Author: Jason Curtis

Transcutaneous electrical acupoint stimulation for people with chronic musculoskeletal pain: an exploratory review (2019)

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Type of publication:
Journal article

Author(s):
Ely, S. ; Barlas, P.

Citation:
Physical Therapy Reviews, Dec 2019 Vol. 24(6) p.377-388

Abstract:
Background: Transcutaneous electrical acupoint stimulation (TEAS) is a form of stimulation-induced analgesia with potential as a non-invasive alternative to acupuncture, suitable for self-application. The clinical evidence for TEAS for people with chronic musculoskeletal pain is limited.
Objectives: This exploratory review aimed to evaluate the potential of TEAS as a pain relief option for people with chronic musculoskeletal pain and explore the evidence relating to dose parameters.
Methods: A literature search was conducted using Medline, EMBASE, CINAHL, AMED and the Cochrane Database for studies that used TEAS or specified the use of Transcutaneous electrical nerve stimulation (TENS) over acupuncture points for people with chronic pain. Data relating to the treatment dose parameters was extracted including frequency, intensity, treatment duration and stimulation location, to identify themes and trends with a narrative analysis and review.
Results: The review included 20 studies consisting of 13 randomised controlled trials, four comparative trials and three cross-over studies. Most RCTs indicated some beneficial effect on pain scores, but the overall quality of evidence was low. Most studies applied a TENS device for 20–40 minutes, several times a week similar to an acupuncture treatment protocol. There was no clear evidence that the electrical parameters of frequency and intensity or the choice of acupuncture points had an effect on the outcomes.
Conclusions: People with chronic musculoskeletal pain may achieve pain relief using TEAS but the existing evidence is limited and high quality clinical evidence is required to establish efficacy. Effects appear to be achieved with short applications, several times a week in a protocol similar to those used with acupuncture. It is not clear whether the choice of acupuncture point, stimulation frequency or intensity has an impact on the results. Further investigation of the effect of stimulation duration for both TEAS and TENS is recommended.

Synchronous versus sequential chemo-radiotherapy in patients with early stage breast cancer (SECRAB): A randomised, phase III, trial (2020)

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Type of publication:
Randomised controlled trial

Author(s):
Fernando I.N.; Spooner D.; Latief T.N.; Stevens A.; Bowden S.J.; Herring K.; Ahmed I.; Rea D.W.; Brookes C.L.; Marshall A.; Dunn J.; Grieve R.; Poole C.J.; Churn M.; *Agrawal R.K.; Brunt A.M.; Goodman A.; Canney P.; Ritchie D.; Bishop J.

Citation:
Radiotherapy and Oncology; 2020; Vol 24; p. 52-61

Abstract:
Background: The optimal sequence of adjuvant chemotherapy and radiotherapy for breast cancer is unknown. SECRAB assesses whether local control can be improved without increased toxicity.
Method(s): SECRAB was a prospective, open-label, multi-centre, phase III trial comparing synchronous to sequential chemo-radiotherapy, conducted in 48 UK centres. Patients with invasive, early stage breast cancer were eligible. Randomisation (performed using random permuted block assignment) was stratified by centre, axillary surgery, chemotherapy, and radiotherapy boost. Permitted chemotherapy regimens included CMF and anthracycline-CMF. Synchronous radiotherapy was administered between cycles two and three for CMF or five and six for anthracycline-CMF. Sequential radiotherapy was delivered on chemotherapy completion. Radiotherapy schedules included 40 Gy/15F over three weeks, and 50 Gy/25F over five weeks. The primary outcome was local recurrence at five and ten years, defined as time to local recurrence, and analysed by intention to treat. ClinicalTrials.gov NCT00003893.
Finding(s): Between 02-July-1998 and 25-March-2004, 2297 patients were recruited (1150 synchronous and 1146 sequential). Baseline characteristics were balanced. With 10.2 years median follow-up, the ten-year local recurrence rates were 4.6% and 7.1% in the synchronous and sequential arms respectively (hazard ratio (HR) 0.62; 95% confidence interval (CI): 0.43-0.90; p = 0.012). In a planned sub-group analysis of anthracycline-CMF, the ten-year local recurrence rates difference were 3.5% versus 6.7% respectively (HR 0.48 95% CI: 0.26-0.88; p = 0.018). There was no significant difference in overall or disease-free survival. 24% of patients on the synchronous arm suffered moderate/severe acute skin reactions compared to 15% on the sequential arm (p < 0.0001). There were no significant differences in late adverse effects apart from telangiectasia (p = 0.03). Interpretation(s): Synchronous chemo-radiotherapy significantly improved local recurrence rates. This was delivered with an acceptable increase in acute toxicity. The greatest benefit of synchronous chemo-radiation was in patients treated with anthracycline-CMF.

