Recent Submissions

  • The Acute VertEbRal AugmentaTion (AVERT) study: protocol for a randomised controlled, feasibility trial of spinal medial branch nerve block in hospitalised older patients with vertebral fragility fractures.

    Fakis, Apostolos
    INTRODUCTION: Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fracture found in older people, resulting in increasing morbidity and excess mortality. These fractures can cause significant pain, requiring admission to hospital. Vertebroplasty (VP) is effective in reducing pain and allowing early mobilisation in hospitalised patients. However, it may be associated with complications such as cement leakage, infection, bleeding at the injection site and fracture of adjacent vertebrae. It is also costly and not readily accessible in many UK hospitals.A recent retrospective study reported that spinal medial branch nerve block (MBNB), typically used to treat facet arthropathy, had similar efficacy in terms of pain relief compared with VP for the treatment of painful VFF. However, to date, no study has prospectively compared MBNB to VP. We therefore propose a prospective feasibility randomised controlled trial (RCT) to compare the role of MBNB to VP, in hospitalised older patients. METHOD: A parallel, two-arm RCT with participants allocated on a 1:1 ratio to either standard care-VP or MBNB in hospitalised patients aged over 70 with acute osteoporotic vertebral fractures. Follow-up will be at weeks 1, 4 and 8 post intervention. The primary objective is to determine the feasibility and design of a future trial, including specific outcomes of recruitment, adherence to randomisation and safety. Embedded within the trial will be a health economic evaluation to understand resource utilisation and implications of the intervention and a qualitative study of the experiences and insights of trial participants and clinicians. Secondary outcomes will include pain scores, analgesia requirements, resource use and quality of life data. ETHICS AND DISSEMINATION: Ethical approval was granted by the Yorkshire & the Humber Research Ethics Committee (reference 21/YH/0065). AVERT (Acute VertEbRal AugmentaTion) has received approval by the Health Research Authority (reference IRAS 293210) and is sponsored by Nottingham University Hospitals NHS Trust (reference 21HC001). Recruitment is ongoing. Results will be presented at relevant conferences and submitted to appropriate journals for publication on completion. TRIAL REGISTRATION NUMBER: ISRCTN18334053.
  • COVID-19 Countermeasures: An Algorithm to Stay Unlocked.

    Izadi, D
    We describe a visual algorithm to help prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contagion as well as manage COVID-19 disease according to categories of clinical severity. The algorithm is timely, with multiple countries worldwide declaring repeat surges in SARS-CoV-2 infections following the easing of lockdown measures. Its flowchart assimilates key effective interventions in a visual manner that will assist healthcare workers to manage COVID-19 disease algorithmically, and policymakers to suppress further SARS-CoV-2 waves. Importantly, we include the innovative use of topical p-menthane-3,8-diol spray by the British Army for COVID-19 Support Force personnel, which in light of its coronavirucidal properties, deserves wider dissemination. This algorithm has the potential to be updated as numerous studies are concluded globally.
  • Research priorities in emergency general surgery (EGS): a modified Delphi approach.

    Tierney, Gillian
    BACKGROUND: Emergency general surgery (EGS) patients account for more than one-third of admissions to hospitals in the National Health Service (NHS) in England. The associated mortality of these patients has been quoted as approximately eight times higher than that of elective surgical admissions. This study used a modified Delphi approach to identify research priorities in EGS. The aim was to establish a research agenda using a formal consensus-based approach in an effort to identify questions relevant to EGS that could ultimately guide research to improve outcomes for this cohort. METHODS: Three rounds were conducted using an electronic questionnaire and involved health care professionals, research personnel, patients and their relatives. In the first round, stakeholders were invited to submit clinical research questions that they felt were priorities for future research. In rounds two and three, participants were asked to score individual questions in order of priority using a 5-point Likert scale. Between rounds, an expert panel analysed results before forwarding questions to subsequent rounds. RESULTS: Ninety-two EGS research questions were proposed in Phase 1. Following the first round of prioritisation, forty-seven questions progressed to the final phase. A final list of seventeen research questions were identified from the final round of prioritisation, categorised as condition-specific questions of high interest within general EGS, emergency colorectal surgery, non-technical and health services research. A broad range of research questions were identified including questions on peri-operative strategies, EGS outcomes in older patients, as well as non-technical and technical influences on EGS outcomes. CONCLUSIONS: Our study provides a consensus delivered framework that should determine the research agenda for future EGS projects. It may also assist setting priorities for research funding and multi-centre collaborative strategies within the academic clinical interest of EGS.
  • The role of resistance exercise training for improving cardiorespiratory fitness in healthy older adults: a systematic review and meta-analysis.

