Folliculitis decalvans managed with long pulsed Nd:YAG; our experience and a review of the literature (2022)

Type of publication:
Conference abstract

Author(s):
*Oh S.; *Badrol S.; *Tzortzis S.; El Shimy N.; Murdoch S.;

Citation:
Lasers in Medical Science. Conference: British Medical Laser Association Annual Conference, BMLA 2022. Edinburgh United Kingdom. 37(9) (pp 3769), 2022. Date of Publication: December 2022.

Abstract:
Background Folliculitis decalvans (FD) is a rare inflammatory disorder predominantly of the scalp that can progress to cicatrical alopecia. Mainstay treatment is antibiotics; however, resolution is difficult, and relapse is common. Only three cases of FD treated with neodymium:yttrium aluminum garnet (Nd:YAG) laser exist in the literature. We present two cases of recalcitrant FD managed with long pulsed Nd:YAG laser and a literature review. Study Design Retrospective case series of two patients with FD treated with long pulsed Nd:YAG laser. Results The first case was a 49-year-old male with Fitzpatrick skin type II. Previous unsuccessful treatment included oral doxycycline and isotretinoin. A course of eight sessions of Nd:YAG laser (CynergyTM, Cynosure) was performed with settings of 50J/cm<inf>2</inf>, 20msec pulse duration, and 10mm spot size. Complete resolution of FD was achieved and remained stable without adjuvant treatment at 6 months post laser. The second case was a 46-year-old male with Fitzpatrick skin type IV with 9-years history of FD. Previously, oral antibiotics (clindamycin, rifampicin, erythromycin, ciprofloxacin) as well as dapsone, intralesional triamcinolone and acitretin treatment was trialled without success. A total of four successful treatments with Nd:YAG laser was completed with settings of 30J/cm<inf>2</inf>, 40msec pulse duration, and 15mm spot size. Treatment is ongoing. Conclusion Our experience of Nd:YAG laser treatment of FD have been positive. All cases from literature report full resolution of FD maintained without adjuvant treatment between 6 months to 1.5 years after final treatment. Treatment with Nd:YAG laser is an option for patients suffering from recalcitrant FD.

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All sleep and no play? An audit and service evaluation of children undergoing radiological imaging (2022)

Type of publication:
Conference abstract

Author(s):
*Muneer K.

Citation:
Archives of Disease in Childhood. Conference: Royal College of Paediatrics and Child Health Conference, RCPCH 2022. Liverpool United Kingdom. 107(Supplement 2) (pp A120-A121), 2022. Date of Publication: August 2022.

Abstract:
Aims The use of sedation in children for radiological imaging is common practice in Paediatrics. However, the risks need to be weighed against the benefits of imaging under sedation. Play therapy has been considered as an alternative to sedation in a cooperative child. This study explored the safety, efficacy and adherence of practice to local trust guidelines for sedation of children (derived from the NICE Sedation under 19s guidelines) and highlighted play therapy as a potential alternative for selected children requiring radiological imaging. Methods Data was gathered retrospectively from a 6 month period with the help of the Trust's medical records department. There were 36 children who underwent sedation for various imaging modalities and 19 children who had imaging done utilising play therapy over the same period. The information gathered from the resources used was collated in an excel database for the purpose of comparative analysis. Results 1. The assignment of patients was based on their clinical presentation, urgency and medical background 2. Children receiving sedation were predominantly below the age of 3 years while those in the play group were between 6-9 years 3. The youngest child to receive sedation was 3 months old and the youngest to have successful MRI using play therapy was 3 years 5 months 4. The success rate of Sedation was 92% vs. 86% for play therapy 5. 83% underwent MRI, 11% DMSA and 6% MAG3 under sedation. 95% had MRI and 5% CT in the play group 6. 14% required a repeat dose of medication for sedation 7. None had complications secondary to sedation 8. One had MRI Head done under sedation and later MRI Spine successfully under play therapy at 3 years 5 months 9. Where all documents were available for analysis, the adherence to local guidelines for sedation was 100% Conclusion 1. Sedation is a safe and effective option available in a DGH setting for young children needing relatively urgent radiological imaging to establish diagnosis where the benefits generally outweigh the risks. 2. Play therapy is a suitable alternative for cooperative children who can be adequately prepared. 3.Healthcare teams and parents need to be made more aware of these options in the future.

