British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab (2021)

Type of publication:
Journal article

Author(s):
Dobson R.; Ghosh A.K.; Stanway S.; Manisty C.; Ky B.; Marwick T.; Stout M.; Pearce K.; Harkness A.; Steeds R.; Robinson S.; Oxborough D.; Adlam D.; Rana B.; *Ingram T.; Ring L.; Rosen S.; Plummer C.; Harbinson M.; Sharma V.; Lyon A.R.; Augustine D.X.

Citation:
Echo Research and Practice; Mar 2021; vol. 8 (no. 1)

Abstract:
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

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Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial (2021)

Type of publication:
Journal article

Author(s):
Okeke Ogwulu, C B; Williams, E V; Chu, J J; Devall, A J; Beeson, L E; Hardy, P; Cheed, V; Yongzhong, S; Jones, L L; La Fontaine Papadopoulos, J H; Bender-Atik, R; Brewin, J; Hinshaw, K; Choudhary, M; Ahmed, A; Naftalin, J; Nunes, N; Oliver, A; Izzat, F; Bhatia, K; Hassan, I; Jeve, Y; Hamilton, J; Deb, S; Bottomley, C; Ross, J; Watkins, L; *Underwood, M; Cheong, Y; Kumar, C S; Gupta, P; Small, R; Pringle, S; Hodge, F S; Shahid, A; Horne, A W; Quenby, S; Gallos, I D; Coomarasamy, A; Roberts, T E

Citation:
BJOG : an international journal of obstetrics and gynaecology; May 2021 [epub ahead of print]

Abstract:
OBJECTIVE To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using non-parametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the NHS perspective.SETTING28 UK NHS early pregnancy units.PARTICIPANTS711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. INTERVENTIONS Mifepristone and misoprostol or matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES Cost per additional successfully managed miscarriage and QALYs. RESULTS For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI: 0.7% to 12.5%) per successfully managed miscarriage and QALYs difference of 0.04% (95% CI: -0.01% to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost-saving of £182 (95% CI: £26 to £338). Hence, MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that MifeMiso intervention is dominant compared to expectant management and the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS The within-trial analysis found that based on cost-effectiveness grounds, MifeMiso intervention is likely to be recommended by decision-makers for the medical management of women presenting with a missed miscarriage.

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Postpartum haemorrhage and risk of long-term hypertension and cardiovascular disease: an English population-based longitudinal study using linked primary and secondary care databases (2021)

Type of publication:
Journal article

Author(s):
*Parry-Smith, William; Šumilo, Dana; Subramanian, Anuradhaa; Gokhale, Krishna; Okoth, Kelvin; Gallos, Ioannis; Coomarasamy, Arri; Nirantharakumar, Krishnarajah

Citation:
BMJ Open; May 2021; vol. 11 (no. 5); p. e041566

Abstract:
OBJECTIVE To investigate the long-term risk of developing hypertension and cardiovascular disease (CVD) among those women who suffered a postpartum haemorrhage (PPH) compared with those women who did not. DESIGN Population-based longitudinal open cohort study. SETTING English primary care (The Health Improvement Network (THIN)) and secondary care (Hospital Episode Statistics (HES)) databases. POPULATION Women exposed to PPH during the study period matched for age and date of delivery, and unexposed. METHODS We conducted an open cohort study using linked primary care THIN and HES Databases, from 1 January 1997 to 31 January 2018. A total of 42 327 women were included: 14 109 of them exposed to PPH during the study period and 28 218 matched for age and date of delivery, and unexposed to PPH. HRs for cardiovascular outcomes among women who had and did not have PPH were estimated after controlling for covariates using multivariate Cox regression models. OUTCOME MEASURES Risk of hypertensive disease, ischaemic heart disease, heart failure, stroke or transient ischaemic attack. RESULTS During a median follow-up of over 4 years, there was no significant difference in the risk of hypertensive disease after adjustment for covariates (adjusted HR (aHR): 1.03 (95% CI: 0.87 to 1.22); p=0.71). We also did not observe a statistically significant difference in the risk of composite CVD (ischaemic heart disease, heart failure, stroke or transient ischaemic attack) between the exposed and the unexposed cohort (aHR: 0.86 (95% CI: 0.52 to 1.43; p=0.57). CONCLUSION Over a median follow-up of 4 years, we did not observe an association between PPH and hypertension or CVD.

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MRI of the Achilles tendon – a comprehensive pictorial review. Part two (2021)

Type of publication:
Journal article

Author(s):
Szaro P.; Nilsson-Helander K.; *Carmont M.

