2021

Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making (2021)

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Type of publication:
Journal article

Author(s):
Hicks A.J.; Carwardine Z.L.; *Hallworth M.J.; Kilpatrick E.S.

Citation:
Biochemia Medica; Feb 2021; vol. 31 (no. 1); p. 10703

Abstract:
Introduction: It is often quoted that 70% of clinical decisions are based on laboratory results, but the evidence to substantiate this claim is lacking. Since clinical guidelines aim to document best-practice decision making for specific disease conditions, inclusion of any laboratory test means that the best available evidence is recommending clinicians use it. Cardiovascular disease (CVD) is the world's most common cause of mortality, so this study reviewed all CVD guidelines published by five national/international authorities to determine what proportion of them recommended laboratory testing. Material(s) and Method(s): Five leading CVD guidelines were examined, namely the European Society of Cardiology (ESC), the UK National Institute for Health and Clinical Excellence (NICE), the American College of Cardiology (ACC), the Australian Heart Foundation (AHF) and the Cardiac Society of Australia and New Zealand (CSANZ). Result(s): A total of 101 guidelines were reviewed. Of the 33 individual ESC guidelines relating to CVD, 24/33 made a direct reference to the use of clinical laboratory tests in either diagnosis or follow-up treatment. The same applied to 15/20 of NICE guidelines, 24/32 from the ACC and 15/16 from the AHF/CSANZ. Renal function and blood count testing were the most recommended (39 and 26 times), with lipid, troponin and natriuretic peptide measurement advocated 25, 19 and 19 times respectively. Conclusion(s): This study has shown that laboratory testing is advocated by between 73% and 94% of individual CVD guideline recommendations from five national/international authorities. This provides an index to assess the potential value of laboratory medicine to healthcare.

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A Complex Case of Adalimumab Induced Pleuropericarditis in a Patient with Underlying Ulcerative Colitis (2021)

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Type of publication:
Journal article

Author(s):
*Abbasi A, *Day S, Subahani M, *Townson G

Citation:
Asploro Journal of Biomedical and Clinical Case Reports, 2021 Jan; 4(1) p.16-21

Abstract:
Introduction: Adalimumab is an anti-tumour necrosis factor (anti-TNF) monoclonal antibody and an important part of the treatment regime for autoimmune conditions including inflammatory bowel disease. We present a case of adalimumab induced pleuropericarditis and discuss the diagnosis challenges we faced.
Case History: A 22-year-old male presented to the emergency department with 3 days history of headache, malaise, fever and right-sided chest pain. He was diagnosed with ulcerative colitis 8 months ago but failed to respond to mesalazine, requiring high dose steroids to induce disease remission. His mesalazine was stopped after 4 months and he was initiated on adalimumab 2 months prior to the current presentation. At presentation, he had a temperature of 38.7 °C (101.6 °F) but no other physical signs. His inflammatory markers were raised, and the chest x-ray was clear. He was started on empirical intravenous antibiotics on suspicion of the underlying infective process. On day 4 the patient developed a new pleural rub and crepitations on both lung bases. An urgent echocardiogram and computed tomography scan of the thorax abdomen and pelvis revealed pleural effusion and a 1.8 cm diameter pericardial effusion. Extensive investigation including virology screen, autoimmune screen and pleural fluid analysis were normal.
Diagnosis, Management and Outcome: This case was discussed in a multidisciplinary meeting. A diagnosis of pleuropericarditis secondary to adalimumab was made. Adalimumab and antibiotics were stopped, and he was started on a course of oral steroids. The patient responded well to the treatment and his symptoms resolved.
Conclusion: Rare drug toxicity should be part of differential diagnosis, especially in young patients with unusual presentation. An early multidisciplinary approach is crucial for a positive outcome. The patient should be actively involved in decision making to improve long term outcome.

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Short statured primigravidae: Options for the obstetric management from a survey of UK obstetricians (2021)

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Type of publication:
Journal article

Author(s):
*Rachaneni S.; Gurol-Urganci I.; Basu M.; Thakar R.; Sultan A.; Freeman R.

