Pulmonary Embolism Presenting As Shoulder and Back Pain: A Case Report (2024)

Type of publication:
Journal article

Author(s):
*Nwaneri, Chukwuemeka; *Race, Rebecca; *Oladele, Romoluwa; *Kumaran, Subramanian.

Citation:
Cureus. 16(7):e64016, 2024 Jul.

Abstract:
Pulmonary embolism (PE) is a common but life-threatening condition, and diagnosis can be challenging. Diagnosis is even more difficult in those patients with atypical presentations such as the absence of pleuritic chest pain, dyspnoea, tachycardia, or symptoms of deep vein thrombosis. We have delineated shoulder and back pain as an atypical sign of PE. However, the significant amount of misdiagnosis highlights the importance of other rare symptoms of this potentially fatal disease. Therefore, eliciting these rare presenting symptoms can significantly reduce morbidity and mortality. Here, we report the case of a patient who, 13 days after a laparoscopic Nissen fundoplication, presented to the emergency department (ED) with left shoulder and left-sided pleuritic back pain. She was managed in the resuscitation area in the ED and was subsequently diagnosed with a left-sided PE. Her care was taken over by the medical team, and she continued her recovery in the acute medical unit.

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Assessing opinion on lower LDL-cholesterol lowering, and the role of newer lipid-reducing treatment options (2023)

Type of publication:
Journal article

Author(s):
Connolly, Derek L; Zaman, Azfar; *Capps, Nigel E; Bain, Steve C; Fernando, Kevin.

Citation:
British Journal of Cardiology. 30(2):14, 2023.

Abstract:
While statins are the gold standard for lipid-lowering therapies, newer therapies, such as PCSK9 inhibitors, have also demonstrated low-density lipoprotein cholesterol (LDL-C) reduction, but with a similar or better
safety profile. Conflicting guidance has contributed to a low uptake. More up-to-date, evidence-led guidance supports greater use of newer therapies, particularly in combination with statins, to reduce LDL-C to levels shown to be effective in trials. The aim of this study was to determine how such guidance can be implemented more effectively in the UK. Using a modified Delphi approach, a panel of healthcare professionals with an interest in the management of dyslipidaemia developed 27 statements across four key themes. These were used to form an online survey that was distributed to healthcare professionals working in cardiovascular care across the UK. Stopping criteria included 100 responses received, a seven-month window for response (September 2021 to March 2022), and 90% of statements passing the predefined consensus threshold of 75%. A total of 109 responses were analysed with 23 statements achieving consensus (four statements <75%). Variance was observed across respondent role, and by UK region. From the high degree of consensus, seven recommendations were established as to how evidence-based guidance can be delivered, including a call for personalised therapy strategies and simplification of LDL-C goals, which should be achieved within as short a time as possible.

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Re-induction of intravenous ustekinumab to maintain drug persistence. A UK experience (2024)

Type of publication:
Conference abstract

Author(s):
*Muir J.; *Hazir Y.; *Butterworth J.

Citation:
Journal of Crohn's and Colitis. Conference: 19th Congress of the European Crohn's and Colitis Organisation, ECCO 2024. Stockholm Sweden. 18(Supplement 1) (pp i1034), 2024. Date of Publication: January 2024.

