Recent Submissions

  • Associations of Muscle Strength with Central Aspects of Pain: Data from the Knee Pain and Related Health in the Community (KPIC) Cohort.

    Walsh, David A (Journal of Personalized Medicine, 2023-09)
    Knee pain is associated with lower muscle strength, and both contribute to disability. Peripheral and central neurological mechanisms contribute to OA pain. Understanding the relative contributions of pain mechanisms to muscle strength might help future treatments. The Knee Pain and related health In the Community (KPIC) cohort provided baseline and year 1 data from people with early knee pain (n = 219) for longitudinal analyses. A cross-sectional analysis was performed with baseline data from people with established knee pain (n = 103) and comparative data from people without knee pain (n = 98). Quadriceps and handgrip strength indicated local and general muscle weakness, respectively. The indices of peripheral nociceptive drive were knee radiographic and ultrasound scores. The indices associated with central pain mechanisms were Pressure Pain detection Threshold (PPT) distal to the knee, and a validated self-report Central Aspects of Pain Factor (CAPF). The associations were explored using correlation and multivariable regression. Weaker quadriceps strength was associated with both high CAPF and low PPT at baseline. Year 1 quadriceps weakness was predicted by higher baseline CAPF (β = -0.28 (95% CI: -0.55, -0.01), p = 0.040). Weaker baseline and year 1 handgrip strength was also associated with higher baseline CAPF. Weaker baseline quadriceps strength was associated with radiographic scores in bivariate but not adjusted analyses. Quadriceps strength was not significantly associated with total ultrasound scores. Central pain mechanisms might contribute to muscle weakness, both locally and remote from the knee.
  • Traumatic injuries of the immature hip and pelvis.

    Gnap, Rose (Current Opinion in Pediatrics, 2023-10)
    PURPOSE OF REVIEW: The pelvis and hip account for 0.3--4% of fractures of the immature skeleton, and generally result from high energy trauma. These fractures range in severity from apophyseal avulsions to complete disruptions of the pelvic ring. The purpose of this article is to review the presentation, diagnosis, treatment and complications of these injuries in order to inform clinicians involved in their management. There is a lack of evidence-based management protocols for fractures of the immature pelvis largely due to their rarity and lack of robust scientific literature on the topic. RECENT FINDINGS: Computed tomography/MRI is essential as up to 30% of pelvis and 70% of acetabular fractures are not identified on initial radiographs. A sub-optimal outcome is common in unstable fractures treated conservatively and adequate reduction and surgical stabilization is often required to avoid long-term morbidity. SUMMARY: A coordinated approach involves resuscitation and temporary stabilization with planned definitive fixation. It is generally accepted that these injures should be managed in paediatric trauma centres. Whilst injuries vary in pattern and severity, we present an overview that considers the evaluation and treatment of the paediatric patient with pelvic and hip fractures to ensure that these injuries are identified promptly and treated by surgeons familiar with contemporary management algorithms.
  • The utility of volumetric MRI in assessment of volume changes in ventral diencephalon in autistic children.

    Mahmoud, Hassan Ali Ahmed (Egyptian Journal of Radiology and Nuclear Medicine, 2023-10)
    Abstract Background Autism spectrum disorder (ASD) is a neurobehavioural disorder, characterized by abnormal affiliative and socio-emotional responses which are generally regulated by certain neuropeptides in the hypothalamus (an anatomic component of the ventral diencephalon (VD)). The use of volumetric MRI for studying VD volume change could provide a novel approach for identification of structural brain changes in ASD; this could assist in understanding the pathophysiology of ASD and would reflect on treatment strategies. The aim of the current work was to investigate the role of MRI volumetric analysis of the ventral diencephalon in young children diagnosed with autism spectrum disorder. Methods Fifty children diagnosed with ASD underwent volumetric brain analysis, on a fully automated MRI brain volumetry system (volBrain), with voxel-based morphometry of various segmental structures of the brain including the VD, using vol2Brain 1.0 pipeline software analysis suite. Results There were 48 out of 50 children who demonstrated abnormal VD volume which was found below the normal limits compared with reference standard normalized volume. All cases were normocephalic demonstrating normal intra-cranial cavity volumes. Forty out of fifty cases showed increased total volume of grey matter, and eighteen out of fifty cases showed increased total volume of white matter. Regarding the amygdala and hippocampus, there were only two cases (4.0%) which showed slightly increased relative volume of the total amygdala, and two other cases (4.0%) demonstrated increased relative volume of the total hippocampus. Comparison between the autistic patients and normal references revealed a significant difference regarding the VD volume and total volume of grey matter, whereas no significant differences were found regarding the white matter amygdala and hippocampus. Conclusions Based on the consistent significant volume decrease in the ventral diencephalon in patients with childhood autism, this study concluded that volumetric MRI analysis could be useful for diagnosis of childhood spectrum disorder and could be utilized as a reliable screening method in the clinically vague cases. Further study with a larger sample size including more age groups is recommended for more validation of the results.
  • Treatment of age-related macular degeneration with aflibercept using a treat, extend and fixed protocol; A 4-year study of treatment outcomes, durability, safety and quality of life (An extension to the MATE randomised controlled trial)

