Staff Publication

Autoregulation versus defaecation: An unusual side effect of CPAP (2014)

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Type of publication:
Conference abstract

Author(s):
*Stone H., *Fazal F., *Moudgil H., *Ahmad N., *Naicker T., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 (Suppl 58)

Abstract:
Introduction Continuous Positive Airway Pressure is the first line treatment for symptomatic moderate to severe obstructive sleep apnoea. Side effects of CPAP are well known; however faecal incontinence secondary to CPAP is not documented. We present the case of a patient with OSA who developed this on commencing CPAP. Case A 50 year old female with ulcerative colitis had a total colectomy in 1992 and a subsequent ileo-anal pouch reconstruction. She was referred to the sleep clinic as she was experiencing daytime somnolence (Epworth score of 15/24). Her sleep study demonstrated severe obstructive sleep apnoea with an apnoea-hypopnoea index of 35.2, and for 12.5% of the study, her Sa02 were below 90%. She was commenced on CPAP using auto titration. Initially, she experienced problems with faecal leakage – defecating up to 4 times per night. During this time her mean CPAP pressure had been 17cm water. She was subsequently converted CPAP at 10cms fixed maximum pressure and now tolerates CPAP very well; having a degree of faecal leakage only 2 or 3 times a week, rather than every night as previously. Her Epworth score has now fallen to 9/24, her AHI is 2.5 and her OSA symptoms have improved, leading to better treatment compliance. Conclusion It was hypothesised that the patient's problems were related to increased intra-thoracic pressure from the CPAP, resulting in raised intra-abdominal pressure, putting a strain on the ileo-anal pouch reconstruction giving rise to the faecal incontinence. This resolved with lower CPAP pressures, resolving the faecal frequency whilst still adequately treating the OSA. Limiting pressures should be considered in the future in patients with colorectal disease to avoid faecal incontinence.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P2292.short?rss=1

 

Recurrence patterns for venous thromboembolism-who is most at risk? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E., *Moudgil H., *Naicker T., *Ahmad N., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 Supp 58

Abstract:
National guidance regarding the treatment of venous thromboembolism (VTE) advocates anticoagulating newly diagnosed patients for three months, followed by consideration of indefinite anticoagulation to reduce the risk of recurrent VTE in certain clinical situations. (NICE Clinical Guideline CG144, issued June 2012.) There is recent evidence that although deep vein thromboses (DVT) and pulmonary emboli (PE) are manifestations of the same disease, their patterns of recurrence and hence future morbidity and mortality risk are different. (Baglin, T. et al. Journal of Thrombosis and Haemostasis 2010; 8(11):2436-2442.) We undertook a retrospective case-note review of 416 patients diagnosed with a VTE event within our institution between January 2010 and January 2011 to assess risk and pattern of VTE recurrence. 35 patients (8.4%) had a recurrent VTE event in the 3 years following diagnosis. Median time to recurrence was 12 months (mean 16.5, SD 10.5). None of the patients were anticoagulated at the time of recurrence and no patients died as a result of their thromboembolic event. Patterns of VTE recurrence The majority of patients with recurrent VTE in our study presented as a further DVT and as such, could be considered at lower risk of associated morbidity and mortality compared to those presenting with PE. Clinicians should consider the likely presentation of any further VTE recurrence as part of their assessment before advocating indefinite anticoagulation in these patients, particularly as the introduction of new oral anticoagulant drugs is likely to make the logistics of prescribing lifelong anticoagulation less complex.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P4114.short?rss=1

 

The diagnosis of malignancy following a venous thromboembolic event-how high is the risk? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E., *Moudgil H., *Naicker T., *Ahmad N., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 Supp 58

Abstract:
UK guidance on the treatment of venous thromboembolism (VTE) recommends that patients with a first, unprovoked VTE should be screened for malignancy. This is based on two historical population-based studies which suggest that between 7.5 and 11% of patients diagnosed with an unprovoked VTE will develop cancer in the following two years. (Murchison, J. T. et al. Br J Cancer 2004;91(1):92-95. Baron, J.A. et al. Lancet 1998; 351(9109):1077-1080.) We wanted to compare local figures with this historical data in order to aid local guideline development. A retrospective case note review identified 417 patients within our institution diagnosed with VTE between January 2010 and January 2011. Ten of these patients (2%) developed cancer in the two years following diagnosis. Results In 2 out of 10 of these patients, tests performed as part of the routine work-up for VTE identified abnormalities that ultimately led to a diagnosis of cancer. None of the patients had extensive malignancy screening as advocated by current UK guidance. Within our local population, the risk of developing cancer in the two years following an unprovoked VTE appears to be significantly less than figures quoted in the literature. UK guidelines may not reflect current medical practice, which could be identifying cancer earlier, nor does it take into account the possibility of regional and national variations of disease. A cautious approach should be taken when counselling patients regarding future cancer risk and when considering further investigations for malignancy.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P4115

 

New-onset diabetes after renal transplant (NODAT) presenting as diabetic ketoacidosis (DKA) in a patient with sickle cell disease (2015)

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Type of publication:
Conference abstract

Author(s):
*Kaldindi S.R., *Moulik P., *Macleod A.

