2022

Recurrence of a second trimester fundal uterine rupture at the old scar site: A case report (2022)

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Type of publication:Journal article

Author(s):*Panesar H.; *Patel R.; Dhaliwal H.

Citation:Radiology Case Reports. 17(11) (pp 4445-4448), 2022. Date of Publication: November 2022.

Abstract:Uterine rupture is a rare life-threatening complication. It can occur in all 3 trimesters with the first and the second being a rarity. It mainly occurs in the third trimester or during labor in a previously scarred uterus. It is rare in an unscarred uterus. The risk fold is further enhanced by the induction and augmentation with prostaglandins and oxytocin. The clinical diagnosis at this early gestation can be a dilemma to the attending physician as in this case. (1) The patient was a holidaymaker with no documented evidence of a dating scan to suggest any evidence of an ovarian/placental pathology at that stage. (2) The ultrasound findings in our department did suggest a viable intrauterine pregnancy with free fluid within both the adnexa. A 6 cm solid homogenous mass in the midline/right adnexa suggested an ovarian torsion or bowel pathology. The differentials in this particular case were that of a ruptured hemorrhagic cyst, ovarian torsion and even a heterotrophic pregnancy as there had been a few documented cases in the department. Ultrasound diagnosis of an intrauterine pregnancy together with a fluid collection does not suggest by any means that the uterus is intact or there is no ectopic pregnancy.

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Airway management, intensive care requirement, and corticosteroid use in cervicofacial infection. A Maxillofacial Trainee Research Collaborative (MTReC) study (2022)

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Type of publication:Journal article

Author(s):Exley R.; Logan G.; Kent S.; McDonald C.; Hennedige A.; Henry A.; Dawoud B.; Kulkarni R.; Kyzas P.; Morrison R.; McCaul J.; Brandsma D.S.; Cashman H.; Swain A.; Java K.; Vithlani G.; Watson M.; Christopher M.; Murray S.; Baniulyte G.; Grant J.; Wareing S.; Kawalec A.; Ng T.; Reedy N.; Tavakoli M.; Underwood C.; Gowrishankar S.; Collins T.; Davies R.; Uppal S.; Elledge R.; Shaheen S.; O'Connor R.; King H.; Tudor-Green B.; Garg M.; Wareing J.; Wicks C.; Mitchell O.; Maarouf M.; Chohan P.; *Otukoya R.; Wu E.; Farooq S.; Brewer E.; King S.; Nandra B.; Stevenson S.; Stiles E.; Davies L.; Madattigowda R.; Mohindra A.; Gilbert K.; Young D.

Citation:British Journal of Oral and Maxillofacial Surgery, 2022 Nov; Vol. 60 (9), pp. 1228-1233.

Abstract:Cervicofacial infection (CFI) is a frequently encountered presentation to Oral and Maxillofacial Departments (OMFS). The United Kingdom has recently seen cessation of all routine community dental treatment due to the Coronavirus (COVID-19) pandemic and consequently an initial modification of treatment received in secondary care. Subsequent airway difficulties and the need for level 2 High Dependency Unit (HDU) or level 3 Intensive Care Unit (ICU) is a concern to surgeons and anaesthetists alike. The availability of skilled staff and appropriate facilities can be variable. It is imperative to understand the resource implications of CFI with respect to airway management and critical care utilisation. Adequate provision is fundamental for optimal care. A national, multicentre, trainee-led audit was carried out across 17 hospitals in the UK from May to September 2017. Information recorded included demographic features, presentation, airway management, medical and surgical treatment, and steroid administration. One thousand and two presentations (1002) were recorded. Forty-five percent were female, with a mean (range) age of 37.5 years (0-94). Regarding surgical airway management, 63.4% had a standard intubation (oral 42%, nasal 21.4%). Awake fibreoptic intubation (AFOI) was performed in 28% and surgical airway required in 0.9%. Impending airway compromise at the time of presentation was 1.7%. Following surgical incision and drainage, 96.1% of patients returned to a general ward, 2.7% to Level 3, and 1.1% to Level 2 care. The return to theatre was 2.8%, and 0.7% required reintubation. There was an association between corticosteroid administration and duration of intubation. Those who received steroids were more likely to remain intubated postoperatively (p = 0.006), require a higher level of postoperative care (p < 0.001), and require a return to theatre (p = 0.019). Postoperatively, patients who received steroids were less likely to be extubated at the close of the procedure. Intubated patients who received multiple steroid doses postoperatively were extubated with less frequency those that received a single dose. To our knowledge, this dataset is the largest ever recorded for CFI. Our results showed a high requirement for advanced airway management in this cohort. The requirement for surgical airway was low, but the significance of this situation should not be underestimated. The relatively frequent need for care at levels 2 or 3 within this cohort also placed a significant demand on already overburdened resources. Knowledge of care requirements for these patients will inform resource planning.