Abstract:
Background: In this study we seek to add to the body of knowledge on the practical use of ustekinumab in patients with Crohns and Colitis. Patients commencing ustekinumab will mostly have failed, or are intolerant to, conventional biologic agents and therefore have a limited number of medical options available to manage their disease. Results from the IM-UNITI long-term extension study have shown that a proportion of patients will lose response to maintenance dose therapy, and a small number of studies have suggested that repeated induction doses of this therapy can prolong its effective use and allow patients a greater period of disease free remission. Shrewsbury and Telford hospital NHS trust is a multi-site UK hospital serving a large population in the west-midlands region which has established the routine use of usetkinumab therapy over 5 years ago and by reviewing data on our patient cohort we aimed to identify characteristics amongst patients who have required reinduction doses and how effective they have been in maintaining remission. Method(s): In this retrospective, interventional study two researchers gathered data including baseline characteristics, disease type and distribution, previous surgical and medical therapies and time from diagnosis on all patients who had received ustekinumab therapy over the past five years. We used biochemical and endoscopic data, as well as clinical records, to determine the efficacy of ustekinumab on the disease course. We identified the subgroup of patients requiring reinduction doses and noted whether this was a successful intervention and sought to describe similarities which could help identify patients at risk of failing maintenance therapy in future. Result(s): Data from 213 patients was gathered (Crohns: 150, UC: 61, IBDU: 2) and of which 87 (Crohns: 63, UC: 24) received reinduction doses. Average time to reinduction from therapy commencement was 19.5 months (Crohns) and 16.3 months (UC) respectively. Of the reinduction group 63% showed improvement in their disease control and a variety of characteristics were noted amongst the successful patients for discussion including disease location, presence of perianal disease and time from diagnosis. Conclusion(s): Ustekinumab reinduction is an important area for further research as it allows patients to prolong their successful therapy and delay the need for surgical intervention for difficult to manage disease. This study suggests characteristics which could inform further trials and establish protocols to aid clinicians when making decisions about switching biologic therapies.

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Are term breech babies who undergo successful external cephalic version still at increased risk of developmental dysplasia of the hip? (2024)

Type of publication:
Journal article

Author(s):
*Stock, Joanne; *Deshpande, Sanjeev A.

Citation:
Archives of Disease in Childhood. 109(4):351-353, 2024 Mar 19.

Abstract:

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A National audit of the care of patients with acute kidney injury in England and Wales in 2019 and the association with patient outcomes (2024)

Type of publication:
Journal article

Author(s):
Graham-Brown M.P.M.; Casula A.; Savino M.; Humphrey T.; Pyart R.; Amaran M.; Williams J.; Crowe K.; Medcalf J.F.; Lee D.K.; Dan Cooper; Carr D.E.; Marthi D.A.; Swift D.O.; Hull D.K.; Nimmo D.A.; Liewm D.H.; Tariq D.B.; Whitehead D.J.; Edney D.N.; Whitbread D.D.; Mohamed D.M.; Duffy D.S.; Edwards D.G.; Czajka D.R.; Ahmad D.S.H.; Joslin D.J.; Yong D.E.S.T.; Chaudry D.S.; McGuinness D.D.; Defreitas D.S.; Nosseir D.H.; Seal D.K.; Amaran D.M.; Gulati D.K.; Azam D.M.J.; Williams D.J.; Smith-Jackson; Yin D.B.-S.; Shuaib D.R.; Akter D.M.; Arimoto D.R.; Oluyombo D.R.; Davies D.M.; Patel D.P.; Best-Trent T.; Handra D.H.; Mackie S.; Wright K.; Rahman D.M.; Cheema D.H.; Sardar D.A.; Harvard D.L.; Brook D.M.; *Elphic D.E.; Ahmed D.M.; Ammar D.K.; Harbe D.M.; Corke D.E.; Stacey D.H.; Yousif D.M.; Mohamed D.D.; Soe D.L.T.; Sherna D.A.; Soutter D.L.; Davari D.M.; Abburu D.S.; Wells D.J.; Winterbottom D.C.; Bottomley D.M.; Morris D.H.; Sadiq D.A.; Youssouf D.S.

Citation:
Clinical Medicine, Journal of the Royal College of Physicians of London. 24(2) (no pagination), 2024. Article Number: 100028. Date of Publication: March 2024.

