2024
Recent Submissions
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Risk of Major Adverse Cardiovascular Events and Venous Thromboembolism with JAK Inhibitors versus TNF Inhibitors in Rheumatoid Arthritis Patients: A Systematic Review and Meta-Analysis.The aim of this study was to compare the risk of major cardiovascular events (MACE) and venous thromboembolic events (VTE) between tumour necrosis factor (TNF) and Janus kinase (JAK) inhibitors in patients with rheumatoid arthritis (RA). We researched PubMed, Scopus, Cochrane Library, and clinicaltrials.gov until December of 2023 for randomised controlled trials (RCTs) and observational studies. The outcomes studied were MACE (stroke, heart attack, myocardial infarction, sudden cardiac death) and VTE (deep vein thrombosis, pulmonary embolism). We pooled data using random effects model. Risk for the reported outcomes was expressed as odds ratio (OR) with a 95% confidential interval (CI). We performed a subgroup analysis based on study design. We identified 23 studies, 20 of which compared the odds for MACE and 14 the odds for VTE between JAK and TNF inhibitors in RA patients. Ten studies were RCTs and the rest were observational. Regarding MACE risk we pooled data from a total of 215,278 patients (52,243 were treated with JAK inhibitors, while the rest 163,035 were under TNF inhibitors). Compared with TNF inhibitors, the OR for JAK inhibitors in regards with MACE risk was 0.87 (0.64-1.17, p<0.01). Regarding VTE, a total of 176,951 patients were analysed (41,375 JAK inhibitors users and 135,576 TNF inhibitors users). The OR for VTE for JAK inhibitors compared with TNF inhibitors was 1.28 (0.89- 1.84, p<0.01). According to our results, there is no statistically significant difference for MACE or VTE in RA patients who receive either JAK or TNF inhibitors.Copyright � (2023) Greek Rheumatology Society and Professional Association of Rheumatologists. All Rights Reserved.
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TCTAP A-054 Incidence and Predictors of Permanent Pacemaker Implantation Following Transcatheter Aortic Valve Replacement.Transcatheter aortic valve replacement (TAVR)has become the standard of care for patients with severe aortic stenosis at high risk for surgery. However, it is associated with a high rate of permanent pacemaker (PPM) implantation. TAVR is now being performed in many centres across the middle east. There is limited data regarding the outcomes of patients undergoing TAVR in this region. The aim of our study was to assess the rates of PPM implantation post TAVR at our institution and to study the factors that could predict the need for one. Method(s): This was a retrospective study involving all patients undergoing TAVR at our institution over a 5-year period from 2015 to 2020. We included patients who survived the procedure to discharge and those that were followed up for one year post procedure. All clinical data was obtained from the electronic case notes of the patients who were identified from our cardiology catheter lab database. Ethical approval was obtained from our Medical ethics committee Results: A total of 153 patients (age: 74.2+/-8.2 years; Male 82 (53.6%), Female 71 (46.4%)) were enrolled into the study. Of these, 15patients (age 74.3+9.8 years, 46.6%male) had required a permanent pacemaker within one year of follow up, giving a pacemaker implantation rate of 9.8%following TAVI in our cohort of patients. Tenof the 15 implants were performed within the first two weeks of the TAVI, with the median delay after TAVI being 6 days (IQR of 3-90 days). At one month, 2 of the 12 patients who had a pacing check had 0% pacing. At 6 months, this increased to 3 of the 8 patients who had a pacing check who were not pacing. At one year, 5 of the 8 patients who had a pacing check were not being paced. The factors that predicted the requirement of a pacemaker were pre-existing RBBB (OR 10.9, 95% CI 3.31-36.33,p<0.001), abnormal QRS axis (OR 9.11, 95% CI 2.77-29.91, p<0.001),prolonged QRS duration (OR 3.26 95%CI 1.06-9.92, p=0.03), and any pre-existing conduction abnormality (OR 1.18, 95% CI 1.08-1.29, p=0.01) Conclusion(s): The rates of pacemaker implantation post TAVI procedure at our institution are similar to those published in literature. The risk factors for requiring a pacemaker are also similar. However, our data seems to suggest that a sizeable proportion of these patients appear to regain their normal conduction. It might be worthwhile observing patients with conduction abnormalities before implanting a pacemaker.Copyright � 2024
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Impact of gold standards framework accreditation on specialist palliative care referrals in acute hospital setting; addressing inequalities in access.It is established that people with a non-cancer diagnosis tend to have less access to supportive and palliative medicine and may have a poorer experience of care in the last phase of their life and this inequality is acknowledged within current end of life care provision. At Dudley Group NHS Foundation Trust (DGFT) we have implemented the Gold Standards Framework (GSF) trust wide, with eight wards achieving GSF accreditation, with continuing engagement across the trust. This review aimed to understand the impact implementing the GSF has had on the hospital specialist palliative care team referrals. Method Using PowerBI data analysis a retrospective review of the proportion of referrals by diagnosis group was performed over 16 months from January 2022 to April 2023 alongside the number of referrals. Results The review identified an increasing trend in the proportion of patients referred with a non-cancer diagnosis. From as baseline around 25% non-cancer and 75% cancer there has been a clear increase in the non-cancer referral to a 50:50 split. During this 16-month timeframe there was also continued growth in the number of referrals, with the increase driven from the non-cancer diagnosis group with a 48% average increase in referrals per quarter, whilst cancer group referral numbers remained stable (3% average growth per quarter). Conclusion This review highlights the benefits of embedding the GSF on improving identification of patients and increasing access to specialist palliative medicine, particularly for noncancer patients. As a Specialist Hospital Palliative Care service, the local response to increased recognition has included the involvement within local non-cancer multidisciplinary meetings. These findings support the benefits of embedding the GSF to improve upon inequality in access to specialist palliative care for non-cancer patients.