    Doleman, Brett; Lund, Jonathan; Toft, Suzanne
    BACKGROUND: Declines in cardiorespiratory fitness (CRF) and muscle mass are both associated with advancing age and each of these declines is associated with worse health outcomes. Resistance exercise training (RET) has previously been shown to improve muscle mass and function in the older population. If RET is also able to improve CRF, as it has been shown to do in younger populations, it has the potential to improve multiple health outcomes in the expanding older population. METHODS: This systematic review aimed to identify the role of RET for improving CRF in healthy older adults. A search across CINAHL, MEDLINE, EMBASE and EMCARE databases was conducted with meta-analysis performed on eligible papers to identify improvements in established CRF parameters (VO2 peak, aerobic threshold (AT), 6-minute walking distance test (6MWT) following RET intervention. Main eligibility criteria included older adults (aged over 60), healthy cohorts (disease-specific cohorts were excluded) and RET intervention. RESULTS: Thirty-seven eligible studies were identified. Meta-analysis revealed a significant improvement in VO2 peak (MD 1.89 ml/kg/min; 95% confidence interval (CI) 1.21-2.57 ml/kg/min), AT (MD 1.27 ml/kg/min; 95% CI 0.44-2.09 ml/kg/min) and 6MWT (MD 30.89; 95% CI 26.7-35.08) in RET interventions less than 24 weeks. There was no difference in VO2 peak or 6MWT in interventions longer than 24 weeks. DISCUSSION: This systematic review adds to a growing body of evidence supporting the implementation of RET in the older population for improving whole-body health, particularly in time-limited timeframes.
  • Room for improvement: diagnosing and managing acute coronary syndromes in persons with reduced eGFR.

    Horne, Kerry; Taal, Maarten; Selby, Nicholas
    Cardiovascular events are the leading cause of death in chronic kidney disease. A recent analysis from the High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome trial focused on results in those with reduced estimated glomerular filtration rate. This commentary discusses aspects of acute coronary syndrome diagnosis in this group and the differential approach to acute coronary syndrome management that was observed between those with normal and reduced kidney function.
  • Equipment-free, unsupervised high intensity interval training elicits significant improvements in the physiological resilience of older adults.

    Doleman, Brett
    BACKGROUND: Reduced cardiorespiratory fitness (CRF) is an independent risk factor for dependency, cognitive impairment and premature mortality. High-intensity interval training (HIIT) is a proven time-efficient stimulus for improving both CRF and other facets of cardiometabolic health also known to decline with advancing age. However, the efficacy of equipment-free, unsupervised HIIT to improve the physiological resilience of older adults is not known. METHODS: Thirty independent, community-dwelling older adults (71(SD: 5) years) were randomised to 4 weeks (12 sessions) equipment-free, supervised (in the laboratory (L-HIIT)) or unsupervised (at home (H-HIIT)) HIIT, or a no-intervention control (CON). HIIT involved 5, 1-minute intervals of a bodyweight exercise each interspersed with 90-seconds recovery. CRF, exercise tolerance, blood pressure (BP), body composition, muscle architecture, circulating lipids and glucose tolerance were assessed at baseline and after the intervention period. RESULTS: When compared to the control group, both HIIT protocols improved the primary outcome of CRF ((via anaerobic threshold) mean difference, L-HIIT: +2.27, H-HIIT: +2.29, both p < 0.01) in addition to exercise tolerance, systolic BP, total cholesterol, non-HDL cholesterol and m. vastus lateralis pennation angle, to the same extent. There was no improvement in these parameters in CON. There was no change in diastolic BP, glucose tolerance, whole-body composition or HDL cholesterol in any of the groups. CONCLUSIONS: This is the first study to show that short-term, time-efficient, equipment-free, HIIT is able to elicit improvements in the CRF of older adults irrespective of supervision status. Unsupervised HIIT may offer a novel approach to improve the physiological resilience of older adults, combating age-associated physiological decline, the rise of inactivity and the additional challenges currently posed by the COVID-19 pandemic. TRIAL REGISTRATION: This study was registered at and coded: NCT03473990 .
  • Oxidized zirconium versus cobalt-chrome femoral heads in total hip arthroplasty: a multicentre prospective randomized controlled trial with ten years' follow-up.

