& Knowledge Service

Title

Development of clinical prediction models for outcomes of complicated intra-abdominal infection

Author(s)

Narula, Harjeet, S

Year

2021

Abstract

Background: Complicated intra-abdominal infections (cIAIs) are associated with significant morbidity and mortality. The aim of this study was to describe the clinical characteristics of patients with cIAI in a multicentre study and to develop clinical prediction models (CPMs) to help identify patients at risk of mortality or relapse.

Methods: A multicentre observational study was conducted from August 2016 to February 2017 in the UK. Adult patients diagnosed with cIAI were included. Multivariable logistic regression was performed to develop CPMs for mortality and cIAI relapse. The c-statistic was used to test model discrimination. Model calibration was tested using calibration slopes and calibration in the large (CITL). The CPMs were then presented as point scoring systems and validated further.

Results: Overall, 417 patients from 31 surgical centres were included in the analysis. At 90 days after diagnosis, 17.3 per cent had a cIAI relapse and the mortality rate was 11.3 per cent. Predictors in the mortality model were age, cIAI aetiology, presence of a perforated viscus and source control procedure. Predictors of cIAI relapse included the presence of collections, outcome of initial management, and duration of antibiotic treatment. The c-statistic adjusted for model optimism was 0.79 (95 per cent c.i. 0.75 to 0.87) and 0.74 (0.73 to 0.85) for mortality and cIAI relapse CPMs. Adjusted calibration slopes were 0.88 (95 per cent c.i. 0.76 to 0.90) for the mortality model and 0.91 (0.88 to 0.94) for the relapse model; CITL was -0.19 (95 per cent c.i. -0.39 to -0.12) and - 0.01 (- 0.17 to -0.03) respectively.

Conclusion: Relapse of infection and death after complicated intra-abdominal infections are common. Clinical prediction models were developed to identify patients at increased risk of relapse or death after treatment, although these require external validation.

Subjects

Intra-abdominal infection; Clinical Predictions

Title

Extensive bony sarcoidosis of the head and neck region: a rare presentation

Author(s)

Hosni, Iman Usama; Karbhari, Bhavesh; Orr, Robert; Opie, Neil.

Year

2021

Abstract

We present a rare case of sarcoidosis with extensive bony destruction of the maxillofacial and skull base bones. A 65-year-old woman was referred with an asymptomatic, non-healing dental socket. Examination revealed an oroantral fistula that was biopsied and repaired under general anaesthesia. Investigations included plain and cross-sectional imaging. Serological tests, in particular ACE, were normal. Histology showed benign florid granulomatous inflammation. At 6 months, the patient remained asymptomatic. She was re-referred 3 years later with further bony destruction of her maxilla and mandible. Repeat imaging showed intrathoracic lymphadenopathy and skull base involvement. Repeat biopsy confirmed granulomatous inflammation. Given the pulmonary, histological and radiological findings, a sarcoidosis diagnosis was made. Following multidisciplinary team meetings, the patient was treated with methotrexate and arrangements made for close monitoring. This case highlights the need for a consensus in identifying, treating and developing a follow-up protocol in such patients.

Subjects

Dentistry and oral medicine; lung function; oral and maxillofacial surgery; respiratory system; rheumatology.

Title

Use of procalcitonin for antibiotic stewardship in patients with COVID-19: A quality improvement project in a district general hospital

Author(s)

Peters, Christina; Williams, Kelly; Un, Elena A; Little, Louisa; Saad, Abeer; Lendrum, Katherine; Thompson, Naomi; Pegden, Amanda.

Year

2021

Abstract

Antibiotic stewardship during the COVID-19 pandemic is an important part of a comprehensive strategy to improve patient outcomes and reduce long-term adverse effects secondary to rising antibiotic resistance. This report describes a quality improvement project which incorporates the use of procalcitonin (PCT) testing to rationalise antibiotic prescribing in patients with suspected or confirmed COVID-19 at Chesterfield Royal Hospital. Data were collected from 118 patients with a total of 127 PCT levels checked over a period of 20 days. Each PCT level was correlated with the subsequent antibiotic outcome as well as the result of the COVID-19 PCR swab. Results indicate that antibiotics were either never started or were stopped within 48 hours in 72% of COVID-confirmed cases with a PCT less than 0.25 μg/L. Our findings suggest that procalcitonin testing, when used in combination with thorough clinical assessment, is a safe, simple and sustainable way of reducing antibiotic use in COVID-19.