Citation:
European Journal of Radiology Open; Jan 2021; vol. 8

Abstract:
The most common disorder affecting the Achilles tendon is midportion tendinopathy. A focal fluid signal indicates microtears, which may progress to partial and complete rupture. Assessment of Achilles tendon healing should be based on tendon morphology and tension rather than structural signal. After nonoperative management or surgical repair of the Achilles tendon, areas of fluid signal is pathologic because it indicates re-rupture. A higher signal in the postoperative Achilles tendon is a common finding and is present for a prolonged period following surgical intervention and needs to be interpreted alongside the clinical appearance.

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BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab (2021)

Type of publication:
Journal article

Author(s):
Dobson R.; Ghosh A.K.; Manisty C.; Ky B.; Marwick T.; Stout M.; Pearce K.; Harkness A.; Steeds R.; Robinson S.; Oxborough D.; Adlam D.; Stanway S.; Rana B.; *Ingram T.; Ring L.; Rosen S.; Lyon A.R.; Plummer C.; Harbinson M.; Sharma V.; Augustine D.X.

Citation:
JACC: CardioOncology; Mar 2021; vol. 3 (no. 1); p. 1-16

Abstract:
The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor receptor (HER) 2-positive targeted treatment (e.g., trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

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

MRI of the Achilles tendon-A comprehensive pictorial review. Part one (2021)

Type of publication:
Journal article

Author(s):
Szaro P.; Nilsson-Helander K.; *Carmont M.

Citation:
European Journal of Radiology Open; Jan 2021; vol. 8

Abstract:
The normal Achilles tendon is composed of twisted subtendons separated by thin high signal septae, which are a potential pitfall on MRI because they mimic a tendon tear. Tendinopathy and full thickness tears may be assessed effectively both on MRI and ultrasound. MRI is superior to ultrasound in detection of partial tears and for postoperative assessment. The use of fat suppression sequences allows the ability to detect focal lesions. Sagittal and coronal sections are useful for assessing the distance between stumps of a ruptured tendon. Sequences with contrast are indicated in postoperative investigations and suspicion of infection, arthritis or tumor. MRI may reveal inflammatory changes with minor symptoms long before the clinical manifestations of seronegative spondyloarthropathy. The most common non-traumatic focal lesion of the Achilles tendon is Achilles tendon xanthoma, which is manifested by intermediate or slightly higher signal on T1- and T2-weighted images compared to that in the normal Achilles tendon. Other tumors of the Achilles tendon are very rare, whereas the involvement of the tendon from tumor in adjacent structures is more frequent. The novel MRI sequences may help to detect disorders of the Achilles tendon more specifically before clinical manifestation. Regeneration or remodeling of the Achilles tendon can be non-invasively detected and monitored in diffusion tensor imaging. Assessment of healing is possible using T2-mapping while evaluating the tendon vascularization in intravoxel incoherent motion MRI.

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Regional experiences of endotracheal intubation during the COVID-19 pandemic in The United Kingdom (2020)

Type of publication:
Conference abstract

Author(s):
Shuker B.; Smith E.; *Checketts P.; Khan Q.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: In the United Kingdom (UK), consensus guidelines for airway management were published early in the COVID-19 pandemic making recommendations to support clinicians during this potentially challenging intervention (1). Adaptions to existing guidance for airway management in critically ill adults from the Difficult Airway Society (2) included: use of personal protective equipment (PPE), preferential use of the best skilled airway manager to maximise chance of first-pass success, avoidance of aerosol-generating procedures (such as noninvasive ventilation, high flow nasal oxygenation), and use of reliable well practiced techniques (including videolaryngoscopy where appropriate). Objective(s): Areas of the West Midlands were some of the worst affected by the COVID-19 pandemic in the UK (3). We aimed to gain insight into the experiences of clinicians involved with airway management during the COVID-19 pandemic in this region. Method(s): An online survey was distributed to multiple centres within the West Midlands region of the UK. Clinicians who had experience of endotracheal intubation in patients with confirmed, suspected, or unknown COVID-19 status were asked to reflect upon their experience of one patient intubation. Result(s): 127 clinicians from 16 hospitals including 3 large university hospitals responded to the online survey, most were consultant grade (56.7%). Clinicians self-reported an average approximate number of pandemic intubations of 7.35 (range 1-30). When asked to reflect on a single intubation, clinicians reflected on intubations in ICU (42.5%), emergency departments (20.5%), wards (8.7%), and theatre (28.3%). Appropriate PPE was available in 96.1%. The most senior clinician available intubated in 65.4%. Clinicians reported first pass success in 93.7% of responses. Most intubators reported use of videolaryngoscopy (74.8%), however 26% reported not using this equipment regularly and 5.5% did not feel confident with their equipment. Despite a high success rate, difficulties were reported in 15.1%. The most common was desaturation. Other common difficulties included equipment or environment unfamiliarity, lack of skilled support. When asked what advice they would give to colleagues, frequently occurring themes included: ensuring familiarity with equipment, use of a checklist, use of videolaryngoscopy, and availability of a second intubator. Desire for simulation and equipment familiarisation was highlighted in multiple responses, and in one example a clinician attributed their success to a simulation session performed in the week prior. Conclusion(s): Experiences from clinicians in this region highlight the specific challenges encountered involved in airway management of patients with COVID-19, in particular highlighting the importance of advance preparation for intubation when faced with unfamiliar circumstances. Simulation sessions, use of checklists and standard operating procedures for emergency intubation may contribute to maintaining preparedness for intubation in this challenging patient group.