    Stephen, Arthur; Hutchinson, James; Haddad, Fares
    AIMS: This study reports the ten-year wear rates, incidence of osteolysis, clinical outcomes, and complications of a multicentre randomized controlled trial comparing oxidized zirconium (OxZr) versus cobalt-chrome (CoCr) femoral heads with ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (XLPE) liners in total hip arthroplasty (THA). METHODS: Patients undergoing primary THA were recruited from four institutions and prospectively allocated to the following treatment groups: Group A, CoCr femoral head with XLPE liner; Group B, OxZr femoral head with XLPE liner; and Group C, OxZr femoral head with UHMWPE liner. All study patients and assessors recording outcomes were blinded to the treatment groups. The outcomes of 262 study patients were analyzed at ten years' follow-up. RESULTS: Patients in Group C were associated with increased mean liner wear rates compared to patients in Group A (0.133 mm/yr (SD 0.21) vs 0.031 mm/yr (SD 0.07), respectively; p < 0.001) and Group B (0.133 mm/yr (SD 0.21) vs 0.022 mm/yr (SD 0.05), respectively; p < 0.001) at ten years' follow-up. Patients in Group C were also associated with increased risk of osteolysis and aseptic loosening requiring revision surgery, compared with patients in Group A (7/133 vs 0/133, respectively; p = 0.007) and Group B (7/133 vs 0/135, respectively; p = 0.007). There was a non-statistically significant trend towards increased mean liner wear rates in Group A compared with Group B (0.031 mm/yr (SD 0.07) vs 0.022 mm/yr (SD 0.05), respectively; p = 0.128). All three groups were statistically comparable preoperatively and at ten years' follow-up when measuring normalized Western Ontario and McMaster Universities Osteoarthritis Index (p = 0.410), 36-Item Short Form Health Survey (p = 0.465 mental, p = 0.713 physical), and pain scale scores (p = 0.451). CONCLUSION: The use of UHMWPE was associated with progressively increased annual liner wear rates after THA compared to XLPE. At ten years' follow-up, the group receiving UHMWPE demonstrated an increased incidence of osteolysis and aseptic loosening requiring revision surgery compared to XLPE. Femoral heads composed of OxZr were associated with trend towards reduced wear rates compared to CoCr, but this did not reach statistical significance and did not translate to any differences in osteolysis, functional outcomes, or revision surgery between the two femoral head components.
  • Infections in relapsed myeloma patients treated with isatuximab plus pomalidomide and dexamethasone during the COVID-19 pandemic: Initial results of a UK-wide real-world study.

    Firas, AK
    OBJECTIVES: There are no real-world data describing infection morbidity in relapsed/refractory myeloma (RRMM) patients treated with anti-CD38 isatuximab in combination with pomalidomide and dexamethasone (IsaPomDex). In this UK-wide retrospective study, we set out to evaluate infections experienced by routine care patients who received this novel therapy across 24 cancer centres during the COVID-19 pandemic. METHODS: The primary endpoint was infection morbidity (incidence, grading, hospitalization) as well as infection-related deaths. Secondary outcomes were clinical predictors of increased incidence of any grade (G2-5) and high grade (≥G3) infections. RESULTS: In a total cohort of 107 patients who received a median (IQR) of 4 cycles (2-8), 23.4% of patients experienced ≥1 any grade (G2-5) infections (total of 31 episodes) and 18.7% of patients experienced ≥1 high grade (≥G3) infections (total of 22 episodes). Median time (IQR) from start of therapy to first episode was 29 days (16-75). Six patients experienced COVID-19 infection, of whom 5 were not vaccinated and 1 was fully vaccinated. The cumulative duration of infection-related hospitalizations was 159 days. The multivariate (MVA) Poisson Regression analysis demonstrated that a higher co-morbidity burden with Charlson Co-morbidity Index (CCI) score ≥4 (incidence rate ratio (IRR) = 3, p = 0.012) and sub-optimal myeloma response less than a partial response.
  • Burnout in diabetes and endocrinology specialist registrars across England, Scotland and Wales in the pre-COVID era.

