Staff Publication

A novel sampling device for collecting mucocellular material from the unprepared rectum (2014)

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Type of publication:
Conference abstract

Author(s):
Booth J., *Lacy-Colson J., Norwood M., Murray C.

Citation:
Gut, June 2014, vol./is. 63/(A124-A125), 0017-5749 (June 2014) (also published in European Journal of Cancer, July 2014, vol./is. 50/(S240), 0959-8049 (July 2014))

Abstract:
Background: In vitro diagnostic tests are being developed to evaluate informative protein or DNA biomarkers in stool or blood samples. Stool samples are inconvenient to collect and handle, and may suffer from contamination that interferes with molecular assays. Blood samples may not be as informative early in the disease process. Studies have shown that significant numbers of exfoliated cells and their products are retained in a muco-cellular layer overlaying the colonic mucosa, but distinct from the stool, and that this material flows toward the rectum, where it can be captured for analysis. Materials and Methods: Origin Sciences (OS) has developed a novel sampling device that incorporates an inflatable nitrile membrane. Following insertion into the unprepared rectum via a standard proctoscope, the membrane is inflated to make contact with the rectal mucosa for 10 seconds. The membrane is then deflated and retracted into the device prior to removal from the patient. Upon retraction the sampled material is retained on the inverted membrane, which acts as a receptacle for the addition of buffer preserving the material for subsequent analysis. Results: The sampler has now been tested in over 2000 patients and healthy volunteers, and has shown excellent acceptability. Tests and in vitro experiments with monolayers of cultured human cells indicate that the membrane captures intact cells, which are easily washed off the membrane for further investigation. Detailed evaluation of the mucous-associated material captured by the device, in both normal and diseased states, shows it to be rich in protein and nucleic acids. Levels of soluble protein present in standard 3 mL capture buffer varied between 90 and 3000 mug/mL, with a mean of 710 mg/muL. OS has detected informative auto-antibodies of isotypes IgA, IgG, and IgM by ELISA in the protein component of these preparations. These preparations are also rich in nucleic acids; DNA was found at levels ranging from 0.5 to 21.9 mg/muL. This DNA appears to retain a high degree of integrity, since a number of informative genes have been detected by quantitative PCR. Conclusions: The sampling device represents a novel and minimally invasive tool for capturing biomarker-rich material from the unprepared rectum. With minimal contamination by stool, the material collected is readily analysable. In principle this device lends itself to point-of-care testing for a range of indications, including infectious and inflammatory diseases of the GI tract, in addition to malignancy.

Link to more details or full-text:
http://gut.bmj.com/content/63/Suppl_1/A124.2

Demonstrating the impact of laboratory medicine on clinical outcomes (2014)

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Type of publication:
Conference abstract

Author(s):
*Hallworth M.

Citation:
Clinical Chemistry and Laboratory Medicine, July 2014, vol./is. 52/(S34), 1434-6621 (July 2014)

Abstract:
Clinical laboratory workers believe that the work they perform in providing laboratory tests is valuable. However, data to validate this has been limited, and evidence of the contribution of laboratory medicine to the overall process of diagnosis and management is not easy to obtain. This session will describe the work of the IFCC Task Force on the Impact of Laboratory Medicine on Clinical Management and Outcomes (TF-ICO). It will examine existing evidence, review the gaps in our understanding and deficiencies in the way laboratory medicine is used, and indicate how these can be remedied. Many articles and presentations seeking to promote the value of laboratory medicine have made use of what has become known as the ”70% claim”. This is presented in various forms, most commonly that ”Laboratory Medicine influences 70% of clinical decisions”, or minor variations around this figure. However, the data on which this estimate was based represents unpublished studies and anecdotal observations, and cannot now be objectively verified. The IFCC TF-ICO was established in 2012 to evaluate the available evidence supporting the impact of laboratory medicine in healthcare, and to develop the study design for new studies to generate evidence of the contribution made by laboratory medicine. This presentation will examine existing evidence, review the gaps in our understanding and deficiencies in the way laboratory medicine is currently used, indicate how these might be remedied and offer a vision of a future state in which laboratory medicine is used effectively to support patient care and enhance patient safety. An approach to measuring value will be proposed in which the net value of a testing process is defined as delivered benefits minus delivered harm (undesirable effects of testing). Value is maximized by increasing the benefits and reducing harm. Much of the evidence relating to the value of laboratory medicine is poorly structured and does not relate to clinical outcomes. A more rigorous approach is required. Laboratory medicine has much to offer, but can cause adverse outcomes if not properly used. Laboratorians need to refocus their attention onto improving outcomes.