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Use of recombinant parathyroid hormone in treatment of bisphosphonate related osteonecrosis leading to spontaneous healing (2019)

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Type of publication:
Conference abstract

Author(s):
*Chundoo S.; *Pilkington R.; *Bhatia S.; *Garton M.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)

Abstract:
Introduction: Case presentation of 61 year old female patient who developed BRONJ (bisphosphonate related osteonecrosis of the jaw) and a pathological triple fracture of the anterior mandible. She had underlying vitamin D deficiency and secondary hypoparathyroidism. She also suffers from anca positive rheumatoid arthritis and is under the active care of rheumatology.
Method(s): Patient was treated with conservative measures which failed to give a good quality of life outcome. Under special license, with involvement from rheumatology, the patient was started on monthly injections of recombinant parathyroid hormone (teriparatide).
Result(s): Over 12-18 months, the serial radiographs reveal bony union of all fracture sites. Patient now has good quality of life and patient is back on disease modifying drugs to control their active rheumatoid arthritis.
Conclusions/Clinical Relevance: Novel approach to using teriparatide for patients with end-stage BRONJ. License of the drug as well as current NICE guidelines for its use and patient specific requirements such as fragility fracture risks age and DEXA scores are also discussed. The action of the drug on osteoblastic formation and bone turnover is discussed. This will help practitioners have another agent to add to their treatment options in treating the effects of BRONJ.

A technical note describing the use of a carotid artery bypass graft in the management of head and neck cancer with carotid artery involvement and review of literature (2019)

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Type of publication:
Conference abstract

Author(s):
*Hamps C.; *Pilkington R.; *Merriman C.; *Thomas S.; *Bhatia S.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)

Abstract:
Introduction Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon but often catastrophic complication of head and neck cancer when arterial wall integrity is compromised,
particularly where surgical procedures and radiotherapy are involved. Rupture occurs most commonly in the common carotid artery in proximity to the furcation, often within 10-40 days post surgery. Methods We present the use of a great saphenous vein carotid artery bypass graft in the management of a 47-year-old woman with recurrent squamous cell carcinoma (T2 N1 M0 RO V1) utilizing the Pruitt F3 carotid shunt system to minimize cerebral perfusion compromise. We explore pre and post-operative surgical considerations including suggested graft-monitoring protocols. Results The body of evidence supporting the use of carotid bypass grafts is limited. Despite data paucity, case series are available demonstrating variable mortality. A systematic review of PubMed was conducted revealing three English language case series. One series reported a 2-year survival of 82% with carotid sacrifice and autogenous venous graft where distant metastatic disease is absent. 96% of patients experienced no neurologic sequela whilst 3.9% suffered CVA post-operatively. Our own patient remains free of neurologic symptoms and graft patency has been confirmed at 3 months. Clinical Relevance Tumour resection involving in the carotid artery presents an array of surgical management possibilities including tumour shaving, artery ligation or resection. The long-term survival of carotid bypass graft is unknown and reported complications vary, it remains a promising technique in the prevention of carotid blowout syndrome.

The change in presentation and treatment of dental abscess in ten years at Telford Hospital (2019)

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Type of publication:
Conference abstract

Author(s):
*Wu E.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)

Abstract:
Background A dental infection often requires simple treatment but an abscess can turn into a life threatening condition. In the UK in April 2006 a new dental contract was introduced, it changed the renumeration tariffs from pay per item to a 3 tier banding payment system in the hope of shifting the balance to prevention rather than treatment. Aims The aim of this project is to study the change in incidence and severity of dental infections presenting to Telford Hospital Emergency Department (ED), the treatment required plus the potential implications on Maxillofacial Services. Methods Data was collected from 2006 and 2016. Using the ED database codes for 'soft tissue infection/abscess or Facio-maxillary conditions' patients were identified. Only those notes stating a clear dental cause were included. Results The median age range in 2006 and 2016 was 30years old. In 2016, 20% of patients had been commenced on Antibiotics (most commonly amoxicillin) compared to only 3% in 2006. The number of patients presenting to ED doubled in 2016 and the procedures (LA/ GA) more than quadrupled resulting in a rise in inpatient stay from 1 to 11 days in total. The increase in GA could indicate increased severity of the abscess. Conclusions It would appear that the work load managed by Maxillofacial Surgeons has increased. There has also been an increase in incidence and severity of dental infections.  Whether this is secondary to deterioration in dental health or unwillingness by the public to pay to for dental health care is unclear.