Subjects

COVID-19; antibiotic stewardship; bacterial resistance; procalcitonin; quality improvement.

Title

Developing a consolidated research framework for clinical allied health professionals practising in the UK.

Author(s)

Harris, Jennifer

Year

2002

Abstract

BACKGROUND: Allied Health Professionals (AHPs) form a significant part of the healthcare workforce and have great potential to improve services through research and research-informed practice. However, there is a lack of tradition in research embedded in practice in these professional groups. Barriers include clinical caseload pressures, a lack of sustainable training and consequent lack of confidence in practitioners. Practice managers are ill-equipped to monitor and guide staff research development. The modern healthcare system is a multi-disciplinary environment focused on the needs of the patient. A common framework across all AHP disciplines, offering equality in research knowledge and skills and shared language, might be helpful in planning and developing clinical career pathways. Our aim is to develop a consolidated research framework to help AHPs to plan and guide research activity throughout their career. METHODS: The study was conducted in three phases. Phase one identified existing AHP research frameworks (AHPRF) through expert consultations and literature searches. Phase two involved framework analysis of the AHPRFs to develop a single consolidated framework. Phase three included a workshop with experts to validate and adapt the framework for practice. RESULTS: Nineteen AHPRFs were identified. A consolidated framework was shaped by analysis of the AHPRFs resulting in a consolidated framework of eight sections, each containing a series of statements. Each section relates to an analytic theme within the framework analysis, and the statements were based on sub-categories of themes. The final framework was further shaped by the phase three workshop into a set of 'stem' statements that can be adapted to reflect different levels of expertise and the inclusion of a set of guiding principles developed through expert consultation. CONCLUSION: The consolidated framework was entitled 'Shaping Better Practice Through Research: A Practitioner Framework' by stakeholders, thus emphasising its ambition to embed research activity into practice. It instigates a new perspective within AHP research by offering practitioners and managers a tool that can be applied across public, private, and voluntary settings for AHPs in all disciplines. Its ambition is to develop capacity in the AHPs that can undertake research to improve services and the health of service users.

Subjects

Allied health professional; Applied research workforce; Research capacity; Research competencies.

Title

Do gastroenterologists have medical inertia towards coeliac disease? A UK multicentre secondary care study

Author(s)

Naylor, Greg, M.

Year

2021

Abstract

Objective: This study aimed to assess if there is secondary care medical inertia towards coeliac disease (CD).
Design: Group (1): Time from primary care presentation to diagnostic endoscopy was quantified in 151 adult patients with a positive endomysial antibody test and compared with 92 adult patients with histologically proven inflammatory bowel disease (IBD). Group (2): Across four hospitals, duodenal biopsy reports for suspected CD were reviewed (n=1423). Group (3): Clinical complexity was compared between known CD (n=102) and IBD (n=99) patients at their respective follow-up clinic appointments. Group (4): 50 gastroenterologists were questioned about their perspective on CD and IBD.
Results: Group (1): Suspected coeliac patients waited significantly longer for diagnostic endoscopy following referral (48.5 (28-89) days) than suspected patients with IBD (34.5 (18-70) days; p=0.003). Group (2): 1423 patients underwent diagnostic endoscopy for possible CD, with only 40.0% meeting guidelines to take four biopsies. Increased diagnosis of CD occurred if guidelines were followed (10.1% vs 4.6% p<0.0001). 12.4% of newly diagnosed CD patients had at least one non-diagnostic gastroscopy in the 5 years prior to diagnosis. Group (4): 32.0% of gastroenterologists failed to identify that CD has greater prevalence in adults than IBD. Moreover, 36.0% of gastroenterologists felt that doctors were not required for the management of CD.
Conclusion: Prolonged waiting times for endoscopy and inadequacies in biopsy technique were demonstrated suggesting medical inertia towards CD. However, this has to be balanced against rationalising care accordingly. A Coeliac UK National Patient Charter may standardise care across the UK.