    Agha, A
    BACKGROUND: Presence of either emotional exhaustion, depersonalization or lack of personal accomplishment define Burnout Syndrome which may lead to decreased workforce productivity, increased absenteeism, depression and medical errors as well as decreased patient satisfaction. OBJECTIVE: The aim of this study was to assess the frequency of burnout syndrome among Diabetes Specialist Registrars across England, Scotland and Wales and to identify any self-reported factors which may be contributory to burnout. METHODS: Over 430 Diabetes Specialist Registrars were invited to anonymously participate in an electronic survey which used Maslach Burnout Inventory and selfreporting questionnaire to identify burnout and contributory factors. RESULTS: In this pre-pandemic times study, Burnout was identified in 61 (57.5%; n = 106) respondents using Maslach burnout cut-off scores. 45.2% (48/106) participants had scored high in Emotional Exhaustion, while lack of personal accomplishment and depersonalization was seen in 24.5% (26/106) and 21.6% (23/106) of the respondents respectively. The commonest self-reported stressors by participants were "General Internal Medicine workload" 60.4% (64/106) followed by "Lack of specialty training" 36.8% (39/106) and "Lack of audit/research/Continuing Professional Development time" 10.8% (11/106) CONCLUSION: Burnout syndrome is frequent among the participating Diabetes Specialist Registrars and urgent steps may be required address this problem nationally to ensure that these physicians remain physically and mentally healthy, especially after the pandemic.
  • Excellent outcomes with combined single stage Physica ZUK medial unicompartment knee replacement and anterior cruciate ligament reconstruction results in young, active patients with instability and osteoarthritis with a mean follow up of 5 years.

    Kurien, T; Stragier, B; Senevirathna, S; Geutjens, G
    BACKGROUND (INCLUDING THE AIM OF THE STUDY): Young and more active patients with medial compartment osteoarthritis (OA) in conjunction with anterior cruciate ligament (ACL) deficiency are difficult to treat. The aim of this study was to explore the outcomes of combined fixed bearing Physica ZUK medial unicompartmental knee replacement (UKR) (Lima Corporate, Udine Italy) with ACL reconstruction for patients presenting with isolated medial compartment OA and symptomatic ACL deficiency. METHODS: Patients who underwent simultaneous single stage ACL reconstruction and medial UKR between 2012 and 2020 by a single surgeon (GG) were included. Preoperative outcome measures including Lysholm, Tegner, Oxford Knee Score and VAS pain score were evaluated and were repeated postoperatively at the most recent follow up appointment. RESULTS: Twenty four patients underwent simultaneous combined ACL and ZUK Medial UKR with a mean follow up of 5.1 years. Significant improvements in Lysholm (p < 0.001), Tegner (p < 0.001), Oxford Knee Score (p < 0.001) and VAS pain scores (p < 0.001) were seen with this combined approach with all patients returning to sport. Two patients had a minor peri-operative complication, which was treated conservatively. There were no revision procedures, and no evidence of implant loosening, however one patient had deceased due to an unrelated illness. CONCLUSION: UKR combined with ACL reconstruction can be an effective treatment option for selected patients suffering from medial unicompartmental knee osteoarthritis and symptomatic ACL deficiency. This allowed active patients to return to sports, addressing both instability and OA pain in a specific patient population.
  • Repeatability of Contrast-Enhanced Ultrasound to Determine Renal Cortical Perfusion.