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Gold standards framework implementation across Dudley Group NHS Foundation Trust and development of an individual plan of care for dying patients.Background At Dudley Group NHS Foundation Trust (DGFT) we have implemented the Gold Standards Framework (GSF) to support identification of patients in the last year of life and development an individual plan of care to support dying patients. A suite of measures and legacy work has been implemented together with the use of GSF to support earlier identification and support for patients dying in the hospital. Method A GSF document is completed on the Trust electronic patient record for patients identified as GSF during their admission. A power BI system reports on the information collected including the percentage of deaths by ward and as a Trust that had been identified as GSF red or amber. Results From 1.4.22 - 31.3.23 61% of hospital deaths were identified as GSF amber or red. This represents an increase from the previous year 1.4.21 - 31.3.22 52% of hospital deaths were identified as GSF red or AMBER. The power BI breaks this down by ward and reports on the number of deaths which also helps the wards implementing GSF to understand their patient population and any educational needs to ensure individual plan of care. Conclusion Implementing the GSF across DGFT has had measurable impacts and the metrics collected provide assurance and demonstrate the improvements. So far eight wards have achieved GSF accreditation including critical care and coronary care which were both the first nationally. As a Specialist Palliative Care Team we aim to continue to support wards with the implementation of GSF and this data provides evidence for the wards and the Trust regarding the provision of end of life care which can be triangulated with other measures including incidents, compliments etc.
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Review of anticipatory medication utilisation across Dudley Group Foundation Trust.The fourth round of the National Audit of Care at the End of Life (NACEL) reported that across The Dudley Group NHS Foundation Trust (DGFT) the use of prescribed anticipatory medications was lower than the national average (40.5% vs. 69.1%). This review aimed to understand if this reduction was suggestive of adverse patient care outcomes or any barriers to their utilisation and if not provide assurance. Over three days, all patients prescribed anticipatory medications or identified as dying on each ward were reviewed twice daily by authors. Using a proforma, authors recorded patient factors and anticipatory use before discussing with the patient's responsible nurse any symptoms they have identified and actions they had taken. This was followed by a visual review of the patient to confirm the reported handover. Clarification was sought from the DGFT Research team to confirm ethical approval was not required. 118 contacts were performed on 27 patients; 33% with cancer and 66% with non-cancer diagnosis. All patients were recognised as either GSF Red or Amber. Reviews were conducted on a mixture of surgical, medical and acute ward areas. In 47% of patient contacts staff had identified a symptom and reported an action for that symptom in 100% of cases. The reported actions included utilising the prescribed anticipatory medication, utilisation of non-pharmacological management or alternative medication (such as oral medication if able to swallow). There was high consensus (99%) with the authors ward review. Conclusion Ward teams across DGFT utilised a breadth of management options to support their patients symptoms at the end of life beyond relying solely on anticipatory medications. Reassuringly there was no evidence that this holistic approach had been detrimental in achieving the desired control of symptoms. There was assurance that teams are empowered to utilise non-pharmacological techniques to support alongside anticipatory medications if needed.
