Staff Publication

Diagnostic laparoscopy in acute right iliac fossa (RIF) pain to take the appendix or to leave it in? (2015)

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Type of publication:
Conference abstract

Author(s):
*Sukha A., *Packer H., *Taylor M., *Goodyear S.

Citation:
Surgical Endoscopy and Other Interventional Techniques, April 2015, vol./is. 29/(S309-S310)

Abstract:
Aims Laparoscopy is used to both investigate acute RIF pain and treat the findings of an inflamed appendix. This study investigates the histology of appendixes where the clinical diagnosis was unclear on presentation and the investigative imaging was inconclusive. Methods Retrospective data collection between January – June 2014 of all appendectomies. Data was collected from Theatre logbooks and the Pathology and PACS computer systems, and analysed in Microsoft Excel. Results 50 patients had an undiagnosed cause of RIF pain. 15% (n = 34) had an USS and 7% (n = 16) had a CT. 58% (n = 29) of scans were reported as negative/inconclusive for appendicitis. All 29 patients had a DL and appendicectomy and 45% (n = 13) were histologically reported as appendicitis. There was 3% (n = 1) associated morbidity and 0% mortality. Conclusion The appendix should be removed when faced with a diagnostic uncertainty and no other pathology is found. The advancement of laparoscopic skills and training has led to low morbidity and mortality as supported by this study. We conclude it is safer to remove the appendix than to leave it in. Key statement The presentation of an acute right iliac fossa pain can sometimes be clinically difficult to diagnose. When investigations are normal or inconclusive and symptoms persist the advancement of laparoscopic surgery allows us to perform diagnostic laparoscopy. When there is no obvious pathology found the appendix should still be removed.

Is the negativity rate of laparoscopic appendicectomies on the increase? (2015)

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Type of publication:
Conference abstract

Author(s):
*Sukha A., *Packer H., *Taylor M., *Goodyear S.

Citation:
Surgical Endoscopy and Other Interventional Techniques, April 2015, vol./is. 29/(S313)

Abstract:
Aims: This study investigates the histological appearance of appendixes from laparoscopic and open appendicectomies. We propose that the negativity rate of laparoscopic appendicectomies is when compared to an open appendicectomy due to the advancements in laparoscopic equipment and surgeon skills. Methods Retrospective data collection of all appendicectomies between January – June 2014. Data was collected from Theatre logbooks and the Pathology and PACS computer systems, and analysed in Microsoft Excel. Results 226 appendectomies were performed on the emergency-operating list. 174 (77%) had a laparoscopic appendicectomy and 52(23%) had an open procedure. The negative appendix rate on histology was significantly higher in the laparoscopic group (28.2%, n = 49) versus the open group (11.5%, n = 6) p = 0.05. There was a 2% (n = 5) associated morbidity and 0% mortality. Conclusion Laparoscopic surgery is considered to be a minimally invasive surgical procedure with low associated risks. The appendix is removed when inflamed and often in right iliac fossa pain when no other pathology is found. Our study shows that laparoscopy may be overused resulting in higher than expected negativity rates. Key statement Laparoscopic surgery is fast becoming the preferred operative procedure for the suspected appendicitis diagnostic tool in the unclear presentation of right iliac fossa pain. The minimally invasive procedure is considered to be a safe procedure perhaps resulting in its overuse. We investigate the negativity rate in laparoscopic verses open appendicectomy.

Complications of airway management and how to avoid them (2014)

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Type of publication:
Journal article

Author(s):
*Chandra P., Frerk C.

Citation:
Trends in Anaesthesia and Critical Care, December 2014, vol./is. 4/6(195-199)

Abstract:
Major complications of airway management are rare, but complications causing minor patient harm are common. Our aim should be to manage our patients airways without causing any injury. Complications arise from technique failure, direct and indirect trauma and as a consequence of cardiovascular instability associated with our airway management techniques. Avoiding complications depends on planning (choosing the lowest risk procedure & having a well thought through strategy), providing optimal conditions, using the best available equipment and using the optimum technique for all practical procedures. This review provides an overview of the technical and non-technical aspects of airway management to help minimise the incidence of complications.