    Pham, A; Williams, John P
    Alterations in renal perfusion play a major role in the pathogenesis of renal diseases. Renal contrast-enhanced ultrasound (CEUS) is increasingly applied to quantify renal cortical perfusion and to assess its change over time, but comprehensive assessment of the technique's repeatability is lacking. Ten adults attended two renal CEUS scans within 14 days. In each session, five destruction/reperfusion sequences were captured. One-phase association was performed to derive the following parameters: acoustic index (AI), mean transit time (mTT), perfusion index (PI), and wash-in rate (WiR). Intra-individual and inter-operator (image analysis) repeatability for the perfusion variables were assessed using intra-class correlation (ICC), with the agreement assessed using a Bland-Altman analysis. The 10 adults had a median (IQR) age of 39 years (30-46). Good intra-individual repeatability was found for mTT (ICC: 0.71) and PI (ICC: 0.65). Lower repeatability was found for AI (ICC: 0.50) and WiR (ICC: 0.56). The correlation between the two operators was excellent for all variables: the ICCs were 0.99 for PI, 0.98 for AI, 0.87 for mTT, and 0.83 for WiR. The Bland-Altman analysis showed that the mean biases (± SD) between the two operators were 0.03 ± 0.16 for mTT, 0.005 ± 0.09 for PI, 0.04 ± 0.19 for AI, and -0.02 ± 0.11 for WiR.
  • Management of Inpatient macroscopic haematuria: a typical urology emergency with a high mortality.

    Pavithran, A
    OBJECTIVE: To review the in-patient (IP) management patterns and 30-day outcomes of patients admitted with macroscopic haematuria (MH) over a 1-year-period in a single-institution, aiming to clarify management for such cases in the future. METHODS: Retrospective cohort study was conducted on all patients admitted with MH in a single-institution over 1-year, excluding patients not requiring an overnight stay. A case note review was performed for patient demographics, MH investigations, and management. RESULTS: A total of 120 patients were admitted with MH over a span of 1-year. 89% (107/120) were males, with an average age of 78 years (36-97 years), an average ASA of 3, mean length-of-stay (LOS) was 5 days (1-31days) and 68% (82/120) had pre-existing urological conditions. 62% (74/120) required bladder irrigation for a mean duration of 3 days (1-16days). 10% (12/120) required an emergency rigid cystoscopy and washout to manage the bleeding, of which 4% (5/12) had malignancy noted. Over 8% (10/120) patients discharged had unplanned readmissions within 30 days. The 1-year mortality for this cohort was 23% (28/120) of which 21% (6/28) died within 30 days from discharge. CONCLUSION: IP MH affects a vulnerable patient cohort. There is no specific pathway guiding the inpatient management of MH; therefore, research is required to produce standardized pathways for managing MH, considering the high-risk patient cohort, the prolonged LOS, and high one-year mortality rate.
  • Posterolateral Corner Reconstruction of the Knee Using Gracilis Autograft and Biceps Femoris.

    Stragier, B; Geutjens, G
    We introduce our technique for posterolateral corner reconstruction, which is based on the principle described in Arciero's technique for anatomic reconstruction of lateral collateral ligament (LCL) and popliteofibular ligament (PFL) to gain static stability in varus strain and external rotation. This technique uses a doubled gracilis autograft to reconstruct the PFL and a split biceps tendon transfer to reconstruct the LCL. Using this technique an anatomical LCL and PFL reconstruction can be performed in combination with anterior cruciate ligament or posterior cruciate ligament reconstruction without contralateral graft harvest or allograft. The technique also enables an isolated reconstruction of LCL or PFL when required and can be performed to augment an acute repair.
  • Pressor therapy in acute ischaemic stroke: an updated systematic review.

    England, Tim
    BACKGROUND: Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. METHODS: We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. RESULTS: We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. CONCLUSION: Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.
  • Efficacy of Isatuximab With Pomalidomide and Dexamethasone in Relapsed Myeloma: Results of a UK-Wide Real-World Dataset.