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Exponentially elevated testosterone in a middle-aged woman with polycystic ovarian syndrome: A therapeutic response to luteinising hormone-releasing hormone agonist.We report a case of a 43-year-old lady referred to the Endocrinology department by her general practitioner (GP) for exponentially elevated testosterone and amenorrhoea persisting for 5 months, excessive weight gain of 153 kg and an elevated testosterone level of 14.8 nmol/L(0.7-2.8 nmol/L). Her body mass index (BMI) was 58.3 kg/m2. Thyroid profile, Prolactin, Cortisol, and 17 hydroxyprogesterone were all within the normal range. Luteinising hormone (LH) and follicle stimulating hormone (FSH) were normal initially. Dehydroepiandrosterone (DHEA) was slightly low. Surprisingly, a contrast-enhanced computer tomography (CT) scan revealed portal vein thrombosis, presenting an unexpected finding in the context of the patient's clinical presentation. Ultrasound pelvis and magnetic resonant imaging (MRI) adrenals did not reveal any abnormalities. The diagnostic process meticulously ruled out potential causes of elevated testosterone, including congenital adrenal hyperplasia, thyroid dysfunction, hyperprolactinemia, adrenal and ovarian tumours, or an exogenous source of testosterone. In view of her amenorrhoea, clinical and biochemical hyperandrogenism, the diagnosis of polycystic ovarian syndrome (PCOS) was reached as per the Rotterdam criteria.1 Although PCOS can be associated with elevated testosterone levels but exponentially high levels of testosterone for example more than 6 nmol/L, as in our patient's case, is not frequently seen in PCOS and such elevated levels warrant further investigations to rule out adrenal or ovarian tumours.2 Given the patient's elevated BMI and the presence of a portal vein thrombus, combined oral contraceptive pills (COCPs) were deemed unsuitable for treatment. Pregnancy was ruled out and given the clinical presentation and laboratory findings, therapeutic intervention was initiated with Leuprorelin, a luteinising hormone-releasing hormone (LHRH) agonist, which is usually used in patients with prostate cancer to lower the testosterone.3,4 She was commenced on Leuprorelin subcutaneous injection once a month for almost 6 months. The response to treatment was notable, resulting in a significant decrease in serum testosterone levels from 14.8 nmol/L to 7.4 nmol/L. Although restoration of regular menstruation wasn't achieved, she started having intermittent spotting and a marked reduction in testosterone levels was noted. However, upon discontinuation of Leuprorelin, testosterone levels began to rise again, reaching 11 nmol/L. In light of this observation, a clinical decision was made to extend the Leuprorelin treatment for an additional 6 months. Simultaneously, the patient was being evaluated by a weight management team for potential bariatric surgery. This case highlights the efficacy of Leuprorelin in the management of hyperandrogenism, particularly in cases where elevated testosterone levels are implicated. The therapeutic response observed underscores the importance of considering LHRH agonists as a treatment option in such scenarios. Further research is warranted to elucidate the long-term effects and optimal dosing regimens of Leuprorelin in similar cases as there is limited data to suggest its use for hyperandrogenism in PCOS. Also, exponentially high levels of testosterone are not routinely seen in patients with PCOS but can be expected as in this case when all the other causes of elevated testosterone were ruled out.Copyright � 2024
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An MDT approach to incorporating GSF into routine practice on a respiratory ward.Introduction The Gold Standards Framework (GSF) can identify people who are coming to the end of life. Earlier identification can prompt advanced care planning (ACP) discussions to be had sooner, therefore tailoring care to peoples' wishes. The aim of this project was for every patient on a 48-bed respiratory ward at a DGH near Birmingham to have an assessment of whether GSF is appropriate at admission, and to have this recorded. Methods Plan, do, study, act cycles were carried out: Junior teaching Consultant education Nursing education Junior teaching helped increase the number of GSF assessments, but due to the rotational nature of jobs and reluctance of juniors to initiate ACP discussions themselves this was not sufficient. Involving consultants was difficult but some started to incorporate GSF discussions into post-take ward rounds. Success was limited by high ward pressures. Nursing staff made the largest difference, as Senior Sisters created a column for GSF on the board round and prompted doctors of all grades for missing GSF assessments. Results Baseline data showed that 69% of patients had their GSF assessed in the month of June 2022. Following the first cycle this increased to 75.8% in September. After consultant education this increased to 84.5% in December. In the third cycle involving nursing staff, this increased to 92.6% of patients having GSF assessed throughout January 2023. Conclusions Involving the wider multidisciplinary team is a good approach for making GSF assessments routine on the ward. Positive change was seen in all interventions through education of different groups. Going forward, further data collection is required to ensure that the change was maintained. Measurement of other outcomes like documentation of preferred place of care would be a good indication of whether increased GSF assessments does lead to better care for patients.
