2015

A model to support staff in raising their concerns (2015)

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Type of publication:
Journal article

Author(s):
McSherry, Robert, *McSherry, Wilfred

Citation:
Nursing Times, 18 February 2015, vol./is. 111/8(15-17)

Abstract:
Sir Robert Francis QC's Freedom to Speak Up review reported that there is still a "serious issue" around the treatment of whistleblowers. This article explores why raising and escalating concerns are integral to healthcare governance systems and processes, and presents Escal8 – a new model that outlines the steps in doing this. It also examines the importance of learning and sharing from escalation, and the impact on quality and safety.

Link to full-text: http://search.proquest.com/docview/1660768724?accountid=49082

 

New-onset diabetes after renal transplant (NODAT) presenting as diabetic ketoacidosis (DKA) in a patient with sickle cell disease (2015)

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Type of publication:
Conference abstract

Author(s):
*Kaldindi S.R., *Moulik P., *Macleod A.

Citation:
Diabetic Medicine, March 2015, vol./is. 32/(117-118)

Abstract:
A 42-year-old Afro-Caribbean female presented with 1 week history of polyuria, polydypsia and vomiting. She had a background of transfusion associated iron overload and renal failure secondary to sickle cell disease. She underwent a live donor renal transplant 8 months prior to admission. Immunosuppressive therapy included tacrolimus, mycophenolate, prednisolone 5mg once a day. There was no family history of diabetes. She had a normal body mass index. Results revealed a pH of 7.08, bicarbonate of 6.6mmol/l, capillary blood glucose tests recorded as greater than 28.7mmol/l, ketones 7.0mmol/l, Hb 84 g/l. Her creatinine was 101mumol/l (baseline 90), eGFR 52 and tacrolimus levels were within therapeutic range. No obvious precipitant for diabetic ketoacidosis (DKA) was found. She responded well to intravenous fluids and insulin. Her glutamic acid decarboxylase (GAD) and islet antigen 2 (IA2) antibodies were negative. Possible causes for her diabetes include iron overload, steroid therapy, tacrolimus. In her case, she presented with a short timeline of symptoms along with severe DKA. This is typical of Type 1 diabetes, even though her antibodies were negative. NODAT usually behaves like Type 2 diabetes but, rarely, such patients can also present with an insulin deficient state similar to Type 1 diabetes. The Renal Association suggests lower levels of tacrolimus to decrease NODAT risk and screening for diabetes post-transplant. A steroid sparing immunosuppressive regimen may help in reducing the incidence of NODAT.

Link to full-text [NHS OpenAthens account required]

Selective diabetic gastroparesis (2015)

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Type of publication:
Conference abstract

Author(s):
*Rai D., *Kalidindi S., *Moulik P., *Macleod A.

Citation:
Diabetic Medicine, March 2015, vol./is. 32/(118)

Abstract:
Up to 5% of people with Type 1 diabetes have been reported to have gastroparesis. We present the case of a 19-year-old female who presented to hospital with diabetic ketoacidosis due to intractable vomiting. She developed Type 1 diabetes aged 8. Initial diabetes control was very poor, with a peak HbA1c of 167mmol/ mol and she developed severe non-proliferative diabetic retinopathy. One year prior to admission, she actively improved her blood sugars and dropped her HbA1c gradually down to 105mmol/mol. Paradoxically this seems to have worsened her vomiting. She denied any other symptoms of enteropathy and had no signs of autonomic or peripheral neuropathy. A CT and MRI brain were negative. She developed malnutrition requiring total parenteral nutrition and trials of prokinetics, dietary modifications were unsuccessful. A percutaneous endoscopic gastrotomy-jejunal tube was inserted which allowed simultaneous post pyloric feeding and gastric decompression. After a period of stable blood glucose with an HbA1c of 48mmol/mol, she had a formal gastric emptying study which confirmed severe delayed gastric emptying with a time (lag) of 87 min (normal <55) and half-life of 119 min (normal <80). Gastroscopy showed severe reflux oesophagitis consistent with delayed gastric emptying. She is currently awaiting a gastric pacemaker and manages to have small frequent meals with supplemental jejunal feeding. Diabetic gastroparesis is usually associated with peripheral and autonomic neuropathy, but she seems to have isolated gastroparesis. She also developed severe depression, psychological issues which required cognitive behavioural therapy. These issues could have worsened her symptoms.

Link to full-text: http://onlinelibrary.wiley.com/doi/10.1111/dme.12668_1/pdf

 

Three-Year delayed presentation of femoral pseudoaneurysm after penetrating limb trauma (2015)

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Type of publication:
Journal article

Author(s):
Butterworth J.W., *Butterworth W.A., Wu R.