Achilles tendon resting angle is able to detect deficits after an Achilles tendon rupture, but it is not a surrogate for direct measurements of tendon elongation, function or symptoms (2022)

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Type of publication:
Journal article

Author(s):
arsson E.; Helander K.N.; Falkheden Henning L.; Heiskanen M.; *Carmont M.R.; Gravare Silbernagel K.; Brorsson A.

Citation:
Knee Surgery, Sports Traumatology, Arthroscopy : official journal of the ESSKA. 2022 Dec; Vol. 30 (12), pp. 4250-4257

Abstract:
PURPOSE: The aim of this study was to investigate how the Achilles tendon resting angle (ATRA), an indirect measurement of tendon elongation, correlates with ultrasonography (US) measurements of the Achilles tendon length 6 and 12 months after an acute ATR and relates to other clinical outcome measurements such as heel-rise height, jumping ability and patient-reported outcome measurements (PROMs). METHOD(S): Patients were included following acute Achilles tendon rupture (ATR). Achilles tendon length, ATRA, heel-rise height (HRH), drop countermovement jump (Drop CMJ) and PROMs (Achilles tendon total rupture score (ATRS) and physical activity scale (PAS)) were evaluated 6 and 12 months after injury. Achilles tendon length was evaluated using US, while the ATRA was measured with a goniometer. RESULT(S): Sixty patients (13 women, 47 men), mean (SD) age 43 (9) years, with an acute ATR undergoing either surgical (35%) or non-surgical (65%) treatment were evaluated. A negative correlation (r=- 0.356, p=0.010) between relative ATRA and tendon elongation was seen at 12 months after ATR. There were also significant positive correlations at 6 and 12 months between relative ATRA and HRH (r=0.330, p=0.011 and r=0.379, p=0.004). There were no correlations between ATRA and ATRS or ATRA and Drop CMJ, at either 6 or 12 months after the injury. CONCLUSION(S): In combination with other clinical evaluations such as HRH and US, ATRA could be a clinical tool for indirect measurements of tendon elongation. However, ATRA cannot be recommended as a direct surrogate for US for determining Achilles tendon length.

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Early Cholecystectomy in the Ageing Population (2022)

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Type of publication:
Conference abstract

Author(s):
*Sturges P.; *Gupta A.; *Rashid U.; *Rupasinghe S.N.; *Adjepong S.; *Parampalli U.; *Kirby G.C.; *Jain R.K.; *Rink J.; *Riera-Portell M.; *Pattar J.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi67), 2022. Date of Publication: September 2022.