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Characteristics of presentation and management of people with hypoglycaemia while on continuous glucose monitoring devices - Pilot data from DEKODE hypoglycaemia study.Continuous glucose monitoring (CGM) is an increasingly important diabetes technology that can provide a more comprehensive picture of glycaemic control, thereby having the potential to reduce exposure to hypoglycaemia.1-2 However, there is a paucity of information on admitted patients' characteristics, management, and outcomes of those admitted with hypoglycaemia despite being on CGM. Within our study, we aim to explore the characteristics of the patient population, precipitating factors and outcomes of people admitted with hypoglycaemia while on CGM. Material(s) and This retrospective study was conducted from October 2023 to January 2024 across five hospitals in the UK. All adults aged over 18 years admitted to these hospitals with hypoglycaemia while on CGM from November 2022 to October 2023 were included in the study. Data on sociodemographic, precipitating factors, management, outcomes and total time spent during hypoglycaemic episodes were collected. Data was analysed on SPSS 29.0. Results and discussion: We identified 39 episodes of hypoglycaemia, with 37 occurrences in individuals with type 1 diabetes and 2 in those with type 2 diabetes. 34 episodes occurred while the person was an inpatient in the hospital. The median (interquartile) age was 49.0 (36.0-50.0) years. Their Charlson comorbidity index was 4 (4-6). 79.5% were men. The median (interquartile) HbA1c before admission was 98.0 (60.0-98.0) mmol/mol. 79.5% were level 1, 10.3% were level 2, and 10.3% were level 3 hypoglycaemia. 48.7% of episodes were due to missed meals. Patients spent 26 (16.0-124.0) min in hypoglycaemia during these episodes. 7.7% of people received glucagon either at home, in an ambulance, or in a hospital for hypoglycaemia. However, only 5.1% were prescribed glucagon upon discharge. Conclusion(s): The majority of hypoglycaemia was due to missed meals. Despite spending a median of 26 min in hypoglycaemia, only a small percentage received glucagon, and a mere 5.1% were prescribed glucagon upon discharge. These findings highlight the need for enhanced education and proactive management strategies for individuals on CGM to effectively prevent and address hypoglycaemic episodes, improve diabetes care, and overall patient outcomes. : 1. Continuous Glucose Monitoring. www.diabetes.co.uk/cgm/continuous-glucose-monitoring.html [Accessed 15 February 2024] 2. Pickup J C, Freeman S C, Sutton A J. Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient data.
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Deep-dermal burn sustained from operative Lighting: A case report.Surgical luminance (also known as operative lighting) allows for adequate visualisation of the operative field, a necessity for delivering safe surgery. Light-emitting diode (LED) surgical luminance systems are widely used in modern medicine. We present a case of a 59-year-old male patient who sustained an iatrogenic burn from operative lights during an emergency vascular bypass revision procedure. According to the author's literature review, this is the first documented case of a burn of this nature to be reported in the United Kingdom. Aim/Purpose of the report: This report highlights an unusual mechanism of sustaining a cutaneous burn intra-operatively by LED lighting. We aim to highlight a potential safety hazard related to using standard operative lighting equipment. We present a thorough review of the patient's progression from the point of injury to definitive treatment, including follow-up. In this case report, we conclude that the surgical operative lights caused the burn. The burn was a mixed depth, deep-dermal and partial-thickness burn in the suprapubic area that was exposed to the operative lights. This required surgical excision and reconstruction with a split-thickness skin graft which healed well with 100% graft take. Operating lights, although regarded safe, have the potential to cause significant cutaneous injury. Increased awareness and education are required to ensure safe practices.
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A Literature Review of Methods of Perioperative Pain Management in Thoracic Outlet Decompression.Postoperative pain control in thoracic outlet decompression (TOD) is difficult due to the complex innervation of the anatomical region. Poor postoperative pain control has been associated with worse patient experiences and prolonged inpatient stays. This study aims to identify evidence-based perioperative analgesic strategies for TOD. MEDLINE and Embase searches were performed to identify literature assessing perioperative pain control methods in patients undergoing TOD. Studies were limited to the English language and within 10 years of publication. Abstracts were screened for relevance by 2 reviewers, and identified review articles on TOD were also included for critical appraisal. The primary literature search yielded 124 studies whose abstracts were screened resulting in a total of 16 studies being included for full review and critical appraisal. This included 1 randomized control trial, 7 retrospective cohort studies, 1 case series study, 2 case report study, and 5 review articles. Studies utilized a baseline of multimodal oral analgesics with their main investigative focus centered on the use of different methods of peripheral nerve blockade. There is only 1 published randomized controlled trial study investigating postoperative analgesic modalities in TOD. This deficit of evidence was reflected in the high variation of pain management strategies employed in the published literature.
