2014

Can hospital early warning score systems be used to predict mortality and readmissions in patients with chronic obstructive pulmonary disease exacerbations requiring hospitalisation? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E.-J.T., *A lvarez E., *Moudgil H., *Naicker T.R., *Srinivasan K.S.

Citation:
American Journal of Respiratory and Critical Care Medicine, 2014, vol./is. 189/

Abstract:
Rationale: Predicting mortality in chronic obstructive pulmonary disease (COPD) can be complex as disease progression does not often follow a smooth downward trajectory. Identifying patients with COPD approaching the end of the ir life is important as it allows clinicians to initiate appropriately time d discussions centred around advance care planning and palliative care. High rates of early readmission to hospital (within 30 days of discharge) for patients with COPD is also of some national concern and to date, effective strategies to reduce this readmission rate have been limited. The use of early warning score (EWS) systems are now widespread in UK hospitals and are used primarily to alert nursing and medical staff to the severity of, or changes in, a patient's condition. This study aimed to understand whether the EWS systems could be used to predict 30 or 90 day mortality, or readmission rates in patients admitted to hospital with a COPD exacerbation. Met hods Data was collected from 73 consecutive patients admitted to hospital over a three month period (May to August, 2013) with an acute exacerbation of COPD. Collected data included early warning scores on admission, discharge and the peak EWS score. Data regarding in-hospital death, death within 30 and 90 days of admission date and readmission within 30 days of discharge was also collected. Results One patient (1.4%) died during their hospital admission. Four patients (5%) had died within 30 days of admission and 11 pa tients (15%) had died within 90 days of admission. 17 patients were re-admitted within 30 days of discharge (23%). There was no significant difference between median admission, peak and discharge early warning scores in those patients who had died within either 30 or 90 days of admission or who were readmitted within 30 days compared to the median values for the rest of th e group (see table). Conclusions According to the findings of this study, measurement of early warning scores cannot be used in clinical practice to p redict readmission rates, 30 or 90 day mortality in patients admitted to hospital with an acute exacerbation of COPD. (Table Presented).

Current trends in head and neck surgery: Use of recurrent laryngeal nerve monitoring (RLNM) (2014)

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Type of publication:
Conference abstract

Author(s):
Babatola O., *Karamchandani D., *Ahsan S.F.

Citation:
International Journal of Surgery, November 2014, vol./is. 12/(S39)

Abstract:
Introduction: Aim is to understand the patterns of use of nerve monitoring in UK surgical practice. Methods: An electronic questionnaire was sent to the 434 members of the ENT-UK expert panel in 2012. 86 members (22.4%) of the panel identified themselves as having an interest or subspecialty related to thyroid surgery. The survey contained 8 questions on their current practice in thyroid or parathyroid surgery, their typical use of the recurrent laryngeal nerve stimulator and any patient selection criteria that they may have. Demographic data on the surgeon's year of gaining consultancy and number of procedures performed per annum was also obtained. Results: Of 100 respondents (23.04% response rate) of this panel, 50 of these surgeons performed thyroid and/or parathyroid surgery on a regular basis and the following results pertain to this group. 58.3% use the RLNS in almost all cases that they perform. A further 12.5% used it in fewer than half of their cases. 29.2% did not use the stimulator at all. Conclusions: Currently there appears to be no true consensus among the surgeons performing thyroid surgery on use of RLNS in thyroid surgery.

Link to more details or full-text:
http://www.journal-surgery.net/article/S1743-9191(14)00373-2/pdf

Laparoscopic anti-reflux surgery (LARS): Determine the hiatal defect repair using the intra-operatively calculated surface area (SA) cm2 (2014)

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Type of publication:
Conference abstract

Author(s):
*Sukha A., *Adjepong S., *Pattar J., *Sigurdsson A.

Citation:
International Journal of Surgery, November 2014, vol./is. 12/(S100)

Abstract:
Introduction: The aim of this study was to evaluate laparoscopic antireflux surgery (LARS) techniques when repairing hiatal defects using the intra operatively calculated surface area (SA) at single-centre Upper Gastrointestinal Laparoscopic Unit. Methods: 100 patients (mean age = 59, average BMI 31) with symptoms of GORD underwent LARS. The SA (cm2) was calculated using an endoscopic ruler and the formula;(1/2 x base x height) x2. The method of closure; Surgisis +/-simple tension free sutures, was recorded for each hiatal closure. Results: The mean calculated SA repaired was 9.0cm2 and there was a 2%(2) recurrence rate. There were 3 modalities of repair; 1) Surgisis, posterior and anterior sutures (mean SA=10.0cm2, average BMI = 28); 2) Surgisis and posterior sutures (mean SA=9.5cm2, average BMI=29); 3) posterior sutures only (mean SA =6.1cm2, average BMI=32, mean number of sutures 3). Conclusions: It was found that the greater the average SA cm2 of the hiatus hernia the greater the number of modalities of repair used. There was no correlation found between BMI and the surface area of the hiatus hernia. Currently there are no set standard for method of repair based on the SA of the defect; however guidelines have been derived from this study.