Citation:
Annals of Vascular Surgery, February 2015, vol./is. 29/2(362.e11-362.e15)

Abstract:
Background Delayed presentations of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare. Methods After presentation of this rare case report, we review relevant published literature. Results We report a rare case of a 55-year-old man with a progressively enlarging mass measuring 15 cm by 15 cm on his right anteromedial thigh 3 years after penetrating trauma. Computer tomography angiogram revealed this to be a large pseudoaneurysm supplied by a side branch artery from the right superficial femoral artery. Using an open approach, the pseudoanerysm was successfully repaired with the side branch oversewn, and the patient made a good recovery being discharged from hospital 4 days later. Conclusions Surgeons must retain pseudoaneurysm as a prominent differential for a patient presenting with a progressively enlarging, expansile mass of an extremity after penetrating trauma to ensure urgent investigation and prompt vascular intervention. Both open surgical ablation and endovascular embolization of pseudoaneurysms of the extremities are effective techniques with low rates of complications and morbidity reported in published literature.

 

Monckeberg's arteriosclerosis: Vascular calcification complicating microvascular surgery (2015)

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Type of publication:
Journal article

Author(s):
*Castling B., *Bhatia S., *Ahsan F.

Citation:
International Journal of Oral and Maxillofacial Surgery, January 2015, vol./is. 44/1(34-36)

Abstract:
Monckeberg's arteriosclerosis is often an incidental finding, identified either clinically or on plain radiography. It can occasionally be associated with diabetes mellitus or chronic kidney disease. It differs from the more common atherosclerosis in that the tunica intima remains largely unaffected and the diameter of the vessel lumen is preserved. Despite such vessels appearing hard and pulseless throughout their affected length, they deliver relatively normal distal perfusion, indeed there is often a bounding pulse at the end of the calcified zone. They appear unremarkable on magnetic resonance angiography but visibly calcified on plain radiography. Monckeberg's arteriosclerosis has a prevalence of < 1% of the population, but when it does occur it can cause consternation at the prospect of using these vessels for microvascular anastamosis. We report our experience of deliberately using these vessels in an osseocutaneous radial forearm free flap reconstruction. Although there are some technical considerations to bear in mind, we would suggest that unlike vessels affected by atherosclerosis, anastomosis of arteries affected by Monckeberg's arteriosclerosis has little or no impact on free flap survival.

 

Fistula formation between the external iliac artery and ileal conduit following a radical cystoprostatectomy: a rare complication with prewarning signs of haemorrhage (2015)

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Type of publication:
Journal article

Author(s):
*Anisha Sukha, *Niamh Smyth

Citation:
BMJ Case Reports 2015:published online 27 March 2015

Abstract:
A 76-year-old man was admitted with bleeding perurostomy following a collapse at home. Three weeks prior to the admission, he had undergone a radical cystoprostatectomy and formation of ileal-conduit for an extensive bladder carcinoma. A CT angiogram revealed a possible small source of bleeding within the ileal-conduit itself, which settled with conservative management. However, prior to discharge he developed profuse fresh bleeding from the urostomy, which could not be controlled. The patient underwent an emergency endoscopy of the conduit and laparotomy, which revealed a fistula between the right external iliac artery and the proximal end of the ileal-conduit. The right iliac artery was ligated and an emergency left-to-right femoral-femoral crossover bypass was performed. The right ureter was stented and rediverted through the ilealconduit and the left ureter was stented at a later date. He unfortunately had a stormy postoperative recovery with further episodes of per-urostomy bleeding and no identified source.

Link to full-text: http://casereports.bmj.com/content/2015/bcr-2014-208914.short?rss=1

 

Success rate of cold coagulation for the treatment of cervical intraepithelial neoplasia: a retrospective analysis of a series of cases (2015)

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Type of publication:
Journal article

Author(s):
*Parry-Smith W, *Underwood M , De Bellis-Ayres S, *Bangs L, Redman CW, *Panikkar J.