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Intensive care unit (ICU) referrals and admissions at a district general hospital (DGH) in light of the COVID-19 pandemic (2020)

Type of publication:
Conference abstract

Author(s):
*Blair J.; *Naughton E.; *Pradhan N.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: The COVID-19 pandemic has led to an increase in ICU referrals and admissions across the UK during 2020 [1]. Intensive care beds are a limited and expensive resource and decisions on patient admission are often very challenging [2]. Proformas help to standardise documentation and decision logging during patient referrals [3]. They provide easily accessible evidence in case of a future referral and allow audit of decision-making processes. A preliminary survey of doctors working in a DGH ICU was undertaken to assess the current referral and admission process in expectation of an increased volume of work.
Objective(s): As a result of the survey, three main areas for improvement were identified: 1. To maintain a record of all ICU referrals and decision-making processes 2. To reduce the time taken for documentation of referrals and admissions 3. To improve the quality and appropriateness of referrals from parent specialities Methods: A proforma was designed for dual use as a referral and admission document. All referrals were recorded on paper and staff received training on how to apply the proforma. After assessment of each referral, irrespective of admission outcome, a completed copy of the proforma was placed in both the patient’s notes and a dedicated referrals folder. After one month, a further survey was designed to assess the response postimplementation of the proforma. All referrals made over a threemonth period between April and June 2020 were audited.
Result(s): The initial survey received 12 responses. Prior to the COVID-19 pandemic, documentation of any referral or admission took on average 10-15 minutes. All survey participants felt that referring teams did not have a good understanding of the role of ICU care and estimated that up to 40% of all referrals received were inappropriate. The follow-up survey received 14 responses. Implementation of the proforma reduced the time taken to document a referral or admission on average by 5-10 minutes. Twelve participants found the proforma a useful aid, helping to provide clear documentation and ease communication between ICU team members. Less than 9% of the referrals made between April and June 2020 were admitted to ICU with over 32% of referrals deemed unsuitable for further escalation. Approximately 50% of referrals were made by registrars, with 13% discussed by consultants. The median age of patients referred was 67.5 and the most common reason was for respiratory deterioration.
Conclusion(s): This quality improvement project successfully reduced the time taken to document ICU referrals and admissions. Use of a proforma has provided many benefits, including standardisation of documentation, decision logging and improvement of intra-and inter-team communication. Only a small proportion of patients referred to ICU have been suitable for admission. A teaching session is being designed so that referral information can be fed-back to parent specialties. Referrals will be reaudited after this. Data analysis of this project has been limited by incomplete proforma documentation from participating users.

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A Tidal volume calculator to improve lung protective ventilation in COVID-19 related Acute Respiratory Distress Syndrome (ARDS) (2020)

