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Mitral valve prolapse presenting as a missed myocardial infarction (2023)

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Type of publication:Conference abstract

Author(s):*Champaneri K.; *Miller A.

Citation:Journal of the Intensive Care Society. Conference: Intensive Care Society State of the Art Congress, SOA 2023. Birmingham United Kingdom. 24(2 Supplement) (pp 194), 2023. Date of Publication: August 2023.

Abstract:Introduction: An elderly but very active gentleman presented overnight with progressive shortness of breath and leg swelling, two weeks after experiencing chest pain while lifting heavy objects in the garden. The presumed diagnosis was a missed myocardial infarction leading to heart failure exacerbated by a new diagnosis of atrial fibrillation. Despite diuresis and rate control, he became progressively more hypoxic and was taken to ICU for non-invasive ventilation. An initial POCUS scan of heart and lungs by an ultrasound fellow undertaking FUSIC accreditation showed a hyperdynamic heart, pulmonary oedema, and bilateral pleural effusions. The echocardiogram was reviewed and repeated by an advanced level operator which dramatically altered the patient's diagnosis and management. Main body: A gentleman in his early 80s presented to the Emergency Department in type one respiratory failure with a high work of breathing. Examination and investigations demonstrated raised inflammatory markers, new atrial fibrillation with a rate of 140, large bilateral plural effusions, and pitting oedema to the groin. Troponin was normal, and the BNP was 4500. ECG showed no ischaemic changes and CXR was consistent with fluid overload and/or pneumonia. Initial management consisted of supplemental oxygen, diuretics, heart rate control, and antibiotics. Despite this his oxygenation deteriorated and he was admitted to the ICU for CPAP, and metaraminol for his hypotension. An initial FUSIC heart scan did not show any signs of ventricular failure. In fact, the heart was hyperdynamic which was more consistent with sepsis. A lung ultrasound did however demonstrate large bilateral plural effusions and the significant pitting oedema of the lower limbs found on clinical examination still suggested a cardiac cause and so help was asked of an advanced level operator. A review of the images and a repeat scan revealed a severe prolapse of the posterior mitral valve leaflet with free, eccentric mitral regurgitation. The leaflet prolapse was not visible on the 1st set of images and was only discovered by more comprehensive scanning. The patient was reviewed by a cardiologist within 30 minutes and transfer to a tertiary centre for emergency mitral valve repair was arranged. <br/>Conclusion(s): Standard history, examination, and investigations of this patient led to a presumed diagnosis of ischaemic ventricular failure. While a basic heart ultrasound did not reveal the pathology, it did demonstrate signs not consistent with the suspected diagnosis prompting a request for a more comprehensive ultrasound assessment. This revealed the underlying pathology, significantly altering the patient's management. This was all done by intensive care clinicians at the bedside, significantly shortening the time to diagnosis and correct management. This case is a good example of why Intensive Care clinicians should be trained in point of care ultrasound at both basic and advanced levels.

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Experience as an international mammographer working in the UK comparing practice between Nigeria and UK (2023)

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Type of publication:Conference abstract

Author(s):*Okeke C.R.; *Njoku G.

Citation:Breast Cancer Research. Conference: Symposium Mammographicum Conference 2023. Glasgow United Kingdom. 25(Supplement 2) (no pagination), 2023. Date of Publication: October 2023.

Abstract:Breast cancer affects women of all races without exception even though severity and survival rate are often diverse. In Nigeria about two thirds of women with breast cancer are diagnosed at an advanced stage, with the possibility of metastatic spread (Akaro- Anthony et al., 2010). A mammographer performs breast imaging techniques that produce mammographic radiographs for diagnosis (American Society of Radiologic Technologist, 2017). In Nigeria, the breast screening programme is performed by radiographers with the additional mammogram-specific training which is comparable to what is found in the United Kingdom; however, the UK screening programme also makes use of trained assistant practitioners which is not obtainable in Nigeria (Lawal et al., 2015). The breast screening programme in Nigeria invites women between the ages of 40 to 70 years, and this is justified by the fear that in Nigeria, a higher percentage of breast cancer cases are seen in younger age groups than in developed world ((Jedy-Agba et al., 2012). The mode of invitation is through public awareness campaigns, but majority of the women in the population do not frequently participate in mammography screening due to high cost and religious belief. The screening programme in Nigeria encourages women to get screened every two years (Lawal et al., 2012). However, the UK breast screening programme advice women to have breast screening mammogram, once every 3 years and is currently inviting women between the ages of 50 and 70 years for breast screening.

