Recent Submissions

  • Battling a rarity: A case of kindler syndrome from a developing country

    Zehra, Tasheen (SAGE Open Medical Case Reports, 2024-02)
    Kindler syndrome, a rare branching of inherited epidermolysis bullosa, is an autosomal recessive condition characterized by the eruption of painful blisters and hemorrhagic vesicles in infancy. With age, the eruption of blisters are seen to decline leaving behind fibrosed, scarred, and paper-like skin, and poikilodermic features. To this date, about 400 cases have been reported worldwide for this disease only. This report aims to discuss the presence and diagnosis of Kindler Syndrome using limited resources in developing countries. It describes the presence of clinically diagnosed Kindler Syndrome in a young male of Pakistani descent that started in infancy and presented with a variety of clinical features over the years. Even though genetic analysis remains the gold standard diagnostic for Kindler syndrome, for third world countries, relying on Diagnostic clinical criteria remains helpful in establishing a diagnosis of Kindler syndrome for further management, as seen in our patient.
  • Management of dyslipidaemia in patients with coronary heart disease: Results from the ESC-EORP EUROASPIRE V survey in 27 countries

    Jan, A; Riaz, A; Gill, M; Sewell, T A (Atherosclerosis, 2019-06)
    Background and aims: One of the objectives of the ESC-EORP EUROASPIRE V survey is to determine how well European guidelines on the management of dyslipidaemias are implemented in coronary patients. Methods: Standardized methods were used by trained technicians to collect information on 7824 patients from 130 centers in 27 countries, from the medical records and at a visit at least 6 months after hospitalization for a coronary event. All lipid measurements were performed in one central laboratory. Patients were divided into three groups: on high-intensity LDL-C-lowering-drug therapy (LLT), on low or moderate-intensity LLT and on no LLT. Results: At the time of the visit, almost half of the patients were on a high-intensity LLT. Between hospital discharge and the visit, LLT had been reduced in intensity or interrupted in 20.8% of the patients and had been started or increased in intensity in 11.7%. In those who had interrupted LLT or had reduced the intensity, intolerance to LLT and the advice of their physician were reported as the reason why in 15.8 and 36.8% of the cases, respectively. LDL-C control was better in those on a high-intensity LLT compared to those on low or moderate intensity LLT. LDL-C control was better in men than women and in patients with self-reported diabetes. Conclusions: The results of the EUROASPIRE V survey show that most coronary patients have a less than optimal management of LDL-C. More professional strategies are needed, aiming at lifestyle changes and LLT adapted to the need of the individual patient.
  • The association of painful and non-painful morbidities with frailty: a cross sectional analysis of a cohort of community dwelling older people in England.

    Walsh, David A (BMC Geriatrics, 2024-02)
    Introduction: The association between chronic pain and frailty might indicate that pain is an independent driver of frailty but might alternatively be explained by inclusion within frailty identification tools of morbidities that commonly lead to chronic pain. This research examines the extent to which the association of pain with frailty might be attributed to morbidities. Methods: A cross-sectional analysis of older people in a UK cohort with or at risk of musculoskeletal problems or frailty (Investigating Musculoskeletal Health and Wellbeing study), used multivariable logistic regression and Z-tests to assess the degrees of associations of pain (McGill Pain Rating Index), and painful and non-painful morbidity counts with frailty (modified FRAIL questionnaire). Results: Data were from 2,185 participants, 56% female, median age 73 (range 60 to 96) years. 430 (20%) participants were classified as frail. In a fully adjusted standardised model, pain (aOR 2.07 (95%CI 1.83 to 2.33) and 'any' morbidity aOR (1.74 (95%CI 1.54 to 1.97) were both significantly associated with frailty. When morbidity was subclassified as painful or non-painful, painful (aOR 1.48 (95%CI 1.30 to 1.68) and non-painful (aOR1.39 (95%CI 1.24 to 1.56)) morbidities each were associated with frailty, as also was pain (aOR 2.07 (95%CI 1.83 to 2.34, p < 0.001). Conclusions: Pain is associated with frailty, over and above any effect of painful and non-painful morbidities. This forms the justification for future research which focuses on pain management in the identification, prevention, and treatment of frailty.
  • Multidisciplinary team approach in breast cancer care: Benefits and challenges

    Blackwood, Owain (Indian Journal of Pathology & Microbiology, 2020-02)
    The multidisciplinary team approach has been employed internationally for decades, as an attempt to bring collaborative decision-making and concentrate clinical experience from multiple specialties on single patient cases in a systematic fashion. Adoption is not yet worldwide, but is increasing. The role of the histopathologist is central, providing vital information and context to clinical diagnosis and management. Our review summarizes some of the most relevant research on the topic of MDT usage and efficacy in relation to breast cancer, attempting to draw together its advantages and challenges. It is hoped that this review will make a contribution to the current international literature regarding multidisciplinary approaches in breast cancer care. Competing Interests: None
  • Advancements in Gene Therapy approaches for Atrial Fibrillation: Targeted delivery, Mechanistic Insights and Future Prospects