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Quality of life and two-year results of a randomized phase III study of dysphagiaoptimized intensity modulated radiotherapy (DO-IMRT) versus standard IMRT (SIMRT) in head and neck cancer (2022)

Type of publication:Conference abstract

Author(s):Nutting C.; Rooney K.; Foran B.; *Pettit L.; Beasley M.; Finneran L.; Roe J.; Tyler J.; Roques T.; Cook A.; Petkar I.; Bhide S.; Srinivasan D.; Boon C.; De Winton E.; Frogley R.; Sydenham M.A.; Emson M.; Hall E.

Citation:Journal of Clinical Oncology. Conference: Annual Meeting of the American Society of Clinical Oncology, ASCO 2022. Online. 40(16 Supplement 1) (no pagination), 2022. Date of Publication: June 2022

Abstract:Background: Most newly diagnosed oro- & hypopharngeal cancers (OPC, HPC) are treated with (chemo) RT with curative intent but at the consequence of adverse effects on quality of life. We investigated if using DO-IMRT to reduce RT dose to the dysphagia/aspiration related structures (DARS) improved swallowing function compared to S-IMRT. Method(s): Patients with T1-4, N0-3, M0 OPC/HPC were randomised 1:1 to S-IMRT (65 Gray (Gy)/30 fractions (f) to primary & nodal tumour; 54Gy/30f to remaining pharyngeal subsite & nodal areas at risk of microscopic disease) or DO-IMRT. The volume of the superior & middle pharyngeal constrictor muscle (PCM) (OPC) or inferior PCM (HPC) lying outside the high-dose target volume was set a mandatory mean dose constraint in DO-IMRT. Treatment allocation was by minimisation balanced by centre, use of induction/concomitant chemotherapy, tumour site & AJCC stage. Primary endpoint was mean MD Anderson Dysphagia Inventory (MDADI) composite score 12 months after RT. Secondary endpoints included University of Washington (UW)-Qol, Performance Status Scale Head & Neck (PSS-HN) domain scores (range: 0-100), swallow volume, swallow capacity and local control. Result(s): 112 patients (56 S-IMRT, 56 DO-IMRT) were randomised from 22 UK & Ireland centres from 06/2016 – 04/2018. 111/112 had RT doses as prescribed (1 patient died before RT). Outcome measures at 12 and 24 months are summarised below. DO-IMRT had higher MDADI scores at 12 (p = 0.04) and 24 (p = 0.07) months. Clinically important improvements in swallowing function were seen in patients receiving DO-IMRT using PSS-HN domains and the UW-QoL tool. Conclusion(s): DO-IMRT improved patient reported swallowing function compared with S-IMRT. Improvements were seen in overall MDADI as well as functional scores in both PSS-HN and UW-QoL.

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CT coronary angiography significantly changes treatment targets versus coronary artery calcium scoring in high-risk dyslipidaemia patients (2022)

Type of publication:Conference abstract

Author(s):Graby J.; Sellek J.; Bayly G.; Avades T.; *Capps N.; Shipman K.; Mbagaya W.; Luvai A.; Khavandi A.; Loughborough W.; Hudson B.; Downie P.; Rodrigues J.;

Citation:Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2022. Manchester United Kingdom. 108(Supplement 1) (pp A135-A136), 2022. Date of Publication: June 2022.