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P2.23-07 Crucial, Complex, Caring: A Professional Development Framework for Lung Cancer Nurse Specialists (2023)

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Type of publication:Conference abstract

Author(s):Clayton K.J.; Fenemore J.; Barton P.; Roberts J.; Ivey S.; *McAdam J.; Shepherd P.; Magee L.

Citation:Journal of Thoracic Oncology. Conference: 2023 World Conference on Lung Cancer. Singapore Singapore. 18(11 Supplement) (pp S397), 2023. Date of Publication: November 2023.

Abstract:Introduction: Lung cancer specialist nursing is a varied, valuable and rewarding career, and the need for lung cancer nurse specialists (LCNS) is increasing. Lung Cancer Nursing UK (LCNUK) wants to encourage nurses to aspire to becoming an LCNS, and to support those already working in lung cancer teams to flourish professionally. We want employers to recognise LCNS' capabilities and to recruit and reward them accordingly. LCNUK therefore set out to draft the first professional development framework for LCNS. The Framework is intended to guide nurses, line managers and employers on the core skills, knowledge and expertise that LCNS will gain and demonstrate as they progress in role. Method(s): LCNUK convened a working group which reviewed exemplars and supporting literature., aligned with the four pillars of advanced practice. Feedback on the draft was sought from expert stakeholders and was approved by the LCNUK Steering Committee. The Framework was developed in a collaboration between LCNUK and MSD, who funded a policy consultancy to provide support. LCNUK retained editorial independence. Result(s): The Framework sets out the qualifications, clinical skills, knowledge, leadership and management and research capabilities that LCNUK expects aspiring and existing LCNS to demonstrate or be working towards. It includes case studies of nurses' career journeys and an example of a successful case for job matching and re-banding. The Framework is available on the LCNUK website at. Conclusion(s): The Framework asserts the crucial role of LCNS in managing safety-critical and complex patient care and in leading service delivery and improvement. We hope it will prove a valuable tool to nurses, employers and policymakers in understanding the complexity and importance of this essential role. Following collaboration with European lung cancer nursing colleagues, via ELCC 2022, while not implemented the value and importance of the framework has been acknowledged by Croatian colleagues.The framework has also been welcomed and acknowledged by the devolved nations of the United Kingdom, Wales, Scotland and Northern Ireland.

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Outcomes Following Internal Bracing for Anterior Sternoclavicular Joint Instability: A Systematic Review (2023)

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Type of publication:
Conference abstract

Author(s):
*Kapur K.; *Zaki P.; Chaudhury S.; Tytherleigh-Strong G.; Panayiotou D.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2023. Liverpool United Kingdom. 110(Supplement 7) (pp vii168), 2023.

Abstract:
Aim: There is a paucity of data regarding optimal treatment strategies for atraumatic sternoclavicular joint (SCJ) instability, as this is a relatively uncommon aetiology. Atraumatic SCJ instability may be due to capsular laxity, muscle sequencing or a combination of both. This study aims to systematically review the literature regarding SCJ instability with isolated capsular laxity to determine whether anterior capsular surgical plication and augmentation with internal bracing can prevent further episodes of instability in a population that is refractory to non-operative management. Method(s): Studies that reported functional surgical outcomes were identified using the search terms "sternoclavicular AND joint AND dislocation AND reconstruction". Nine studies and a total of 111 patients were identified to have met the inclusion criteria. Result(s): Of the 111 patients identified, 9% of patients reported residual instability. 5.4% required a reoperation due to persistent impairment of shoulder function related to SCJ instability or osteoarthritis. There were satisfactory reported outcomes in 91% of patients. Conclusion(s): Internal stabilisation techniques for atraumatic sternoclavicular joint (SCJ) instability have shown to be an effective method to improve shoulder function and patient symptoms. Revision rates remained at only 5.4% with a significant improvement in functional status. Complications were rare and included haematoma formation and discharging wound site. Therefore, internal bracing techniques should be considered in patients with chronic anterior SCJ instability after a course of failed conservative treatment.

