2019

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.

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.

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.

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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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Human immunodeficiency disease in new diagnoses of head and neck squamous cell cancer: are we testing? (2019)

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Type of publication:
Journal article

Author(s):
*McNamara K.J.; Saunders T.F.C.; *Ahsan F.; *Fernandez C.

Citation:
Journal of Laryngology and Otology; Vol. 133(12) p. 1038-1040

Abstract:
BACKGROUND: Human immunodeficiency virus infected patients have a three-fold increased risk of head and neck squamous cell carcinoma. The British HIV Association recommends human immunodeficiency virus testing in all new diagnoses of head and neck squamous cell carcinoma.
OBJECTIVE(S): This observational study aimed to examine the current routine practice of human immunodeficiency virus testing in patients with newly diagnosed head and neck squamous cell carcinoma, and to address the importance of this test in promoting the early diagnosis and treatment of human immunodeficiency virus.
METHOD(S): All head and neck cancer multidisciplinary teams in England were questioned on their protocol for human immunodeficiency virus testing in new diagnoses of head and neck squamous cell carcinoma.
RESULT(S): Only 1 out of 30 hospitals leading head and neck multidisciplinary teams (3.3 per cent) routinely offered human immunodeficiency virus testing in this high-risk patient group.
CONCLUSION(S): This observational study highlights that head and neck specialists are not aware of, and are consequently not complying with, routine human immunodeficiency virus testing as recommended by the British HIV Association guidelines.

Distress in patients with end-stage renal disease: Staff perceptions of barriers to the identification of mild-moderate distress (2019)

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Type of publication:
Journal article

Author(s):
Combes G.; Damery S.; Sein K.; Allen K.; *Nicholas J. ; Baharani J.

Citation:
PLoS ONE; 2019; vol. 14 (no. 11)

Abstract:
Objectives To explore staff perceptions of barriers to the identification of mild to moderate distress and the provision of emotional support in patients with end-stage renal disease.
Methods Qualitative semi-structured interviews with staff in two hospitals (n = 31), with data analysed using a hybrid approach combining thematic analysis with aspects of grounded theory.
Results Staff appeared very aware that many patients with end-stage renal disease experience distress, and most thought distressed patients should be helped as part of routine care. However, practice was variable and looking for and addressing distress was not embedded in care pathways. Interviews identified six themes: i) staff perceptions about how distress is manifested and what causes distress were variable; ii) staff perceptions of patients could lead to distress being overlooked because patients were thought to hide their distress whilst some groups were assumed to be more prone to distress than others; iii) role perceptions varied, with many staff believing it to be their role but not feeling comfortable with it, with doctors being particularly ambivalent; iv) fears held back some staff, who were concerned about what might happen when talking about distress, or who found the emotional load for themselves to be too high; v) staff felt they lacked skills, confidence and training, vi) capacity to respond may be limited, as staff perceive there to be insufficient time, with little or no specialist support services to refer patients to.
Conclusions Staff perceived significant barriers in identifying and responding to patient distress. Barriers related to skills and knowledge could be addressed through training, with training ideally targeted at staff with positive attitudes, but who currently lack skills and confidence. Barriers related to role perceptions would be harder to address. The study is relevant internationally as part of improving long-term condition pathways.

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

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Pitfalls in the study of neovascularisation in achilles and patellar tendinopathy: a review of important factors for clinicians to consider and the need for greater standardisation (2019)

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Type of publication:
Journal article

Author(s):
Fallows, R. and *Lumsden, G.

Citation:
Physical Therapy Reviews; Dec 2019 Vol. 24(6) p.346-357

Abstract:
Background: The search for new vessels in pathological tendons is a relatively new field. In spite of a rapid growth in research and clinical experience, there is still poor agreement in the musculoskeletal community regarding the significance and measurement of so called “neovascularisation”. Any relationship between vascularity, tendon healing, degeneration and pain is not yet clear, as it has been considered as a normal physiological adaptation to loading yet also seen in chronic painful Achilles tendons. An expression of the degree of “neovascularisation” could potentially have significance if the amount of neovascularisation could be related to the degree of symptoms or dysfunction caused by the pathology in the tendon.
Objectives: This review examines the potential variables that can affect the quantification of the Doppler signal in Achilles and patellar tendinopathy under three perspectives. Firstly, the variables that arise from the actual technology that allows the capturing of the Doppler signal from intra-tendinous microvasculature flow, secondly by an awareness of known and highly likely physiological factors that may alter the rate of flow and thirdly by an exploration describing the actual methods and qualities of acquiring quantitative data of the microvascular flow with Doppler.
Methods: A literature search was conducted across AMED, CINAHL, Google Scholar, SPORTDiscus, MEDLINE and NCBI (PubMed) for studies related to the qualitative or quantitative measure of the Doppler signal in relation to a clinical outcome of Achilles or patellar tendinopathy. Parameters regarding machine settings and examination conditions were extracted to identify the utilisation of important factors and consistency with a narrative analysis.
Discussion: Many of these influential factors have never been controlled for in previous studies and the methods have been unreliable and poorly reported. There is a need for international agreement on a standardised protocol in the assessment of the microvascularity of tendons, which could then help determine if the quantification of “neovascularisation” is a reliable and clinically relevant finding.