2024

Acute stroke goes viral: cases of young and old stroke secondary to primary varicella zoster infection (2024)

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Author(s):

European Stroke Journal. Conference: 10th European Stroke Organisation Conference Abstracts. Basel Switzerland. 9(1 Supplement) (pp 499), 2024. Date of Publication: 01 May 2024.

Citation:

*Kondalkar K.; *Craik S.; *Osineye B.; *Srinivasan M.

Abstract:

Background and aims: Varicella zoster is a documented risk factor for development of ischemic stroke for up to 1 year following infection. Multiple cases of stroke following zoster reactivation have been reported previously. Here we outline two admissions to our ward in 2023 in which a stroke developed following primary zoster infection. Method(s): An 18 year old woman was admitted with right hand numbness, speech disturbance and headache. A CT angiogram revealed occlusion of the left middle cerebral artery. She was treated with dual antiplatelets. A lumbar puncture was performed and cerebrospinal fluid was positive for Varicella zoster. On further history the patient revealed she had chicken pox 3 months prior. She was treated with intravenous aciclovir and discharged with her neurological symptoms largely resolved. Result(s): A 75 year old male with a background of Non-Hodgkin lymphoma was admitted with acute confusion and right sided weakness and high fever. Examination also revealed a rash to the torso and head. CT revealed an area of low attenuation in the right basal ganglia, MRI revealed multiple bilateral infarctions. Lumbar puncture was performed due to suspected encephalitis and PCR was positive for Varicella zoster. The patient was treated with intravenous aciclovir however suffered a drop in consiousness. A repeat CT revealed catastrophic intracerebral bleed extending into the ventricles. The patient received palliative care and died one day later. Conclusion(s): Varicella zoster infection is an important risk factor for stroke in both younger and older adults and should be considered in unusual presentations.

DOI: 10.1177/23969873241245672

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External validation of the novel prognostic Meet-URO score in Metastatic Renal Cell Carcinoma on First Line Immune-combination therapy (2024)

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Conference abstract

Author(s):

Ghose A.; Signori A.; Brown N.; Haywood S.; Tapia J.; Vijay A.; Cheung M.; Mahajan I.; Fiala O.; Abrol R.; Chauhan V.; Soe Y.S.Y.; Zargham A.; Ashley S.; Smith M.; Hardy O.; Johnston E.; Sarwer A.; Tun K.K.; Challapalli A.; Shrestha R.; Urun Y.; *Meegan J.; Rescigno P.; Parkes J.; Smalley B.; Anpalakhan S.; Buono F.; Poprach A.; Teoh J.Y.C.; Murianni V.; Catalano F.; Bimbatti D.; Buti S.; Fornarini G.; Banna G.; Rebuzzi S.E.

Citation:

Therapeutic Advances in Urology. Conference: Second International Urology Cancer Summit. Portsmouth United Kingdom. 16 (pp 13-14), 2024. Date of Publication: 01 Sep 2024.

Abstract:

Objective: First-line immune-combination therapy based on immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) are the new mainstay in metastatic renal cell cancer (mRCC). In this setting, there is a dearth of standard prognostic/predictive parameters to guide treatment choice. The novel prognostic Meet-URO score (IMDC score + bone metastases and neutrophil-to-lymphocyte ratio – NLR) showed a higher prognostic accuracy than IMDC in 306 patients on first-line nivolumab + ipilimumab in the Italian Expanded Access Program (PMID: 36493602). Hence, the necessity to externally validate and expand to other first-line immune-combination settings. Method(s): Twenty-seven European centres were included. Baseline patient and tumour characteristics were collected, including the IMDC score along with the presence of pre-treatment bone metastases, neutrophils, and lymphocytes for calculating the Meet-URO score. The prognostic performance of Meet-URO and IMDC scores were compared and defined by the Harrell's c-index. Result(s): 1174 mRCC patient data was retrospectively collected. The median age was 64. 72.8% were male, 54.2% received nephrectomy, 62% were metastatic at diagnosis and 86.7% had clear-cell histology. 35% had bone metastases and 51.6% had NLR >= 3.2. 672 (57.2%) patients received ICI-ICI (nivolumab + ipilimumab) whereas 502 (42.8%) an ICI-TKI combination, mainly avelumab + axitinib (27.1%) and pembrolizumab + lenvatinib (14.3%). Overall, median overall survival (mOS) was 36.2 months (95% CI 31.1 – 38.5) with a median follow up of 15.5 months. The c-index of Meet-URO resulted higher than IMDC score (0.68 vs 0.65). In particular, the mOS resulted more distinctive within the Meet-URO prognostic groups: 45.8 months for group 1 (12.9% of patients), 55.0 for group 2 (25.7%), 38.1 for group 3 (23.5%), 20.9 months for group 4 (29.6%) and 10.4 for group 5 (8.2%). On the other hand, mOS was 45.8 months for IMDC favorable-risk (19.5% of patients), 38.2 for intermediate-risk (53.7%) and 16.2 for poor-risk (26.8%). Conclusion(s): In this large-scale real-world external validation analysis on mRCC patients receiving first-line immune-combinations, Meet-URO confirmed higher prognostic accuracy compared to IMDC. A further validation is planned in the ongoing Italian prospective Meet-URO 33 (REGAL) study (PMID: 38914928).