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Life Expectancy of Octogenarians Following EVAR (2023)

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Type of publication:
Conference abstract

Author(s):
*Sultana E.; *Seraj S.; *Jones S.

Citation:

British Journal of Surgery. Conference: ASiT Surgical Conference 2023. Liverpool United Kingdom. 110(Supplement 7) (pp vii183), 2023.

Abstract:
Background: The aim of elective Abdominal Aortic Aneurysm (AAA) repair is to prevent premature death from rupture. The Endovascular Aneurysm Repair (EVAR) 2 trial showed that patients with AAA who are not fit for open repair do not benefit in terms of life-expectancy from EVAR. In our region, the average life expectancy for men is above the national average but controversy remains when offering octogenarians expensive procedures with the aim of prolonging life. This study aimed to quantify the life-expectancy following an EVAR between octogenarians and younger patients. Method(s): A retrospective review was performed of the electronic notes of all patients receiving EVAR at our unit between October 2009 to October 2019. Survival post EVAR was compared between the octogenarian group and the younger patient group. A survival analysis was undertaken using the SPSS software to calculate a Kaplan-Meier curve. Result(s): 294 patients received EVAR between 2009-2019. Patients were between ages 45 and 89 (Median: 75); 87.4% were male. 169 patients died during follow up (n = 64 >=80 years, n = 105 <80 years). Time of death post-EVAR in octogenarians (average age 82.91 years) ranged between 0 – 131 months, whilst those under 80 years (average age 71.77 years) ranged between 1 – 152 months. Log rank (Mantel-Cox) analysis demonstrated statistical significance (p = 0.017). Median years post-EVAR for >=80 years was 3.02 – 4.98 and <80 years was 5.12 – 6.87. Conclusion(s): Octogenarians undergoing EVAR have a shorter life-expectancy compared to those under 80 years of age. This should be considered when discussing elective options with patients and their relatives.

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A case of disseminated herpes zoster in an immunocompetent child (2023)

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Type of publication:
Conference abstract

Author(s):
*Jacob M.A.; *Kelly S.

Citation:
British Journal of Dermatology. Conference: 103rd Annual Meeting of the British Association of Dermatologists. Liverpool United Kingdom. 188(Supplement 4) (pp iv156-iv157), 2023. Date of Publication: June 2023

Abstract:
Herpes zoster (HZ) caused by the reactivation of varicella-zoster virus (VZV) affects mainly the adult population. The incidence is low in children (0.45 cases per 1000 individuals annually), especially in the immunocompetent. It is said to be disseminated when there are >20 lesions outside the primary and adjacent affected dermatome. We present this case to highlight a rare complication of cutaneous dissemination in a previously healthy child with HZ, following in utero exposure to varicella at 28 weeks' gestation. A 15-year-old boy presented with painful blisters in the T2 dermatome of 1 week's duration, which later spread to trunk, extremities and face. This was associated with fever and neuralgia. There was no previous history of varicella and no recent contact history. He had no significant past medical history and was not on any medications. Antenatal history revealed that his mother had varicella at 28 weeks' gestation and was treated with aciclovir. He was febrile on admission (39degreeC). There were coalesced vesiculopustules and crusted lesions with marked perilesional erythema in the T2 dermatome. In addition, disseminated vesicular lesions were seen on the trunk, extremities and face. Remaining systemic examination was unremarkable. C-reactive protein was elevated. Complete blood count and renal function tests were normal. Liver function tests, namely alanine transaminase and 7gamma;-glutamyl transferase were elevated. Blood culture showed no growth. Varicella-zoster IgG was positive. Viral swab (polymerase chain reaction) from the skin lesions was positive for varicella-zoster DNA. Infectious serology for HIV, hepatitis B and hepatitis C was negative. Antinuclear antibody and antineutrophil cytoplasmic antibodies were negative. A clinical diagnosis of HZ with cutaneous dissemination was made, and he was treated with intravenous aciclovir. Intravenous antibiotics were added for suspected secondary bacterial infection. Disseminated zoster is less common in children and mainly occurs in patients with underlying immunodeficiency like HIV, immunosuppressive drug use or malignancy. In immunocompetent children, this can happen when primary infection (varicella) has occurred in utero or the first year of life due to the low response in specific varicella-zoster virus immunity. Complications like cutaneous dissemination due to viraemia are rare in healthy children, but can affect 2-10% of immunocompromised patients. It occurs 3-4 days after the onset of dermatomal lesions. It is important to look for other complications, especially in the immunocompromised, as viraemia can affect the brain, kidneys, lung and liver. Sequelae like postherpetic neuralgia is rare, but it is important to follow-up these children to look for its development.