Temporal artery biopsy harvesting length audit, patient satisfaction with post op management. A guide for clinical commissioning group planning (2019)

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Type of publication:
Conference abstract

Author(s):
*Pilkington R.; *Chundoo S.; *Rollings L.; *Messahel A.; *Thomas S.; *Bhatia S.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)

Abstract:
Introduction: Giant cell or temporal arteritis (GCA) is a vasculitis mainly affecting patients over 50yrs. Diagnosis is facilitated by a temporal artery biopsy (TAB). Due to the increased risk loss of visual loss, patients are started on high dose steroids to reduce this risk. However, a timely diagnosis with the aid from a TAB can help steer the patient into a more medically directed pathway of an appropriate reduction or prolonged use of steroids. We used British Society of Rheumatology (BSR) guidelines to audit our harvest length (recommend > 20 mm) and a telephone questionnaire to follow up patients. Method Retrospective audit over 2.5 years, 146 patients underwent a TAB performed at the Princess Royal and Royal Shrewsbury Hospital.
Results: Male:female (30:70), average age 69yrs.We had a 99.3% TAB harvest of the artery and harvest length > 10 mm was 100% and > 20 mm was 87%. Mean length 24 mm. A positive diagnosis of GCA was made from 24.6% of the TAB. A telephone questionnaire was conducted with a 44% response. 11% reported some postoperative bleeding and 4% some discomfort from the sutures. 0% reported any ongoing problems from the surgical site or concerns from the scar. Clinical relevance In our unit we provide a comprehensive service to a large geographical region. In line with Clinical Commissioning Groups (CCG) this audit shows that we are providing a quality service to the practitioners who refer their patients for this treatment provision. Hopefully this audit can be used to further improve our service.

Reconstruction of the radial forearm free flap donor site with an acellular dermal regenerative matrix "Integra" on Fitzpatrick Type 1 skin (2019)

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Type of publication:
Conference abstract

Author(s):
*Pilkington R.; *Saggu M.; *Thomas S.; *Bhatia S.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)

Abstract:
Introduction: The radial forearm free flap (RFFF) is still one of the most commonly used free flaps in oral and maxillofacial surgery. The flap provides a thin flap making intra-oral repair less bulky however, one of the drawbacks to this flap is the donor site morbidity. We report the use of an acellular dermal regenerative matrix material (Integra, Integra Life Sciences, Plainsboro, NJ) to provide a substrate for wound coverage. Method: Our novel approach is used to minimise the donor site scarring and is used to treat a fit and healthy right handed 37-year-old man who presented with a mucoepidermoid carcinoma arising from minor salivary glands in the hard palate. He required resection with reconstruction with a left RFFF. He has Type 1 Fitzpatrick skin and is prone to severe keloid scarring and is not keen to have a skin graft taken to cause further scarring.
Results: We review the types of techniques to close the RFFF donor site. This is the first case using integra to close this site and show the healing stages involved. Clinical relevance This case reveals that the use of the Integra has resulted in a neodermis which then allowed ingress of the surrounding epidermis to fully cover the donor site. It has alleviated the need to take a split skin or full thickness graft which would have added more keloid scarring for the patient.

The diagnostic value of cytology in parotid Warthin's tumors: international multicenter series (2020)

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Type of publication:
Journal article

Author(s):
Borsetto, Daniele; Fussey, Jonathan M; Cazzador, Diego; Smith, Joel; Ciorba, Andrea; Pelucchi, Stefano; Donà, Sara; Boscolo-Rizzo, Paolo; Tomasoni, Michele; Lombardi, Davide; Nicolai, Piero; Zanoletti, Elisabetta; Colangeli, Roberta; Emanuelli, Enzo; *Osborne, Max S; *Ahsan, Syed F; Tofanelli, Margherita; Tirelli, Giancarlo; McNamara, Katherine; Liew, Leonard; *Harrison, Katherine; Fassina, Ambrogio; Sarcognato, Samantha; Sharma, Neil; Rao, Kanishka; Pracy, Paul; Nankivell, Paul