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Top 15 research priorities for preterm birth with clinicians and service users' involvement-outcomes from a james lind alliance priority setting partnership (2014)

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Type of publication:
Conference abstract

Author(s):
Uhm S., Alderdice F., Chambers B., Gyte G., Gale C., Duley L., James C.P., David A.L., McNeill J., Turner M.A., Shennan A., *Deshpande S., Crowe S., Chivers Z., Brady I., Oliver S.

Citation:
Archives of Disease in Childhood: Fetal and Neonatal Edition, June 2014, vol./is. 99/(A158), 1359-2998 (June 2014)

Abstract:
Background Preterm birth is the single most important determinant of adverse infant outcomes in terms of survival, quality of life, psychosocial and emotional impact on the family, and health care costs. Research agenda in this area has been determined primarily by researchers, and the processes for priority setting in research have often lacked transparency. Objectives To identify 15 most important priorities for future research for practitioners and service users in the area of preterm birth. Methods A priority setting partnership was established by involving clinicians, adults who were born preterm, and parents and families with experience of preterm birth. Research uncertainties were gathered from surveys of service users and clinicians, and analyses of systematic reviews and clinical guidance, and then prioritised in a transparent process, using a methodology advocated by the James Lind Alliance. Results 593 uncertainties were submitted by 386 respondents and 52 were identified from literature reviews. After merging similar questions, a long list of 104 questions were distributed for voting. The 30 most popular items were then prioritised at a workshop. The top 15 research priorities included prevention of preterm birth, management of neonatal infection, necrotising enterocolitis, pain and lung damage, care package at discharge, feeding strategies, pre-eclampsia, emotional and practical support, attachment and bonding, premature rupture of membranes and best time for cord clamping. Conclusions These top research priorities in preterm birth provide guidance for researchers and funding bodies to ensure that future research addresses questions that are important to both clinicians and service users.

Link to more details or full-text: http://fn.bmj.com/content/99/Suppl_1/A158.1.abstract

 

Is it a time to consider introducing simulation training for 'Child Safeguarding'? (2014)

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Type of publication:
Conference abstract

Author(s):
*Saran S., *Brough R., *Ganesh M., *Vadali Y.

Citation:
Archives of Disease in Childhood, April 2014, vol./is. 99/(A64), 0003-9888 (April 2014)

Abstract:
Background Child protection medical examination is an essential competency for any trainee to progress through CCT. Often trainees are apprehensive when asked to perform Child Protection medicals. Inadequate training may lead to poor quality assessments resulting in potential risk to the child, family and possible litigations. Aim To elucidate the learning opportunities which Paediatric trainees get in an average sized district general hospital in England. Methods We have audited notes of children who were referred for the ”Child Protection Medical Examination” to our hospital between 01/05/2012 to 30/09/2013. Results There were 24 ”Child Protection Medical Assessments” performed during 16 months. Both boys and girls were equal in number (12 each). 3 (12%) children were under the age of 12 months, 11 (46%) were between 1 and 5 years and 10 (42%) were older than 5 years. 20 (84%) of these assessments were performed during the weekday and 4 (16%) were done during the weekends. 9 (38%) of the assessments were performed by the ’Community Paediatric Registrars’ who are on call to perform this task in the weekdays during the normal working hours. Equal number 9 (38%) of assessments was performed by the ’Ward Registrars’. On call general paediatric consultants did remaining 6 (24%) assessments. Conclusion Child safeguarding attracts media attention often due to medical inadequacies. We are aware about various serious case reviews in the past and a common recommendation in all of them was to ensure proper training of the front line staff. 24 child protection examinations in 16 months imply an average of 1.5 per month. Just to add to our worry is that on call registrars for child safeguarding have only performed 9 assessments in 16 months, i.e. approximately one assessment every other month. We are seriously concerned about lack of exposure which trainees are getting in this very important component of Paediatric training. We strongly feel to consider other training modalities including introducing simulation technique for ”Child Safeguarding” in the Paediatric curriculum.

