2022

Creating and employing an admission bloods based diagnostic aide for COVID-19 to assist cohort-based isolation strategies (2022)

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Type of publication:
Conference abstract

Author(s):
*Baker J.; *Day S.; *Marsh A.

Citation:
Emergency Medicine Journal. Conference: Royal College of Emergency Medicine Annual Scientific Conference, RCEM 2022. Belfast United Kingdom. 39(3) (pp 259-260), 2022. Date of Publication: March 2022.

Abstract:
Aims/Objectives/Background In the COVID-19 pandemic the Shrewsbury and Telford Hospital NHS Trust has isolated suspected cases in high and low suspicion cohort bays to reduce nosocomial infection. Before rapid PCR swabs were in routine use, we sought tools to aide identifying COVID-19 positive patients. Methods/Design We collected data from two cohorts in April and June 2020 totalling 317 patients, with positivity rates of 33% and 5% respectively. We retrospectively correlated neutrophil count, lymphocyte count, LDH and AST to positive and negative swab results. Predictive value of COVID-19 positivity was assessed via their receiver operator characteristic. Areas under the curve were as follows: Neutrophils 0.75, lymphocytes 0.64, combined neutrophil and lymphocyte count 0.82, AST 0.65 and LDH 0.7. We developed a diagnostic aide to assist in allocation of high and low suspicion based on parameters for neutrophil count, lymphocyte count and LDH, each of which was assigned red (higher probability) or green (lower probability) in a 'traffic light' system. Combined and applied retrospectively to 252 patients with suspected COVID-19, with a positivity prevalence of 5%, three green values generated a negative predictive value for COVID-19 of 100%, two greens 98% and three reds a positive predictive value for COVID-19 of 44%. Results/Conclusions This diagnostic aide was applied from August 2020 within the Trust Emergency Departments and Acute Medical Units to aide cohort decisions. A retrospective application to all 213 patients with positive swabs admitted from August to November 2020 demonstrated that 69% were highlighted as at least two 'red lights' and only 1.4% were erroneously highlighted as three 'green lights'. The aide is an example of a rapidly developed evidence based tool and, particularly if updated with data from other centres, could be widely employed in low-resource healthcare settings. (Figure Presented).

The changing landscape for the management of patients with neovascular AMD: brolucizumab in clinical practice (2022)

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Type of publication:
Journal article

Author(s):
Pearce I; Amoaku W; Bailey C; Downey L; Gale R; Ghanchi F; Hamilton R; Mahmood S; Menon G; *Nosek J; Talks J; Yang Y

Citation:
Eye. 36(9) (pp 1725-1734), 2022. Date of Publication: September 2022.

Abstract:
Untreated neovascular age-related macular degeneration (nAMD) can lead to severe and permanent visual impairment. The chronic nature of the disease can have a significant impact on patients' quality of life and an economic and time burden on medical retina (MR) services, with the care need outweighing the growth of resources that clinical services can access. The introduction of a new treatment into clinical services can be challenging, especially for services that are already under capacity constraints. Guidance for practical implementation is therefore helpful. Roundtable meetings, facilitated by Novartis UK, between a working group of MR experts with experience of leading and managing NHS retinal services in the intravitreal era were conducted between 2020 and 2021. These meetings explored various aspects and challenges of introducing a new anti-vascular endothelial growth factor (VEGF) therapy to the UK medical retina services. Provision of clear expert recommendations and practical guidance nationally, that can be adapted locally as required to support clinicians and healthcare professionals (HCPs), is valuable in supporting the introduction of a new anti-VEGF therapy within the NHS environment. The experts provide ophthalmologic HCPs with a collation of insights and recommendations to support the introduction and delivery of brolucizumab in their local service in the face of current and projected growth in demand for retina care.