Subjects

antiendomysial antibodies; coeliac disease; endoscopic procedures; gluten; inflammatory bowel disease

Title

Emergency treatment of bleeding hemorrhoids in a patient taking aspirin and clopidogrel using a 1470 nm diode laser and the ELITE minimal invasive technique

Author(s)

Papaioannou, Antigoni

Year

2020

Abstract

A 74-year-old male patient, receiving anticoagulation treatment after previous angioplasty stenting for severe coronary artery disease, was admitted to the clinic with a 2-day rectal bleeding. Clinical examination followed by an urgent colonoscopy to exclude other potential reasons for his symptoms both confirmed the diagnosis of Grade III thrombosed hemorrhoids. Due to the acute presentation of the case along with the existing medication of the patient, the decision was made to treat the problem using the expert laser intrahemorrhoidal therapy technique, which is a diode laser minimally invasive operation without the need to stop any of the patient's medication.

Subjects

Hemorrhoids; Laser Intrahemorrhoidal Therapy; Rectal Bleeding

Title

Association between gestational cannabis exposure and maternal, perinatal, placental, and childhood outcomes

Author(s)

Ayonrinde, Oyekunle

Year

2020

Abstract

Globally, the availability and formulations for the administration of cannabis are changing with decriminalization or legalization of recreational use in some jurisdictions, and the prescription of cannabis also occurring. These changes are likely to affect the prevalence of use, including by women of childbearing age. The effects of in utero and infant alcohol and tobacco exposure are well-documented, but the outcomes of cannabis exposure are less certain. The content of delta-9-tetrahydrocannabinol (THC), the psychoactive component of cannabis has progressively increased over several decades. This review explores the limited knowledge surrounding the epidemiology of gestational and postnatal cannabis exposure and implications for the mother-placenta-fetus/neonate triad. We examine cannabis' effects from antenatal and lactation exposure on (a) pregnancy and perinatal outcomes, (b) placental health, and (c) longer term cardiometabolic and neurodevelopmental risks and outcomes. Though definitive outcomes are lacking, gestational cannabis has been associated with increased risk of other substance use during pregnancy; impaired placental blood flow; increased risk of small for gestational age births; and associated complications. Childhood and adolescent outcomes are sparsely assessed, with suggested outcomes including increased risk of depression and attention-deficit hyperactivity disorder. Cardiometabolic implications of gestational cannabis use may include maternal fatty liver, obesity, insulin resistance, and increased risk of gestational diabetes mellitus (GDM), with potential consequences for the fetus. Clinical implications for pediatric practice were explored in a bid to understand any potential risk or impact on child health and development.

Subjects

Cannabis; fetus; maternal; placenta; pregnancy.

Title

Adrenal haemorrhage as a complication of COVID-19 infection

Author(s)

Baxter, Conal Thomas.

Year

2020

Abstract

We report an unusual complication of COVID-19 infection in a 53-year-old Caucasian man. He presented with shortness of breath, fever and pleuritic chest pain. A CT pulmonary angiogram (CTPA) demonstrated acute bilateral pulmonary embolism and bilateral multifocal parenchymal ground glass change consistent with COVID-19 (SARS-CoV-2) infection. Right adrenal haemorrhage was suspected on the CTPA which was confirmed on triple-phase abdominal CT imaging. A short Synacthen test revealed normal adrenal function. He was treated initially with an intravenous heparin infusion, which was changed to apixaban with a planned outpatient review in 3 months' time. He made an uncomplicated recovery and was discharged. Follow-up imaging nearly 5 months later showed near complete resolution of the right adrenal haemorrhage with no CT evidence of an underlying adrenal lesion.

Subjects

adrenal disorders; infections; radiology

Title

Localised conjunctival AL-amyloid deposits secondary to a retinal detachment surgery radial explant

Author(s)

Stafanous, Sabah

Year

2020

Abstract

Purpose: To describe a hitherto unreported late ocular surface complication of retinal detachment surgery around a radial segment explant.

Methods: A single case report of a 72 year-old white Caucasian male, with a previous history of right scleral buckling surgery for retinal detachment surgery 25 years ago, presented with right-sided ptosis of 6 months duration.

Results: Ocular surface examination showed a prominent right supero-nasal quadrant radial segment explant, around which there was bulky pink conjunctival mass, extending from the supero-medial fornix down to the medial canthal area and inferior medial fornix with similar changes seen on the upper medial tarsal conjunctiva. The clinical differential diagnosis was either inflammation from an exposed radial explant or lymphoma. Biopsies of the conjunctival mass showed perivascular and interstitial solid eosinophilic deposits of amyloid, with scattered giant cells; the amyloid was of AL type. There was no morphological or immunohistochemical evidence of lymphoma or a plasma cell neoplasm in the specimen.