Link to more details or full-text: http://adc.bmj.com/content/99/Suppl_1/A64.1

 

Does compliance with the 2 week wait colorectal cancer referral system lead to a higher cancer detection rate? (2014)

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Type of publication:
Conference abstract

Author(s):
*Kaur P., *Cheetham M. , *McCloud J.

Citation:
Colorectal Disease, July 2014, vol./is. 16/(73), 1462-8910 (July 2014)

Abstract:
Background: Current guidelines suggest that patients with a suspected colorectal cancer are seen within 2 weeks of the referral made by general practitioners. Recent data has shown an increase in referrals with a decrease in cancer yield, with up to 25% of all referrals made not meeting referral guidelines. This study aims to determine if there is a higher cancer detection rate in referrals compliant with the referral criteria. Method: A retrospective study of patients referred to a 2-week wait colorectal clinic over a 3-month period was performed. Referral proformas and initial clinic letters were assessed to determine compliancy with the 2 week wait criteria and number of cancers diagnosed. Results: 287 patients were seen in the 3 month period. 38% of referrals were not compliant with the referral criteria. The main reasons for noncompliance were age of the patient (28%) and duration of symptoms (21%). 15 (5.2%) patients were diagnosed with cancer. Compliant referrals had higher cancer detection rate, 13/180 patients (7.2%) when compared with non-compliant referrals, 2/107 patients (1.9%). Conclusion: Compliance with the referral criteria is associated with a higher cancer detection rate. Better education for general practitioners may help to reduce the number of non-compliant referrals reducing work load on strained colorectal units.

 

Laparoscopic ileocaecal resection for Crohn's disease: Initial experience in Shrewsbury (2014)

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Type of publication:
Conference abstract

Author(s):
*Vidyasankar V., *Cheetham M. , *McCloud J

Citation:
Colorectal Disease, July 2014, vol./is. 16/(189), 1462-8910 (July 2014)

Abstract:
Aim: Randomised controlled trials have demonstrated short-term advantages to laparoscopic surgery for ileocaecal Crohn’s disease. Following the introduction of laparoscopic colorectal surgery, we extended our repertoire to include laparoscopic Crohn’s resections. The aim of our study was to assess the safety and outcome following the introduction of laparoscopic resection for ileocaecal Crohn’s. Method: Between January 2008 and November 2012, 30 patients (12 men and 18 women, Median age 30 years), underwent laparoscopic ileocaecal resection for Crohn’s disease. 27 patients had stricturing disease, 2 patients presented with a mass and 1 presented with perforation. Patients were given an intraoperative spinal anaesthetic followed by PCA for 48 hours. All patients were commenced on an enhanced recovery programme. Results: Mean operative time was 90 min. Mean hospital stay was 3 days (range 3-7 days). Two patients (6%) required conversion to open surgery because of a fixed mass (n = 1) and dense adhesions (n = 1). One patient (3%) required reoperation due to haemorrhage. One patient (3%) had prolonged hospital stay due to ileus. One patient (3%) had an anastomotic leak. There were no deaths in this series. Conclusion: Our study demonstrates that laparoscopic resection of ileocaecal Crohn’s disease can be safely performed at a district general hospital with a short length of stay and minimal morbidity.

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Does traction on the cervix under anaesthesia tell us when to perform a concomitant hysterectomy? A 2-year follow-up of a prospective cohort study (2014)

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Type of publication:
Journal article

Author(s):
Madhu C., *Foon R., Agur W., Smith P.