Link to more details or full-text:
http://www.journal-surgery.net/article/S1743-9191(14)00735-3/pdf

Mortality following acute native artery embolecotmy for arterial embolism unrelated to peripheral arterial disease (PAD): 18 year review (2014)

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Type of publication:
Conference abstract

Author(s):
*Lambert J., *Premaratne S., *Jaipersad A., *Houghton A., *Fox A., *Merriman K.

Citation:
International Journal of Surgery, November 2014, vol./is. 12/(S114)

Abstract:
Introduction: Arterial embolism unrelated to peripheral vascular disease (AEUPAD) is known to be associated with risk factors such as malignancy, atrial fibrillation and thrombophilias. This study aimed to determine survival following embolecotmy of native arteries for AEUPAD. Methodology: Retrospective analysis was performed of a prospectively maintained database in a single vascular centre for the past 18 years, for all native artery embolectomies. Patients with PAD and graft embolectomies were excluded. Kaplan-Meier survival analysis was performed to calculate overall survival. Relationship between death and known risk factors were also assessed. Results: From 1994 to 2012, 192 patients had 204 native artery embolectomies for AEUPAD. 11 had multiple embolectomies. 100(49%) were male, mean age 72.5 (range: 9-102) years. Embolectomies performed; femoral 115 (56%), popliteal 47(23%), brachial 40 (17%), iliofemoral 1(0.4 %) and tibial 2(0.8%). 80 (41.60%) of patients were alive at the time of analysis. Kaplan-Meier estimates 69.77% survival 12 months post embolecotmy, decreased to 46.42% and 18.61% within 2 and 5 years respectively. Age (p<0.0001) and male sex (p=0.0451) were associated with death. Smoking had a negative correlation with mortality (p=0.0080). Conclusions: There is high mortality following embolecotmy. Though basic investigations are performed, further assessment may be necessary to prevent high mortality.

Link to full-text:
http://www.journal-surgery.net/article/S1743-9191(14)00812-7/pdf

The subscapularis splitting technique: Beware the aberrant axillary nerve (2014)

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Type of publication:
Journal article

Author(s):
Singh R.A., Ahmed B., Hay B.A., *Hay S.M.

Citation:
Techniques in Shoulder and Elbow Surgery, December 2014, vol./is. 15/4(130-133)

Abstract:
The subscapularis splitting technique has become a very common approach for the open management of shoulder instability, including repair of Bankart lesions, capsular shift procedures, and the increasingly popular Latarjet procedure. It is often used for young athletes, as the attachment and the length of subscapularis are preserved while other open approaches may result in restricted rotation of the shoulder, particularly external rotation. The current literature reports that routine exposure of the axillary nerve is not necessary during anterior stabilization procedures using a subscapularis muscle-splitting approach if proper precautions are taken to protect the nerve. We present a case in which the axillary nerve was fortuitously noted to be coursing in an abnormally lateral position anterior to the subscapularis belly exposing the nerve at risk during subscapularis split. Our case clearly represents an important anatomic variant which must be considered when performing the subscapularis splitting approach, as serious and functional deficits will result if the nerve is irrevocably damaged. Beware the aberrant axillary nerve.

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Complications of airway management and how to avoid them (2014)

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Type of publication:
Journal article

Author(s):
*Chandra P., Frerk C.

Citation:
Trends in Anaesthesia and Critical Care, December 2014, vol./is. 4/6(195-199)

Abstract:
Major complications of airway management are rare, but complications causing minor patient harm are common. Our aim should be to manage our patients airways without causing any injury. Complications arise from technique failure, direct and indirect trauma and as a consequence of cardiovascular instability associated with our airway management techniques. Avoiding complications depends on planning (choosing the lowest risk procedure & having a well thought through strategy), providing optimal conditions, using the best available equipment and using the optimum technique for all practical procedures. This review provides an overview of the technical and non-technical aspects of airway management to help minimise the incidence of complications.

