2024

Does tranexamic acid really matter in reducing blood loss? A critical evaluation of its efficacy in orthognathic surgery through a comprehensive systematic review and meta-analysis (2024)

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Type of publication:
Systematic Review

Author(s):
Mortada, Hatan; Hussain, Samar Ali; Liyanage, Dinithi Dilruvi; Zou, Yutong; Subbiah, Praveen; *George, Jefferson; Mansour, Hamid Reza Khademi; Khajuria, Ankur.

Citation:
British Journal of Oral & Maxillofacial Surgery. 2024 Jul 09.

Abstract:
Tranexamic acid (TXA) is acknowledged for reducing blood loss and transfusion requirements in various surgical specialties, yet its role in orthognathic procedures is less defined. Our study seeks to fill this knowledge gap by reviewing the available data and summarising the efficacy and clinical outcomes of TXA in orthognathic surgery. We performed a systematic review and meta-analysis, searching five databases for studies until 16 April, 2023. Our key outcome measures were intraoperative blood loss, postoperative bleeding, and transfusion rate. Previous weaknesses in systematic review and meta-analyses (SRMA) were identified using Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2). The risk of bias was evaluated with the RoB-2 tool. A total of 15 studies were included, involving a combined total of 1060 patients. Compared with the control, the TXA group demonstrated significant reductions in intraoperative blood loss (mean difference -135.60 mL; p < 0.00001; 95% CI, -177.51 to -93.70 mL), Hb level drop (mean difference: 2.67 [-0.63, 5.98]), and improved surgical field visibility [p < 0.00001. (MD -0.99) (CI -1.11 to -0.86)]. No significant differences were observed in postoperative haematocrit levels (mean difference: -0.42 [-2.19, 1.35]; p = 0.003; I2 = 75%), operation duration (p = 0.21), or duration of hospital stay (p = 0.63) between TXA and control groups. In orthognathic surgery, TXA effectively minimises blood loss, demonstrating both safety and efficiency. Well-designed, larger studies and comparisons with other haemostatic agents could solidify TXA evidence.

A Prognostic Model to Predict Hearing Recovery in Patients With Idiopathic Sudden Onset Sensorineural Hearing Loss (2024)

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Type of publication:
Journal article

Author(s):
Mandavia, Rishi; Joshi, Nikhil; Hannink, Gerjon; Ahmed, Muhammad Nayeem; *Parmar, Dilen; Di Bonaventura, Silvia; Gomes, Paola; Iqbal, Isha; Lyles, James; Schilder, Anne G M; Mehta, Nishchay

Citation:
JAMA Otolaryngology– Head & Neck Surgery. 2024 Sep 05. [epub ahead of print]

Abstract:
Importance: The prognosis of idiopathic sudden onset sensorineural hearing loss (iSSNHL) is uncertain, which creates challenges in clinical decision-making for ear, nose, and throat (ENT) physicians and adds to the burden of the condition experienced by patients. Objective: To develop and internally validate a prognostic model for hearing recovery among patients with iSSNHL to support ENT surgeons in making informed and individualized treatment decisions. Design, Settings, and Participants: This prognostic study and model used cohort data from the Sudden Onset Sensorineural Hearing Loss study, which included 812 patients (age >=16 years) diagnosed with iSSNHL at 76 National Health Service ENT departments in the UK from December 2019 to May 2022. Nine variables previously reported as independent prognostic
factors for complete recovery of patients with iSSNHL were selected for inclusion. The final model was internally validated using bootstrapping with 500 repetitions, then coefficients were adjusted for the degree of optimism in the model. The model intercept was reassessed after adjustment of model coefficients. Impact of individual predictors was evaluated by estimating odds ratios with corresponding 95% CIs. Model performance was re-evaluated after internal validation and expressed by discrimination, calibration, and clinical utility. Data analyses were performed from March 2022 to April 2024. Intervention: Routine treatment (per National Health Service standards), including oral steroids and intratympanic steroid injections. Main Outcome and Measures: Complete hearing recovery defined as a return to within 10 dB of the patient's before iSSNHL hearing levels at all frequencies in the affected ear at 6 to 16 weeks after iSSNHL symptom onset. Results: The study sample included 498 patients (mean [SD] age, 58.7
[16.0] years; 215 [46.9%] females and 243 [53.1%] males) who met the criteria for inclusion in the model. Of those, 210 (46%) were classified as having experienced complete hearing recovery. Five variables were found to be independent predictors for complete hearing recovery: steroid treatment within 7 days from symptom onset (OR, 5.23 vs no treatment ), lower severity of hearing loss at presentation (OR, 0.19 if loss is mild), absence of vertigo (OR, 0.56 vs no vertigo), younger patient age (OR, 0.64 per year), and a history of cardiovascular disease (OR, 1.84 vs no cardiovascular disease). The model showed good performance after internal validation with a c-index of 0.77 (95% CI, 0.7-0.81). Predictions for complete recovery aligned well with observed complete recovery rates, and greater clinical utility than treat all or treat none strategies was shown. Conclusion and Relevance: This prognostic model evaluated in this study
may be able to assist ENT surgeons in making informed treatment decisions for individual patients with iSSNHL. It is available online at no cost.