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Effect of hyperventilation on rate corrected QT interval of children (2013)

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Type of publication:
Journal article

Author(s):
*A Kannivelu, V Kudumula, V Bhole

Citation:
Archives of Disease in Childhood. 2013 Feb;98(2):103-6

Abstract:
BACKGROUND: Hyperventilation is known to cause ST segment changes and QT variability in adults, but this has not been systematically studied in children.
AIM: To investigate the effect of hyperventilation on rate corrected QT interval (QTc) in children.
METHODS AND RESULTS: 25 children (male=10) with a median age of 14 (range 8.3-17.6) years were asked to hyperventilate for 1 min before exercise testing using the modified Bruce protocol. Mean QTc at rest, after hyperventilation, at peak exercise and at 1 min of recovery was 425(±31), 460(±30), 446(±38) and 420(±32) ms, respectively. Mean increase (95% CI) in QTc after hyperventilation was 35(19 to 51) ms (p<0.001), while there was minimal difference between QT interval at rest and after hyperventilation (mean QT 352(±41) vs 357(±44) ms). In six children, there were abnormalities in T wave morphology following hyperventilation. The QTc increment following hyperventilation was more pronounced in children with resting QTc <440 ms (n=14, mean increment (95% CI): 55 (33 to 78) ms) compared to children with QTc ≥440 ms (n=11, mean increment (95% CI): 9 (-4 to 22) ms) (p=0.001). QTc prolongation following hyperventilation was seen in children with both low and intermediate probability of long QT syndrome (LQTS). Peak exercise and early recovery did not cause a statistically significant change in QTc in either of these groups.
CONCLUSIONS: Hyperventilation produces repolarisation abnormalities, including prolongation of QTc and T wave abnormalities in children with low probability of LQTS. The likely mechanism is delayed adaptation of QT interval with increased heart rate. Thus, a hyperventilation episode can be misdiagnosed as LQTS, especially in an emergency department.

Link to more details or full-text: http://adc.bmj.com/content/early/2012/12/13/archdischild-2012-302663.full.pdf

Enhance It - Enhancing Hospital Laboratory Standards for Continuing Professional Development: Transnational Evaluation of a Novel CPD Activity for Specialists in Laboratory Medicine (2014)

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Type of publication:
Conference abstract

Author(s):
Martin J, Gasljevic V, Sálek T, Horvath A, Borg C, Flegar-Meštrić Z, Jakovcic M, Silhavik J, Adonics A, Szlamka Z, Brincat I, Buttigieg D, Ciantar N, Sciortino AL, Mifsud A, Adkins A, *Bennett T, Rice K, Taylor Y.

Citation:
The Future of education 2014

Abstract:
A project which has received funding of over 100,000 euros from the European Union’s Lifelong Learning Leonardo Program is developing good practice in continuing professional development (CPD) for Specialists in Laboratory Medicine. The Partnership is developing an EU-toolkit for delivery of high quality CPD activities provided by European hospital laboratories. This paper reports on the first stage of the project which is transnational evaluation of a novel European CPD activity by hospital laboratories in Croatia, Czech Republic, Malta and the United Kingdom. An innovative CPD activity was designed to facilitate participation by Specialists in Laboratory Medicine in all partner countries. The topic of Health and Safety was chosen to enable maximum European participation as it is a multi-disciplinary topic of relevance to all Specialists in Laboratory Medicine in all partner countries. A series of thirty images of either good or bad laboratory practice in Health and Safety were provided to participants who were required to state whether the photograph depicted good or bad practise. If bad practise was shown Specialists in Laboratory Medicine were asked to explain what further actions would be taken including reporting procedures. On completion of the exercise, participants took part in a discussion group, completed a reflective learning sheet and filled in an evaluation questionnaire. Subsequently, in order to contextualise the CPD activity within their own laboratories participants will be asked to note any poor practice in their laboratory, discuss with colleagues, develop an action plan, repeat at monthly intervals and report on Health and Safety improvements. Over one hundred Specialists in Laboratory Medicine from four different European countries Croatia (n=14), Czech Republic (n= 10), Malta (n=65) and UK (n=29) took part in this new CPD activity. Several different grades of laboratory staff evaluated the activity and indicated that the exercise had been useful and appropriate to their scope of practice (99.2%) and relevant for their own CPD (97%). For over 80% of participants, this was the first time that they had taken part in this novel format of CPD activity. Discussion with colleagues following completion of the activity provided useful enhancement to both scope of practice (92%) and CPD (87%). Subsequent completion of a reflective learning sheet was shown to be beneficial for 86% of participants. We conclude that participation in this novel CPD activity which demonstrated a 100% overall satisfaction rate, has facilitated enhanced European cooperation between participating hospital laboratories and will provide a platform for future more intensive European co-operation by Specialists in Laboratory Medicine to work closely together to harmonise their practice and profession throughout the European Union.