Citation:
Head & Neck; 2020; Vol 42(3) p. 522-529

Abstract:
INTRODUCTION Warthin's tumor (WT) is a common benign salivary gland neoplasm with a negligible risk of malignant transformation. However, there is a risk of malignant tumors being misdiagnosed as WT on cytology and inappropriately managed conservatively.
METHODS Patients from nine centers in Italy and the United Kingdom undergoing parotid surgery for cytologically diagnosed WT were included in this multicenter retrospective series. Definitive histology was compared with preoperative cytological diagnoses. Surgical complications were recorded.
RESULTS A total of 496 tumors were identified. In 88.9%, the final histological diagnosis was WT. In 21 cases (4.2%) a malignant neoplasm was diagnosed, which had been incorrectly labeled as WT on cytology.
CONCLUSIONS The risk of undiagnosed malignancy should be balanced against surgical risks when considering the management of WT. Although nonsurgical management remains an appropriate option, there may be a rationale for serial clinical or radiological evaluation if surgical excision is not performed.

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A method to improve the accuracy between the presumed depth of excision and the actual depth of excision in women (2018)

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Type of publication:
Journal article

Author(s):
*Papoutsis D.; *Kandanearachchi P.; *Sahu B.; Antonakou A.; Tzavara C.

Citation:
Hippokratia; 2018; vol. 22 (no. 3); p. 113-121

Abstract:
Background: We aimed to determine whether continuous auditing of the presumed depth of excision and
comparing with the actual depth of excision in women having large loop excision of the transformation zone (LLETZ) improves the ability to acquire the desired depth of excision.
Method(s): This was a prospective study of women submitted to a single LLETZ treatment between 2017-2018. Two senior colposcopists recorded what they presumed was the depth of excision at the time of treatment and the subsequent histopathology report provided the actual excised depth. Multiple linear regression identified independently associated parameters with the difference between presumed and actual excision depth. Nonlinear regression determined the learning plateau defined as the theoretical minimal score of difference one could achieve with infinite practice.
Result(s): There were significant differences in practices with the first colposcopist using an 18-mm loop and the second colposcopist a 15-mm loop in the majority of cases. The median absolute and percentage difference between the presumed and actual excised depth was 2 mm and 16.6% and 3.5 mm and 35.4% for the two colposcopists, respectively. A learning plateau was identified only for the first colposcopist. We found that auditing consecutive excisions decreased significantly the difference between the presumed and actual depth of excision with a learning plateau at 2.2 mm of absolute difference and 22.6% of percentage difference and with a learning rate of 13 cervical excisions.
Conclusion(s): There might be a benefit in auditing our treatment practice as there seems to be a learning
plateau through this method

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HEART UK consensus statement on Lipoprotein(a): A call to action (2019)

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Type of publication:
Journal article

Author(s):
Cegla J.; Neely R.D.G.; France M.; Ferns G.; Byrne C.D.; Halcox J.; Datta D.; *Capps N.; Shoulders C.; Qureshi N.; Rees A.; Main L.; Payne J.; Cramb R.; Viljoen A.; Soran H.

Citation:
Atherosclerosis; Dec 2019; vol. 291 ; p. 62-70

Abstract:
Lipoprotein(a), Lp(a), is a modified atherogenic low-density lipoprotein particle that contains apolipoprotein(a). Its levels are highly heritable and variable in the population. This consensus statement by HEART UK is based on the evidence that Lp(a) is an independent cardiovascular disease (CVD) risk factor, provides recommendations for its measurement in clinical practice and reviews current and emerging therapeutic strategies to reduce CVD risk. Ten statements summarise the most salient points for practitioners and patients with high Lp(a). HEART UK recommends that Lp(a) is measured in adults as follows: 1) those with a personal or family history of premature atherosclerotic CVD; 2) those with first-degree relatives who have Lp(a) levels >200 nmol/l; 3) patients with familial hypercholesterolemia; 4) patients with calcific aortic valve stenosis and 5) those with borderline (but <15%) 10-year risk of a cardiovascular event. The management of patients with raised Lp(a) levels should include: 1) reducing overall atherosclerotic risk; 2) controlling dyslipidemia with a desirable non-HDL-cholesterol level of <100 mg/dl (2.5 mmol/l) and 3) consideration of lipoprotein apheresis.

Link to full-text [open access - no password required]

Corrigendum: It has been brought to our attention that the wording of the German reimbursement criteria for apheresis is not clear in the above paper (Section 7. Management of patients with raised Lipoprotein(a), Subheading: Apheresis). This should read: “In Germany, Lp(a) levels exceeding 60 mg/dl and LDL-cholesterol in normal range along with progressive CVD has been approved as an indication for regular lipoprotein apheresis since 2008.”

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