    Al-Kaisi, F
    Real-world data on the efficacy and tolerability of isatuximab with pomalidomide and dexamethasone (IsaPomDex) in relapsed/refractory myeloma patients have not been reported. In this UK-wide retrospective study, IsaPomDex outcomes were evaluated across 24 routine care cancer centers. The primary endpoint was overall response rate (ORR). Secondary endpoints included progression-free survival (PFS), duration of response (DOR) for patients who achieved an objective response (≥partial response [PR]), and adverse events (AEs). In a total cohort 107 patients, median follow up (interquartile range [IQR]) was 12.1 months (10.1-18.6 mo), median age (IQR) was 69 years (61-77). Median (IQR) Charlson Comorbidity Index (CCI) score was 3 (2-4); 43% had eGFR <60 mL/min. Median (IQR) number of prior therapies was 3 (3-3). Median (IQR) number of IsaPomDex cycles administered was 7 (3-13). ORR was 66.4%, with responses categorized as ≥ very good partial response: 31.8%, PR: 34.6%, stable disease: 15.9%, progressive disease: 15%, and unknown 2.8%. Median PFS was 10.9 months. Median DOR was 10.3 months. There was no statistical difference in median PFS by age (<65: 10.2 versus 65-74 13.2 versus ≥75: 8.5 mo, log-rank P = 0.4157), by CCI score (<4: 10.2 mo versus ≥4: 13.2, log-rank P = 0.6531), but inferior PFS was observed with renal impairment (≥60: 13.2 versus <60: 7.9 mo, log-rank P = 0.0408). Median OS was 18.8 months. After a median of 4 cycles, any grade AEs were experienced by 87.9% of patients. The most common ≥G3 AEs were neutropenia (45.8%), infections (18.7%), and thrombocytopenia (14%). Our UK-wide IsaPomDex study demonstrated encouraging efficacy outcomes in the real world, comparable to ICARIA-MM trial.
  • How Do Orthopaedic Patients Prefer to Be Contacted During a Pandemic?

    Fellows, David; Hind, Jamie; Sidhu, Gur Aziz; Amara, Veda; Ashwood, Neil
    Introduction: Communication with patients is a vital part of the surgical pathway, and when done effectively, it can greatly improve patient outcomes and patient satisfaction and reduce canceled appointments. Different forms of communication work well for different patient demographics, and it is important to optimize communication techniques. We designed a study to review the communication preferences of orthopedic patients during the COVID-19 pandemic. Methods: A cross-sectional study was performed by asking patients who were due to undergo orthopedic procedures to answer a questionnaire on their communication preferences, the reminder notice period for appointments, and safety and satisfaction ratings during the COVID-19 pandemic.Results:Communication method preferences are influenced by patient factors such as gender and age. Phone calls were the most popular communication method throughout all patient groups, with 61% selecting it as their preference. Younger patients preferred multiple communication methods of phone calls, texts, and emails, whereas the older group had a stronger preference for letters. Letters were more popular among females (28% compared to 10% of males), whereas males had a stronger preference for other communication methods. The majority of patients said they would not have liked a letter prior to their clinic appointment (65%). Of those who indicated a preferred notice period, 73% would have liked five days or less notice prior to their clinic appointment, while 65% would have liked 10-14 days notice prior to their surgery. The average safety rating was 55%. The overall satisfaction rating with the communication process was 71.7%. Conclusion: The COVID-19 pandemic has changed patient feelings towards healthcare and, as a result, changed the way healthcare is delivered. Communication method preferences among trauma and orthopedic patients vary and depend on factors such as gender and age. If healthcare departments can optimize their communication processes, they will improve their patient outcomes and enhance their resources.
  • FARGO-360: a multi-disciplinary survey of practice and perspectives on provision of care for patients with frailty presenting with gynecological cancers in the UK and Ireland.