    Dhar-Munshi, Sushma
    Purpose: Data are limited pertaining to the long-term benefits of aflibercept treatment for neovascular age-related macular degeneration (nAMD). The aim of this study was to provide outcomes, safety, durability and quality-of-life data with aflibercept using a modified treat, extend and fixed regime over 4 years. Methods: Prospective, multicentre, single cohort observational study of treatment-naïve nAMD participants treated with aflibercept as 2-year extension of the MATE-trial that compared early and late Treat-and-Extend for 2 years. Refracted ETDRS best corrected visual acuity (BCVA), central retinal thickness (CRT), treatment interval and adverse events were assessed. Quality-of-life was measured using the Macular Disease Dependent Quality of Life (MacDQoL) and Macular Disease Treatment Satisfaction Questionnaires (MacTSQ). Results: Twenty-six of 40 participants completing the MATE-trial were enrolled with 20 completing the total 4-year study. Mean BCVA was 60.7 at Month 0 and 64.8 ETDRS letters at Month 48 while CRT decreased from 423.7 μm to 292.2 μm. Five participants discontinued treatment due to inactivity. The mean number of treatments and visits for the remaining participants was 27 and 30.0, respectively, with treatment intervals extended to 12 weeks in four participants at Month 48. Both AMD-specific QoL and treatment satisfaction remained stable between Months 0 and 48 and mean BCVA significantly correlated with AMD-specific QoL scores at Months 12, 24 and 48. Conclusions: Results suggest that BCVA can be maintained over 48 months when following a treat-extend-and-fix regimen of aflibercept with intervals out to 12 weeks, while maintaining AMD-specific QoL and treatment satisfaction.
  • The Molecular Epidemiology of Clostridioides difficile Infection in Central India: A Prospective Observational Cohort Study.

    Ambalkar, Shrikant (Microbiology Research, 2023-09)
    This prospective observational cohort study aimed to establish and compare baseline rates of Clostridioides difficile infection (CDI) in community and hospitalized patients in Nagpur and rural Melghat Maharashtra, including adults aged ≥18 years with a diagnosis of diarrhoea as defined as 3 or more loose stools in a 24 h period. All diarrhoeal samples were tested for CDI using the C. diff Quik Chek Complete enzyme immunoassay. C. difficile-positive stool samples were characterised by toxigenic culture, antimicrobial susceptibility testing and PCR ribotyping. C. difficile testing was performed on 1683 patients with acute diarrhoea. A total of 54 patients (3.21%; 95% CI: 2.42–4.17) tested positive for both the GDH antigen and free toxin. The risk factors for CDI included the presence of co-morbidities, antibiotic usage, and immunosuppression. The detected PCR ribotypes included 053-16, 017, 313, 001, 107, and 216. Our findings show that toxigenic C. difficile is an important but neglected aetiologic agent of infective diarrhoea in Central India. These results underscore the need to enhance the awareness and testing of patients with diarrhoea in India regarding the presence of toxigenic C. difficile, particularly in high-risk individuals with multiple co-morbidities, immunosuppression, and recent or ongoing antibiotic exposure or hospitalization.
  • A Modified Technique for Lateral Column Lengthening as Part of Adult Acquired Flatfoot Deformity Correction: An Intact Medial Calcaneal Cortex, a Low-Profile Locking Plate with a Combination of Autologous Calcaneal Bone Graft and Demineralized Human Bone Matrix