Global prevalence of medicalised female genital mutilation: a systematic review (2024)

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Type of publication:
Conference abstract

Author(s):
*Andrew O.; Jones L.; *Farley A.;

Citation:
Archives of Disease in Childhood. Conference: Royal College of Paediatrics and Child Health Conference, RCPCH 2024. Birmingham United Kingdom. 109(Supplement 1) (pp A280), 2024. Date of Publication: August 2024.

Abstract:
Objectives Despite the ongoing efforts to eradicate female genital mutilation (FGM), the shift towards medicalised FGM is concerning. It is advocated that eliminating medicalised FGM is an important component in the holistic approach to end FGM. This review therefore aimed to systematically identify literatures to determine the global prevalence of medicalised FGM. Methods Studies included were cross-sectional studies that reported the prevalence of FGM in a female population of any age and the performer of the FGM to be a health care professional (HCP). Medline, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature and a range of grey sources were searched between March and April 2020. In duplicates, eligible papers were screened, quality assessed using JBI tool and data extracted using a proforma. The main outcome extracted was the prevalence of medicalised FGM and this was defined as FGM performed by any category of HCP irrespective of the location. A meta-analysis using a random- effect model was carried out to synthesise the global prevalence of medicalised FGM. Subgroup analysis by country's level of income, study setting, continent and study date was undertaken to investigate heterogeneity (I2). Results Out of 4875 records obtained after a systematic search, 21 papers and one piece of grey literature were included, all describing medicalised FGM in 26 countries. Most of the studies (93.3%) were conducted in low and lowmiddle income countries. Overall, the global prevalence of medicalised FGM was 13% (95% confidence interval (CI) 7%-21%, I2 = 100%). The high heterogeneity observed was explored using subgroup analysis; however, there was little change in I2 value. Conclusion Amidst the high heterogeneity, this research highlights that the prevalence of medicalised FGM worldwide can be as high as 21% (~1 in 5 survivors). Further research is required to investigate the various context where the prevalence of medicalised FGM is high. Specific nationally representative data across several settings are necessary in all regions to ensure surveillance of the problem. There is need for interventions to prevent HCP from cutting women and girls thereby strengthening the path to eradicate FGM.

Lateral femoral wall thickness in trochanteric hip fractures: a systematic review (2024)

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Type of publication:
Systematic Review

Author(s):
*Selim, Amr; Ponugoti, Nikhil; Daoub, Ahmed; Johnson-Lynn, Sarah; *Rhee, Shin Jae.

Citation:
Hip International. 2024 Aug 26.[epub ahead of print]

Abstract:
BACKGROUND: Thin lateral femoral wall has been investigated as a sign of instability in trochanteric hip fractures, necessitating lateral wall reconstruction or the use of a cephalomedullary nail (CMN). Various cut-off values have been proposed to guide implant choice. This review aims to determine the clinical significance of the lateral femoral wall thickness (LWT) in trochanteric hip fractures and identify an optimal cut-off value for increased risk of lateral wall (LW) fracture when using Dynamic Hip Screw (DHS). METHODS: A comprehensive search was conducted in databases including Medline, Embase, and the Cochrane library up to July 2023. A predefined strategy was employed, with 5 eligible studies critically appraised using the methodological index for non-randomized studies (MINORS) criteria. Outcomes assessed encompassed the standardised mean difference (SMD) of LWT between the LW fracture and non LW fracture groups, aggregate LWT mean in LW fracture group, and the relation between AO/OTA fracture type with LW fracture utilising the chi-square test. RESULTS: Among 481 patients from 5 studies, 112 experienced LW fractures, while 369 did not postoperatively. Analysis indicated a significantly lower LWT in the LW fracture group (SMD -1.13, I2 = 41.3%, p = 0.146). The mean LWT in the LW fracture group was 18.2 mm, with a 95% confidence interval of 17.29-19.10 mm. CONCLUSIONS: A preoperative thin lateral femoral wall is a critical predictor of fixation failure and suboptimal functional outcomes when using a DHS. Thorough evaluation of pre- and intraoperative x-rays is essential. CMN is recommended over DHS in cases with LWT measurements <19 mm.