Link to more details or full-text: http://conference.pixel-online.net/FOE/acceptedabstracts_scheda.php?id_abs=554#null

 

How good are surgeons at identifying appendicitis? Results from a multi-centre cohort study (2015)

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Type of publication:
Journal article

Author(s):
Strong S., Blencowe N., Bhangu A., Panagiotopoulou I.G., Chatzizacharias N., Rana M., Rollins K., Ejtehadi F., Jha B., Tan Y.W., Fanous N., Markides G., Tan A., Marshal C., Akhtar S., Mullassery D., Ismail A., Hitchins C., Sharif S., Osborne L., Sengupta N., Challand C., Pournaras D., Bevan K., King J., Massey J., Sandhu I., Wells J.M., Teichmann D.A., Peckham-Cooper A., Sellers M., Folaranmi S.E., Davies B., Potter S., Egbeare D., Kallaway C., Parsons S., Upchurch E., Lazaridis A., Cocker D., King D., Behar N., Loukogeorgakis S.P., Kalaiselvan R., Marzouk S., Turner E.J.H., Kaptanis S., Kaur V., Shingler G., Bennett A., Shaikh S., Aly M., Coad J., Khong T., Nouman Z., Crawford J., Szatmary P., West H., MacDonald A., Lambert J., Gash K., Hanks K.A., Griggs E., Humphreys L., Torrance A., Hardman J., Taylor L., Rex D., Bennett J., Crowther N., McAree B., Flexer S., Mistry P., Jain P., Hwang M., Oswald N., Wells A., Newsome H., Martinez P., Alvarez C.A.B., Leon J., Carradice D., Gohil R., Mount M., Campbell A., Iype S., Dyson E., Groot-Wassink T., Ross A.R., Charlesworth P., Baylem N., Voll J., Sian T., Creedon L., Hicks G., Goring J., Ng V., Tiboni S., Palser T., Rees B., Ravindra P., Neophytou C., Dent H., Lo T., Broom L., O'Connell M., Foulkes R., Griffith D., Butcher K., Mclaren O., Tai A., Yano H., Torrance H.D.T., Moussa O., Mittapalli D., D.Watt, Basson S., Gilliland J., Pilgrim S., Wilkins A., Yee J., Cain H., Wilson M., Pearson J., Turnbull E., Brigic A., Yassin N.A., Clarke J., Mallappa S., Jackson P., Jones C., Lakshminarayanan B., Sharma A., Velineni R., Fareed K., Yip G., Brown A., Patel N., Ghisel M., Tanner N., Jones H., Witherspoon J., Phillips M., Ho M.F., Ng S., Mak T., Campain N., Mukhey D., Mitchell W.K., Amawi F., Dickson E., Aggarwal S., Satherley L.K., Asprou F., Keys C., Steven M., Johnstone M., Muhlschlegel J., Hamilton E., Yin J., Dilworth M., Wright A., Spreadborough P., Singh M., Mockford K., Morgan J., Ball W., Royle J., Lacy-Colson J., Lai W., Griffiths S., Mitchell S., Parsons C., Joel A.S., Mason P.F., Harrison G.J., Steinke J., Rafique H., Battersby C., Hawkins W., Gurram D., Hateley C.A., Penkethman A., Lambden C., Conway A., Dent P., Yacob D., Oshin O.A., Hargreaves A., Gossedge G., Long J., Walls M., Futaba K., Pinkney T., Puig.S, Boddy A., Jones A., Tennuci C., Battersby N., Wilkin R., Lloyd C., Sein E., McEvoy K., Whisker L., Austin S., Colori A., Sinclair P., Loughran M., Lawrence A., Horsnell J., Bagenal J., Pisesky A., Mastoridis S., Solanki K., Siddiq I., Merker L., Sarmah P., Richardson C., Hanratty D., Evans L., Mortimer M., Bhalla A., Bartlett D., Beral D., Cornish J., Haddow J.B., Hall N.J.