    Salem, Hatem; Goyal, Achal (Techniques in Foot & Ankle Surgery, 2023-09)
    Adult acquired flatfoot deformity encompasses deformities of the entire foot and ankle, with most clinical presentations comprising of a flexible planovalgus deformity and forefoot abduction. Numerous operative procedures have been proposed, and a lateral column–lengthening procedure is advocated to correct the forefoot abduction. Autologous iliac crest bone graft is routinely inserted into the opening-wedge osteotomy at the anterior calcaneum. Fixation methods are also variable with increasing use of locking plates to achieve stability at this osteotomy. Harvesting the iliac crest graft exposes the patient to significant donor site morbidity. We describe a modified lateral column–lengthening technique, leaving the medial calcaneum cortex intact, packing a combination of autologous calcaneal bone graft, and demineralized bone matrix into the osteotomy site, fixed with a low-profile locking plate. In the short term, our technique offers reduced rates of wound complications, symptomatic hardware, nonunion, and deformity recurrence when compared with published rates.

    Thanawala, Nehal (Archives of Disease in Childhood, 2023-07)
    Objective There are a range of health needs for children and young people who attend special schools. Some have regular paediatric and specialist outpatient appointments whereas some are discharged from formal paediatric follow up. These health appointments were traditionally delivered within the SEND school itself. The Covid-19 pandemic gave the opportunity to explore alternative methods of paediatric health appointments. Face to face appointments in school have advantages and disadvantages. Professionals, teachers and parents have different opinions and preferences about how we should move forward delivering health reviews for this complex group of children and young people. But this needs to take into account the facilities, time and support available to professionals to deliver meaningful health reviews. We sought to gather opinions regarding health appointments, including preference of patient’s families to help formulate recommendations for service delivery moving forward. Methods An online survey was conducted to obtain feedback from parents/carers, special school teachers and health professionals regarding different types of appointment, availability of staff, and information sharing. Results 71 parents/carers; 11 teachers; 4 health professionals responded: 60% of parents/carers expressed preference for all face to face appointments (school based with or without TA or hospital appointment) over video consultations. 42% of parents/carers expressed preference for appointment at special school. 68% of clinicians prefer face to face appointments (school based with or without TA or hospital appointment) but expressed preference for an opportunity to speak to teachers pre/post appointment. 50% of clinicians expressed preference for appointment based at the special schools. 84% of parents/carers feel having teachers attend the appointment would be valuable. 100% of clinicians reported having a teacher who knows the child, at the assessment is valuable (or at least a pre/post appointment). Conclusion 42% parents/carers and 50% health professionals preferred face to face appointments within the special school setting, despite lack of secure private clinic room, examination couch and handwashing facilities. Therefore there is an argument that to provide appropriate, safe and meaningful health appointments, facilities in hospital would be better than school setting. It would be difficult to deliver a service where only some SEND schools were offered onsite clinics. Video clinic can be useful for children who have mostly behavioural problems and less physical concerns, allowing the option of video consultations. Liaison with schools is needed to discuss their important contribution and how that can be managed.

    Fernee, Hester; Slater, Jessica (Archives of Disease in Childhood, 2023-07)
    Objectives To improve time scales for blood borne infection (BBI) screening for looked after children after initial health assessment (IHA). Methods Retrospective data collection from IHAs completed over 6 months. Data analysis reviewed time intervals within process from IHA to action of blood tests. This was re-audited after 6 months of implemented changes. Results Initial data collection identified 49 patients with completed IHAs between June-November 2021; 34 with BBI screening recommended, of whom 11 had BBI blood tests completed. Reasons for not having blood tests included: prior antenatal testing, non-attendance, patient/parent refusal, moved out of area, referral to sexual health. Initial data demonstrated significant time between IHA to BBI bloods taken, on average 129.8 days (range 46–230). Analysis identified time from posting consent form to receipt of completed consent via social care as the longest stage: 79 days (10–257). Significant time intervals were also identified between: IHA to consent form posted 22.3 days (6–61). Receipt of consent to bloods taken 47.5 days (8–82). Bloods taken to issue of results letter 23.6 days (3–106). Several interventions were made BBI consent obtained at IHA where possible, local guideline issued outlining indications for BBI screening as per national guidance1 Blood test availability increased, next available allocated instead of partial booking. Doctor informed when blood test completed, prompting timely review of results and issue of standardised results letter. Several interventions were madeReaudit after 6 months identified 53 completed IHAs; 28 with BBI screening recommended, of whom 8 consented in clinic. Of those consented in clinic, 5 had bloods tests, with mean time from IHA to blood test of 28.2 days (range 14–40). For the 20 not consented at IHA, 14 had blood tests; mean time from IHA to bloods taken was 53.1 days (7–79 days). Reasons for not having blood tests remained comparable: return to care of birth parent, non-responders, non-attendance, declining blood test. In summary data from reaudit demonstrates that completing consent at IHA reduced interval between IHA and bloods by 24.9 days. Compared with initial data prior to all interventions a reduction of 101.6 days (78%) from IHA to bloods taken. Conclusion We highlighted lengthy timescales in process of BBI screening recommended from IHA and where these delays occurred. After implementing quality improvement strategies, the most pertinent of which was obtaining consent at IHA, we have demonstrated significant improvement in timescales for BBI screening for looked after children.