Abstract:
Background: The age group of patients presenting acutely with biliary pathology is rising and gallstone disease can no longer be said to be a disease of the young. The World Health Organisation classifies those aged 65 and over as elderly. Early cholecystectomy is accepted as a safe and effective method of managing acute biliary pathology, reducing further admissions, and reducing in-hospital stays. Our unit does not use age as barrier but uses performance status and co-morbidity to identify potential candidates for cholecystectomy. Method(s): Patients over the age of 65 who underwent acute cholecystectomy (AC) via the emergency cholecystectomy lists, were audited from 31st December 2019 to 31st June 2021. Patient demographics, co-morbidities and surgical factors were recorded. The primary outcome measures were in-hospital stay and re-admission, secondary outcomes were complications and perioperative mortality. Result(s): 41 elderly patients underwent AC during the audit period, (Female 56%, Male 44%). 30 patients had acute cholecystitis (73%). The median inpatient stay following surgery was 2 days (range 2-5 days) and the median admission to surgery time was 6 days (range 5-12 days). Three patients had a subtotal cholecystectomy. There were 3 complications from surgery which were all between a Clavien-Dindo score of 2 and 3. There were 3 immediate post-operative readmissions, with one 30-day mortality from ERCP pancreatitis and not from the operation. Conclusion(s): Early cholecystectomy appears to be a safe and effective treatment for this group of patients and based on this evidence we should continue to offer this treatment to patients irrespective of age.

Intussusception of the Appendix in a Young Adult with Cystic Fibrosis: An Important Differential Diagnosis of Abdominal Pain in Cystic Fibrosis Patients? (2022)

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Type of publication:
Conference abstract

Author(s):
*Venkatasami M.; *Cobby E.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi57), 2022. Date of Publication: September 2022.

Abstract:
Background: Cystic fibrosis (CF) is commonly associated with gastrointestinal manifestations from infancy to adulthood. Intussusception in the paediatric CF population is widely reported, whereas in the adult, distal intestinal obstruction syndrome (DIOS) is common affecting 20%, of which, intussusception is rare and appendiceal intussusception is rarer, affecting 1%. Case-Description: A 20-year-old male with CF presented with 3 days of right iliac fossa pain and diarrhoea. On admission, he was hypotensive and afebrile. Clinical examination revealed tenderness of the right flank with a palpable mass in the right iliac fossa. Serum investigations showed mildly raised inflammatory markers. Contrast CT of the abdomen-pelvis confirmed intussusception of the appendix into the ascending colon. Histological analysis of the appendix further demonstrated intussusception, with intraluminal mucinous material. Fascinatingly, no transmural inflammation was present. The patient underwent a laparotomy-open appendicectomy. Interestingly, intraoperative findings showed the intussusception resolved, no longer requiring surgical reduction. Patient postoperative recovery was complicated by pneumonia for which he was transferred for specialist CF respiratory care and thereafter, discharged. Discussion(s): Literature review highlighted a paucity of data, with 10 reported cases of appendiceal intussusception in adult CF patients. Interestingly, we report the intussusception had reduced by the time of operation. This is in-keeping with previous case reports of transient intussusception which spontaneously resolved. Conclusion(s): From this rare case presentation, we have learnt it is imperative to carry a high index of suspicion for gastrointestinal manifestations in CF patients where acute appendicitis is seen less often and differential diagnoses like DIOS and intussusception should be considered.

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The Rise in Trauma & Orthopaedic Trainee-Led Research and Audit Collaborative Projects in the United Kingdom Since the Start of the COVID-19 Pandemic (2022)

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Type of publication:
Conference abstract

Author(s):
*Khaleeq T.; *Kabariti R.; *Ahmed U.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi35), 2022. Date of Publication: September 2022.

Abstract:
Introduction: There has been a rise in trainee-led trauma & orthopaedic multi-centre research collaborative projects globally. These increase trainee involvement in research with an opportunity to deliver highly generalisable results on a particular topic. Objective(s): To evaluate the number of trauma & orthopaedic trainee-led research collaborative projects that took part since the start of the COVID-19 pandemic in the UK and compare them to projects from 2019. Method(s): This was a retrospective study that evaluated trauma & orthopaedic trainee-led national collaborative projects within the UK since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021). Our exclusion criteria included any regional collaborative projects, pre Covid- 19 projects and projects of other surgical specialities. Result(s): In 2019, 0 trainee-led collaborative projects were commenced nationally in the UK. Since the COVID-19 pandemic, we identified 10 trainee-led collaborative trauma & orthopaedic projects with 6 being published so far. The level of evidence ranged between 3 and 4 and included 5 Audits and 5 cohort studies. The patients that were included in the studies ranged from 927 to 140,231 from a total of 2249 centres. Conclusion(s): Covid-19 has placed significant challenges across healthcare. However, one positive aspect is the increase in multi-centre trainee-led collaborative projects within the UK. Our study highlights the feasibility of a trainee-led high quality collaborative research projects in the UK and the availability of new tools such as social media and centralised confidential online databases such as Redcap facilitates such projects. Therefore, we recommend expanding this trainee-led collaborative platform in the field of trauma & orthopaedics worldwide.