Abstract:
Background: Acute kidney injury (AKI) is a common complication of hospitalisations. This national audit assessed the care received by patients with AKI in hospital Trusts in England and Wales. Method(s): Twenty four hospital Trusts across England and Wales took part. Patients with AKI stage2/3 were identified using the UK Renal Registry AKI master patient index. Data was returned through a secure portal with linkage to hospital episode statistic mortality and hospitalisation data. Completion rates of AKI care standards and regional variations in care were established. Result(s): 989 AKI episodes were included in the analyses. In-hospital 30-day mortality was 31-33.1% (AKI 2/3). Standard AKI interventions were completed in >80% of episodes. Significant inter-hospital variation remained in attainment of AKI care standards after adjustment for age and sex. Recording of urinalysis (41.9%) and timely imaging (37.2%) were low. Information on discharge summaries relating to medication changes/re-commencement and follow-up blood tests associated with reduced mortality. No quality indicators relating to clinical management associated with mortality. Better communication on discharge summaries associated with reduced mortality. Conclusion(s): Outcomes for patients with AKI in hospital remain poor. Regional variation in care exists. Work is needed to assess whether improving and standardising care improves patient outcomes.

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Baseline Expression of Immune Gene Modules in Blood is Associated With Primary Response to Anti-TNF Therapy in Crohn's Disease Patients (2024)

Type of publication:
Journal article

Author(s):
Journal of Crohn's and Colitis. 18(3) (pp 431-445), 2024. Date of Publication: 01 Mar 2024

Citation:
Reppell M.; Smaoui N.; Waring J.F.; Pivorunas V.; Guay H.; Lin S.; Chanchlani N.; Bewshea C.; Goodhand J.R.; Kennedy N.A.; Anderson C.A.; Patel V.; Mazhar Z.; Saich R.; Colleypriest B.; Tham T.C.; Iqbal T.H.; Kaushik V.; Murugesan S.; Singhi S.; Weaver S.; Preston C.; Butt A.; Smith M.; Basude D.; Beale A.; Langlands S.; Direkze N.; Parkes M.; Torrente F.; De La Revella Negro J.; MacDonald C.E.; Evans S.M.; Gunasekera A.V.J.; Thakur A.; Elphick D.; Shenoy A.; Nwokolo C.U.; Dhar A.; Cole A.T.; Agrawal A.; Bridger S.; Doherty J.; Cooper S.C.; de Silva S.; Mowat C.; Mayhead P.; Lees C.; Jones G.; Hart J.W.; Gaya D.R.; Russell R.K.; Gervais L.; Dunckley P.; Mahmood T.; Banim P.J.R.; Sonwalkar S.; Ghosh D.; Phillips R.H.; Azaz A.; Sebastian S.; Shenderey R.; Armstrong L.; Bell C.; Hariraj R.; Matthews H.; Jafferbhoy H.; Selinger C.P.; Zamvar V.; De Caestecker J.S.; Willmott A.; Miller R.; Babu P.S.; Tzivinikos C.; Bloom S.L.; Chung-Faye G.; Croft N.M.; Fell J.M.E.; Harbord M.; Hart A.; Hope B.; Irving P.M.; Lindsay J.O.; Mawdsley J.E.; McNair A.; Monahan K.J.; Murray C.D.; Orchard T.; Paul T.; Pollok R.; Shah N.; Bouri S.; Johnson M.W.; Modi A.; Kabiru K.D.; Baburajan B.K.; Bhaduri B.; Fagbemi A.A.; Levison S.; Limdi J.K.; Watts G.; Foley S.; Ramadas A.; MacFaul G.; Mansfield J.; Grellier L.; Morris M.-A.; Tremelling M.; Hawkey C.; Kirkham S.; Charlton C.P.J.; Rodrigues A.; Simmons A.; Lewis S.J.; Snook J.; Tighe M.; Goggin P.M.; De Silva A.N.; Lal S.; Smith M.S.; Panter S.; Cummings F.; Dharmisari S.; Carter M.; Watts D.; Mahmood Z.; McLain B.; Sen S.; Pigott A.J.; Hobday D.; Wesley E.; Johnston R.; Edwards C.; Beckly J.; Vani D.; Ramakrishnan S.; Chaudhary R.; Trudgill N.J.; Cooney R.; Bell A.; Prasad N.; Gordon J.N.; Brookes M.J.; Li A.; Gore S.; Bai B.Y.H.; Ahmad T.;