    Ng, Christabella (Archives of Disease in Childhood, 2023-07)
    Objectives In the UK there is national guidance for provision of Paediatric Respiratory Medicine (PRM) services in tertiary hospitals.1 However, no such guidance exists for district general hospitals (DGHs). We wanted to explore if there are any disparities in the provision of PRM services across DGHs in the UK. To evaluate the variabilities in provision of PRM services in DGHs in the UK. Methods An online survey was conducted amongst PRM in DGHs between April and December 2020. Information obtained: demographics, workforce, respiratory investigations, clinic and referral pathways. Results Level of completed training and composition of the multi-disciplinary team (MDT): 34 responses were received, of whom 16 (47%) completed the PRM special interest module, 8 (24%) completed PRM subspecialty training, and 10 (29%) had no specific PRM training. Over 25 (74%) respondents have respiratory nurse specialists and physiotherapists in their multi-disciplinary team (MDT). Less than 19 (56%) respondents have psychologists and allied health professionals in their MDT. There is a variation between DGHs for the types of respiratory conditions that are managed locally or shared care with a tertiary centre from less than a third to nearly 100% (table 1). Referral pathways for tertiary care exist for certain conditions. There is a similar variability in availability of various respiratory investigations in DGHs (table 2). Conclusions There is a variability in the level of completed training, composition of MDT, conditions managed, investigations available and established referral pathways to tertiary centres. The challenges in providing adequate respiratory care vary from the MDT to difficulty in accessing respiratory investigations. Further evaluation is required to establish the reasons for differences in DGH Paediatric respiratory service and identify the expected standard of care.

    Aye, Thandar; Appalanaidu, Nageswary (Heart, 2023-06)
    Introduction The 2021 ESC guidelines emphasise the importance of appropriate diagnosis and management of heart failure as it represents a condition with significant heterogeneity. Based on the NICOR heart failure audit 2021, the mortality rates are high with 40% of newly diagnosed patient are dying within a year and 50% of patients are either readmitted to hospital or dying within a year of admission to hospital. Pharmacotherapies such as beta blockers, angiotensin-converting enzyme inhibitors (ACEi) / angiotensin receptor neprilysin inhibitor (ARNI), sodium-glucose co-transporter 2 inhibitor (SGLTi) and mineralocorticoid receptor antagonists (MRA) have proven to show marked reduction in mortality and morbidity. It is the cornerstone prior to considering non-pharmacological interventions such as device therapy. The aim of our study is to assess prescribing practice in commencing appropriate medications in patients with heart failure with reduced ejection fraction (HFrEF) in a district general hospital setting. Method A retrospective analysis based on data from NICOR of patients presenting to Kings Mill Hospital with diagnosis of heart failure between December 2020 – December 2021 was performed. We looked into parameters such as co-morbidities including a diagnosis of pre-existing heart failure, echocardiography results, heart failure medications on admission and on discharge, blood tests (potassium levels and eGFR) and haemodynamic (blood pressure and heart rates) were collected and collated. Results A total of 219 patients with diagnosis of heart failure were admitted. The mean age is 80 years old with a slight predominance of female patients at 51%. It was noted that 55% of these admissions had pre-existing diagnosis of HFrEF. 51% of the patients had echocardiogram during the admission and 40.2% have HFrEF. The calculated mortality is 26.5% in this cohort. Patients with new diagnosis of HFrEF were better optimised with medications (Figure 1) compared to the ones with pre-existing diagnosis. Substandard heart failure medication optimisations are due to medication intolerance, worsening renal function / hyperkalemia and haemodynamic effects such as hypotension. Only 2% of patients were on SGLT2i and ARNI compared to ACEi/ARB due to lack of familiarity of indication for prescribing. All patients had appropriate potassium levels as well as establishment of optimal heart rate and blood pressure control prior to discharge. Conclusion This analysis highlights that patients are not fully optimized on oral heart failure therapies prior to hospital discharge. Robust measures must be taken in commencing on SGLT2i and ARNI. We need to take opportunities to optimise the medications of patients with established diagnosis. These findings will form the basis of our quality improvement project on heart failure medications optimization and more analysis will follow in future.
  • Reminder to quote myocardial infarction and emergency angioplasty when consenting for dobutamine stress echo – a rare case