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The Surgical Trainee Perception of the Operating Room Educational Environment (2022)

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Type of publication:
Conference abstract

Author(s):
Rupani N.; Evans A.; *Iqbal M.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi9-vi10), 2022. Date of Publication: September 2022

Abstract:
Aim: Limited hours and service provision are diminishing training opportunities for surgical trainees. It is therefore imperative to maximise each educational event in theatre. The Operating Room Educational Environment Measure (OREEM) evaluates each component of the theatre learning environment; however, it has not been validated in higher surgical trainees in England. We aim to validate the OREEM and evaluate surgical trainees' objective perspectives of the current operating room educational environment in one region. Method(s): Data was collected over one month from surgical trainees within Health Education Thames Valley using an online questionnaire consisting of: demographic data; the OREEM; a global satisfaction score. Result(s): 54 trainees participated. The OREEM had good internal consistency (alpha=0.906, variables=40) and unidimensionality. Mean OREEM score was 79.16%. Areas for improvement included better learning opportunities (72.9%) and pre/post-operative teaching (70.4%). Trainees were most satisfied with the level of supervision and workload (82.9%). No differences between gender (p=0.535) or hospital type (p=0.099) were demonstrated. The learning environment favoured senior trainees (p=0.017). There was a strong correlation between OREEM and the global satisfaction score (p<0.001). Conclusion(s): The OREEM was shown to be a reliable measure of the educational environment in theatre. It can be used to identify areas of improvement and as an audit tool. Suggested areas of improvement include facilitating pre- and post-operative teaching, reducing service provision, empowering trainees to plan lists, improving teamwork and using tools to optimise the educational value of each operation. There is a favourable attitude regarding the use of such improvement tools, especially for dissatisfied trainees.

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Exploring the Impact of Interhospital Transfers on Patients Who Are Managed Conservatively Following Traumatic Spinal Injury: A Scoping Review (2022)

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Type of publication:
Conference abstract

Author(s):
*Nedham M.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi132), 2022. Date of Publication: September 2022.

Abstract:
Introduction: Traumatic spinal injury (TSI) is a devastating event that could lead to serious permanent disability to patients. Therefore, a multidisciplinary team is needed to manage such cases. In the UK, patients with a TSI score a minimum of 16 on the Injury Severity Score (ISS) and are transported to a Major Trauma Centre (MTC). In cases where patients initially present to a none MTC, patients are stabilised and transferred to MTC prominently. Specialised Spinal Cord Units (SCIU) are centres specialised in the definitive management of TSI patients and it is advised that patients get referred to SCIU in a timely manner as studies demonstrate improved patient outcomes. Early transfers are recommended due to the positive impact of early surgical decompression of the injury, which relieves the pressure on the neural tissue. Nevertheless, is this impact still positive if patients are managed conservatively? Aim: To explore the impact of intermediate interhospital transfers on TSI patients when no surgical intervention is taking place. Method(s): A scoping review is utilised to explore the research question. CINAHL, MEDLINE, Pubmed, Cochrane library and ASSIA were the search engines utilised. Result(s): The search resulted in 4,595 papers. 15 met the inclusion and exclusion criteria and included in the review. Conclusion(s): There are no studies that directly explored the impact of transfer on conservatively managed patients, and most of the studies were of low-quality evidence. Age, length of stay, mechanism of injury and cost were all explored as factors related to patients transfer status.