Citation:
International Journal of Surgery, March 2015, vol./is. 15/(107-112)

Abstract:
Background: Convincing arguments for either removing or leaving in-situ a macroscopically normal appendix have been made, but rely on surgeons' accurate intra-operative assessment of the appendix. This study aimed to determine the inter-rater reliability between surgeons and pathologists from a large, multicentre cohort of patients undergoing appendicectomy. Materials and methods: The Multicentre Appendicectomy Audit recruited consecutive patients undergoing emergency appendicectomy during April and May 2012 from 95 centres. The primary endpoint was agreement between surgeon and pathologist and secondary endpoints were predictors of this disagreement. Results: The final study included 3138 patients with a documented pathological specimen. When surgeons assessed an appendix as normal (n=496), histopathological assessment revealed pathology in a substantial proportion (n=138, 27.8%). Where surgeons assessed the appendix as being inflamed (n=2642), subsequent pathological assessment revealed a normal appendix in 254 (9.6%). There was overall disagreement in 392 cases (12.5%), leading to only moderate reliability (Kappa 0.571). The grade of surgeon had no significant impact on disagreement following clinically normal appendicectomy. Females were at the highest risk of false positives and false negatives and pre-operative computed tomography was associated with increased false positives. Conclusions: This multi-centre study suggests that surgeons' judgements of the intra-operative macroscopic appearance of the appendix is inaccurate and does not improve with seniority and therefore supports removal at the time of surgery.

Establishing a large prospective clinical cohort in people with head and neck cancer as a biomedical resource: head and neck 5000 (2015)

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Type of publication:
Journal article

Author(s):
Ness A.R., Waylen A., Hurley K., Jeffreys M., Penfold C., Pring M., Leary S., Allmark C., Toms S., Ring S., Peters T.J., Hollingworth W., Worthington H., Nutting C., Fisher S., Rogers S.N., Thomas S.J., Rogers S., Thiruchelvam J.K., Abdelkader M., Anari S., Mehanna H., Sheehan T., Dyker K., McCaul J., Benson R., Stewart S., Hall C., Lester J., Homer J., Hamid A., Lamont A., Fresco L., Lester S., Cogill G., Roy A., Foran B., Bisase B., Balfour A., Evans A., Gollins S., Conway D., Gunasekaran S.P., Lees L., Lowe R., England J., Scrase C., Wight R., Sen M., Doyle M., Moule R., Goodchild K., Rowell N., Beaumont-Jewell D., Loo H.W., Jankowska P., Paleri V., Casasola R., Roques T., Tierney P., Hwang D., Dyson P., Andrade G., Tatla T., Christian J., Winter S., Baldwin A., Davies J., King E., Barnes D., Repanos C., Kim D., Richards S., Dallas N., McAlister K., Berry S., Cole N., Moss L., Palaniappan N., Evans M., Siva M., *Hari C. , Wood K., Simcock R., Waldron J., Hyde N., Ahmed I., Gahir D., O'Hara J., Carr R., Forster M., Thomas S., Wagstaff L., Mano J., Brammer C., Tyler J., Coatesworth A.