    Aye, Thandar; Appalanaidu, Nageswary (Heart, 2023-06)
    Background Dobutamine stress echocardiogram (DSE) is a widely used diagnostic tool for patients with new onset chest pain in whom angina cannot be ruled out by clinical assessment alone. It is also used for risk stratification to guide coronary revascularization for patients with known ischaemic heart disease. It is a low-risk procedure and myocardial infarction is quoted as a rare complication of the test. Case Summary A 38-year-old gentleman presented to chest pain clinic for symptoms of atypical chest pain. He has been getting a central throbbing discomfort with no radiation. His pain was normally exacerbated on exertion lasting for 20 minutes and eased with rest; associated with feeling hot and sweatiness. Similar symptoms could also occur at rest with some episodes lasting for a few hours; associated with nausea as well as pins and needles. In view of these atypical symptoms, he had Spider flash monitor, echocardiography and dobutamine stress echocardiography for further assessment. The Spiderflash did not capture arrhythmias and echocardiogram showed normal left ventricular systolic function. He attended DSE which showed no evidence of regional wall motion abnormality nor ischaemic changes at any stages of the test including peak stress. He later developed vasovagal response to high dose of Dobutamine (40mcg/Kg/min) with blood pressure dropping to 58/39 mmHg. He had chest discomfort at this stage but there was no regional wall motion abnormality or ECG changes. This all resolved after stopping Dobutamine and systolic blood pressure returned to >90mmHg. As per practice, the patient was kept outside to monitor for delayed complications. A few minutes later, he experienced severe chest discomfort, sweatiness, and clamminess. He was promptly assessed, and subsequent echo showed new hypokinesia at inferoseptum and inferior walls. 12 lead ECG showed inferolateral ST elevation with new LBBB (Figure 1). He was then transferred to the primary PCI centre. Coronary angiogram revealed complete occlusion of distal segment of the right coronary artery (Figure 2) which was successfully treated with angioplasty and drug eluting stent. Recovery was uneventful and he was discharged with dual antiplatelets and secondary prevention therapies. Conclusion and Discussion In our case, the clinical timeline and imaging features suggest that initial DSE was normal, however, the test may have contributed to endothelial shear stress and plaque rupture leading to ST elevation acute myocardial infarction. Although the occurrence of acute coronary syndrome after dobutamine administration during stress testing may be coincidental, clinicians should be aware of the possible rare complications and should educate patients when ordering stress tests. Such risk should be clearly mentioned when consenting patients for DSE.