Abstract:Introduction Dyslipidaemia accelerates atherosclerosis. Patients with genetic dyslipidaemias, Familial Hypercholesterolaemia (FH) being the most common, are at heightened risk of premature cardiovascular events. However, this risk is heterogeneous within identical genotype diseases, and modifiable with treatment. Coronary imaging identifies subclinical atherosclerosis, personalises risk stratification and treatment targets. Coronary artery calcium scoring (CACS) is first-line for primary prevention. However, calcification is a late-stage process in CAD pathogenesis and the CACS has low specificity in young patients with severe FH. CT coronary angiography (CTCA) may identify non-calcific CAD and high risk plaque (HRP) features unseen with CACS. This study aimed to quantify the impact of CTCA vs traditional CACS on clinical management in real-world asymptomatic Lipid Clinic patients. Methods A retrospective single-centre review of asymptomatic Lipid Clinic electronic patient records with both CACS and CTCA from May 2019 to December 2020. A vignette was compiled for each patient providing all relevant clinical data. CACS was recorded as Agastston score and CTCA as the Coronary Artery Disease – Reporting and Data System (CAD RADS) grading of anatomical stenosis with a modifier for HRP features.Findings were compiled into an anonymised online survey which Consultant Biochemists from across the UK were invited to complete. Data was revealed in a stepwise fashion to the participating clinician: (i) vignette only, (ii) CACS, and (iii) CAD RADS. Clinicians were asked their lipid target and management after each data-point was unblinded. Background information on CACS and CTCA result interpretation was provided prior to participation. Statistical analysis was performed using SPSS v.21 and significance was defined as two-tailed p<0.05. Results 45 asymptomatic patients (55+/-9 years, 49% female) were included. 7 Consultant Biochemists from 6 institutions (4 [67%] tertiary/teaching Hospitals and 2 [33%] district general Hospitals) participated.CACS and CAD RADS assessment of disease burden is presented in Figure 1, with CTCA re-classifying CAD severity vs CACS in 28/45 (62%) patientsLipid targets were altered significantly more frequently with CTCA vs CACS (19% vs 12%; chi2 57.0, p<0.005), even after CACS result available (Figure 2). The LDL target selected was altered by CACS in 12%, and in a further 19% when CAD RADS result was unblinded, which was statistically significant (c2 57.0, p<0.005). This finding was consistent across FH and non-FH patients. Increasing CACS and CAD RADS severity were significantly associated with change in lipid target (c2 54.2, p<0.001; chi2 27, p<0.001), the latter even after a high CACS result was available, as did presence of HRP (chi2 9.3, p=0.002). Conclusion In high-risk asymptomatic dyslipidaemia, CTCA alters treatment targets beyond CACS by demonstrating higher CAD severity burden and HRP. This may differentiate high risk and very high risk patients in an important population.

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A multi-dimensional approach towards implementing the effective use of remote electrocardiographic monitoring - evaluation of clinical correlation and patient experience (2022)

Type of publication:Conference abstract

Author(s):*Asad M.; Younas W.; *Kazi S.I.; Alaguraja P.; *Makan J.

Citation:Heart. Conference: British Cardiovascular Society Annual Conference, BCS 2022. Manchester United Kingdom. 108(Supplement 1) (pp A74-A75), 2022. Date of Publication: June 2022.

