Hypercalcaemia in Intensive Care: An unusual cause (2019)

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Type of publication:
Conference abstract

Author(s):
*Zi Hao Reuel Heng, *Rhys Parry, *Omu Davies, *Roger Slater

Citation:
State of the Art 2019, Intensive Care Society Conference, Birmingham, December 9-12.

Abstract:
Background: Severe hypercalcemia is defined as serum calcium > 3.5 mmol/l.
Major causes of hypercalcemia in adults include primary hyperparathyroidism, milk-alkali syndrome and malignant neoplasms. Neoplasms cause hypercalcaemia either by direct invasion (metastasis) or through factors that stimulate osteoclasts (Parathyroid hormone related peptide or PTHrP). Very rarely a benign tumour can be responsible. Clinical features of hypercalcemia correlate with degree and rapidity of rise of serum calcium. Severe hypercalcemia is associated with neurological, renal and gastrointestinal symptoms.
The differential diagnosis of the cause is determined by measuring parathyroid hormone (PTH) levels.
The case: A 33-year-old woman 37/52 pregnant presented with epigastric pain, vomiting, proteinuria and hypertension and a deteriorating GCS (11/15). A CT head was normal. Blood showed hyperuricaemia and acute kidney injury. She was transferred to the operating room for caesarean section with suspected fulminating pre-eclampsia following a fall in GCS to 8. Immediately prior to general anaesthetic induction she had a generalized seizure. She was induced, intubated and commenced on IV magnesium and labetolol. Following successful delivery, a large pedunculated fibroid was noted on the left side of the uterus. She was transferred to intensive care sedated, intubated and ventilated. Routine blood testing demonstrated severe hypercalcaemia, corrected serum calcium of 5.05 mmol/l. PTH was at the lower limit at 1.3 pmol/l (normal range 1.3 – 7.6 pmol/l). Treatment consisted of IV rehydration with 0.9% sodium chloride 4 litres in 24hr, IV Pamidronate (a bisphosphonate) 60mg over 2 hours. Over the next 3 days the serum calcium returned to normal. A literature search uncovered 3 reports of benign uterine leiomyomas having been the source of ectopic PTHrP leading to hypercalcaemia [1,2,3]. In this case, the uterine fibroid was presumed to have been the source of PTHrP. Unfortunately, direct measurement of PTHrP was not possible at the time of presentation. In view of the fact that the calcium had returned to normal with medical treatment and post-delivery, it was decided to defer further surgery. The patient was successfully weaned from ventilatory support after 5 days. She was monitored and calcium remained within normal limits. 3/12 later the fibroid was removed. The histology showed a mitotically active smooth muscle leiomyoma.
Conclusion: Uterine leiomyoma can rarely be a cause of hypercalcaemia in the critically ill obstetric patient. Severe hypercalcaemia can present in a similar manner to pre-eclampsia, and can worsen pre-eclampsia. Intensivists need to be aware of this condition.
Discussion: The clinical picture was strongly suggestive of severe hypercalcaemia associated with a uterine fibroid. The history did not reveal ingestion of excessive calcium-containing antacids sufficient to cause hypercalcaemia. A hypercalcaemic crisis can occur during pregnancy; the immediate postpartum period being the most likely time,. At this time, relative dehydration and an abrupt decrease in placental transport of calcium to the foetus can coexist. Severe hypercalcaemia can rarely produce seizures, the mechanism is thought to be due to cerebro-vasospasm.
References
1.Ravakhah K, Gover A, Mukunda B. Humoral Hypercalcemia Associated with a Uterine Fibroid. Annals of Internal Medicine 1999; 130: 702.
2.Tarnawa E, Sullivan S, Underwood P et al. Severe hypercalcemia Associated with Uterine Leiomyoma in Pregnancy. Obstetrics & Gynecology 2011;117: 473-476
3.Garcha A, Gumaste P, Cherian S et al. Hypercalcemia: An Unusual Manifestation of Uterine Leiomyoma. Case Reports in Medicine 2013; Article ID 815252.

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Categorising sub-massive pulmonary thromboembolism: No isolated role for shock index or its modified form (2019)

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Type of publication:
Conference abstract

Author(s):
*Abdulsamad S.P.; *Crawford E.; *Makan A.; *Ahmad N.; *Srinivasan K.; *Moudgil H.

Citation:
European Respiratory Journal; Sep 2019; vol. 54, PA1469

Abstract:
Background and Objectives: Managing sub-massive pulmonary thromboembolism (PTE) remains a therapeutic challenge and efforts have been made to sub-categorise continued risk based on clinical assessment and objective measures such as a raised serum lactate (>4 mmol/l) or abnormal Shock Index (Heart rate/systolic blood pressure, SIndex). The objective here was to investigate the SIndex and its modified form (MSIndex) to (1) report frequency of abnormal results in a population being investigated for PTE and (2) assess potential benefits in avoiding adverse outcome.
Method(s): Retrospective analysis of 1505 CT pulmonary angiograms undertaken over a 12 month period. Abnormal SIndex was taken as outside limits 0.5-0.9. MSindex was calculated conventionally as heart rate divided by (2xdiastolic blood pressure+systolic blood pressure)/3 and considered abnormal if <0.7 or >1.3. Analysis was on Excel.
Result(s): Mean age for the population was 67.7 (range 17-101) years. 337/1505 (22.4%) scans showed PTE and of this population 19 patients had adverse outcome either died within 3 months (7 had malignancy) or requiring Intensive Care during the admission. For patients without PTE (n=1168), the SIndex was abnormal in 334(28.6%) and the MSindex in 293 (25.1%). For patients with PTE (n=337), respectively these figures were 89 (26.4%) and 68 (20.2%). Of those with adverse outcomes, 13/19 Sindex and 17/19 MSIndex values were not abnormal.
Conclusion(s): Neither the SIndex not the MSIndex are discriminatory in helping distinguish the at risk groups with PTE and therefore cannot be used as an isolated criteria.