    Kyaw, Myat; Aye, Thandar
    Background Association between the heart and the thyroid gland has been well-known for 200 years, from hyperthyroidism leading to cardiac arrhythmias and high-output heart failure to cardiovascular diseases in hypothyroidism through accelerated atherosclerosis and endothelial dysfunction. We present a case which demonstrates another conjunction between the heart and the thyroid. Case Presentation A 32-year-old female presented to the A&E department with chest pain, vomiting, and generalized unwellness. She has been well previously, without any underlying medical disease. Her EWS score was 7 with tachycardia and high fever. Blood results showed microcytic anaemia, leucocytosis and raised C-reactive protein. She was treated for sepsis which later turned out to be infective endocarditis. Blood culture was positive for Staph aureus. The subsequent echocardiogram showed a vegetation of 1.2cm x 0.8cm at the posterior mitral valve (figure 1). Interestingly, she was found to be hyperthyroid from thyroid screening prompted by tachycardia presentation. Thyroid stimulation hormone (TSH) was high <0.01 (0.5–5 μIU/mL). TSH receptor antibodies and thyroid peroxidase (TPO) antibodies were also high. Carbimazole and beta-blocker were initiated. Despite antibiotic therapy, the patient required mitral valve replacement because of the vegetation size, persistently raised inflammatory markers and incompetent mitral valve. Surgical findings include large vegetation on P2 segment of the mitral valve, with deep abscess cavity underneath. She was discharged without further complications and her thyroid status normalized 3 months later with carbimazole. Discussion Although thyrotoxicosis together with infective endocarditis is a rare presentation, any organ involvement is possible with endocarditis. There have been a few case reports of suppurative thyroiditis or thyroid abscess in infective endocarditis. In our case, there have been no symptoms such as neck pain or swelling and thyroid gland appears normal from CT scan. Presence of TSH receptor antibodies and TPO antibodies suggest autoimmune thyroiditis nature. Association between autoimmune thyroiditis and infected cardiac valves can be explained by several mechanisms. In Graves’ disease, circulating TSH receptor autoantibodies activate mucopolysaccharide-secreting endothelial cells leading to thickening and myxomatous changes with likelihood of endocarditis in transient bacteremia. Conversely, various infections are suggested to trigger autoimmune thyroid disorders due to the release of sequestered antigens from inflammation and molecular mimicry of the infective organisms. Psychological stress is also a factor known to precipitate autoimmunity. Infective endocarditis reflects both. Conclusion This case highlights the importance of thyroid investigation in the management of infective endocarditis. It also illustrates the possible association between autoimmune thyroid disease and infective endocarditis.
  • Exploring the influence of postnatal depression on neonatal care practices among mothers in Western Kenya: A qualitative study.

    Gribbin, Catherine
    Background: Postnatal depression (PND) is associated with adverse infant neurodevelopmental outcomes. Evidence is limited on how PND influences neonatal (<28 days old) outcomes in low- and middle-income countries, such as Kenya, which bear the global burden of neonatal morbidity and mortality. Objectives: To explore how PND influences neonatal feeding and care practices among women in the early postnatal period in rural Western Kenya. Design: A cross-sectional study. Methods: Semi-structured interviews were conducted at 2-weeks postpartum among mothers of newborn infants identified <72 h old from the postnatal wards and clinics across five health facilities in Kisumu County of Western Kenya. They were all screened for features suggestive of postnatal depression using the Edinburgh Postnatal Depression Scale. Results: Twenty-four mothers were interviewed, 13 of whom had features suggestive of PND. All mothers experienced health or socio-economic adversities in the perinatal period, including traumatic deliveries, financial constraints, and challenging relationships with partners/other family members. Feeding difficulties due to perceived insufficient breastmilk were a particular challenge for mothers with features of PND, who were more likely to introduce complementary feeds. Maternal health-seeking decisions were influenced by high financial cost, long waiting times and poor interactions with health care providers that induced stress and fear among mothers. Maternal caregiving capacity was influenced by her ability to juggle other household duties, which was difficult for mothers with features suggestive of PND. Support from friends and relatives positively impacted maternal mood and caregiving ability. Conclusion: Mothers experienced many stress-inducing events in the perinatal period which potentially exacerbated features of PND in the immediate postnatal period. Women with features of PND were particularly vulnerable to these stressors that influenced infant caregiving practices. Addressing the socio-economic challenges and health system gaps that include scale up of compassionate and respectful care for women during pregnancy and childbirth, as well as early screening and intervention of PND, through enhanced referral pathways between health facilities and community support structures, could mitigate against the impact of PND on neonatal caregiving.
  • Health economic impact of moderate-to-severe chronic pain associated with osteoarthritis in England: a retrospective analysis of linked primary and secondary care data