DOI: 10.1177/17562872241277067

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Evaluation of the Impact of an Emergency Focused Ophthalmology Teaching Course on the Confidence of Emergency Doctors (2024)

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Author(s):

*Mahon E.J.E.; *Ahnood D.

Citation:

Eye (Basingstoke). Conference: The Royal College of Ophthalmologists Annual Congress 2024. Belfast United Kingdom. 38 (pp 142), 2024. Date of Publication: 01 Nov 2024.

Abstract:

Introduction: It has been established that doctors in Accident and Emergency (A&E) departments have minimal confidence in managing ophthalmic presentations (Murray, P., et al. Eye 2016; https://doi.org/10.1038/eye.2016.99). The lack of confidence to accurately assess and manage patients presenting to A&E will likely have an impact on the quality of patient management and the quality of referrals made to eye casualties. We hypothesize that a teaching course covering core emergency ophthalmic examination and management skills will improve attendees' confidence in these areas. Method(s): Doctors currently or potentially working in A&E were invited to attend a teaching session where they would rotate between three stations which included slit lamp examination, simulation of foreign body removal and managing chemical eye injury. Teaching was delivered in small groups, with experienced staff leading the sessions. Pre-and post-course questionnaires included a 1-5 Likert scale self-assessment confidence rating on the three areas of teaching and overall confidence. Result(s): The course was attended by 13 doctors, with 46% of attendees being junior emergency specialty trainees or trainee equivalents, 38% were foundation doctors and 15% were A&E staff grade doctors equivalent to registrar. 92% of those who attended reported less than one hour of slit lamp examination time. Overall, the attendees' overall confidence went from 1.9 to 4.2 on the Likert scale. Conclusion(s): Our findings demonstrate a lack of confidence from the A&E doctors in assessing patients presenting with ophthalmic issues, with an overall confidence score of

DOI: 10.1038/s41433-024-03254-3

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Impact of the new UK guidelines on the emergency management of anaphylaxis at two hospitals (2024)

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Author(s):

*Elshahawy M.; *Kadambi M.; *Inani M.; Hughes D.; Clarke D.; Cooper A.; Goddard S.; Diwakar L.

Citation:

Allergy: European Journal of Allergy and Clinical Immunology. Conference: European Academy of Allergy and Clinical Immunology Hybrid Congress. Virtual. 79(Supplement 113) (pp 328-329), 2024. Date of Publication: 01 Oct 2024.

Abstract:

Background: In 2021, the UK Resuscitation Council made changes to the guidance on the management of acute anaphylaxis. The most significant of these included a) removal of antihistamine (chlorpheniramine) and steroid (hydrocortisone) from the algorithm b) Advise to administer repeated doses of IM adrenaline every 5 minutes until there has been an improvement in breathing and circulation. We carried out an audit to understand how the change in guideline has impacted patient care. Other aspects audited include measurement of serum tryptase and referral to specialist clinic. Method(s): This was a retrospective study using Ambulance Service and hospital notes to assess management of all patients presenting to the accident and emergency department at the university hospital of North Midlands (UHNM) and Shrewsbury and Telford hospitals (SaTH) with anaphylaxis in the years 2018 and 2022. ICD 10 codes were used to identify patients. Result(s): A total of 103 and 109 patients presented in 2018 and 2022 respectively with anaphylaxis. A&E and ambulance notes were available for 100 patients in 2018 (97%) and 103 (95%) patients in 2022. There were no deaths. Patient groups similar in age (range: 1-90 yrs) and gender (60% female) for both years across both sites. Less than half had tryptase measured. A significant number of patients with only skin symptoms were classified as having anaphylaxis. There was a significant reduction in the use of steroids and antihistamines between 2018 and 2022. Use of adrenaline was lower in 2022. Very few patients were referred to specialist clinics in both years, particularly from SaTH hospital. Conclusion(s): Anaphylaxis maybe over diagnosed in the emergency department. There has been some adherence to the new UK guideline for anaphylaxis management. Most patients still do not have serum tryptase checked. Referral rates are low.