Citation:
European Journal of Obstetrics Gynecology and Reproductive Biology; Jan 2021; vol. 256 ; p. 379-384

Abstract:
Objective: To assess the current antenatal and intrapartum management options for primigravid women of short stature with a clinically large fetus by a survey of UK Obstetricians. Study design: An online survey comprised of 15 questions including the options on timing and mode of delivery, counselling about the risk of long-term pelvic floor morbidity following spontaneous vaginal and instrumental deliveries, choice of instruments and the role of episiotomy. The survey was sent to the participants as a part of Royal College of Obstetricians and Gynaecologists (RCOG) Newsletter between September 2017 to October 2018. The scenario described was of a primigravid short stature woman (i.e. height of 160 cm or less) who presents with a clinically large fetus at 38 weeks gestation. Result(s): 424 Obstetricians participated in the survey. The participation ratio cannot be identified as the survey was emailed as a part of the RCOG Newsletter. Sixty five percent respondents stated that they would scan for estimated fetal weight, 48 % would offer induction of labour at 40 weeks and 14 % would offer an elective/planned caesarean section (CS) at 39-40 weeks. Fifty nine percent would discuss all these risks: obstructed labour, shoulder dystocia, instrumental delivery and obstetric anal sphincter injury (OASI). 73 % would not discuss the long-term risks of urinary and/or faecal incontinence and pelvic organ prolapse. In the presence of failure to progress in the second stage of labour, 69 % would attempt a rotational instrumental delivery and 5% would offer a caesarean section. Manual rotation and 'straight' forceps application were the most frequent type of rotational delivery, followed by Ventouse and Kiellands forceps. Thirty four percent stated that they do not routinely perform an episiotomy in this scenario. Seventy three percent stated that their choice of instrument was not based on the long-term risk of urinary and faecal incontinence. Conclusion(s): The results suggest that 40 % of the respondents would not discuss all of the complications after vaginal delivery in women of short stature. The most common delivery option would be vaginal delivery.

Oral and maxillofacial surgery patient satisfaction with telephone consultations during the COVID-19 pandemic (2020)

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Type of publication:
Journal article

Author(s):
*Horgan T.J.; *Alsabbagh A.Y.; *McGoldrick D.M.; *Bhatia S.K.; *Messahel A.

Citation:
The British Journal of Oral & Maxillofacial Surgery; Apr 2021; vol. 59 (no. 3); p. 335-340

Abstract:
Due to the COVID-19 pandemic most oral and maxillofacial surgical (OMFS) units have moved to conducting patient consultations over the telephone. The aim of this study was to assess patients' satisfaction with telephone consultations during the COVID-19 pandemic. A retrospective survey was conducted of OMFS patients at our hospital who had telephone consultations between 1 April – 8 June 2020. The survey was conducted by independent interviewers and used the Generic Medical Interview Satisfaction Scale (G-MISS) along with a previously published additional questionnaire. Variables recorded included age, gender, theme of consultation, grade of clinician, and type of consultation. Statistical analysis was performed to assess for any differences between patient groups. The records of 150 consecutive patients were reviewed and 135 met inclusion criteria. A total of 109 patients completed the survey giving a response rate of 80.74%. The total G-MISS score for satisfaction was high, which indicates a high level of satisfaction among all patients. We found no statistical difference in satisfaction when comparing patients in terms of gender, age, theme of consultation, or level of clinician. A significant difference was found in compliance levels between review and new patients, with review patients demonstrating higher compliance levels (p=0.004). Overall, 83.48% of patients said they would be willing to have a telephone consultation in future. The majority of patients in this study reported high levels of satisfaction with telephone consultations. New patients reported lower levels of compliance which may suggest this type of consultation is less suited to telephone consultation.

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Coronavirus Disease 2019: the Pivotal Role of UK Clinical Oncology and the UK Coronavirus Cancer Monitoring Project (2021)

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Type of publication:
Journal article

Author(s):
*Best ; Starkey, T.; *Chatterjee, A.; Fackrell, D.; *Pettit, L.; *Srihari, N.; Tween, H.; Olsson-Brown, A.; Cheng, V.; Hughes, D.J.; Lee, A.J.X.; Purshouse, K.; Arnold, R.; UK Coronavirus Cancer Monitoring Project Team; Sivakumar, S.; Cazier, J.-B.; Lee, L.Y.W.