Citation:
Diabetic Medicine, March 2015, vol./is. 32/(117-118)

Abstract:
A 42-year-old Afro-Caribbean female presented with 1 week history of polyuria, polydypsia and vomiting. She had a background of transfusion associated iron overload and renal failure secondary to sickle cell disease. She underwent a live donor renal transplant 8 months prior to admission. Immunosuppressive therapy included tacrolimus, mycophenolate, prednisolone 5mg once a day. There was no family history of diabetes. She had a normal body mass index. Results revealed a pH of 7.08, bicarbonate of 6.6mmol/l, capillary blood glucose tests recorded as greater than 28.7mmol/l, ketones 7.0mmol/l, Hb 84 g/l. Her creatinine was 101mumol/l (baseline 90), eGFR 52 and tacrolimus levels were within therapeutic range. No obvious precipitant for diabetic ketoacidosis (DKA) was found. She responded well to intravenous fluids and insulin. Her glutamic acid decarboxylase (GAD) and islet antigen 2 (IA2) antibodies were negative. Possible causes for her diabetes include iron overload, steroid therapy, tacrolimus. In her case, she presented with a short timeline of symptoms along with severe DKA. This is typical of Type 1 diabetes, even though her antibodies were negative. NODAT usually behaves like Type 2 diabetes but, rarely, such patients can also present with an insulin deficient state similar to Type 1 diabetes. The Renal Association suggests lower levels of tacrolimus to decrease NODAT risk and screening for diabetes post-transplant. A steroid sparing immunosuppressive regimen may help in reducing the incidence of NODAT.

Link to full-text [NHS OpenAthens account required]

Selective diabetic gastroparesis (2015)

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Type of publication:
Conference abstract

Author(s):
*Rai D., *Kalidindi S., *Moulik P., *Macleod A.

Citation:
Diabetic Medicine, March 2015, vol./is. 32/(118)

Abstract:
Up to 5% of people with Type 1 diabetes have been reported to have gastroparesis. We present the case of a 19-year-old female who presented to hospital with diabetic ketoacidosis due to intractable vomiting. She developed Type 1 diabetes aged 8. Initial diabetes control was very poor, with a peak HbA1c of 167mmol/ mol and she developed severe non-proliferative diabetic retinopathy. One year prior to admission, she actively improved her blood sugars and dropped her HbA1c gradually down to 105mmol/mol. Paradoxically this seems to have worsened her vomiting. She denied any other symptoms of enteropathy and had no signs of autonomic or peripheral neuropathy. A CT and MRI brain were negative. She developed malnutrition requiring total parenteral nutrition and trials of prokinetics, dietary modifications were unsuccessful. A percutaneous endoscopic gastrotomy-jejunal tube was inserted which allowed simultaneous post pyloric feeding and gastric decompression. After a period of stable blood glucose with an HbA1c of 48mmol/mol, she had a formal gastric emptying study which confirmed severe delayed gastric emptying with a time (lag) of 87 min (normal <55) and half-life of 119 min (normal <80). Gastroscopy showed severe reflux oesophagitis consistent with delayed gastric emptying. She is currently awaiting a gastric pacemaker and manages to have small frequent meals with supplemental jejunal feeding. Diabetic gastroparesis is usually associated with peripheral and autonomic neuropathy, but she seems to have isolated gastroparesis. She also developed severe depression, psychological issues which required cognitive behavioural therapy. These issues could have worsened her symptoms.

Link to full-text: http://onlinelibrary.wiley.com/doi/10.1111/dme.12668_1/pdf

 

Three-Year delayed presentation of femoral pseudoaneurysm after penetrating limb trauma (2015)

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Type of publication:
Journal article

Author(s):
Butterworth J.W., *Butterworth W.A., Wu R.

Citation:
Annals of Vascular Surgery, February 2015, vol./is. 29/2(362.e11-362.e15)

Abstract:
Background Delayed presentations of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare. Methods After presentation of this rare case report, we review relevant published literature. Results We report a rare case of a 55-year-old man with a progressively enlarging mass measuring 15 cm by 15 cm on his right anteromedial thigh 3 years after penetrating trauma. Computer tomography angiogram revealed this to be a large pseudoaneurysm supplied by a side branch artery from the right superficial femoral artery. Using an open approach, the pseudoanerysm was successfully repaired with the side branch oversewn, and the patient made a good recovery being discharged from hospital 4 days later. Conclusions Surgeons must retain pseudoaneurysm as a prominent differential for a patient presenting with a progressively enlarging, expansile mass of an extremity after penetrating trauma to ensure urgent investigation and prompt vascular intervention. Both open surgical ablation and endovascular embolization of pseudoaneurysms of the extremities are effective techniques with low rates of complications and morbidity reported in published literature.