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Focused transoesophageal TOE (fTOE): A new accreditation pathway (2023)

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Type of publication:
Journal article

Author(s):
Rubino A.; Peck M.; *Miller A.; Edmiston T.; Klein A.A.; Orme R.; Sankar V.; Fletcher N.; O'Keeffe N.; Skinner H.

Citation:
Journal of the Intensive Care Society. Date of Publication: 2023. [epub ahead of print]

Abstract:
The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.

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Cardiovascular disease morbidity is associated with social deprivation in subjects with familial hypercholesterolaemia (FH): a study comparing FH individuals in UK primary care and the UK Simon Broome register linked with secondary care records (2022)

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Type of publication:
Conference abstract

Author(s):
Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:
Atherosclerosis Plus. Conference: HEART UK 35th Annual Medical & Scientific Conference. Virtual. 49(Supplement 1) (pp S4-S5), 2022. Date of Publication: October 2022

Abstract:
Background: Measures of social deprivation are associated with higher cardiovascular diseases (CVD) morbidity and mortality. To determine if this is also seen in subjects with Familial Hypercholesterolaemia (FH), CVD morbidity has been examined in participants in the UK primary care database (CPRD) and in the UK Simon Broome (SB) register using linkage to the UK secondary care Hospital Episodes Statistics (HES). Method(s): A composite CVD outcome was analysed (first HES outcome of coronary heart disease, myocardial infarction, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG). The measure of socio-economic status/deprivation used was the English index of multiple deprivation (IMD). Cox proportional hazards regression estimated hazards ratios (HR) for incident CVD and mortality [95% CI] in each IMD quintile. <br/>Result(s): We identified 4,309 patients with FH in UK CPRD primary care database (followed from 1988 to 2020), free from CVD, and 2988 SB register participants, with linked secondary care HES records. In both groups, the prevalence of FH was considerably lower in the most deprived quintile (60% in CPRD and 52% in SB). CPRD patients in the most deprived quintile (IMD-5) had the highest prevalence of obesity and of smoking compared to those from IMD quintiles 1,2,3 and 4 (p-value for trend, all <0.001). Compared to least deprived, the most deprived individuals had the highest risk of composite CVD (unadjusted HR 1.71 [CI 1.22-2.40]), however, on adjustment for smoking and alcohol consumption, there were no statistical differences in CVD risk between socio-economic groups. In the FH Register patients there was an increase in the incidence rates and hazards ratios for composite CVD with increasing quintiles of deprivation. After adjustment for age, sex, smoking and alcohol consumption, this effect remained statistically significant (quintile 5 vs 1, HR = 1.83 [1.54-2.17]. Conclusion(s): Patients with FH are underdiagnosed in lower socio-economic groups. In both CPRD and the SB Register the most deprived FH patients had the highest risk of CVD and mortality, but in CPRD but not in the SB register this was largely explained by smoking and alcohol consumption. Clinicians should adopt more effective strategies to detect FH in lower socio-economic groups, and to optimise risk factor management and to support lifestyle changes and medication adherence for this group.

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Formative Objective Structured Clinical Examinations (OSCEs) as an Assessment Tool in UK Undergraduate Medical Education: A Review of Its Utility (2023)

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Type of publication:
Journal article

Author(s):
*Al-Hashimi, Khalid; Said, Umar N; Khan, Taherah N.