Citation:
Clinical Oncology; Jan 2021; vol. 33 (no. 1), e50-e53

Abstract:

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Emotional Resilience and Bariatric Surgical Teams: a Priority in the Pandemic (2021)

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Type of publication:
Journal article

Author(s):
Graham, Yitka; Mahawar, Kamal; *Riera, Manel; Islam, Omar; Bhasker, Aparna Ghovil; Wilson, Michael; Tahrani, Abd; Moize, Violeta; Leal, Angela; Hayes, Catherine

Citation:
Obesity Surgery; Apr 2021; vol. 31 (no. 4); p. 1887-1890

Abstract:
The infection control measures implemented as a result of COVID-19 led to a postponement of bariatric surgical procedures across many countries worldwide. Many bariatric surgical teams were in essence left without a profession, with many redeployed to other areas of clinical care and were not able to provide the levels of patient support given before COVID-19. As the pandemic continues, some restrictions have been lifted, with staff adjusting to new ways of working, incorporating challenging working conditions and dealing with continuing levels of stress. This article explores the concept of emotional labour, defined as 'inducing or suppressing feelings in order to perform one's work', and its application to multidisciplinary teams working within bariatric surgery, to offer insight into the mental health issues that may be affecting healthcare professionals working in this discipline.

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The reliability, reproducibility and utilization of the radiographic Achilles Tendon Loading Angle in the management of Achilles Tendon rupture (2021)

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Type of publication:
Journal article

Author(s):
*Carmont M.R.; *Littlehales J.; Brorsson A.; Karlsson J.; Nilsson-Helander K.; Barfod K.W.; Ginder L.

Citation:
Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons; Oct 2021; vol. 27 (no. 7); p. 760-766

Abstract:
Background: During management of Achilles tendon rupture, determination of tendon-end approximation, either clinically or by ultrasound is difficult, following brace application of during loading. The Radiographic Achilles Tendon Loading Angle (RadATLA) is proposed as a method of measuring ankle position whilst loading in a brace during the management of Achilles tendon rupture. This study aims to determine the reliability and reproducibility of the RadATLA. Method(s): A loaded true lateral ankle radiograph including the fifth metatarsal head was taken when wearing a brace at the 6-week time point in 18 patients (19 ankles). following Achilles tendon repair or reconstruction. The RadATLA was compared with the Tibio-talar angle, other radiographic and clinical measures used to quantify foot and ankle position during the first 6 weeks of early rehabilitation in a resting position and during loading. Result(s): The intra-rater reliability of both angles was found to be good (>0.8). The RadATLA was found to have an excellent intra-rater reliability with Intra-class correlation of (ICC) 0.992-0.996 (95%CI 0.889-0.999), standard error of the measurement (SEM) 1.03-3.65 and Minimal Detectable Change (MDC) 2.86-10.12. The inter-rater reliability was good with ICC of 0.798-0.969 (95%CI-0.03 to 0.964), SEM 2.9-7.6, and MDC 8.1-20.9. The RadATLA loaded at 6 weeks in all patients was at mean (SD) (range) 41.9 (16.5), (18.5-75.9). There was a significant difference between the patients in the Repair group compared with patients in the Reconstruction group both in RadATLA loaded at 6 weeks: 35.6 (11.2), (18.5-56.5) versus 55.5 (19), (20-75.9), (p = 0.01). The amount loaded in all patients was at mean (SD) (range) 29.2Kg (17.7), (2-56) and the percentage Body Weight was 30.7% (19), (2.1-63.2). There were no differences between the groups neither in amount loaded nor in percentage Body weight (p = 0.614-0.651). Conclusion(s): The RadATLA is a reliable and reproducible angle and can be used to determine the position of the ankle, when loaded in a brace during rehabilitation following Achilles tendon rupture.