Abstract:Background Inappropriate use of telemetry results in the overuse of limited resources, disrupted provider workflow, higher costs of care, and false alarms with resultant alarm fatigue. Moreover, identifying a useful implementation blueprint is an important component of promoting its appropriate use. Telemetry can influence patient experience during their stay as potentially it can disturb sleep, contribute to delirium, and increase patient frustration and anxiety. We stipulate that even minor adjustments to monitoring practices can influence optimised patient care. We aimed to evaluate the co-existing standards of practice regarding use of telemetry across Shrewsbury and Telford Hospital NHS Trust (SaTH). We implemented a patient-centred approach towards quality improvement by incorporating record of patient experience as a tool to guide effective use of this limited resource across our district general hospital settings. Methods Patients across two hospital sites were selected to conduct a prospective health service evaluation related to the use of telemetry. A likert scale survey was conducted to record patient perspective of telemetry monitoring including a section with an opportunity to provide feedback towards service improvement. The data of patients receiving telemetry was collected from December 2021 to February 2022.American Heart Association (AHA) consensus statement for remote electrocardiographic monitoring was utilized to evaluate the proposed indication for telemetry. However, the rating system helped group patients receiving telemetry monitoring as Class I (definitely indicated), Class II (maybe indicated), or Class III (not indicated). Clinical notes and electronic telemetry system was employed to record parameters including patient demographics; presenting complaint; class (I-III) of indication; whether an indication for telemetry was documented; the length of telemetry; and the details of any significant events that occurred during monitoring including escalation. Where possible, patients were asked to anonymously provide feedback via set questionnaire focusing on quality of care received by the patient. Result(s):Among the 30 patients who were included in our analysis, 7 were females and the average age in our cohort was found to be 72.8. In about 56% of the patients, there was no clear indication mentioned in the clinical notes regarding continuation/discontinuation of telemetry. Based on proposed indication, about 36.66% (11 patients out of which 2 were female) were identified to be at significant risk of an immediate life-threatening arrhythmia (Class I). Among this group, 2 patients were reported to have significant arrhythmia event necessitating treatment. Further analysis revealed that from our cohort, 46.66% (14 patients) had a Class II indication for their telemetry monitoring out of which only 2 patients had a significant event recorded. However, only 16.66% (5 patients) were found to meet the eligibility for Class III indications and none of them encountered a significant arrhythmia. From anonymously filled patient questionnaires, around two-third of the patients reported not being informed about the utility of telemetry and its predicted duration of stay. One-third of patients reported the device to be inconvenient, intrusive and heavy. Conclusions To accomplish a sustainable improvement, a patient-centred approach should be exercised to help identify the gaps in quality of care delivered. Our analysis showed that significant number of patients received telemetry when it was not clinically indicated. The proposed interventions include adopting formal request process for telemetry, predicting its duration, use of patient education tools and exploring compatibility of telemetry device used. Larger scale studies are required to gain more insight into the appropriateness and impact of telemetry in a hospital setting.

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Reducing intra-hospital telephone communication time using app technology (2020)

Type of publication:
Conference abstract

Author(s):
*Hamid M.

Citation:
BMJ Leader. Conference: Leaders in Healthcare Conference 2020. Virtual. 4(Supplement 1) (pp A42), 2020. Date of Publication: November 2020.

Abstract:
Background Lengthy switchboard waiting times result in delayed communication between healthcare professionals in a hospital. Wasted time impedes patient care, costs the Trust a substantial financial sum and impacts healthcare professional's morale. Aim(s): To reduce intra-hospital telecommunication time utilising the Induction phone application, an easy to use, regularly updated telephone directory. Method(s): Initial audit: Five chosen specialities were contacted between 9-10 AM from the Emergency department for 2 consecutive weeks. The time taken to reach each speciality via switchboard was recorded. A survey seeking the number of calls made per day, the preferred method of contact and the feelings associated with telephone waiting times was sent to department doctors. PDSA cycle 1: One-month application advertisement and re-audit. PDSA2: Eye-catching tele-directory board with the most used extensions and bleeps displayed in the department. Satisfaction survey sent post PDSA2. Sustainability: New doctors were provided induction information. Result(s): Initial average waiting time via switchboard was 48 seconds. The average calls made per doctor each day was 12. This calculated to a total departmental loss of 20.16 hours per week waiting on the phone, equating an annual loss of 26, 208. PDSA1: Average waiting times reduced to 12 seconds utilising the application; saving an estimate ~19,656 per annum. PDSA2: Instant availability of contact details on the display board further reduced waiting times to an average 6 seconds. 84% of doctors (n=16) disliked waiting more than 20 seconds, with associated feelings of frustration. 100% preferred the display board, then the use of the application before resorting to switchboard. 100% Sustainability was recorded one year later. Conclusion(s): The use of application technology reduces wasted time which hampers patient care; reduces Trust running costs; and improves health care professional's morale at work.