    Addley, Susan
    OBJECTIVES: Frailty has been associated with worse cancer-related outcomes for people with gynecological cancers. However, the lack of clear guidance on how to assess and modify frailty prior to instigating active treatments has the potential to lead to large variations in practice and outcomes. This study aimed to evaluate current practice and perspectives of healthcare practitioners on the provision of care for patients with frailty and a gynecological cancer. METHODS: Data were collected via a questionnaire-based survey distributed by the Audit and Research in Gynecological Oncology (ARGO) collaborative to healthcare professionals who identified as working with patients with gynecological malignancies in the United Kingdom (UK) or Ireland. Study data were collected using REDCap software hosted at the University of Manchester. Responses were collected over a 16 week period between January and April 2021. RESULTS: A total of 206 healthcare professionals (30 anesthetists (14.6%), 30 pre-operative nurses (14.6%), 51 surgeons (24.8%), 34 cancer specialist nurses (16.5%), 21 medical/clinical oncologists (10.2%), 25 physiotherapists/occupational therapists (12.1%) and 15 dieticians (7.3%)) completed the survey. The respondents worked at 19 hospital trusts across the UK and Ireland. Frailty scoring was not routinely performed in 63% of care settings, yet the majority of practitioners reported modifying their practice when providing and deciding on care for patients with frailty. Only 16% of organizations surveyed had a dedicated pathway for assessment and management of patients with frailty. A total of 37% of respondents reported access to prehabilitation services, 79% to enhanced recovery, and 27% to community rehabilitation teams. CONCLUSION: Practitioners from all groups surveyed considered that appropriate training, dedicated pathways for optimization, frailty specific performance indicators and evidence that frailty scoring had an impact on clinical outcomes and patient experience could all help to improve care for frail patients.
  • What Is the Most Effective Management of the Primary Tumor in Men with Invasive Penile Cancer: A Systematic Review of the Available Treatment Options and Their Outcomes.

    Kailavasan, Mithun
    CONTEXT: The primary lesion in penile cancer is managed by surgery or radiation. Surgical options include penile-sparing surgery, amputative surgery, laser excision, and Moh's micrographic surgery. Radiation is applied as external beam radiotherapy (EBRT) and brachytherapy. The treatment aims to completely remove the primary lesion and preserve a sufficient functional penile stump. OBJECTIVE: To assess whether the 5-yr recurrence-free rate and other outcomes, such as sexual function, quality of life, urination, and penile preserving length, vary between various treatment options. EVIDENCE ACQUISITION: The EMBASE, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED), Google Scholar, and were searched for publications from 1990 through May 2021. Randomized controlled trials, nonrandomized comparative studies (NRCSs), and case series (CSs) were included. EVIDENCE SYNTHESIS: The systematic review included 88 studies, involving 9578 men from 16 NRCSs and 72 CSs. The cumulative mean 5-yr recurrence-free rates were 82.0% for penile-sparing surgery, 83.9% for amputative surgery, 78.6% for brachytherapy, 55.2% for EBRT, 69.4% for lasers, and 88.2% for Moh's micrographic surgery, as reported from CSs, and 76.7% for penile-sparing surgery and 93.3% for amputative surgery, as reported from NRCSs. Penile surgery affects sexual function, but amputative surgery causes more appearance concerns. After brachytherapy, 25% of patients reported sexual dysfunction. Both penile-sparing surgery and amputative surgery affect all aspects of psychosocial well-being. CONCLUSIONS: Despite the poor quality of evidence, data suggest that penile-sparing surgery is not inferior to amputative surgery in terms of recurrence rates in selected patients. Based on the available information, however, broadly applicable recommendations cannot be made; appropriate patient selection accounts for the relative success of all the available methods. PATIENT SUMMARY: We reviewed the evidence of various techniques to treat penile tumor and assessed their effectiveness in oncologic control and their functional outcomes. Penile-sparing as well as amputative surgery is an effective treatment option, but amputative surgery has a negative impact on sexual function. Penile-sparing surgery and radiotherapy are associated with a higher risk of local recurrence, but preserve sexual function and quality of life better. Laser and Moh's micrographic surgery could be used for smaller lesions.
  • Intraoperative robotic-assisted low anterior rectal resection performance assessment using procedure-specific binary metrics and a global rating scale.