Severe hyponatraemia in two patients with breast cancer caused by low-dose cyclophosphamide and precipitated by aprepitant (2022)

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Type of publication:
Journal article

Author(s):
*Parikh S; *Pettit L; *AbdelGadir H

Citation:
BMJ Case Reports, 2022 Mar 22; Vol. 15

Abstract:
Two postmenopausal women with breast cancer developed acute confusion and seizures, less than 24 hours after the first cycle of neoadjuvant chemotherapy with fluorouracil, epirubicin and low-dose cyclophosphamide. They were found to have severe, life-threatening hyponatraemia with sodium levels of 113 and 115 mEq/L, respectively. Both women made a full recovery within 24 hours of admission with slow correction of sodium levels. Following investigational workup, the most likely diagnosis was cyclophosphamide-associated syndrome of inappropriate antidiuretic hormone secretion (SIADH). Aprepitant – a commonly used antiemetic and moderate cytochromeP450 3A4 inhibitor was identified as the precipitating factor. Aprepitant was discontinued and both women were successfully re-challenged with full dose cyclophosphamide in an outpatient setting with no subsequent adverse events. This is a typical case of a rare cause of a common medical problem. A systematic approach to diagnosis and treatment of hyponatraemia in an oncology patient requires awareness of toxicities of systemic anticancer agents.

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A Systematic Review of Long-Distance Triathlon Musculoskeletal Injuries (2022)

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Type of publication:Journal article

Author(s):Rhind JH; Dass D; Barnett A; *Carmont M

Citation:Journal of Human Kinetics 2022 Feb 10; Vol. 81, pp. 123-134.

Abstract:The distribution of injuries affecting long-distance triathletes is yet to be fully understood. A systematic review was performed of the clinical literature to determine the epidemiology of musculoskeletal injuries affecting long-distance triathletes. Searched databases in Feb 2020 were PubMed, Medline, EMBASE, EMCARE, and CINHAL databases. Published observational research articles related to the incidence or prevalence of musculoskeletal injuries in long-distance triathletes (competing at "Ironman" full distance or greater), written in the English language and not restricted by age or gender or date were eligible. Of the 975 studies identified on the initial search, six studies met the inclusion criteria for analysis. The mean age (SD) of the long-distance triathletes in these studies was 35.1 (2.7) and the range was 21-68 years. Overuse injuries were most frequent with the incidence range of 37-91%, and acute injury incidence range was 24-27%. The knee and spine were the most frequent location of injury. Running and cycling were the most frequently affected disciplines. Elite athletes had a lower incidence of overuse injury (37%). The highest acute injury incidence (27%) was recorded in non-elite athletes. The quality of the studies was relatively poor with only one study satisfying >50% of the quality assessment tool questions and only two studies were prospective, the rest were retrospective cross-sectional studies. Overall, there is a lack of literature reporting on musculoskeletal injuries in long-distance triathletes. Overuse injuries, particularly in the knee, are the most frequently reported, running and cycling are the most frequent disciplines associated. Long-distance triathletes may have a lower incidence of both overuse and acute injuries.

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Observation versus screening spinal MRI and pre-emptive treatment for spinal cord compression in patients with castration resistant prostate cancer and spinal metastases in the UK (PROMPTS): an open-label, randomised, controlled, phase 3 trial (2022)

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Type of publication:Randomised controlled trial

Author(s):Dearnaley, David; Hinder, Victoria; Hijab, Adham; Horan, Gail; *Srihari, Narayanan; Rich, Philip; Houston, J Graeme; Henry, Ann M; Gibbs, Stephanie; Venkitaraman, Ram; Cruickshank, Clare; Hassan, Shama; Miners, Alec; Mason, Malcolm; Pedley, Ian; Payne, Heather; Brock, Susannah; Wade, Robert; Robinson, Angus; Din, Omar; Lees, Kathryn; Graham, John; Worlding, Jane; Murray, Julia; Parker, Chris; Griffin, Clare; Sohaib, Aslam; Hall, Emma; PROMPTS investigators

Citation:
The Lancet Oncology. 23(4) (pp 501-513), 2022. Date of Publication: April 2022.