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Yet Again: Accessary Left Ventricle Mistaken for Ventricular Septal Defect.Description of Clinical Presentation: A 37-year-old female presented a diagnostic challenge to the outpatient echocardiography laboratory when she was noted to have a possible large ventricular septal defect (VSD) on the background of previously reported spontaneously closed peri membranous VSD as a child. She had recent acute hospitalisation with shortness of breath and random chest pains and only past medical history of controlled asthma. Physical examination was unremarkable apart from a murmur. She had normal routine blood tests, inflammatory markers, and NT- pro-BNP. 12 lead ECG revealed incomplete RBBB. D Dimer slightly but Lung VQ scan excluded pulmonary emboli. Diagnostic Techniques and Their Most Important Findings: Initial 2D/3D transthoracic echocardiography (TTE) showed an abnormal contractile chamber around the right heart connected to the left ventricle through the wide defect with bidirectional flow located proximal to aortic valve at left ventricular outflow tract (LVOT) level (Fig 1). Cardiac magnetic resonance imaging (CMRI) confirmed the TTE findings of a small muscular contractile chamber with similar wall thickness and trabeculation as of the left main ventricle and no communication with the right ventricle. No intracardiac shunt identified on the phase contrast measurement of flow through the great arteries (Qp: Qs = 1.0) (Fig 2). Prospective gated computed tomography cardiac angiogram (CTCA) confirmed the findings of the TTE and CMRI, excluding premature coronary artery disease but revealing abnormal coronary anatomy. There was left coronary dominance with left main stem trifurcating into an LAD, LCX and a separate coronary artery to this abnormal contractile chamber. Also, a large calibre RV branch seen arising from the LAD running along anterolateral surface of the right ventricle supplying the territory normally supplied by the right coronary artery. RCA itself was a very recessive vessel. All the above scans confirmed this rare incidental congenital cardiac condition as being an accessary left ventricle than a true VSD (Fig 3). Associated dynamic LVOT obstruction was ruled out with a semi supine exercise bike stress echocardiogram with no associated exercise induced dysrhythmias or myocardial ischaemia. Patient reassured and clinic follow up arranged. Learning Points from this Case: Although rare2, appearance of ALV on routine bedside imaging can lead to diagnostic challenges. The differentials include an LV pseudoaneurysm, double chambered right ventricle (DCRV), LV diverticulum, persistent VSD, and accessary left ventricle. An LV pseudoaneurysm was considered unlikely because of the synchronous contraction of the structure with rest of the ventricle3. LV diverticulum was ruled out due to wide connection with the main LV4. Absence of the advanced cyanotic heart disease signs led to accurate diagnosis of ALV rather than large VSD. From our experience, systematic clinical and multi-modality imaging approach nicely illustrated in confirming the final diagnosis. [Formula presented] [Formula presented] [Formula presented] Author Disclosure: S Roghani: Nothing to disclose; M Shahid: N/A; I Cox: N/A; J Lee: N/ACopyright � 2024
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The value of having multidisciplinary input in early arthritis clinicsNo abstract available
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The management of acute complete ruptures of the ulnar collateral ligament of the thumbComplete ruptures of the ulnar collateral ligament (UCL) of the thumb are a common injury, yet little is known about their current management in the UK. The objective of this study was to assess the way complete UCL ruptures are managed in the UK. We carried out a multicentre, survey-based cross-sectional study in 37 UK centres over a 16-month period from June 2022 to September 2023. The survey results were analyzed descriptively. A total of 37 centres participated, of which nine were tertiary referral hand centres and 28 were district general hospitals. There was a total of 112 respondents (69 surgeons and 43 hand therapists). The strongest influence on the decision to offer surgery was the lack of a firm 'endpoint' to stressing the metacarpophalangeal joint (MCPJ) in either full extension or with the MCPJ in 30� of flexion. There was variability in whether additional imaging was used in managing acute UCL injuries, with 46% routinely using additional imaging while 54% did not. The use of a bone anchor was by far the most common surgical option for reconstructing an acute ligament avulsion (97%, n = 67) with a transosseous suture used by 3% (n = 2). The most common duration of immobilization for those managed conservatively was six weeks (58%, n = 65) and four weeks (30%, n = 34). Most surgeons (87%, n = 60) and hand therapists (95%, n = 41) would consider randomizing patients with complete UCL ruptures in a future clinical trial. Conclusion: The management of complete UCL ruptures in the UK is highly variable in certain areas, and there is a willingness for clinical trials on this subject. Competing Interests: B. J. F. Dean and M.Mikhail report a British Society for Surgery of the Hand (BSSH) pump priming grant for this study. B. J. F. Dean also reports a British Medical Association Doris Hillier grant which was unrelated to this study. B. J. F. Dean is also a member of the BSSH research committee. D. J. Beard holds a Senior Investigator grant from the National Institute for Health and Care Research, unrelated to this study. M. Mikhail reports a BSSH grant to the ULCTEAR steering group for this study