DOI: 10.1111/all.16299

Outcomes of TEMS (Trans-anal Endoscopic Micro-Surgery) for early rectal cancer in a DGH - 10 years' experience (2024)

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Conference abstract

Author(s):

Kumar S.; *Rehman S.; *McCloud J.; *Clarke R.G.

Citation:

Colorectal Disease. Conference: Association of Coloproctology of Great Britain and Ireland Annual Meeting. Wales United Kingdom. 26(Supplement 1) (pp 71-72), 2024. Date of Publication: 01 Sep 2024.

Abstract:

Introduction: Trans-anal Endoscopic excision for Early Rectal Cancer (ERC) is low risk with excellent outcomes. Strict patient selection with discussion in an ERC MDT identifies appropriate patients for local excision. Trans-anal Endoscopic microsurgery (TEMS) with full-thickness excision is suitable for T1 rectal cancers as well as more advanced cancers in patients with significant comorbidity not fit for major surgery. We present results over a 10-year period. Method(s): We reviewed outcomes of patients undergoing TEMS for ERC, staged on MRI scans between March 2012 and Jan 2022 with follow up to Dec 2023. We included all patients withpotentially curable tumours and excluded patients deemed palliative at presentation. Result(s): 241 TEMS cases were performed with 73 for ERC with T1, T2 and T3 cancers being 70% (51/73), 24% (17/73) and 6% (5/73) respectively. Recurrence rates for T1 Cancer (Sm1, Haggit 1) was 0%. T1/2 with adverse histology was 18.7% to 41.7% and T3 was 80%. Resection margin R0 for T1 lesions was 86%-100% and for T2-T3 lesions was 20-60%. Correlation of T stage, resection margin and adverse histology to recurrence rates was significant. There were no major complications or deaths with 90 days. Conclusion(s): TEMS is a curative option for patients with ERC offering organ preservation and significantly less comorbidity than major resection. This is particularly important in the comorbid patient. Combination treatments with oncology can optimise outcomes in cancers with poor prognostic features and close surveillance will identify any local recurrence requiring salvage surgery.

DOI: 10.1111/codi.17066

An audit of testosterone referrals to the menopause clinic (2024)

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Conference abstract

Author(s):

*Clark M.; *Magar C.P.; *Ritchie J.

Citation:

Post Reproductive Health. Conference: 33rd British Menopause Society Annual Scientific Conference, BMS 2024. Kenilworth United Kingdom. 30(1 Supplement) (pp 12S), 2024. Date of Publication: 01 Sep 2024.

Abstract:

Objective: Referrals to the menopause clinic for testosterone and low libido have steadily increased. Locally, we have written prescribing information for primary care to follow, after testosterone initiation in the menopause clinic. This prescribing information adheres to British Menopause Society (BMS) guidelines but has only recently been introduced. The objective of this audit was to determine if the BMS guidelines are currently being followed. Method(s): Retrospective case note review of a selection referrals to the Menopause by two speciality registrars training in Menopause. The electronic patient records were reviewed using pre-determined criteria and recorded on the same secure spreadsheet. Result(s): A total of 245 patient notes were reviewed, of these patients 35 had been specifically referred to request testosterone. 33 of these 35 patients were able to fully discuss testosterone in the menopause clinic. All patients were already taking Hormone replacement therapy (HRT). 32 patients reported that their libido had changed around the time of the menopause. Only 15 patients were already taking vaginal estrogen. 6 patients did not have a baseline testosterone level prior to commencement of testosterone. 24 patients were subsequently started on testosterone. Only 10 patients had reported testosterone levels at 3 months. 4 were referred for psychosexual counselling. Conclusion(s): This audit demonstrated how locally we would benefit from keeping a specific log of patients on testosterone. This is to ensure that patients have their baseline testosterone levels and subsequent monitoring, to make sure testosterone levels are being kept in the physiological range. Our audit showed only a small proportion of patients were already using vaginal estrogen, Vaginal dryness can be a contributing factor to low libido. By increasing uptake in vaginal estrogen this may help some patients prior to their referral or potentially reduce the need for referral. In addition, psychosexual counselling was provided for some of these patients and identified further contributing factors towards low libido, highlighting the importance of a holistic approach to the management of low libido. In those where testosterone was not commenced, this was mostly due to low estrogen levels therefore HRT regimes were altered to optimise absorption prior to considering testosterone.