Abstract:BACKGROUND Early diagnosis of malignant spinal cord compression (SCC) is crucial because pretreatment neurological status is the major determinant of outcome. In metastatic castration-resistant prostate cancer, SCC is a clinically significant cause of disease-related morbidity and mortality. We investigated whether screening for SCC with spinal MRI, and pre-emptive treatment if radiological SCC (rSCC) was detected, reduced the incidence of clinical SCC (cSCC) in asymptomatic patients with metastatic castration-resistant prostate cancer and spinal metastasis. METHODS We did a parallel-group, open-label, randomised, controlled, phase 3, superiority trial. Patients with metastatic castration-resistant prostate cancer were recruited from 45 National Health Service hospitals in the UK. Eligible patients were aged at least 18 years, with an Eastern Co-operative Oncology Group performance status of 0-2, asymptomatic spinal metastasis, no previous SCC, and no spinal MRI in the past 12 months. Participants were randomly assigned (1:1), using a minimisation algorithm with a random element (balancing factors were treatment centre, alkaline phosphatase [normal vs raised, with the upper limit of normal being defined at each participating laboratory], number of previous systemic treatments [first-line vs second-line or later], previous spinal treatment, and imaging of thorax and abdomen), to no MRI (control group) or screening spinal MRI (intervention group). Serious adverse events were monitored in the 24 h after screening MRI in the intervention group. Participants with screen-detected rSCC were offered pre-emptive treatment (radiotherapy or surgical decompression was recommended per treating physician's recommendation) and 6-monthly spinal MRI. All patients were followed up every 3 months, and then at month 30 and 36. The primary endpoint was time to and incidence of confirmed cSCC in the intention-to-treat population (defined as all patients randomly assigned), with the primary timepoint of interest being 1 year after randomisation. The study is registered with ISRCTN, ISRCTN74112318, and is now complete. FINDINGS Between Feb 26, 2013, and April 25, 2017, 420 patients were randomly assigned to the control (n=210) or screening MRI (n=210) groups. Median age was 74 years (IQR 68 to 79), 222 (53%) of 420 patients had normal alkaline phosphatase, and median prostate-specific antigen concentration was 48 ng/mL (IQR 17 to 162). Screening MRI detected rSCC in 61 (31%) of 200 patients with assessable scans in the intervention group. As of data cutoff (April 23, 2020), at a median follow-up of 22 months (IQR 13 to 31), time to cSCC was not significantly improved with screening (hazard ratio 0·64 [95% CI 0·37 to 1·11]; Gray's test p=0·12). 1-year cSCC rates were 6·7% (95% CI 3·8-10·6; 14 of 210 patients) for the control group and 4·3% (2·1-7·7; nine of 210 patients) for the intervention group (difference -2·4% [95% CI -4·2 to 0·1]). Median time to cSCC was not reached in either group. No serious adverse events were reported within 24 h of screening. INTERPRETATION Despite the substantial incidence of rSCC detected in the intervention group, the rate of cSCC in both groups was low at a median of 22 months of follow-up. Routine use of screening MRI and pre-emptive treatment to prevent cSCC is not warranted in patients with asymptomatic castration-resistant prostate cancer with spinal metastasis. FUNDING Cancer Research UK.

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The global level of harm among surgical professionals during the COVID-19 pandemic: A multinational cross-sectional cohort study (2022)

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Type of publication:Journal article

Author(s):Abouelazayem, Mohamed; Viswanath, Yirupaiahgari K S; Bangash, Ali Haider; Herrera Kok, Johnn Henry; Cheruvu, Chandra; Parmar, Chetan; Atici, Semra Demirli; Yang, Wah; Galanis, Michail; Di Maggio, Francesco; Isik, Arda; *Bandyopadhyay, Samik Kumar

Citation:Surgery; Mar 2022 [epub ahead of print]

Abstract:BACKGROUND Health care workers, including surgical professionals, experienced psychological burnout and physical harm during the coronavirus 2019 pandemic. This global survey investigated the coronavirus 2019 pandemic impact on psychological and physical health.
METHODS We conducted a global cross-sectional survey between February 18, 2021 and March 13, 2021. The primary outcome was to assess the psychological burnout, fulfillment, and self-reported physical level of harm. A validated Stanford Professional Fulfilment Index score with a self-reported physical level of harm was employed. We used a practical overall composite level ofharm score to calculate the level of harm gradient 1-4, combining psychological burnout with self-reported physical level of harm score.
RESULTS A total of 545 participants from 66 countries participated. The final analysis included 520 (95.4%) surgical professionals barring medical students. Most of the participants (81.3%)were professionally unfulfilled. The psychological burnout was evident in 57.7% and was significantly common in those <50 years (P = .002) and those working in the public sector (P = .005). Approximately 41.7% of respondents showed changes in the physical health with self-remedy and no impact on work, whereas 14.9% reported changes to their physical health with <2 weeks off work, and 10.1% reported changes in physical health requiring >2 weeks off work. Severe harm (level of harm 4) was detected in 10.6%, whereas moderate harm (level of harm 3) affected 40.2% of the participants. Low and no harm (level of harm 2 and level of harm 1) represented 27.5% and 21.7%, respectively. CONCLUSION Our study showed that high levels of psychological burnout, professional unfulfillment, work exhaustion, and severe level of harm was more frequent in younger professionals working in the public sector. The findings correlated with a high level of harm in surgical professionals impacting surgical services.