Abstract:
Background and Aims: Anti-tumour necrosis factor [anti-TNF] therapy is widely used for the treatment of inflammatory bowel disease, yet many patients are primary non-responders, failing to respond to induction therapy. We aimed to identify blood gene expression differences between primary responders and primary non-responders to anti-TNF monoclonal antibodies [infliximab and adalimumab], and to predict response status from blood gene expression and clinical data. Method(s): The Personalised Anti-TNF Therapy in Crohn's Disease [PANTS] study is a UK-wide prospective observational cohort study of anti-TNF therapy outcome in anti-TNF-naive Crohn's disease patients [ClinicalTrials.gov identifier: NCT03088449]. Blood gene expression in 324 unique patients was measured by RNA-sequencing at baseline [week 0], and at weeks 14, 30, and 54 after treatment initiation [total sample size = 814]. Result(s): After adjusting for clinical covariates and estimated blood cell composition, baseline expression of major histocompatibility complex, antigen presentation, myeloid cell enriched receptor, and other innate immune gene modules was significantly higher in anti-TNF responders vs non-responders. Expression changes from baseline to week 14 were generally of consistent direction but greater magnitude [i.e. amplified] in responders, but interferon-related genes were upregulated uniquely in non-responders. Expression differences between responders and non-responders observed at week 14 were maintained at weeks 30 and 54. Prediction of response status from baseline clinical data, cell composition, and module expression was poor. Conclusion(s): Baseline gene module expression was associated with primary response to anti-TNF therapy in PANTS patients. However, these baseline expression differences did not predict response with sufficient sensitivity for clinical use.

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Evidence-based frozen elephant trunk practice: a narrative review (2023)

Type of publication:
Journal article

Author(s):
Kayali F.; Chikhal R.; Agbobu T.; Jubouri M.; *Patel R.; Chen E.P.; Mohammed I.; Bashir M.

Citation:
Cardiovascular Diagnosis and Therapy. 13(6) (pp 1104-1117), 2023. Date of Publication: 2023.

Abstract:
Background and Objective: The frozen elephant trunk (FET) allows a single-stage repair of complex arch pathologies due to its stented and non-stented hybrid prosthesis (HP) features. FET inherently has its own related complications including distal stent graft-induced new entry (dSINE), failure of aortic remodelling, endoleak, reintervention, and kinking of the stent. The aim of this narrative review is to discuss the latest evidence regarding the postoperative clinical outcomes of the FET procedure. Another aim is to provide an overview of results achieved using different FET devices on the global arch prostheses market. <Method(s): A comprehensive literature search was conducted using multiple electronic databases to identify and extract the relevant data and information. Key Content and Findings: This review found that the literature reported a 5-12% mortality rate post- FET, with varying figures depending on the prosthesis type. Between 0-18.2% of patients developed dSINE, while 0.1-28% developed endoleak. Reintervention occurred in 0-28% of patients and the incidence of kinking has been quoted between 0-8% in the literature. Reporting aortic remodelling rates was challenging due to the lack of standardisation and various measurements reported; however, all studies included in this review reported relative increase in true lumen diameter, reduction in the false lumen diameter, and/or false lumen thrombosis. Conclusion(s): In conclusion, FET can achieve a favourable postoperative profile in terms of survival, complications and aortic remodelling, and remains the gold-standard treatment for thoracic aortic pathologies implicating the arch and descending thoracic aorta.

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Mitral valve prolapse presenting as a missed myocardial infarction (2023)

Type of publication:Conference abstract

Author(s):*Champaneri K.; *Miller A.

Citation:Journal of the Intensive Care Society. Conference: Intensive Care Society State of the Art Congress, SOA 2023. Birmingham United Kingdom. 24(2 Supplement) (pp 194), 2023. Date of Publication: August 2023.