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Survival and Decision-Making in Patients Turned Down for Abdominal Aortic Aneurysm Repair: A Retrospective Study with Focus on COVID-19 ImpactTo investigate and analyse various aspects related to patients who have been placed on a "turn-down list" for elective or emergency repair of abdominal aortic aneurysms (AAA). This retrospective study analysed data from the Black Country Vascular Network (BCVN). Multidisciplinary team (MDT) meetings assessed AAA patients referred through National Abdominal Aortic Aneurysm Screening Programme (NAAASP)or directly to vascular surgery. Patients considered unfit for intervention were added to a prospectively kept turndown list. Survival and cause of death data were collected, along with cardiopulmonary exercise testing (CPET) results and British Aneurysm Repair (BAR) scores for some patients. The study covered a period from January 2015 to May 2023. After exclusions 247 (16%) patients were placed on the turndown list with a median age of 85 years (IQR 8 years). The mortality of turndown cases on medical grounds was 74.1%. Survival was significantly higher for patients who completed CPET before being turned down (p = 0.004). Gender analysis revealed a higher proportion of females being turned down compared to males (p = 0.044). COVID-19 led to a notable reduction in the number of discussed cases and interventions, while the turndown rates remained consistent. Survival at one year in turndown patients was 66%, at three it was 29%, at four years it was18% and at 7 years it was 5%. Most patients whose cause of death was known died of respiratory complications (30%) or malignancy (19%). BAR scores and aneurysm size were not significant predictors of mortality. Patients on the turndown list have a substantial mortality rate. A significant proportion of female patients were being turned down compared to men and the reasons for this are not clear. Patients who completed CPET before being turned down had a longer survival time. While COVID-19 impacted healthcare services reducing the number of interventions, it did not influence turndown decisions. The study showed that the cause of death for a significant number of patients was respiratory complications or malignancy.
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Statin use attenuates the impact of systemic inflammation on ischemic cardiovascular risk in patients with rheumatoid arthritis.Baseline and cumulative inflammation have both been associated with increased cardiovascular event (CVE) risk in patients with rheumatoid arthritis (RA). Statin therapy reduced systemic inflammation, attenuated coronary atherosclerosis progression and promoted plaque calcification and stabilization1 both in general as well as RA patients Objectives: We here explored whether baseline statin use influenced the impact of baseline C-reactive protein (CRP) on long-term cardiovascular risk in patients with RA. We evaluated 4,357 patients without known cardiovascular disease upon registration to An International Cardiovascular Consortium for people with RA (ATACC-RA) and who were followed prospectively. The primary outcome was ischemic CVE defined as the composite endpoint of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, coronary revascularization, stable angina pectoris, transient ischemic attack, and peripheral arterial disease with or without revascularization. Missing data were imputed using multiple imputation with 10 repetitions. Multivariable Cox models stratified by center evaluated the effect of natural logarithm of CRP, statin use and their interaction on CVE risk after adjusting for age, gender, hypertension, diabetes, family history, smoking, age at RA diagnosis, and total cholesterol to high-density lipoprotein (TC/HDL) ratio. A sensitivity analysis was performed using inverse probability of treatment weights to balance differences between statin treated and untreated patients. Result(s): At baseline 462 patients were treated with statins whereas 3,895 were not. Statin therapy inversely associated with low density lipoprotein cholesterol (p<0.001), TC/HDL ratio (p<0.001) and CRP(ln) (p=0.048). Over 26,356 patient years (PY) of follow-up, 361 total ischemic CVE were recorded, 321 over 24,235 PY in statin nonusers and 40 over 2,121 PY in statin users. Incidence of any ischemic CVE was 13.3 (95% CI 11.9-14.8)/1000PY among statin nonusers and 18.9 (95% CI 13.8-25.7)/1000PY in statin users (incidence rate difference 5.62 [95% CI -0.41 to 11.64]). In the entire cohort, baseline CRP(ln) was not associated with ischemic CVE risk, [adjusted hazards ratio- aHR 1.07 (95% CI 0.98-1.17), p=0.138]. However, higher CRP(ln) associated with greater risk of the composite outcome exclusively in statin nonusers [aHR 1.10 (95% CI 1.01-1.21), p=0.036] but not in statin users (p-interaction= 0.032, Figures 1 and 2). While CRP(ln) was not different between statin groups after inverse probability weighting adjustment (p=0.333), the sensitivity analysis yielded similar results: higher CRP(ln) associated with greater ischemic CVE risk in statin nonusers [aHR 1.11 (95% CI 1.01-1.22), p=0.030] but not among statin users (p-interaction=0.046). Higher inflammation at baseline associated with greater risk of any ischemic CVE among statin nonusers but not in users. This points to the potential of statin-specific effects directly on atherosclerotic plaque such as lower progression and stabilization1above and beyond effects on cholesterol metabolism and systemic inflammation. .