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Learning curves in minimally invasive pancreatic surgery: a systematic review (2022)

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Type of publication:Systematic Review

Author(s):Fung, Gayle; Sha, Menazir; Kunduzi, Basir; Froghi, Farid; *Rehman, Saad; Froghi, Saied

Citation:
Langenbeck's Archives of Surgery. 407(6) (pp 2217-2232), 2022. Date of Publication: September 2022.

Abstract:BACKGROUND The learning curve of new surgical procedures has implications for the education, evaluation and subsequent adoption. There is currently no standardised surgical training for those willing to make their first attempts at minimally invasive pancreatic surgery. This study aims to ascertain the learning curve in minimally invasive pancreatic surgery.
METHODS A systematic search of PubMed, Embase and Web of Science was performed up to March 2021. Studies investigating the number of cases needed to achieve author-declared competency in minimally invasive pancreatic surgery were included.
RESULTS In total, 31 original studies fulfilled the inclusion criteria with 2682 patient outcomes being analysed. From these studies, the median learning curve for distal pancreatectomy was reported to have been achieved in 17 cases (10-30) and 23.5 cases (7-40) for laparoscopic and robotic approach respectively. The median learning curve for pancreaticoduodenectomy was reported to have been achieved at 30 cases (4-60) and 36.5 cases (20-80) for a laparoscopic and robotic approach respectively. Mean operative times and estimated blood loss improved in all four surgical procedural groups. Heterogeneity was demonstrated when factoring in the level of surgeon's experience and patient's demographic.
CONCLUSIONS There is currently no gold standard in the evaluation of a learning curve. As a result, derivations are difficult to utilise clinically. Existing literature can serve as a guide for current trainees. More work needs to be done to standardise learning curve assessment in a patient-centred manner.

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Rare histological subtypes of breast cancer: A study of 10 years' experience at (SATH) UK District General Hospital (2022)

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Type of publication:Conference abstract

Author(s):*Mansour A.; *Pettit L.

Citation:European Journal of Surgical Oncology; Feb 2022; vol. 48 (no. 2)

Abstract:Background: Breast cancer is a heterogeneous disease with different histologic subtypes, molecular characteristics, oestrogen receptors (ER) and HER2 status. Common subtype include lobular and ductal cancers. The rare subtypes are a heterogeneous group with differing behaviour specific for each subtype. This study aims to determine the clinicopathological features, management pathway and survival outcome of rare subtypes of invasive breast cancer (IBC) at a single U.K. hospital.Material(s) and Method(s): Data was obtained from the department of Cellular Pathology at The Shrewsbury and Telford Hospital (SATH) NHS Trust. All patients diagnosed with a rare subtype of breast cancer from January 2005 to December 2014 were identified. The histology diagnosis of a rare subtype of breast cancer was reviewed. Biological behaviour, management, follow up and prognosis were obtained from surgical and oncology clinic letters. Also, survival data and cause of death when applicable is reviewed from Clinical Portal (our hospital digital documentation system). Patients with imaging, after the introduction of the digital format to the system in 2012, were also reviewed.
Result(s): Total number of patients diagnosed with IBC was 3049. 201 patients (6.59%) were identified to have a rare subtype of IBC. Patients were divided into subgroups according to their specific rare subtype and included mucinous, tubular, medullary, metaplastic, papillary, neuroendocrine, cribriform, apocrine, malignant phyllodes, angiosarcoma, lymphoma and metastatic from non-breast primary. Some cancers had good prognosis with 100% 5 years overall survival like tubular carcinoma and some have poor prognosis like metaplastic and angiosarcoma.Conclusion(s): Our experience with these heterogeneous groups of rare subtypes of breast cancer identified the clinical behaviour and prognosis of each type. This could be the basis to improve the management of these subtypes and for further studies to improve the outcome for patients with identified breast cancer known to have poorer prognosis.