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Reduction in cardiovascular disease morbidity of men and women with familial hypercholesterolaemia (FH) associated with availability of high intensity statins: A cohort study using data from the UK Simon Broome Register linked with secondary care records (2021)

Type of publication:Conference abstract

Author(s):Iyen B.; Qureshi N.; Roderick P.; *Capps N.; Durrington P.N.; McDowell I.F.W.; Cegla J.; Soran H.; Schofield J.; Neil H.A.W.; Kai J.; Weng S.; Humphries S.E.

Citation:Atherosclerosis Plus. Conference: HEART UK 34th Annual Medical & Scientific Virtual Conference. Virtual, Online. 43(Supplement) (pp S5), 2021. Date of Publication: September 2021.

Abstract:Background: Previous studies of the Simon Broome (SB) FH register reported that, compared to the low-intensity statin period (1992-2008), the standardised cardiovascular disease (CVD) mortality ratio in the high-intensity statin period (2009-2015) was 22% lower in men but 115% higher in women. Linkage of the register with Hospital Episodes Statistics (HES) data has now enabled prospective evaluation of CVD morbidity based on inpatient care. Method(s): Standardised Morbidity Ratios (SMbR) compared to age and sex-matched UK primary care patients were calculated [95% confidence intervals] for risk of composite CVD (first HES outcome of CHD, MI, stable or unstable angina, stroke, TIA, PVD, heart failure, PCI and CABG) in men and women under and over the age of 50 years. Result(s): 2,988 (52.5% women) SB register participants had HES records. The SMbR was higher in women than men in both age groups and during both time periods. Compared to 1997-2007, in both men and women aged <50 years the SMbR fell significantly in the 2008-2017 period (8.7[7.3-10.3] vs 17.9[15.7-20.5] and 12.8[10.4-15.7] vs 20.8[17.1-25.4] respectively. By contrast in both sexes in those >50 years in the later time period there was no significant reduction in CVD-admission incidence rates or in SMbR (Men, 6.6[5.3-8.2] vs 5.8[5.0-6.8], Women, 9.2[7.8-10.7] vs 7.5 [6.6-8.5]). Conclusion(s): While the rate of CVD morbidity due to FH has encouragingly fallen significantly over time in both sexes aged <50 years, it has not done so in those >50. This emphasises the importance of early identification and optimal lipid-lowering throughout life for subjects with FH. Funded by the NIHR HTA project 15/134/02 and BHF grants RG3008 and PG008/08.

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Establishment of virtual fracture clinic in Princess Royal Hospital Telford: Experience and recommendations during the first 9 months (2022)

Type of publication:
Conference abstract

Author(s):
*Khaleeq T.; *Lancaster P.; *Fakoya K.; *Ferreira P.; *Ahmed U.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Innovation Summit – Future Surgery Show. London United Kingdom. 109(SUPPL 1) (pp i13), 2022. Date of Publication: March 2022.

Abstract:
Introduction: Virtual fracture clinics (VFC) have been shown to be a safe and cost-effective way of managing outpatient referrals to the orthopaedic department. During the coronavirus pandemic there has been a push to reduce unnecessary patient contact whilst maintaining patient safety. Method(s): A protocol was developed by the clinical team on how to manage common musculoskeletal presentations to A&E prior to COVID as part of routine service development. Patients broadly triaged into 4 categories; discharge with advice, referral to VFC, referral to face to face clinic or discussion with on call team. The first 9 months of data were analysed to assess types of injury seen and outcomes. Result(s): In total 2489 patients were referred to VFC from internal and external sources. 734 patients were discharged without follow-up and 182 patients were discharged for physiotherapy review. Only 3 patients required admission. Regarding follow-ups, 431 patients had a virtual follow-up while 1036 of patients required further face to face follow up. 87 patients were triaged into subspecialty clinics. 37 patients were felt to have been referred inappropriately. Conclusion(s): BOA guidelines state all patients must be reviewed within 72 hours of their orthopaedic injury. Implementation of a VFC allows this target to be achieved and at the same time reduce patient contact. Almost half the patients were discharged following VFC review, the remaining patients were followed up. This is especially relevant in the current pandemic where reducing unnecessary trips to hospital will benefit the patient and make the most of the resources available.