Citation:
International Urogynecology Journal and Pelvic Floor Dysfunction, September 2014, vol./is. 25/9(1213-1217), 0937-3462;1433-3023 (September 2014)

Abstract:
Introduction and hypothesis: Variations exist in urogynaecological practice to decide on hysterectomy in managing prolapse. This study evaluates the outcomes of uterine preservation during anterior colporrhaphy with apparent uterine descent with cervical traction under anaesthesia. We hypothesize that cervical traction should not be used to assess uterine prolapse. Methods: Thirty-five women opting for surgery for symptomatic anterior prolapse (> stage 2) with no uterine prolapse (point C at -3 or above) were recruited. ”Validated cervical traction” was applied under anaesthesia. Only an anterior repair was performed. Incontinence Modular Questionnaire Vaginal Symptoms (ICIQ-VS) questionnaires were used for follow-up. Wilcoxon test was used for statistical analysis. Results: Stage 2 uterine prolapse (POPQ) was demonstrated in all women with traction under anaesthesia. Follow-up was possible in 29 women, 5 did not respond and 1 needed a hysterectomy at 6 months (2.86 %, 95 % CI 0.07-14.91 %). The mean follow-up time was 23 months (range: 13-34 months). There was a significant reduction in the ICIQ-VS scores from 22.7 (pre-operative) to 7.97 at 23 months (p

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Use of a massive haemorrhage protocol in a UK district general hospital is associated with a reduction in mortality (2014)

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Type of publication:
Conference abstract

Author(s):
Lambert L.,Taylor B.,Alistair W.

Citation:
Intensive Care Medicine, September 2014, vol./is. 40/1 SUPPL. 1(S208), 0342-4642 (September 2014) (also published in Anaesthesia, June 2014, vol./is. 69/(118), 0003-2409 (June 2014))

Abstract:
INTRODUCTION. Massive haemorrhage is associated with significant morbidity and mortality. In the context of major trauma managed in a large centre, the use of a massive haemorrhage protocol emphasizing early haemostatic resuscitation reduces mortality (1). However, it is not clear if these models are effective in non-trauma patients (2). There is some concern that these protocols may increase the wastage of blood products which might be a concern in smaller hospitals. (3) OBJECTIVES. To audit the activation of and compliance with a massive haemorrhage protocol in a UK district general hospital. To assess if compliance with the protocol resulted in a difference in mortality, morbidity, length of ICU stay, or use of blood products. METHODS. Retrospective audit over 12 months analyzing the case notes of all patients who had suffered a massive haemorrhage against a massive haemorrhage protocol which emphasizes early haemostatic resuscitation. RESULTS. The protocol was activated in 9 patients, but unfortunately notes were unavailable for one as he was undergoing outpatient treatment. A further 9 patients were identified as having had a massive transfusion, without activation of the protocol, from blood bank data as having been issued emergency uncrossmatched group O blood, or having had more than 10 units of any blood products in a 24 h period. Where a massive haemorrhage protocol was used, 1/8 patients (12.5 %) died. Where a major transfusion was conducted without activation of the protocol, 7/9 patients died (77.8 %). This finding was statistically significant (p = 0.0152) using a 2-tailed fishers exact test. Fewer units of red cells (p = 0.0011) and FFP (p = 0.0034) were used in patients managed according to the protocol, but there was no difference in the use of platelets or cryoprecipitate. Two patients in the group where the protocol had not been activated were given cryoprecipitate despite normal fibrinogen levels, and a further two in this group were not given cryoprecipitate despite fibrinogen levels under 1 g/l CONCLUSIONS. Use of a massive haemorrhage protocol which focuses on rapid haemorrhage control, haemostatic resuscitation and early use of blood is associated with a lower mortality than management of major bleeds without the protocol. This appears to apply in predominantly non-trauma patients in a non-specialist centre. This was a retrospective audit, and the group in whom the protocol was not activated had a higher expected mortality, therefore the results warrant further research.

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