Conclusion: This is the first report of localised conjunctival amyloid deposition, secondary to a retinal detachment radial explant. It is proposed that the localised amyloid deposit arose from the ocular surface irritative effects of the radial explant.

Subjects

Retinal detachment; Surgery

Title

Glandular Odontogenic Cyst with Metaplastic Cartilage: Report of an Unusual Case and Literature Review

Author(s)

Karbhari, Bhavesh

Year

2020

Abstract

Glandular odontogenic cysts are rare odontogenic cysts with a wide range of histopathological features. In this paper we describe the clinical and pathological features of an unusual case of a glandular odontogenic cyst with metaplastic cartilage. The previous literature of odontogenic cysts presenting with metaplastic cartilage is reviewed alongside a discussion of the differential diagnoses. To our knowledge this is the first reported case of a glandular odontogenic cyst with metaplastic cartilage.

Subjects

Diagnosis; Glandular odontogenic cyst; Odontogenic cysts; Pathology.

Title

How to Create a Great Radiology Report

Author(s)

Bickle, Ian, C.

Year

2020

Abstract

The use of key principles when dictating radiology report findings, impressions, and recommendations helps radiologists create reports that are readily understood and that provide relevant, clear, and actionable information to advance patient care.
The radiology report represents the sum of a radiologist’s highest level of synthesis and insight into a patient’s condition. It is the most important product that radiologists generate to help direct patient care. Despite the self-evident importance of clear and effective radiology reporting, radiologists usually receive little or no formal reporting education during training. Instead, it is learned in a piecemeal and often indirect fashion through occasional correction and imitating the reports of other radiologists. The audience of the radiology report extends far beyond the ordering provider and includes patients and their families, medical support staff, subspecialty providers, other radiologists, and research interests. Creating a report that fulfills the needs of this diverse group is a formidable if not quixotic ambition. However, there are certain key principles to reporting the imaging findings, impression, and recommendations that serve as a guide and promote careful consideration about how reports are understood. The findings section should emphasize short, informative, and factual observations while avoiding inappropriate interpretation, excessive use of terms of perception, and redundancy. The impression is the thoughtful synthesis of the meaning of the findings leading to a diagnosis, a differential diagnosis, and management recommendations. Creating a clear and impactful impression allows radiologists to provide the highest level of clinical care and direction but takes time and effort beyond simply restating the findings. The impression should use language that is understandable, memorable, and actionable. Reporting skills require ongoing attention and must adapt to the evolving practice patterns and communication styles in medicine.

Subjects

Radiology; Reports

Title

Direct versus indirect laryngoscopy using a Macintosh video laryngoscope: a mannequin study comparing applied forces

Author(s)

Gordon, Joanna, K.

Year

2020

Abstract

Purpose: Upper airway injury and sympathetic activation may be related to the forces applied during laryngoscopy. We compared the applied forces during laryngoscopy using direct and indirect visualization of a standardized mannequin glottis.
Methods: Force transducers were applied to the concave surface of a GlideScope T-MAC Macintosh-style video laryngoscope that can also be used as a conventional direct-view laryngoscope. Thirty-four anesthesiologists performed four laryngoscopies (two direct and two indirect views) on an Ambu mannequin in a randomized sequence. During each laryngoscopy, participants were instructed to obtain views corresponding to > 80% and 50% of the glottic opening aperture. Peak and impulse forces were measured for each view.
Results: To achieve a 50% glottic opening view, the top 10th percentile force was higher with direct vs indirect laryngoscopy in terms of peak (difference, 9.1 newton; 99% confidence interval [CI], 7.4 to 13.9) and impulse (difference, 56.4 newton·sec; 99% CI, 49.0 to 81.7) forces. To achieve >80% view of the glottic opening, median force was higher with direct vs indirect laryngoscopy in terms of peak (difference, 3.6 newton; 99% CI, 1.6 to 7.3) and impulse (difference, 20.4 newton·sec; 99% CI, 11.7 to 35.1) forces.
Conclusions: In this mannequin study, lower forces applied during indirect vs direct laryngoscopy may reflect an advantage of video laryngoscopy, but additional studies using patients are required to confirm the clinical implications of these findings.

Subjects

Laryngoscopy; Anaesthesia