DOI: 10.1177/20533691241273937

Postmenopausal bleeding in women taking HRT - Quality improvement project (2024)

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Conference abstract

Author(s):

*Magar C.K.P.; *Radothra A.; Gbenga A.; *Ritchie J.;

Citation:

Post Reproductive Health. Conference: 33rd British Menopause Society Annual Scientific Conference, BMS 2024. Kenilworth United Kingdom. 30(1 Supplement) (pp 33S-34S), 2024. Date of Publication: 01 Sep 2024.

Abstract:

Objective: Since the 'Davina Effect', there has been rise in the demand for HRT, with a significant increase in HRT prescriptions up by 35% compared to 2021/22, as result there has been an increase in patients presenting with Postmenopausal bleeding on HRT attending our one stop hysteroscopy clinic. The aim of this study was to identify the number of cancers in patients presenting with postmenopausal bleeding who are taking HRT attending our one stop hysteroscopy clinic. Method(s): Prospective study with a sample size of 100 cases. Patient selection – Any patient coming to one stop hysteroscopy clinic with Postmenopausal bleeding on HRT. Sample period: 1st January 2023 to end of August 2023. Data was collected from the patient directly in the designed proforma then scanned to the Microsoft Excel. Result(s): 91% were postmenopausal with average age of 50-59 years and 90% of patient were taking continuous combined HRT. 9% were premenopausal on sequential HRT. 61% of women were on HRT for >12 months however 4% were referred within 3 months of HRT and 10% within 3-6 months. Following transvaginal ultrasound scan, 9% of patients were reassured and discharged, 36% underwent endometrial biopsy and 55% underwent hysteroscopy and endometrial biopsy. 2% were diagnosed with endometrial cancer and 89% had normal histology with a benign cause to explained their postmenopausal bleeding. Of the two patients diagnosed with endometrial cancer, one patient had a endometrial thickness (ET) of 4mm and one of 13mm. The patient with an ET of 4mm was also low risk with a normal BMI, and had been on HRT for 6 months. Conclusion(s): Cancer rate detected in our population is 2% which is very similar to the national rate (1-2%). This result highlights the importance of investigating patients with Postmenopausal bleeding on HRT with endometrial thickness of >=4 mm.

DOI: 10.1177/20533691241273937

Streamlining administrative processes by analysing how delayed benign histology results letters were done for 2-Weeks- Wait (2WW) gynaecology oncology patients (2024)

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Conference abstract

Author(s):

*Khanh Kieu X.M.; *Sahu B.; *Ghumaann M.K.

Citation:

BJOG: An International Journal of Obstetrics and Gynaecology. Conference: BGCS ASM 2024. Liverpool United Kingdom. 131(Supplement 4) (pp 34), 2024. Date of Publication: 01 Oct 2024.

Abstract:

Aims: A quality improvement project to identify bottlenecks to the delayed result letters to patients on the 2WW pathway and evaluate the use of a template letter that can be beneficial to both staff and patients. Background(s): The aim of the 2-week- wait pathway is to expedite the diagnosis and treatment of potential cancer cases. From the patient's point of view, the 2WW pathway would not officially end until the final histology result reached the patient. Method(s): We conducted two retrospective audits before and after the implementation of the benign histology template in a span of one month. The date of the primary care referral is day 0. The date and time for the 2WW patients' histology final report can be obtained from SATH's medical electronic platform called Portal. We can then calculate how many days it will take for the result letter to be ready from day 0 of the initial referral. Result(s): Roughly 80% of these patients have benign histology results. Yet, the average time for a 2WW benign histology result letter to be issued is 51 days, counting from their initial 2WW referral. After implementation of template letter, the average waiting time for result has decreased to 37 days. Conclusion(s): The implementation proposal depends greatly on the Trust budget, and further consideration for speech recognition technology training will need a thorough discussion. A benign histology result template would be a cost-effective solution to reduce the unnecessary typing delay.

DOI: 10.1111/1471-0528.17941

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Triple line stapled jejunojejunal anastomosis does not completely prevent post-operative bowel obstruction following laparoscopic Rouxen- Y gastric bypass (2025)

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Conference abstract

Author(s):

*Gungadin P.; *Bhandari M.; *Riera M.;

Citation:

Obesity Surgery. Conference: BOMSS 2024 Congress. Harrogate . 34(Supplement 1) (pp S26), 2024. Date of Publication: 01 Jun 2024.