The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study (2024)

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Type of publication:
Journal article

Author(s):
Flower, Luke; Waite, Alicia; Boulton, Adam; Peck, Marcus; Akhtar, Waqas; Boyle, Andrew J; Gudibande, Sandeep; Ingram, Thomas E; Johnston, Brian; Marsh, Sarah; *Miller, Ashley; Nash, Amy; Olusanya, Olusegun; Parulekar, Prashant; Wagstaff, Daniel; Wilkinson, Jonathan; Proudfoot, Alastair G.

Citation:
Intensive Care Medicine. 2024 Aug 19. [epub ahead of print]

Abstract:
PURPOSE: Echocardiography is recommended as a first-line tool in the assessment of patients with shock. The current provision of echocardiography in critical care is poorly defined. The aims of this work were to evaluate the utilisation of echocardiography in patients presenting to critical care with shock, its impact on decision making, and adherence to governance guidelines. METHODS: We conducted a prospective, multi-centre, observational study in 178 critical care units across the United Kingdom (UK) and Crown Dependencies, led by the UK's Trainee Research in Intensive Care Network. Consecutive adult patients (>= 18 years) admitted with shock were followed up for 72 h to ascertain whether they received an echocardiogram, the nature of any scan performed, and its effect on critical treatment decision making. RESULTS: 1015 patients with shock were included. An echocardiogram was performed on 545 (54%) patients within 72 h and 436 (43%) within 24 h of admission. Most scans were performed by the critical care team (n = 314, 58%). Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases. Patients with obstructive or cardiogenic shock had their management altered numerically more often by echocardiography (n = 15 [75%] and n = 100 [58%] respectively). Twenty-five percent of echocardiograms performed adhered to current national governance and image storage guidance. CONCLUSION: Use of echocardiography in the assessment of patients with shock remains heterogenous. When echocardiography is used, it improves diagnostic certainty or changes management in most patients. Future research should explore barriers to increasing use of echocardiography in assessing patients presenting with shock.

Sounds fishy: a case of Mycobacterium marinum infection secondary to infliximab infusion. (2024)

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Type of publication:
Conference abstract

Author(s):
*Khan A.; *Jain D.

Citation:
British Journal of Dermatology. Conference: 104th Annual Meeting of the British Association of Dermatologists, BAD 2024. Manchester United Kingdom. 192(Supplement 1) (pp i157), 2024. Date of Publication: July 2024.

Abstract:
Mycobacterium marinum is a waterborne, atypical mycobacterium that is known to cause infection in fish, mice and bats. M. marinum in humans is rare and can manifest as a skin/soft tissue infection following exposure of damaged skin to polluted water from aqueous environments such as swimming pools, wells, rivers and fish tanks. We report the case of a 73-year-old White man with a history of collagenous colitis on treatment with infliximab. He presented with pustules, ulcerated plaques and nodules on his left wrist and left deltoid as well as some nodules on the right forearm in a sporotrichoid distribution following a second infliximab infusion. A skin biopsy revealed prominent dermal abscess formation with extension of acute inflammation into the subcutis with fat necrosis. Small granulomas were also seen at the edges without caseating necrosis. Numerous acidfast bacilli were present on a Ziehl-Neelsen stain in keeping with mycobacterial infection. He was started empirically on rifampicin, ethambutol and clarithromycin; however, minimal improvement was noted. A subsequent mycobacteria microscopy, culture and sensitivity revealed sensitivity to ciprofloxacin, and fortunately his skin responded well to this. Tumour necrosis factor (TNF)-alpha inhibitors such as infliximab are widely used treatments in managing chronic inflammatory dermatoses as well as inflammatory bowel disease. These agents increase the risk of granulomatous disease. A diagnosis of M. marinum is challenging and multiple biopsies and tissues cultures may be necessary for identifying the correct diagnosis. Although this case did not have any typical exposures to M. marinum, it highlights the importance of screening and educating patients regarding the risks of certain environmental exposures prior to commencing anti-TNF treatments.

Altered body image, disordered eating, and suboptimal glycaemic control in type 1 diabetes: Is technology and GLP1 agonists an option? (2024)

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Type of publication:
Conference abstract

Author(s):
*Basavaraju N.; *Jones M.; *Moulik P.

Citation:
British Journal of Diabetes. Conference: ABCD Diabetes Update. Loughborough United Kingdom. 24(1) (pp 112-113), 2024. Date of Publication: June 2024.