The Incidence of and Predictors for Severe Perineal Trauma and Intact Perineum in Women Having a Waterbirth in England: A Hospital-Based Study (2021)

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Type of publication:
Journal article

Author(s):
*Dimitrios Papoutsis, Angeliki Antonakou, *Adam Gornall, and Chara Tzavara

Citation:
Journal of Women's Health; May 2021; vol. 30 (no. 5); p. 681-688

Abstract:
Background: To determine the incidence of and predictors for obstetric anal sphincter injuries (OASIS) and intact perineum in women giving birth in the water and compare with the general obstetric population.
Materials and Methods: Data were retrospectively collected for women who had singleton cephalic presentation vaginal births in the water and the general obstetric population between August 2007 and December 2017.
Results: We identified 1,007 women who had a waterbirth and 36,924 women from the general obstetric population. There was no significant difference in the incidence of OASIS between waterbirths and the general obstetric population (2.3% vs. 2.0%). Having a waterbirth was associated with a lower probability for an intact perineum (odds ratio [OR] = 0.83; confidence interval [95% CI]: 0.73–0.94) when compared with the general obstetric population (44.7% vs. 51.3%). Nulliparous women with a waterbirth when compared with multiparous women had an eightfold higher likelihood for the occurrence of OASIS (OR = 8.28; 95% CI: 2.64–25.86). The risk for a higher degree of OASIS was associated with increased maternal age in the total sample (OR = 1.08; 95% CI: 1.06–1.11) and with a lower body mass index (BMI) at booking in multiparous women (OR = 0.96; 95% CI: 0.92–0.99). The risk for any type of perineal trauma was associated with increased maternal age in the total sample (OR = 1.10; 95% CI: 1.07–1.13) and with a lower BMI at booking in multiparous women (OR = 0.95; 95% CI: 0.91–0.99).
Conclusions: We found that giving birth in the water reduced the chance of having an intact perineum. We have also shown that nulliparity, increased maternal age in all women, and a lower BMI at booking in multiparous were associated with OASIS and lower rates of intact perineum in waterbirths.

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Randomized Trial of Ciprofloxacin Doxycycline and Hydroxychloroquine Versus Budesonide in Active Crohn's Disease (2021)

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Type of publication:
Randomised controlled trial

Author(s):
Rhodes J.M.; Subramanian S.; Martin K.; Probert C.; Flanagan P.K.; Horgan G.W.; Mansfield J.; Parkes M.; Hart A.; Dallal H.; Iqbal T.; *Butterworth J.; Culshaw K.

Citation:
Digestive Diseases and Sciences; Aug 2021; vol. 66 (no. 8); p. 2700-2711

Abstract:
Background: Increased mucosa-associated E. coli are present in Crohn's disease, but their role in pathogenesis is uncertain. Aim(s): To assess efficacy and safety of an antibiotic/hydroxychloroquine combination effective against E. coli inside macrophages. Method(s): Adults with moderately active disease (CDAI > 220-450 plus C reactive protein >= 5 mg/l and/or fecal calprotectin > 250 mug/g) were randomized to receive (open-label) oral budesonide (Entocort CR 9 mg/day 8 weeks, 6 mg/day 2 weeks, 3 mg/day 2 weeks) or oral ciprofloxacin 500 mg bd, doxycycline 100 mg bd, hydroxychloroquine 200 mg tds for 4 weeks, followed by doxycycline 100 mg bd and hydroxychloroquine 200 mg tds for 20 weeks. Primary endpoints were remission (CDAI <= 150) at 10 weeks, remission maintained to 24 weeks, and remission maintained to 52 weeks. Patients not responding (CDAI fall by > 70) by 10 weeks were invited to crossover onto the alternative therapy. Result(s): Fifty-nine patients were recruited across 8 sites. Including crossover, 39 patients received antibiotics/hydroxychloroquine and 39 received budesonide. At 10 weeks, 24 weeks, and 52 weeks on initial therapy, only 2/27, 2/27, and 1/27 were in remission on antibiotics/hydroxychloroquine compared with 8/32, 1/32, and 1/32 on budesonide (P = 0.092 at 10 weeks). Withdrawals by 10 weeks due to adverse events were seen in 15 receiving antibiotics/hydroxychloroquine and 6 budesonide. Results including crossover were more promising with 9/24 patients receiving antibiotics/hydroxychloroquine per protocol in remission by 24 weeks. No correlation was seen between response to antibiotics/hydroxychloroquine and ASCA/OmpC antibody status or disease location. Conclusion(s): Overall results with this antibiotic/hydroxychloroquine combination were unimpressive, but long-term remission is seen in some patients and justifies further study.

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