 

Monckeberg's arteriosclerosis: Vascular calcification complicating microvascular surgery (2015)

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Type of publication:
Journal article

Author(s):
*Castling B., *Bhatia S., *Ahsan F.

Citation:
International Journal of Oral and Maxillofacial Surgery, January 2015, vol./is. 44/1(34-36)

Abstract:
Monckeberg's arteriosclerosis is often an incidental finding, identified either clinically or on plain radiography. It can occasionally be associated with diabetes mellitus or chronic kidney disease. It differs from the more common atherosclerosis in that the tunica intima remains largely unaffected and the diameter of the vessel lumen is preserved. Despite such vessels appearing hard and pulseless throughout their affected length, they deliver relatively normal distal perfusion, indeed there is often a bounding pulse at the end of the calcified zone. They appear unremarkable on magnetic resonance angiography but visibly calcified on plain radiography. Monckeberg's arteriosclerosis has a prevalence of < 1% of the population, but when it does occur it can cause consternation at the prospect of using these vessels for microvascular anastamosis. We report our experience of deliberately using these vessels in an osseocutaneous radial forearm free flap reconstruction. Although there are some technical considerations to bear in mind, we would suggest that unlike vessels affected by atherosclerosis, anastomosis of arteries affected by Monckeberg's arteriosclerosis has little or no impact on free flap survival.

 

Fistula formation between the external iliac artery and ileal conduit following a radical cystoprostatectomy: a rare complication with prewarning signs of haemorrhage (2015)

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Type of publication:
Journal article

Author(s):
*Anisha Sukha, *Niamh Smyth

Citation:
BMJ Case Reports 2015:published online 27 March 2015

Abstract:
A 76-year-old man was admitted with bleeding perurostomy following a collapse at home. Three weeks prior to the admission, he had undergone a radical cystoprostatectomy and formation of ileal-conduit for an extensive bladder carcinoma. A CT angiogram revealed a possible small source of bleeding within the ileal-conduit itself, which settled with conservative management. However, prior to discharge he developed profuse fresh bleeding from the urostomy, which could not be controlled. The patient underwent an emergency endoscopy of the conduit and laparotomy, which revealed a fistula between the right external iliac artery and the proximal end of the ileal-conduit. The right iliac artery was ligated and an emergency left-to-right femoral-femoral crossover bypass was performed. The right ureter was stented and rediverted through the ilealconduit and the left ureter was stented at a later date. He unfortunately had a stormy postoperative recovery with further episodes of per-urostomy bleeding and no identified source.

Link to full-text: http://casereports.bmj.com/content/2015/bcr-2014-208914.short?rss=1

 

UK consensus position on the management of homozygous familial hypercholesterolaemia and the introduction of new agents (2014)

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Type of publication:
Conference abstract

Author(s):
R. Cramb, H. Soran, *N. Capps, A. Rees, K. Ray, W. Madira, J. Deanfield, G. Thompson

Citation:
Atherosclerosis, August 2014, vol./is. 235/2(e252-e253), 0021-9150 (August 2014)

Abstract:
Objectives: To provide a consensus position on the potential use of new therapies in the management of homozygous familial hypercholesterolaemia (HoFH) based on a review of the current standards of care, unmet medical need and new clinical evidence. The term HoFH is used to include compound heterozygous familial hypercholesterolamia as defined in the National Institute for Clincal Excellence guidelines. Methods: Participants in this discussion included clinicians managing HoFH in specialist centres, clinicians from lipid clinics and cardiologists with an interest in lipid disorders. Results: HoFH is a rare inherited disorders of cholesterol metabolism with a historical reported prevalence of 1/1,000,000. A survey in the United Kingdom (UK) identified 43 patients with a diagnosis of HoFH who receive care in one of 8 UK specialist centres. Conventional lipid lowering agents have a limited variable effect on low density lipoprotein cholesterol (LDLC) levels in HoFH. The current standard of care is by the use of lipoprotein apheresis that provides a temporary reduction in LDL-C with repeat apheresis at weekly or fortnightly intervals. Some of these patients are unable to tolerate regular apheresis, a high proportion may not achieve the European Athereosclerosis Society LDL-C targets for apheresis and there is uncertainty whether regular apheresis will prevent progression of disease. With the advent of new therapeutic approaches, the first of these being a microsomal transfer protein (MTP) inhibitor, UK clinicians have considered adopting a potentital management pathway to enhance care of patients with HoFH. Conclusion: HoFH are rare but life-threatening conditions, that require specialist therapeutic options. We describe a management pathway for patients with HoFH that considers current therapeutic options and directs the indications for new treatments to ensure maximum clinical benefit.

Link to more details or full-text:

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