Abstract:
Introduction: Disordered eating in type 1 diabetes (T1DM) is associated with diabetes distress and suboptimal glycaemic control. We present a case of T1DM with binge eating disorder, discussing the benefits of GLP-1 analogues with continuous subcutaneous insulin infusion (CSII) therapy. Case: A 35-year-old female was diagnosed with T1DM in 2012, at 24 years of age, and commenced on basal bolus insulin. She had two pregnancies over the next seven years with good glycaemic control. There was pronounced dawn phenomenon post-pregnancy which was reflected in her erratic Freestyle Libre glucose readings. CSII therapy with Tandem T-slim was commenced a year later, in October 2020. Over the next 12-18 months, she was diagnosed with depression and hypertension, missed her outpatient diabetes clinic appointments, and struggled with diabetes management and fear of hypoglycaemia. During mid-2022 she developed mental health issues, with hallucinations and binge eating and a likely diagnosis of bipolar personality disorder. Later in the year, she was commenced on Tandem T-slim CSII and Dexcom G6 with Basal IQ technology. There was no evidence of retinopathy or neuropathy on annual diabetes screening. During outpatient diabetes review in February 2023, there was recurrent insulin pump auto-suspend followed by rebound hyperglycaemia and hence overnight basal insulin was reduced. Six months later, her weight had increased and glycaemic control worsened due to continued binge eating, missing pre-meal boluses, and she continued to be under the mental health liaison team. Her insulin was changed from Novorapid to Lyumjev (after discussion with the patient due to licensing criteria with the insulin pump) to accommodate binge eating hyperglycaemia and she was supported by motivational interviewing whilst awaiting review by eating disorders services. A month later, in October 2023, after CSII MDT discussion, she was commenced on control IQ – hybrid closed loop (HCL). In November 2023, her GMI (Glucose Management Indicator) improved, and she was commenced on dulaglutide after full discussion and patient consent including licensing criteria in T1DM. A month later, her food cravings reduced, she felt more positive about diabetes self-management and her insulin requirement reduced from 108 units to 98 units (basal 38%, bolus 62%). Her weight, BMI, HbA1c and ambulatory glucose profile data are shown in the Table. Discussion(s): HCL helped to improve glycaemic control by increasing TIR and reducing HbA1c. GLP-1 analogues have shown positive effects on reducing binge eating and weight loss. The combination of HCL and GLP-1 analogue in this patient resulted in lower insulin doses, positive attitude towards diabetes self-management along with improved clinical parameters and patient satisfaction. Binge eating disorders are associated with obesity and increase in cardiovascular risk. GLP-1 analogues in obese T1DM patients improve metabolic profile, weight, HbA1c and insulin requirement, with no increase in incidence of diabetic ketoacidosis or hypoglycaemia. There are no reported cases of T1DM with binge eating disorder on GLP-1 analogues in the literature and hence further studies are warranted.

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Identification and optimisation of perioperative factors for patients with von Willebrand disease undergoing elective total hip and knee (2024)

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Type of publication:
Journal article

Author(s):
*Patel, Ravi; Golding, Steven; Nandra, Rajpal; Banerjee, Robin

Citation:
Journal of Perioperative Practice. 2024 Aug 12. [epub ahead of print]

Abstract:
Von Willebrand disease stands as the most prevalent bleeding disorder seen in both medical and surgical practice. Due to recurrent bleeding episodes within the joints, many patients endure arthropathy, leading to substantial pain and restricted function. Total joint arthroplasty emerges as a final option for managing such cases. Nevertheless, the existence of von Willebrand disease presents several challenges in this regard. This review aims to explore the perioperative strategies tailored for patients with von Willebrand disease undergoing elective total joint arthroplasty.

Pulmonary Embolism Presenting As Shoulder and Back Pain: A Case Report (2024)

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Type of publication:
Journal article

Author(s):
*Nwaneri, Chukwuemeka; *Race, Rebecca; *Oladele, Romoluwa; *Kumaran, Subramanian.

Citation:
Cureus. 16(7):e64016, 2024 Jul.

Abstract:
Pulmonary embolism (PE) is a common but life-threatening condition, and diagnosis can be challenging. Diagnosis is even more difficult in those patients with atypical presentations such as the absence of pleuritic chest pain, dyspnoea, tachycardia, or symptoms of deep vein thrombosis. We have delineated shoulder and back pain as an atypical sign of PE. However, the significant amount of misdiagnosis highlights the importance of other rare symptoms of this potentially fatal disease. Therefore, eliciting these rare presenting symptoms can significantly reduce morbidity and mortality. Here, we report the case of a patient who, 13 days after a laparoscopic Nissen fundoplication, presented to the emergency department (ED) with left shoulder and left-sided pleuritic back pain. She was managed in the resuscitation area in the ED and was subsequently diagnosed with a left-sided PE. Her care was taken over by the medical team, and she continued her recovery in the acute medical unit.

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