Citation:
Cureus. 15(5):e38519, 2023 May.

Abstract:
The Objective Structured Clinical Examination (OSCE) is a globally established clinical examination; it is often considered the gold standard in evaluating clinical competence within medicine and other healthcare professionals' educations alike. The OSCE consists of a circuit of multiple stations testing a multitude of clinical competencies expected of undergraduate students at certain levels throughout training. Despite its widespread use, the evidence regarding formative renditions of the examination in medical training is highly variable; thus, its suitability as an assessment has been challenged for various reasons. Classically, Van Der Vleuten's formula of utility has been adopted in the appraisal of assessment methods as means of testing, including the OSCE. This review aims to provide a comprehensive overview of the literature surrounding the formative use of OSCEs in undergraduate medical training, whilst specifically focusing on the constituents of the equation and means of mitigating factors that compromise its objectivity.

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Treatment and outcomes of patients with gastrointestinal toxicity following immunotherapy: A large multi-center retrospective study in the United Kingdom by the National Oncology Trainees Collaborative for Healthcare Research (NOTCH) (2022)

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Type of publication:
Conference abstract

Author(s):
Swaminathan M.; Angelakas A.; Baxter M.; Cotton J.; Dobeson C.B.; Feeney L.; Gault A.C.; Hughes D.J.; Jones C.; Lee R.; Mughal S.A.; *Parikh S.P.; Pritchard M.; Rodgers L.J.; Rowe M.P.; Salawu A.T.; Shotton R.; Tinsley N.; Tivey A.; Olsson-Brown A.C.;

Citation:
Immuno-Oncology and Technology. Conference: ESMO Immuno-Oncology Congress 2022. Geneva Switzerland. 16(Supplement 1) (no pagination), 2022. Article Number: 100230. Date of Publication: December 2022.

Abstract:
Background: Immune checkpoint inhibitors (ICIs) have revolutionised the treatment of many cancers, but their use has been associated with the development of gastrointestinal (GI) toxicities such as colitis and hepatitis. Method(s): A multi-center retrospective study across 12 National Health Service centers across the United Kingdom (UK) was conducted by the UK National Oncology Trainees Collaborative for Healthcare Research (NOTCH) over a 2-year period. The study included patients receiving ICIs for malignant melanoma, non-small lung cancer and renal cell cancer as standard of care. Occurrence of clinically significant (>=grade 2) GI toxicity was assessed and correlated with subsequent treatment and outcomes. Multiple logistic regression was used to assess correlation. For overall survival (OS), Kaplan-Meier and log-rank tests were utilised. Result(s): The cohort included 2049 patients. 1230 (60%) were male with a median age of 66. Colitis occurred in 182 (8.9%) patients and hepatitis in 129 (6.3%). Of the patients where treatment was recorded, 129 (70.9%) received treatment with systemic steroids alone and 37 (20.3%) required second-line immunosuppressants (IS) in the colitis group. In the hepatitis group, 101 (78.3%) had steroids alone with 19 (14.7%) having IS. Improved OS was found in patients who experienced colitis (HR 2.59 95%CI: 2.15 to 3.11, p<0.0001) and hepatitis (HR 2.26, 95%CI: 1.84 to 2.79, p=<0.0001) compared to those with no adverse events. Pre-existing autoimmune disease (p=0.02) and combination ICIs (p=0.006) were predictors of colitis that required IS whilst grade 2 and 3 hepatitis (p<0.001) were predictors of hepatitis needing IS. The use of IS did not affect OS significantly in the colitis group (p=0.372) but did correlate with survival in the hepatitis group (p=0.037). Patients that were able to continue treatment with ICIs after toxicity had an increased OS in both groups (p<0.001). Conclusion(s): Patients with GI toxicity following treatment with ICIs have improved OS. The use of IS did not significantly affect OS which suggests they should continue to be utilised in the treatment of GI toxicity. Legal entity responsible for the study: United Kingdom National Oncology Trainees Collaborative for Healthcare Research (NOTCH).

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