Abstract:Introduction: An elderly but very active gentleman presented overnight with progressive shortness of breath and leg swelling, two weeks after experiencing chest pain while lifting heavy objects in the garden. The presumed diagnosis was a missed myocardial infarction leading to heart failure exacerbated by a new diagnosis of atrial fibrillation. Despite diuresis and rate control, he became progressively more hypoxic and was taken to ICU for non-invasive ventilation. An initial POCUS scan of heart and lungs by an ultrasound fellow undertaking FUSIC accreditation showed a hyperdynamic heart, pulmonary oedema, and bilateral pleural effusions. The echocardiogram was reviewed and repeated by an advanced level operator which dramatically altered the patient's diagnosis and management. Main body: A gentleman in his early 80s presented to the Emergency Department in type one respiratory failure with a high work of breathing. Examination and investigations demonstrated raised inflammatory markers, new atrial fibrillation with a rate of 140, large bilateral plural effusions, and pitting oedema to the groin. Troponin was normal, and the BNP was 4500. ECG showed no ischaemic changes and CXR was consistent with fluid overload and/or pneumonia. Initial management consisted of supplemental oxygen, diuretics, heart rate control, and antibiotics. Despite this his oxygenation deteriorated and he was admitted to the ICU for CPAP, and metaraminol for his hypotension. An initial FUSIC heart scan did not show any signs of ventricular failure. In fact, the heart was hyperdynamic which was more consistent with sepsis. A lung ultrasound did however demonstrate large bilateral plural effusions and the significant pitting oedema of the lower limbs found on clinical examination still suggested a cardiac cause and so help was asked of an advanced level operator. A review of the images and a repeat scan revealed a severe prolapse of the posterior mitral valve leaflet with free, eccentric mitral regurgitation. The leaflet prolapse was not visible on the 1st set of images and was only discovered by more comprehensive scanning. The patient was reviewed by a cardiologist within 30 minutes and transfer to a tertiary centre for emergency mitral valve repair was arranged. <br/>Conclusion(s): Standard history, examination, and investigations of this patient led to a presumed diagnosis of ischaemic ventricular failure. While a basic heart ultrasound did not reveal the pathology, it did demonstrate signs not consistent with the suspected diagnosis prompting a request for a more comprehensive ultrasound assessment. This revealed the underlying pathology, significantly altering the patient's management. This was all done by intensive care clinicians at the bedside, significantly shortening the time to diagnosis and correct management. This case is a good example of why Intensive Care clinicians should be trained in point of care ultrasound at both basic and advanced levels.

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Experience as an international mammographer working in the UK comparing practice between Nigeria and UK (2023)

Type of publication:Conference abstract

Author(s):*Okeke C.R.; *Njoku G.

Citation:Breast Cancer Research. Conference: Symposium Mammographicum Conference 2023. Glasgow United Kingdom. 25(Supplement 2) (no pagination), 2023. Date of Publication: October 2023.

Abstract:Breast cancer affects women of all races without exception even though severity and survival rate are often diverse. In Nigeria about two thirds of women with breast cancer are diagnosed at an advanced stage, with the possibility of metastatic spread (Akaro- Anthony et al., 2010). A mammographer performs breast imaging techniques that produce mammographic radiographs for diagnosis (American Society of Radiologic Technologist, 2017). In Nigeria, the breast screening programme is performed by radiographers with the additional mammogram-specific training which is comparable to what is found in the United Kingdom; however, the UK screening programme also makes use of trained assistant practitioners which is not obtainable in Nigeria (Lawal et al., 2015). The breast screening programme in Nigeria invites women between the ages of 40 to 70 years, and this is justified by the fear that in Nigeria, a higher percentage of breast cancer cases are seen in younger age groups than in developed world ((Jedy-Agba et al., 2012). The mode of invitation is through public awareness campaigns, but majority of the women in the population do not frequently participate in mammography screening due to high cost and religious belief. The screening programme in Nigeria encourages women to get screened every two years (Lawal et al., 2012). However, the UK breast screening programme advice women to have breast screening mammogram, once every 3 years and is currently inviting women between the ages of 50 and 70 years for breast screening.

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