    Walsh, David A (BMJ Open, 2023-07)
    Objective Despite the prevalence of osteoarthritis (OA) in England, few studies have examined the health economic impact of chronic pain associated with OA. The aim of this study was to compare outcomes in patients with moderate-to-severe chronic pain associated with OA and matched controls without known OA. Design Retrospective, longitudinal, observational cohort study. Setting Electronic records extracted from the Clinical Practice Research Datalink GOLD primary care database linked to Hospital Episode Statistics (HES) data set. Participants Patients (cases; n=5931) ≥18 years and with existing diagnosis of OA and moderate-to-severe pain associated with their OA, and controls matched on age, sex, comorbidity burden, general practitioner (GP) practice and availability of HES data. Interventions None. Primary and secondary outcome measures Total healthcare resource use (HCRU) and direct healthcare costs during 0–6, 0–12, 0–24 and 0–36 months of follow-up. Secondary outcomes measures included pharmacological management and time to total joint replacement. Results Patients with moderate-to-severe chronic pain associated with OA used significantly more healthcare services versus matched controls, reflected by higher HCRU and significantly higher direct costs. During the first 12 months’ follow-up, cases had significantly more GP consultations, outpatient attendances, emergency department visits and inpatient stays than matched controls (all p<0.0001). Total mean costs incurred by cases during 0–12 months’ follow-up were five times higher in cases versus controls (mean (SD): £4199 (£3966) vs £781 (£2073), respectively). Extensive cycling through pharmacological therapies was observed; among cases, 2040 (34.4%), 1340 (22.6%), 841 (14.2%), 459 (7.7%) and 706 (11.9%) received 1–5, 6–10, 11–15, 16–20 and >20 lines of therapy, respectively. Conclusions This wide-ranging, longitudinal, observational study of real-world primary and secondary care data demonstrates the impact of moderate-to-severe chronic pain associated with OA in patients compared with matched controls. Further studies are required to fully quantify the health economic burden of moderate-to-severe pain associated with OA.
  • A surgeon's trial success of curing pedal eumycetoma

    Mitchell, James (BMJ Case Reports, 2023-07)
    Mycetoma is a chronic infection of underlying fungal (eumycetoma) or bacterial (actinomycetoma) origin. It is characterised by a clinical triad of tumour-like swelling, actively draining sinuses and macroscopic grains of characteristic colours. We the case of a 66-year-old woman on immunosuppressive therapy presenting with eumycetoma of the foot (Madura foot). The fungal organism cultured was Acrophialophora fusispora. This case was managed with a combination of extensive surgical debridement, and packing with calcium sulfate (Stimulan) beads impregnated with vancomycin and voriconazole. As far as the authors are aware, this is a novel adjunct to the surgical treatment of deep fungal infection in the foot. Eumycetoma treated with surgery and oral antifungal therapy leads to cure rates of 25%–35%. This novel treatment seems to bear further investigation for the potential to improve cure rates. At 8 months follow-up, our patient appears to be making good progress with no current signs of recurrence.
  • Association between pain intensity and depressive symptoms in community-dwelling adults: longitudinal findings from the Survey of Health, Ageing and Retirement in Europe (SHARE).

    Walsh, David A
    Purpose: To investigate the longitudinal associations between pain and depressive symptoms in adults. Methods: Prospective cohort study on data from 28,515 community-dwelling adults ≥ 50 years, free from depression at baseline (Wave 5), with follow-up in Wave 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE). Significant depressive symptoms were defined by a EURO-D score ≥ 4. The longitudinal association between baseline pain intensity and significant depressive symptoms at follow-up was analysed using logistic regression models; odds ratios (ORs) and confidence intervals (CI) were calculated, adjusting for socio-demographic and clinical factors, physical inactivity, loneliness, mobility and functional impairments. Results: Mean age was 65.4 years (standard deviation 9.0, range 50-99); 14,360 (50.4%) participants were women. Mean follow-up was 23.4 (standard deviation 3.4) months. At baseline, 2803 (9.8%) participants reported mild pain, 5253 (18.4%) moderate pain and 1431 (5.0%) severe pain. At follow-up, 3868 (13.6%) participants-1451 (10.3%) men and 2417 (16.8%) women-reported significant depressive symptoms. After adjustment, mild, moderate and severe baseline pain, versus no pain, were associated with an increased likelihood of significant depressive symptoms at follow-up: ORs (95% CI) were 1.20 (1.06-1.35), 1.32 (1.20-1.46) and 1.39 (1.19-1.63), respectively. These associations were more pronounced in men compared to women, and consistent in participants aged 50-64 years, those without mobility or functional impairment, and those without loneliness at baseline. Conclusion: Higher baseline pain intensity was longitudinally associated with a greater risk of significant depressive symptoms at 2-year follow-up, in community-dwelling adults without baseline depression.
  • British Thoracic Society Clinical Statement on pleural procedures