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The rise in trauma & orthopaedic trainee-led research and audit collaborative projects in the united kingdom since the start of the COVID-19 pandemic. (2022)

Type of publication:
Conference abstract

Author(s):
*Khaleeq T.; *Kabariti R.; *Ahmed U.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Innovation Summit – Future Surgery Show. London United Kingdom. 109(SUPPL 1) (pp i13), 2022. Date of Publication: March 2022.

Abstract:
Introduction: There has been a significant rise in trainee-led trauma & orthopaedic (T&O) multi-centre research collaborative projects globally. Since the start of the COVID-19 pandemic, more emphasis has been on global collaborative research efforts to tackle important research questions. The aim was to evaluate the number of T&O trainee-led research collaborative projects that took part since the start of the COVID-19 pandemic in the UK. Method(s): A retrospective study that evaluated T&O trainee-led national collaborative projects within the UK since the start of the COVID-19 pandemic lockdown (March 2020 to June 2021). Our exclusion criteria included any regional collaborative projects, projects that were started pre-COVID and projects of other surgical specialities. The number of projects identified was compared to that in 2019. Result(s): In 2019, 0 trainee-led collaborative projects were commenced nationally in the UK. Since the COVID-19 pandemic, we identified 10 trainee-led collaborative trauma & orthopaedic projects with 3 being published so far. The level of evidence ranged between 3 and 4. Conclusion(s): Covid has placed significant challenges across healthcare. One positive aspect that has been noted is the increase in multi-centre trainee-led collaborative projects within the UK. Our study highlights the feasibility of a trainee-led high quality collaborative research projects in the UK, emphasising the growing contribution of trainees towards research. Wide-spread availability of new technological tools suchas social media and Redcap facilitates such projects in terms of recruitment and data collection. We would, therefore, recommend expanding this trainee-led collaborative platform across in Europe and Worldwide.

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Plain film x-ray reporting in orthopaedic patients: A reaudit in a district general hospital (2022)

Type of publication:
Conference abstract

Author(s):
*Khaleeq T.; *Shah Foridi J.; *Reading J.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Innovation Summit – Future Surgery Show. London United Kingdom. 109(SUPPL 1) (pp i13), 2022. Date of Publication: March 2022.

Abstract:
Aim: To assess clinical evaluation of plain film x-rays requested for patients in the orthopaedic department (clinic and ward) Standards: Ionising radiation (medical exposure) regulations irmer 2017 procedure j: recording clinical exposure, national guideline and local guidance is in keeping with irmer and good clinical practice. Method(s): 50 plain films of randomly selected (using random number generator) who had attended new patient fracture clinic and ward. An initial audit was done in June and an reaudit in September. The radiology system, clinical notes and clinic letters were reviewed to obtain the relevant data. Result(s): Audit: 20 films were documented 30 were not documented Reaudit 32 films were documented by referring clinician 18 films were not documented by referring clinician Audit: Clinical evaluation documented 18 Clinical evaluation not documented 32 Reaudit: Clinical evaluation documented – 29 Clinical evaluation not documented – 21 Discussion: Whose responsibility? Radiographs commented on in trauma meetings not documented. New radiographs not commented on in clinic. Limitations – access to more notes from ward. Conclusion(s): As outlined in guidance orthopaedic and fracture clinic plain films should be reported by referring clinician or their team. Currently this is being done 64% of the time, significant improvement was seen. This may have medicolegal consequences as it does not follow GMC guidance for good medical practise. Recommendations: Clinicians to specifically dictate x-ray findings in fracture clinic. Junior staff to take responsibility for documenting x-ray findings as discussed with senior clinicians for trauma patients. Junior staff to review post-op x-rays for all patients and to document.

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