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Outcomes for Paediatric Patients Awaiting Bilateral Myringotomy and Ventilation Tube Insertion for Otitis Media with Effusion Listed Prior to the COVID-19 Pandemic (2022)

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Type of publication:Conference abstract

Author(s):*Lovett A.; Walters B.; Kumar Bhimrao S.

Citation:British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi38), 2022. Date of Publication: September 2022

Abstract:Aim: The decline in the incidence of otitis media with effusion (OME) during the COVID-19 pandemic has become apparent. This review investigates the outcomes for children with OME awaiting bilateral myringotomy and ventilation tube (BMT) who were referred prior to the COVID-19 pandemic. Method(s): All patients were reviewed in otolaryngology clinics between 1st February and 30th April 2021. Patients included were referred due to hearing, vestibular or developmental disorders prior to the first COVID-19 lockdown on 23rd March 2020. Analysis of routine consultation and audiological assessment was completed from records. Result(s): There were a total of 48 patients awaiting BMT. The average age was 6.8 years, with a male to female ratio of 1.38:1. Most initial referrals (54.2%) were due to hearing loss, followed by recurrent ear infections (33.3%). Forty-four patients were diagnosed with OME. Of those, only 9% remained awaiting BMT. All others were removed from the waiting list. One patient remained listed for an adenotonsillectomy, 30 were discharged, and nine required follow-up appointments. Conclusion(s): Our review demonstrates a significant reduction of BMT for OME following COVID-19. Further research on public health measures and changes in clinical practice during the 2020 lockdown would clarify the impact on OME.

Response to Tofacitinib in British Asians with ulcerative colitis: a real-world tertiary centre experience (2022)

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Type of publication:Conference abstract

Author(s):Forsyth K.; *Bhandal H.; Macfarlane M.; Gray C.; Hannah G.; Parkes G.

Citation:Gut. Conference: Annual Meeting of the British Society of Gastroenterology, BSG 2022. Birmingham United Kingdom. 71(Supplement 1) (pp A47), 2022. Date of Publication: June 2022

Abstract:Introduction We have previously shown UK South Asians (SA) with IBD are prescribed TNF antagonists earlier in disease course in comparison with white British (WB) patients, but are more likely to stop due to treatment failure (Gadhok 2020). However, it is currently unknown whether there is a similar variation in response to Tofacitinib, a non-selective JAK inhibitor. We aim to determine whether persistence to tofacitinib varies with ethnicity and evaluate real world efficacy in an inner-city tertiary referral centre. Methods Patients prescribed Tofacitinib since 2019 were identified from electronic prescribing records. The following data was collected: ethnicity (as per UK standard coding), disease history including Montreal classification of disease extent, prior advanced therapies, persistence on therapy, indication for cessation, side effects, and endoscopic and biochemical markers of disease activity. Results 30 adults with UC were prescribed tofacitinib, with a median duration of follow up of 833 days (n=31). 11 patients were female, and ethnicity was as follows: SA:11: Black:1:WB:12:Other/unstated:7. The median failure free survival was 447 days, with no significant variation associated with number of prior advanced therapies (1 prior biologic, 303.5 days (n=12) vs >1 prior biologic, 715 days (n=19) p=0.28). Comparison between characteristics and response to treatment of South Asian and White British patients, presented in table 1: There was no difference between median failure free survival of SA and WB patients (304 days vs 447 days, p=0.28). There was a trend towards lower primary non-response in SA patients, with fewer stopping treatment by 12 weeks, although this was not statistically significant (9.09% vs 33.33% p=0.17). No difference in disease duration at first prescription of tofacitinib between SA and WB patients was found (78.75 months vs 86.80 months p=0.78). 2 patients stopped treatment due to side effects, with 1 patient (SA) stopping due to MACE. Conclusion In contrast to our previous work on TNF antagonists, British SA patients prescribed tofacitinib for UC had failure free survival comparable with WB patients, with a trend towards fewer primary non responders. Although limited by sample size, these findings are reassuring given that SA patients are underrepresented in trials of novel therapies in IBD and warrants a larger study.

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