Type of publication:
Conference abstract

Author(s):
*Blair J.; *Hester S.; Baldwin A.; Ali T.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: Routine use of lower tidal volumes (TVs) for the mechanical ventilation of patients with ARDS results in decreased mortality and increases the number of days without ventilator use [1]. Severe COVID-19 pneumonia has been associated with the development of ARDS as characterised by the Berlin definition [2]. A multi-centre preliminary audit was undertaken to identify whether ventilated COVID-19 related ARDS patients were receiving optimal TVs, as recommended by the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) ARDS management guidelines [3]. Objective(s): As a result of the audit, three main areas for improvement were identified. 1. To achieve accurate calculations for ideal body weight (IBW) and target TV 2. To improve documentation of IBW and target TV 3. To achieve TVs no greater than 6 ml/kg Methods: A ‘tidal volume calculator’ tool was developed using Microsoft Excel, which was simple, colour coded and kept on all Intensive Care Unit (ICU) computer desktops. This tool was designed to use height to calculate IBW and, if the patient’s height was unavailable, could also be utilised to calculate height from ulna length. IBW was subsequently used to calculate a target TV. Staff received training on how to apply the tool. Two snapshot audits were carried out in April and May 2020 at two ICUs. The first was conducted prior to the tool’s introduction with the second two weeks after its implementation. All patients receiving mechanical ventilation, except those spontaneously breathing, were included. Data was extracted from patient notes, charts and ventilator settings. Result(s): The initial audit included 14 patients. Six patients did not have an IBW documented. Three patients had documented IBWs that were 12 kg, 15 kg and 23 kg greater than the weight calculated using the tool, leading to increased tidal volume targets. Only three patients were achieving TVs of 4-6 ml/kg. Eleven patients were achieving a TV greater than 6 ml/kg, with two of these achieving a TV of greater than 8 ml/kg. The follow-up audit included ten patients. This revealed that all patients had an IBW clearly documented. Moreover, nine patients were achieving TVs within 4-6 ml/kg, with only one patient found to be achieving a TV greater than 6 ml/kg. Conclusion(s): This audit cycle revealed that initially adherence to lung protective ventilation and documentation of IBW was poor. In some instances, documented IBW was vastly different to the calculated IBW, suggesting that in these situations actual body weight may have been used. In a time when clinicians were being redeployed to support ICU, this simple tool was shown to support staff by clearly calculating and displaying IBW and target TV for reference. This directly led to improved adherence to lung protective ventilation and optimisation of patient care. Limitations include that no consideration was made for overall patient outcome, and only a snapshot of achieved TVs from ventilators were recorded; daily/weekly trends were not studied.

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Babies in occiput posterior position are significantly more likely to require an emergency cesarean birth compared with babies in occiput transverse position in the second stage of labor: A prospective observational study (2020)

Type of publication:
Journal article

Author(s):
Tempest, Nicola; Lane, Steven; Hapangama, Dharani; UK Audit Ressearch Trainee Collaborative in Obstetrics, Gynecology (UK-ARCOG) (*William Parry-Smith is a core committee member of UK-ARCOG)

Citation:
Acta Obstetricia et Gynecologica Scandinavica; Apr 2020; vol. 99 (no. 4); p. 537-545

Abstract:
INTRODUCTION Malposition complicates 2-13% of births at delivery, leading to increased obstetric interventions (cesarean section and instrumental delivery) and higher rates of adverse fetal and maternal outcomes. Limited data are available regarding the likely rates of obstetric intervention and subsequent neonatal and maternal outcomes of births with babies in persistent occiput posterior position vs those in persistent occiput transverse position. The UK Audit and Research trainee Collaborative in Obstetrics and Gynecology (UK-ARCOG) network set out to collect data prospectively at delivery on final mode of delivery and immediate outcomes.MATERIAL AND METHODS The UK-ARCOG network collected data on all births with malposition of the fetal head complicating the second stage of labor (n = 838) (occiput posterior/occiput transverse) requiring rotational vaginal operative birth or emergency cesarean to expedite delivery across 66 participating UK National Health Service maternity units over a 1-month period. The outcomes considered were the need for emergency cesarean section without a trial of instrumental delivery, success of the first method of delivery employed in achieving a vaginal delivery and neonatal/maternal outcomes.RESULTS Obstetricians regarded assistance with an operative vaginal delivery method to be unsafe in 15% of babies in occiput posterior position and 6.1% of babies in occiput transverse position, and they were delivered by primary emergency cesarean section. When vaginal delivery was deemed safe (defined as attempted assisted vaginal rotational delivery), the first instrument attempted was successful in 74.4% of occiput posterior babies and 79.3% of occiput transverse babies.CONCLUSIONS Our data facilitates decision making by obstetricians to increase safety of assisted rotational operative delivery of a malpositioned baby at initial assessment and in counseling women. Until data from a well-designed randomized controlled trial of instrumental delivery vs emergency cesarean section are available, this manuscript provides contemporaneous national data from a high resource setting within a structured training program, to assist the selection of an appropriate instrument/method for the delivery of a malpositioned baby.

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