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Enhance It - Enhancing Hospital Laboratory Standards for Continuing Professional Development: Transnational Evaluation of a Novel CPD Activity for Specialists in Laboratory Medicine (2014)

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Type of publication:
Conference abstract

Author(s):
Martin J, Gasljevic V, Sálek T, Horvath A, Borg C, Flegar-Meštrić Z, Jakovcic M, Silhavik J, Adonics A, Szlamka Z, Brincat I, Buttigieg D, Ciantar N, Sciortino AL, Mifsud A, Adkins A, *Bennett T, Rice K, Taylor Y.

Citation:
The Future of education 2014

Abstract:
A project which has received funding of over 100,000 euros from the European Union’s Lifelong Learning Leonardo Program is developing good practice in continuing professional development (CPD) for Specialists in Laboratory Medicine. The Partnership is developing an EU-toolkit for delivery of high quality CPD activities provided by European hospital laboratories. This paper reports on the first stage of the project which is transnational evaluation of a novel European CPD activity by hospital laboratories in Croatia, Czech Republic, Malta and the United Kingdom. An innovative CPD activity was designed to facilitate participation by Specialists in Laboratory Medicine in all partner countries. The topic of Health and Safety was chosen to enable maximum European participation as it is a multi-disciplinary topic of relevance to all Specialists in Laboratory Medicine in all partner countries. A series of thirty images of either good or bad laboratory practice in Health and Safety were provided to participants who were required to state whether the photograph depicted good or bad practise. If bad practise was shown Specialists in Laboratory Medicine were asked to explain what further actions would be taken including reporting procedures. On completion of the exercise, participants took part in a discussion group, completed a reflective learning sheet and filled in an evaluation questionnaire. Subsequently, in order to contextualise the CPD activity within their own laboratories participants will be asked to note any poor practice in their laboratory, discuss with colleagues, develop an action plan, repeat at monthly intervals and report on Health and Safety improvements. Over one hundred Specialists in Laboratory Medicine from four different European countries Croatia (n=14), Czech Republic (n= 10), Malta (n=65) and UK (n=29) took part in this new CPD activity. Several different grades of laboratory staff evaluated the activity and indicated that the exercise had been useful and appropriate to their scope of practice (99.2%) and relevant for their own CPD (97%). For over 80% of participants, this was the first time that they had taken part in this novel format of CPD activity. Discussion with colleagues following completion of the activity provided useful enhancement to both scope of practice (92%) and CPD (87%). Subsequent completion of a reflective learning sheet was shown to be beneficial for 86% of participants. We conclude that participation in this novel CPD activity which demonstrated a 100% overall satisfaction rate, has facilitated enhanced European cooperation between participating hospital laboratories and will provide a platform for future more intensive European co-operation by Specialists in Laboratory Medicine to work closely together to harmonise their practice and profession throughout the European Union.

Link to more details or full-text: http://conference.pixel-online.net/FOE/acceptedabstracts_scheda.php?id_abs=554#null

 

Case report of generalized pustular psoriasis of von Zumbusch associated with hypothyroidism (2014)

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Type of publication:
Conference abstract

Author(s):
*Mirhadi S., Moazenzade M.

Citation:
British Journal of Dermatology, December 2014, vol./is. 171/6(e147-e148), 0007-0963 (December 2014)

Abstract:
Generalized pustular psoriasis (GPP), a rare subtype of psoriasis, is characterized by abrupt extensive pustular eruptions with potentially fatal outcome. This report describes a case of GPP associated with hypothyroidism. A 28-year-old Iranian woman presented 5 years ago with pustular lesions with underlying erythematous background, which spread over > 50% of her body and was particularly severe in her calf and lower abdomen. The size of lesions was 4-20 cm. She also had systemic symptoms including fever, rigors, arthralgia, loss of appetite and severe depression. In addition, she had peripheral oedema and lymphadenopathy in the submental and anterior cervical chain. She had no significant past medical history. Her family history included mild localized psoriasis in her mother. She was admitted on five occasions, for 2 weeks, at intervals of 6-12 months with acute relapses. The attacks occurred mainly during the winter and summer. No drugs have been implicated. Skin biopsy confirmed pustular psoriasis. Unbroken pustules were sterile. The main biochemical abnormalities were elevated erythrocyte sedimentation rate, leucocytosis, iron-deficiency anaemia, hyperlipidaemia and hypoproteinaemia in the acute phase. During her third attack, it was noticed that she had hypothyroidism. She was treated with low-dose systemic corticosteroid for her acute attacks. Both the skin lesions and peripheral oedema started to respond on day 5 of steroids. Weaning of steroids was commenced in week 3. Among systemic drugs, she tolerated only a retinoid (Neotigason) and she had longer remissions with retinoids. Following the correction of her anaemia, hypothyroidism and peripheral circulation using tensile bandage, and additional family support, her condition is now improving. She occasionally gets small localized lesions that respond well to combined topical steroid with mupirocin. Following resolution of her pustules, topical Daivonex (calcipotriol) and steroid are used. The plan is to reduce the dose of Neotigason gradually. Multiple trigger factors for GPP have been described, including low thyroid activity. GPP is associated with autoimmune conditions such as hypothyroidism. Its prognosis is better in younger age and when the pustular psoriasis is preceded by ordinary psoriasis. In conclusion, we report a typical case of GPP with systemic symptoms, raised inflammatory markers, leucocytosis, hypoalbuminaemia, anaemia, hyperlipidaemia and hypothyroidism. Pharyngitis and emotional stress were identified as triggers. Her management was quite complicated and the disease finally responded to steroids, retinoid and calcipotriol. This patient did not develop any life-threatening complication.