    Roberts, Helen (Thorax, 2023-07)
    Introduction A total of 21 659 pleural aspirations or drain insertions were conducted in England in 2019/2020 with a combined cost of £13.4 million.1 There are now a variety of different pleural procedures, which have different invasiveness, risks and benefits, and an abundance of data driving high-quality practice in interventional pleural practice. In the context of a number of national safety alerts related to pleural procedures in the last 10 years, it is therefore important that clinicians are as up to date as possible in interventional practice. This statement is intended to sit in parallel with the BTS Guideline for Pleural Disease 2023,2 and with a particular focus on pleural interventions in adults. The statement provides a narrative review of areas not covered in the main guideline. The main statement focuses on important areas of safe clinical practice, patient selection, evidence for complication rates, the consent process and troubleshooting guidance in the following areas: Safety and preparation for pleural procedures. Pleural aspiration (diagnostic and therapeutic). Intercostal drain insertion. Indwelling pleural catheter (IPC) insertion, management and removal. Image-guided pleural biopsy. Medical thoracoscopy.
  • British Thoracic Society Guideline for pleural disease

    Roberts, Mark E (Thorax, 2023-07)
    Conservative management can be considered for the treatment of minimally symptomatic (ie, no significant pain or breathlessness and no physiological compromise) or asymptomatic primary spontaneous pneumothorax in adults regardless of size. (Conditional—by consensus) Ambulatory management should be considered for the initial treatment of primary spontaneous pneumothorax (PSP) in adults with good support, and in centres with available expertise and follow-up facilities. (Conditional) In patients not deemed suitable for conservative or ambulatory management, needle aspiration or tube drainage should be considered for the initial treatment of primary spontaneous pneumothorax in adults. (Conditional) Chemical pleurodesis can be considered for the prevention of recurrent of secondary spontaneous pneumothorax (SSP) in adults (eg, patients with severe chronic obstructive pulmonary disease who significantly decompensated in the presence of a pneumothorax, even during/after the first episode). (Conditional) Thoracic surgery can be considered for the treatment of pneumothorax in adults at initial presentation if recurrence prevention is deemed important (eg, patients presenting with tension pneumothorax, or those in high-risk occupations). (Conditional)
  • Case 11-2023: A Man with Mantle-Cell Lymphoma and Hypoxemia.

    Gupta, Anindya (NEJM, 2023-07)
    To the Editor: Schmidt and colleagues (April 13 issue)1 provide a logical rationale for administering methylene blue therapy in a patient with hypoxemia caused by dapsone-induced methemoglobinemia. It is important to consider testing for glucose-6-phosphate dehydrogenase (G6PD) deficiency before administering methylene blue therapy, particularly in the context of possible dapsone-induced hemolytic anemia. Methylene blue would be ineffective for the treatment of methemoglobinemia in a patient with G6PD deficiency2,3 because the drug requires a reduction to leukomethylene blue by NADPH,4 which is depleted in patients with G6PD deficiency. Furthermore, methylene blue — an oxidant — may paradoxically precipitate hemolysis in G6PD-deficient . . .
  • Understanding organizational learning in a healthcare organization during sudden and disruptive change.

    Feltbower, Ceri
    Purpose Complex and sudden change that healthcare organizations often have to respond to, such as during the recent pandemic, can create major disruptions and a prolonged state of alert. Although the impact of such crises can be predominantly negative, rapid adjustments during this time can also yield positive change that can support organizational response to crisis, if managed well. Using insights from organizational learning and organizational change theory, the aim of this study was to understand organizational learning during sudden change. Specifically, the authors aimed to understand the experiences and types of gains and losses in the processes of complex and disruptive change in one large healthcare organization in the UK. Design/methodology/approach Focus group data were used from 23 focus group discussions with 575 participants representing all functions and departments in one Healthcare Trust. Findings The participants revealed the rich gains, losses, and lessons experienced in response to sudden change that can promote organizational learning. Perceived losses are more likely to drive a desire to refreeze “back to normal” and perceived gains more likely to lead to an emphasis on embedding gains and changing to better. Therefore, on balance, the substantial, in number and variety, gains and learnings point to a learning organization. This is an essential attribute for responding to disruptive change successfully and facilitating organizational recovery in a post-pandemic world. Practical implications The findings highlight the importance of timely harnessing of the organizational learning emerging from crises and how this can inform a more resilient organization, as well as supporting sustainable organizational cross-learning. Originality/value By extending these insights on workers’ adaptation to sudden change, the findings can help to advance the science and practice of organizational learning and support organizational recovery, especially as they describe the new status in UK healthcare organizations.

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