    Tou, Samson
    BACKGROUND: This study aimed to evaluate the use of binary metric-based (proficiency-based progression; PBP) performance assessments and global evaluative assessment of robotic skills (GEARS) of a robotic-assisted low anterior rectal resection (RA-LAR) procedure. METHOD: A prospective study of video analysis of RA-LAR procedures was carried out using the PBP metrics with binary parameters previously developed, and GEARS. Recordings were collected from five novice surgeons (≤30 RA-LAR previously performed) and seven experienced surgeons (>30 RA-LAR previously performed). Two consultant colorectal surgeons were trained to be assessors in the use of PBP binary parameters to evaluate the procedure phases, surgical steps, errors, and critical errors in male and female patients and GEARS scores. Novice and experienced surgeons were categorized and assessed using PBP metrics and GEARS; mean scores obtained were compared for statistical purpose. Also, the inter-rater reliability (IRR) of these assessment tools was evaluated. RESULTS: Twenty unedited recordings of RA-LAR procedures were blindly assessed. Overall, using PBP metric-based assessment, a subgroup of experienced surgeons made more errors (20 versus 16, P = 0.158) and critical errors (9.2 versus 7.8, P = 0.417) than the novice group, although not significantly. However, during the critical phase of RA-LAR, experienced surgeons made significantly fewer errors than the novice group (95% CI of the difference, Lower = 0.104 - Upper = 5.155, df = 11.9, t = 2.23, p = 0.042), and a similar pattern was observed for critical errors. The PBP metric and GEARS assessment tools distinguished between the objectively assessed performance of experienced and novice colorectal surgeons performing RA-LAR (total error scores with PBP metrics, P = 0.019-0.008; GEARS scores, P = 0.029-0.025). GEARS demonstrated poor IRR (mean IRR 0.49) and weaker discrimination between groups (15-41 per cent difference). PBP binary metrics demonstrated good IRR (mean 0.94) and robust discrimination particularly for total error scores (58-64 per cent). CONCLUSIONS: PBP binary metrics seem to be useful for metric-based training for surgeons learning RA-LAR procedures.
  • Retrospective analysis of outcomes of outpatient parenteral antimicrobial therapy (OPAT) for necrotising otitis externa.

    Slucka, A
    Necrotising otitis externa (NOE) is an uncommon but life-threatening infection that requires prolonged systemic antimicrobial therapy. This study aims to identify factors associated with treatment response and outcome in patients with NOE treated through outpatient parenteral antimicrobial therapy (OPAT). We performed a retrospective analysis of patients with NOE treated over a 4-year period (January 2018-January 2022) at a tertiary referral hospital in Derbyshire, UK. We defined OPAT failure as unplanned readmission within 30 days of discontinuation of OPAT. Prolonged duration of therapy was defined as length of parenteral antimicrobial treatment of more than 8 weeks. A total of 46 cases of NOE were reviewed. OPAT failure and prolonged therapy were recorded in 9 (19.6%) and 23 (50.0%) episodes respectively. Facial nerve involvement (odds ratio [OR], 14.54; 95% confidence interval [CI], 2.76-76.60; p = 0.002), dementia (OR, 7.65; 95% CI, 1.23-47.46; p = 0.029), Charlson comorbidity score (OR, 1.41 per unit increase; 95% CI, 1.00-2.00; p = 0.049) and peak CRP level (OR, 1.03 per unit increase; 95% CI, 1.00-1.06; p = 0.027) were associated with increased risk of treatment failure. Facial nerve involvement (OR, 16.30; 95% CI, 2.60-102.31; p = 0.003) and peak CRP level (OR, 1.04; 95% CI, 1.01-1.07; p = 0.016) were also associated with an increased need for prolonged antimicrobial therapy. In addition, extent of disease (based on imaging findings) was linked to prolonged therapy (OR, 22.89; 95% CI, 3.62-144.76; p = 0.001). NOE could be effectively managed as outpatient via OPAT. However, vigorous antimicrobial treatment and close monitoring of patients with pre-existing comorbidities, facial nerve paralysis, extensive disease and markedly elevated inflammatory markers are essential to optimise clinical outcomes.

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