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Autoregulation versus defaecation: An unusual side effect of CPAP (2014)

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Type of publication:
Conference abstract

Author(s):
*Stone H., *Fazal F., *Moudgil H., *Ahmad N., *Naicker T., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 (Suppl 58)

Abstract:
Introduction Continuous Positive Airway Pressure is the first line treatment for symptomatic moderate to severe obstructive sleep apnoea. Side effects of CPAP are well known; however faecal incontinence secondary to CPAP is not documented. We present the case of a patient with OSA who developed this on commencing CPAP. Case A 50 year old female with ulcerative colitis had a total colectomy in 1992 and a subsequent ileo-anal pouch reconstruction. She was referred to the sleep clinic as she was experiencing daytime somnolence (Epworth score of 15/24). Her sleep study demonstrated severe obstructive sleep apnoea with an apnoea-hypopnoea index of 35.2, and for 12.5% of the study, her Sa02 were below 90%. She was commenced on CPAP using auto titration. Initially, she experienced problems with faecal leakage – defecating up to 4 times per night. During this time her mean CPAP pressure had been 17cm water. She was subsequently converted CPAP at 10cms fixed maximum pressure and now tolerates CPAP very well; having a degree of faecal leakage only 2 or 3 times a week, rather than every night as previously. Her Epworth score has now fallen to 9/24, her AHI is 2.5 and her OSA symptoms have improved, leading to better treatment compliance. Conclusion It was hypothesised that the patient's problems were related to increased intra-thoracic pressure from the CPAP, resulting in raised intra-abdominal pressure, putting a strain on the ileo-anal pouch reconstruction giving rise to the faecal incontinence. This resolved with lower CPAP pressures, resolving the faecal frequency whilst still adequately treating the OSA. Limiting pressures should be considered in the future in patients with colorectal disease to avoid faecal incontinence.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P2292.short?rss=1

 

Recurrence patterns for venous thromboembolism-who is most at risk? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E., *Moudgil H., *Naicker T., *Ahmad N., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 Supp 58

Abstract:
National guidance regarding the treatment of venous thromboembolism (VTE) advocates anticoagulating newly diagnosed patients for three months, followed by consideration of indefinite anticoagulation to reduce the risk of recurrent VTE in certain clinical situations. (NICE Clinical Guideline CG144, issued June 2012.) There is recent evidence that although deep vein thromboses (DVT) and pulmonary emboli (PE) are manifestations of the same disease, their patterns of recurrence and hence future morbidity and mortality risk are different. (Baglin, T. et al. Journal of Thrombosis and Haemostasis 2010; 8(11):2436-2442.) We undertook a retrospective case-note review of 416 patients diagnosed with a VTE event within our institution between January 2010 and January 2011 to assess risk and pattern of VTE recurrence. 35 patients (8.4%) had a recurrent VTE event in the 3 years following diagnosis. Median time to recurrence was 12 months (mean 16.5, SD 10.5). None of the patients were anticoagulated at the time of recurrence and no patients died as a result of their thromboembolic event. Patterns of VTE recurrence The majority of patients with recurrent VTE in our study presented as a further DVT and as such, could be considered at lower risk of associated morbidity and mortality compared to those presenting with PE. Clinicians should consider the likely presentation of any further VTE recurrence as part of their assessment before advocating indefinite anticoagulation in these patients, particularly as the introduction of new oral anticoagulant drugs is likely to make the logistics of prescribing lifelong anticoagulation less complex.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P4114.short?rss=1