Citation:
Journal of Lower Genital Tract Disease, January 2015, vol./is. 19/1(17-21), 1089-2591;1526-0976 (13 Jan 2015)

Abstract:
OBJECTIVE: To establish the cure rate at 1 year of patients who have undergone cold coagulation for the treatment of cervical intraepithelial neoplasia (CIN).DESIGN: Retrospective review of data for all patients at Shrewsbury and Telford NHS Trust who had undergone cold coagulation as part of their treatment for CIN between 2001 and 2011. Follow-up data up to December 2012 were analyzed. SETTING: Colposcopy Department, Shrewsbury and Telford NHS Trust, United Kingdom.POPULATION: Women undergoing cold coagulation for the treatment of CIN between 2001 and 2011, with cytologic follow-up until December 2012. METHODS: Patients were identified using a local colposcopy database. Data were obtained via the local histopathology reporting systems. Statistical analyses were performed using Stata/IC 10.1 software. MAIN OUTCOME MEASURES: Posttreatment cytology and whether subsequent treatment was required, with histology results. RESULTS: Data on 557 patients were collected and analyzed. Pre-cold coagulation treatment histologic findings were CIN 1 in 156 patients (28.01%), CIN 2 in 260 patients (46.68%), and CIN 3 in 141 patients (25.31%). The median length of time between cold coagulation treatment and first follow-up smear, used to calculate cure rates at around 1 year, was 406 days (interquartile range 123 days, range 169-3,116 days). The cure rate after cold coagulation was 95.7% at around 1 year. CONCLUSIONS: Cold coagulation has a cure rate comparable to that of excisional treatments such as large loop excision of the transformation zone and should be considered more widely in patients undergoing primary treatment for CIN, where there is no suspicion of invasive disease on history, examination and cytologic results.

 

Descemet's membrane endothelial keratoplasty (DMEK): first UK prospective study of 1-year visual outcomes, graft survival and endothelial cell count (2015)

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Type of publication:
Journal article

Author(s):
*Robert A Reid, *Ewan A Craig, *Hanif Suleman

Citation:
British Journal of Ophthalmology, February 2015, vol./is. 99/2(166-169), 0007-1161;1468-2079 (01 Feb 2015)

Abstract:

Aim: To evaluate the clinical outcomes of Descemet’s membrane endothelial keratoplasty (DMEK) in the treatment of patients with Fuchs’ endothelial dystrophy.

Methods: This prospective study involved 16 consecutive patients who had DMEK done and who were evaluated over a year. Measurements included best corrected visual acuity (BCVA), endothelial cell count, and central corneal thickness.

Results: Two patients had failed grafts. Of the remaining 14 patients with successful grafts, after 12 months, 79% had BCVA of 6/6 or better, and all patients had a BCVA of 6/9 or better. Median endothelial cell count was 1567 cells per mm2 (range=900–2359) representing a 40% reduction compared with preoperative counts. Median central corneal thickness was 498 µm (range 445–567 µm) compared with a median of 649 µm (range 548–740 µm) preoperatively. All patients attained total visual rehabilitation without further surgical intervention.

Conclusions: In our experience, DMEK has the potential to become the primary procedure for treating Fuchs’ endothelial dystrophy and endothelial disease as it produces rapid total visual rehabilitation with few complications, and an easy follow-up and management regimen. Donor preparation and graft insertion, however, remain important challenges.

Perineal support and risk of obstetric anal sphincter injuries: a Delphi survey (2015)

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Type of publication:
Journal article

Author(s):
Ismail KM, Paschetta E, *Papoutsis D, Freeman RM

Citation:
Acta Obstetricia Et Gynecologica Scandinavica 2015 Feb; Vol. 94 (2), pp. 165-74. Date of Electronic Publication: 2014 Dec 30.

Abstract:
Objective: To explore the views of a multidisciplinary group of experts and achieve consensus on the importance of perineal support in preventing obstetric anal sphincter injuries (OASIS).
Design: A three-generational Delphi survey.
Setting: A UK-wide survey of experts.
Population: A panel of 20 members consisting of obstetricians, midwives and urogynecologists recommended by UK professional bodies.
Methods: A 58-item web-based questionnaire was sent to all participants who were asked to anonymously rate the importance of each item on a six-point Likert scale. They were asked to rate their level of agreement on statements related to hands-on/hands-poised techniques, the association of hands-poised/hands-off approach with OASIS, the need to implement perineal support and the need to improve the evidence to support it. Systematic feedback of responses from previous rounds was provided to participants.
Main Outcome Measures: To achieve consensus on key areas related to perineal support.
Results: The response rate was 100% in all three iterations. There was consensus that current UK practice regarding perineal protection was not based on robust evidence. The respondents agreed that hands-poised/hands-off and OASIS are causally related and that hands-poised was misinterpreted by clinicians as hands-off. Although 90% of experts agreed that some form of randomized trial was required and that all would be prepared to take part, there was also consensus (75%) that in the meantime, hands-on should be the recommended technique.
Conclusions: Our results highlight the current lack of evidence to support policies of perineal support at time of birth and the need to address this controversial issue.