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Progressive Lung Consolidation in HIV Amidst the COVID-19 Pandemic: Evaluating Probable Cytomegalovirus Pneumonia and the Importance of Early Empirical TreatmentWe present the case of a young male who was diagnosed with HIV in 2012. However, his initiation of antiretroviral therapy (ART) was delayed until 2018 due to issues related to his acceptance and acknowledgment of the disease. In April 2021, the patient presented with hemoptysis, shortness of breath, and constitutional symptoms. Initial extensive workup for tuberculosis (TB) and other respiratory pathogens returned negative. Despite this, he was treated for smear-negative pulmonary TB and pneumocystis pneumonia (PCP) and was subsequently discharged. He then had recurrent hospital admissions due to worsening respiratory symptoms, with short intervals between recovery and recurrence. Each admission saw an increase in his oxygen requirements. Throughout these hospitalizations, tests for coronavirus disease 2019 (COVID-19) were consistently negative. TB and PCP treatment continued throughout his admissions. Despite various treatments, his condition continued to deteriorate. A DNA polymerase chain reaction (DNA PCR) test for cytomegalovirus (CMV) was eventually conducted. Unfortunately, the patient succumbed to progressive respiratory failure, and the CMV DNA PCR returned positive a week after his death. In the era of COVID-19, this case underscores the importance of early diagnosis and timely antiviral treatment. Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Clinical Research Centre (CRC) of Hospital Sultan Abdul Halim and in accordance to Malaysian Research Ethics Committee (MREC) issued approval N/A. Informed consent was obtained from the late patient's family for his information to be published in this article. The design of the work accords to the Malaysian Research Ethics Committee (MREC) and Hospital Sultan Abdul Halim Clinical Research Centre (CRC). Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. Copyright � 2024, Krishnasamy Naido et al.
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REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use.Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, yet operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 (97%) of 75 units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computerised tomography angiography being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. Conclusion(s): This comprehensive consensus statement provides a strong insight into the standard of care for these patients.