Citation:
BMC Cancer, December 2014, vol./is. 14/1, 1471-2407 (December 17, 2014)

Abstract:
Background: Head and neck cancer is an important cause of ill health. Survival appears to be improving but the reasons for this are unclear. They could include evolving aetiology, modifications in care, improvements in treatment or changes in lifestyle behaviour. Observational studies are required to explore survival trends and identify outcome predictors. Methods: We are identifying people with a new diagnosis of head and neck cancer. We obtain consent that includes agreement to collect longitudinal data, store samples and record linkage. Prior to treatment we give participants three questionnaires on health and lifestyle, quality of life and sexual history. We collect blood and saliva samples, complete a clinical data capture form and request a formalin fixed tissue sample. At four and twelve months we complete further data capture forms and send participants further quality of life questionnaires. Discussion: This large clinical cohort of people with head and neck cancer brings together clinical data, patient-reported outcomes and biological samples in a single co-ordinated resource for translational and prognostic research.

Link to full-text: http://europepmc.org/articles/PMC4301458

Case report of generalized pustular psoriasis of von Zumbusch associated with hypothyroidism (2014)

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Type of publication:
Conference abstract

Author(s):
*Mirhadi S., Moazenzade M.

Citation:
British Journal of Dermatology, December 2014, vol./is. 171/6(e147-e148), 0007-0963 (December 2014)

Abstract:
Generalized pustular psoriasis (GPP), a rare subtype of psoriasis, is characterized by abrupt extensive pustular eruptions with potentially fatal outcome. This report describes a case of GPP associated with hypothyroidism. A 28-year-old Iranian woman presented 5 years ago with pustular lesions with underlying erythematous background, which spread over > 50% of her body and was particularly severe in her calf and lower abdomen. The size of lesions was 4-20 cm. She also had systemic symptoms including fever, rigors, arthralgia, loss of appetite and severe depression. In addition, she had peripheral oedema and lymphadenopathy in the submental and anterior cervical chain. She had no significant past medical history. Her family history included mild localized psoriasis in her mother. She was admitted on five occasions, for 2 weeks, at intervals of 6-12 months with acute relapses. The attacks occurred mainly during the winter and summer. No drugs have been implicated. Skin biopsy confirmed pustular psoriasis. Unbroken pustules were sterile. The main biochemical abnormalities were elevated erythrocyte sedimentation rate, leucocytosis, iron-deficiency anaemia, hyperlipidaemia and hypoproteinaemia in the acute phase. During her third attack, it was noticed that she had hypothyroidism. She was treated with low-dose systemic corticosteroid for her acute attacks. Both the skin lesions and peripheral oedema started to respond on day 5 of steroids. Weaning of steroids was commenced in week 3. Among systemic drugs, she tolerated only a retinoid (Neotigason) and she had longer remissions with retinoids. Following the correction of her anaemia, hypothyroidism and peripheral circulation using tensile bandage, and additional family support, her condition is now improving. She occasionally gets small localized lesions that respond well to combined topical steroid with mupirocin. Following resolution of her pustules, topical Daivonex (calcipotriol) and steroid are used. The plan is to reduce the dose of Neotigason gradually. Multiple trigger factors for GPP have been described, including low thyroid activity. GPP is associated with autoimmune conditions such as hypothyroidism. Its prognosis is better in younger age and when the pustular psoriasis is preceded by ordinary psoriasis. In conclusion, we report a typical case of GPP with systemic symptoms, raised inflammatory markers, leucocytosis, hypoalbuminaemia, anaemia, hyperlipidaemia and hypothyroidism. Pharyngitis and emotional stress were identified as triggers. Her management was quite complicated and the disease finally responded to steroids, retinoid and calcipotriol. This patient did not develop any life-threatening complication.

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