Are we doing enough to prevent colectomy in inflammatory bowel disease (IBD) patients? A 5-year review of colectomy rates in Shropshire and Mid-Wales UK (2015-2019) (2022)

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Type of publication:Conference abstract

Author(s):*Javed A.; *Butterworth J.; *Townson G.

Citation:Journal of Crohn's and Colitis; Jan 2022; vol. 16

Abstract:Background: Colectomy for IBD significantly impacts the psycho-social aspects & quality of life.Method(s): Electronic records were retrospectively analysed for colectomy rates & parameters of interest.Result(s): 68 patients (Men 37:Women31), median age 30 years had colectomies. Annual colectomy rates remained constant;7 (2015), 20 (2016), 11 (2017) & (2018) each and 19 (2019). 28% had colectomy within 1 year of diagnosis and only 63% received a biologic agent. Over half, (54%)had emergency surgeries & 37% experienced infections, re-laparotomy and ileus (20% each).Conclusion(s): There is an opportunity to risk-stratify patients at diagnosis based on the risk factors (men, younger age, severe/extensive disease) to a top-down therapy & treat to target strategy to reduce colectomy rates. (Table Presented).

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Her-2 expression pattern evaluation in breast invasive lobular carcinoma and its association to the clinicopathomorphological characteristics and female sex hormones expression in 71 cases (2022)

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Type of publication:Conference abstract

Author(s):Barron M.; Asaad A.; Ali S.; Chicken W.; Elamass M.; Alkistawi F.; Abdalla Al-Zawi A.S.; *Khan K.A.; Idaewor P.; Osayi K.

Citation:European Journal of Surgical Oncology; Feb 2022; vol. 48 (no. 2)

Abstract:Background: HER2 status is considered as an important prognostic and predictive factor in breast cancer treatment The cellular E-cadherin protein (encoded by the CDH1 gene) is expressed in the breast epithelial cells. Its function is functions is epithelial-to epithelial cell adhesion and epithelial-to-mesenchymal transition. Invasive lobular carcinoma (ILC) is characterised by the absence of E-cadherin expression, usually its oestrogen /progesterone positive however lack Her-2 amplification. Approximately, about 20% of breast cancers are Her2 +ve. The evidence revealed that, HER2 amplification or overexpression is encountered predominantly in invasive ductal carcinomas (NST) of high nuclear grade and infrequently in pleomorphic lobular carcinomas. The aim is to analyse the Her-2 expression pattern in breast invasive lobular carcinoma.Material(s) and Method(s): The clinical records of 71 patients diagnosed in the period between 2014 -2019,with ILC has been analysed. The lobular phenotype was confirmed by the absence of E-cadherin expression. We have evaluated the following criteria: clinico-pathologic variables, female sex hormone receptor status as well as Her-2 expression status.Result(s): ILC cases has been identified in 71 cases, the age ranges between 39-85 yrs, with mean of 68.In 22.% of cases, the phenotype was mixed ILC& invasive ductal carcinoma. Her-2 overexpression detected in 13% cases, 89% of Her2+ve group are above 65 years of age. Her2 overexpression was more associated with ER+ve group (13%), where 60% were ER+ve,PR+ve and Her2-ve, also 23% noticed to have PR-ve status. Triple negative status was seen only in two cases(2.8%), one of them was pleomorphic lobular carcinoma, both cases age was > 80 yrs.Ki-67 was tested in 58 patients, it was low or moderate in 66%, 7% was Her2 +ve with high Ki-67.Her2+ve status was associated with tumour grade 2 in 7% of cases, grade 3(1.4%) and grade 1 (4%).Conclusion(s): ER expression is noticed to in HER2+ classical ILCs, in spite of the fact that the level of expression is significantly low, compared with the Her2ve- disease.