Abstract:

Introduction: Small bowel obstruction following jejunojejunal anastomosis (JJ) during a gastric bypass is a recognised complication. Common causes include strictures, intussusception, internal herniae and bowel kinking, thus preventing passage of bowel contents into the common limb (CL). Bidirectional jejunal stapled anastomosis, or triple line anastomosis is meant to decrease the risk of obstruction. However, this risk may not completely be avoided. Case presentation: A patient with history of gastroesophageal reflux, after a sleeve gastrectomy, underwent a conversion to laparoscopic Roux-en-Y gastric bypass. The JJ anastomosis was successfully tested intraoperatively for leak and patency with methylene blue. The patient still developed post-operative bilious vomiting after 24 hours. Abdominal CT confirmed obstruction at the JJ anastomosis. Subsequent laparoscopy demonstrated collapsed CL and dilated both alimentary (AL) and biliopancreatic (BP) limbs. There was no stricture or narrowing. Upon straightening the limbs, bowel contents successfully emptied into the common limb. However, the common limb would appear kinked again when the anastomosis was released, thus causing obstruction. A further stapled anastomosis was performed between CL and BP which straightened the kinked CL. This solved the obstruction. The patient was discharged home three days later. Discussion(s): Small bowel obstruction secondary to kinking despite a triple stapler approach is uncommon. Unfortunately, anastomotic leak and patency test may not completely preclude this complication. Awareness and careful intraoperative inspection of the anastomosis may help to detect probable obstruction.

DOI: 10.1007/s11695-024-07287-1

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Learning from Interventions Within Cancer Services (2024)

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Conference abstract

Author(s):

*Flynn K.; *Poulsom R.; *Wilfred D.;* Lindsey K.; *Tibitendwa A.

Citation:

Journal of Oncology Pharmacy Practice. Conference: 26th Annual BOPA Symposium. Wales United Kingdom. 30(1 Supplement) (pp 74), 2024. Date of Publication: 01 Mar 2024.

Abstract:

Introduction / objectives: This Service Evaluation was carried out to assess interventions for oncology SACT prescriptions, identify trends and potential areas for improvement. The primary objective was to quantify and categorise the interventions of the Cancer Pharmacist team, encompassing IV and oral oncology SACT prescriptions in the inpatient and outpatient setting, over a 12-week period. The secondary objective was to look in more detail at the interventions logged under the high-risk categories of 'Regimen query/error', 'Dose query' and 'Dose error'. This would enable greater understanding of the issues contributing to prescription errors and will form the basis for future work to improve patient safety. Method(s): Cancer pharmacists completed a data collection form for each oncology SACT prescription query over a 12-week period. A support document defining each category ensured standardisation among pharmacists when classifying queries. The data was collated and analysed using Microsoft Excel. Each patient case in the specified high-risk categories was examined retrospectively to provide more detailed insight into the intervention and identify common themes. Result(s): In total, 124 interventions were logged (Fig.1), the highest number related to 'funding queries', 36%, with 'missing prescription' and 'dose query' both at 15%. The high-risk categories accounted for 31%, (n = 39). Of the 39 high-risk interventions, 9 related to intended dose changes that had not been actioned; 14 related to patient factors (bloods, DPYD, co-morbidities), of which 6 involved carboplatin; 5 prescriptions were missing a critical element. Discussion / conclusions: Funding queries were identified as the largest category of interventions; consultants were reminded to complete Blueteq forms when planning treatment to ensure the patient is eligible for the chosen regime. Prescriptions not available in advance mean that treatment cannot be ordered in time from third-party compounders. Pharmacy and oncology are working to find an efficient way of identifying patients scheduled for treatment that has not yet been prescribed to reduce delays to patients due to treatment not being available. From the in-depth analysis of high-risk categories, key areas for service development were identified. 1) Establishing a clear process for communicating changes to planned treatment. 2) Creating a policy and educating staff on carboplatin dosing to reduce unnecessary changes. 3) Improving blood test scheduling with the administration team. 4) Reviewing regimens requiring two prescriptions and considering combined prescriptions. This would reduce the number of prescriptions missing a critical element. Our Service Evaluation had limitations, mainly due to manual documentation. There was a noticeable drop in number of queries logged during extremely busy periods; it is likely that some interventions have been missed. Some duplication was identified when collating the data, particularly where more than one pharmacist was involved in following up a query. Of the 39 high-risk interventions, 4 were excluded from the data, 3 were duplicate entries and 1 had the incorrect patient number documented so further follow up was not possible. Future work will involve liaising with the oncology team to address the areas identified above with reference to improvement projects that have been successful in other hospitals.

DOI: 10.1177/10781552241228011

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