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Outcomes of patients undergoing elective DC cardioversion for atrial fibrillation: a district general hospital experience.Atrial fibrillation (AF) is the most common cardiac arrhythmia seen in the adult population, affecting around 1-2% of those above the age of 18. For newly diagnosed patients, DC Cardioversion (DCCV) is an effective method of restoring normal sinus rhythm in those where rhythm control strategy is considered. The earlier DCCV is performed, the higher the likelihood of successful conversion to sinus rhythm. However, in practice, long waiting times may preclude any benefit of early DCCV. The aim of our audit was to evaluate the outcomes of patients undergoing DCCV in a large district general hospital and to evaluate the factors that could predict restoration of sinus rhythm including the effect of waiting times. This was a retrospective audit involving patients who had undergone an elective DCCV during the year 2021 at our hospital. Results A total of 247 patients were booked for DCCV, but 4 patients did not proceed (three were in sinus rhythm and one patient failed sedation). The remaining 243 patients (mean age 67.5+11.7 years, 66.5% male) were included in the analysis. Hypertension (62.1%) was the commonest co-morbidity, followed by hypercholesterolemia (53.2%). Eighty-nine patients (35.9%) had undergone a previous DCCV with a median delay 341(189-667) days since the initial cardioversion. The median delay from the decision for DCCV was 265 (107- 816) days. At the time of diagnosis, a decision for rate control was initially made in 159 (64%) of patients, with the remaining being put forward for DCCV directly. Those who were for rate control initially had a longer wait for the DCCV (308(134-1066) vs 114(57-376) p<0.001) Amiodarone was started in 70(28.3%) patients. At the time of diagnosis, all patients had a dilated left atrium (LA) by diameter, though 54 had normal LA volume. Of these 243 patients, 227 received one shock, 14 patients received two shocks and two received three shocks. DCCV was immediately successful in 232 (93.1%) patients and of this, 226 (91.5%) remained in sinus rhythm (SR) when discharged that day. This number fell to 120 (48.6%) at 6 months and 103 (41.7%) at one year. Those who maintained SR at discharge had lower number of shocks (p<0.001). Lower number of shocks also predicted those who maintained SR at 6 months and one year. Those who maintained SR at one year also were likely to have amiodarone continued post DCCV (p=0.01). There was no difference in other factors including demographics, risk factors, the delay in DCCV from diagnosis or the left atrial size between those who maintained SR either at discharge or during follow up and those who reverted to AF. The initial decision for DCCV or rate control did not affect the outcome of the DCCV. This however, could reflect the long waiting times in both groups. Conclusion In our audit, most patients waited significant durations before getting their elective cardioversion especially where the decision for rate control was taken initially. Only around half of patients maintained SR at one year, which could be a reflection of the delay in getting the DCCV and the dilated LA, which in turn could be a reflection of the delays. Amiodarone needs to be continued post DCCV in accordance with the guidelines as this affects long term maintenance of SR.
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Pre-Operative Group and Save in Elective and Emergency Laparoscopic Cholecystectomy: Necessity, Cost-Effectiveness, and Own ExperienceLaparoscopic cholecystectomy is associated with a high safety profile. This study seeks to quantify the incidence of blood transfusion in both the elective and emergency settings, examine related patient outcomes, and investigate selection criteria for pre-operative Group and Save (G&S) sampling. A prospective multi-centre observational study was conducted to investigate patients undergoing either elective or emergency laparoscopic cholecystectomy in the UK between January 2020 and May 2021. Multivariate logistical regression models were used to identify patient factors associated with the risk of transfusion and explore outcomes linked to pre-operative G&S sampling. This study comprised 959 patients, with 631 (65.8%) undergoing elective cholecystectomy and 328 (34.2%) undergoing emergency surgery. The median age was 48 years (range: 35-59), with 724 (75.5%) of the patients being female. Only five patients (0.5%) required blood transfusions, receiving an average of three units, with the first unit administered approximately six hours post-operatively. Among these cases, three patients (60%) had underlying haematological conditions. In adjusted models, male gender was significantly associated with the need for a blood transfusion (OR 11.31, p = 0.013), while the presence of a pre-operative Group and Save sample did not demonstrate any positive impact on patient outcomes. Conclusions: The incidence of blood transfusion following laparoscopic cholecystectomy is very low. Male gender and haematological conditions may present as independent risk factors. Pre-operative G&S sampling did not yield any positive impact on patient outcomes and could be safely excluded in both elective and emergency cases, although certain population subsets will warrant further consideration.
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Physical activity, sedentary behaviour and well-being: experiences of people with knee and hip osteoarthritisLiving with knee and hip osteoarthritis (OA) means living with pain and difficulty in movement. Given the beneficial effects of physical activity (PA) and reduction of sedentary behaviour (SB), these behaviours need to be understood in the context of individuals' daily lives and sense of well-being. Twelve individuals (age: 43-79 years; 67% female) with knee and/or hip OA purposively selected (e.g., age, OA duration, OA severity) participated in semi-structured interviews. Data was analysed using inductive thematic analysis. PA and SB were narrated as multifaceted experiences with two overarching themes, PA negotiations ( valuing mobility, the burden of osteoarthritis, keep going, the feel-good factor ), SB negotiations ( the joy of sitting, a lot is too bad, the osteoarthritis confines ), and two overlapping themes ( the life context , finding a balance ). Physical and psychological aspects of PA and SB experiences were interwoven. Participants valued mobility and were proactively trying to preserve it by keeping active. A constant negotiation among the OA burden, the need to enjoy life and life circumstances was underlying PA behaviour. Prescription and encouragement of a physically active lifestyle in this population should be linked to mobility-related personal values and sense of well-being, while addressing concerns around OA-safety and normalizing PA trade-offs.