    Toru, Hamza Khan (Current Problems in Cardiology, 2024-04)
    Atrial fibrillation (AF) remains a complex and challenging arrhythmia to treat, necessitating innovative therapeutic strategies. This review explores the evolving landscape of gene therapy for AF, focusing on targeted delivery methods, mechanistic insights, and future prospects. Direct myocardial injection, reversible electroporation, and gene painting techniques are discussed as effective means of delivering therapeutic genes, emphasizing their potential to modulate both structural and electrical aspects of the AF substrate. The importance of identifying precise targets for gene therapy, particularly in the context of AF-associated genetic, structural, and electrical abnormalities, is highlighted. Current studies employing animal models, such as mice and large animals, provide valuable insights into the efficacy and limitations of gene therapy approaches. The significance of imaging methods for detecting atrial fibrosis and guiding targeted gene delivery is underscored. Activation mapping techniques offer a nuanced understanding of AF-specific mechanisms, enabling tailored gene therapy interventions. Future prospects include the integration of advanced imaging, activation mapping, and percutaneous catheter-based techniques to refine transendocardial gene delivery, with potential applications in both ventricular and atrial contexts. As gene therapy for AF progresses, bridging the translational gap between preclinical models and clinical applications is imperative for the successful implementation of these promising approaches.
  • Monitoring thyroid function during amiodarone use.

    Sharma, Priya; Sheikh, Riyad; Siribaddana, Nipuna; Sathyanarayanan, Abilash; Fernando, Devaka; Muralheedharan, Vakkat (British Journal of Hospital Medicine, 2024-01)
    Amiodarone is an antiarrhythmic drug used to treat cardiac tachyarrhythmias. It has many adverse effects, with thyroid dysfunction one of the most notable. Through various mechanisms, both thyrotoxicosis and hypothyroidism can occur secondary to amiodarone therapy. There are two types of amiodarone-induced thyrotoxicosis: type 1 occurs in those with pre-existing thyroid disease and is treated with thionamide, whereas type 2 occurs in those without and is treated with glucocorticoids. Patients with amiodarone-induced hypothyroidism may be given levothyroxine to replace thyroid hormone, but in some cases, the appropriate management may be cessation of amiodarone.
  • Beyond Symptoms: Unlocking the Potential of Coronary Calcium Scoring in the Prevention and Treatment of Coronary Artery Disease

    Mahmoud, Hassan Ali Ahmed
    Coronary Artery Disease (CAD) represents a persistent global health menace, particularly prevalent in Eastern European nations. Often asymptomatic until its advanced stages, CAD can precipitate life-threatening events like myocardial infarction or stroke. While conventional risk factors provide some insight into CAD risk, their predictive accuracy is suboptimal. Amidst this, Coronary Calcium Scoring (CCS), facilitated by non-invasive computed tomography (CT), emerges as a superior diagnostic modality. By quantifying calcium deposits in coronary arteries, CCS serves as a robust indicator of atherosclerotic burden, thus refining risk stratification and guiding therapeutic interventions. Despite certain limitations, CCS stands as an instrumental tool in CAD management and in thwarting adverse cardiovascular incidents. This review delves into the pivotal role of CCS in CAD diagnosis and treatment, elucidates the involvement of calcium in atherosclerotic plaque formation, and outlines the principles and indications of utilizing CCS for predicting major cardiovascular events.

    Pang, YL; Bhardwaj, K; Nataraju, K; Black, M; Na, A (Thorax, 2023-11)
    Introduction Acute exacerbations of interstitial lung disease (AE-ILD) often lead to hospitalisation but have limited evidence-based treatment options. Patient-specific outcomes from AE-ILD are difficult to predict, making decisions regarding prioritisation for specialist palliative care input challenging. The PCR (PaO­2/FiO2 ratio, C-reactive protein (CRP), and CT chest pattern) score has been shown to predict mortality risk in AE-idiopathic pulmonary fibrosis (AE-IPF),1 however this has not been assessed in AEs of non-IPF ILDs. Aims Describe a real-world patient population with AE-ILD and establish the relationship between PCR score and mortality. Methods Clinical records of ILD patients admitted to six NHS trusts over one year were reviewed. Patients with a deterioration in respiratory symptoms not explained by heart failure or pulmonary embolism were included. Demographic, treatment, investigation, and mortality data were collected. Participating hospitals provided information on local services. The PCR score, where one point is gained for each of CRP >55 mg/l, PaO2/FiO2 ratio <250, and diffuse ground glass changes on CT chest, was calculated. Results 443 patients with 602 admissions were included. IPF was the commonest ILD (29.8%), and other ILD diagnoses were represented (table 1). Antibiotics and steroids were prescribed in 82.9% and 66.9% of admissions, respectively. Just one participating hospital had a protocol for the management of AE-ILD, which was specific to AE-IPF. Mortality after AE-ILD was high, with 14% in-hospital, 21.7% 30-day, 39.8% 6-month, and 53.9% 12-month mortality. Higher PCR scores were associated with increased in-hospital (p=0.03), 30-day (p=0.01), and 6-month mortality (p=0.003), with a trend towards increased 12-month mortality (p=0.07) (88 index admissions, p for trend). No specialist palliative care input was recorded in 29.3% of admissions with in-hospital mortality, and 49.2% of admissions where death occurred within 30 days. This could be explained by hetereogeneity in specialist palliative care availability, particularly out-of-hours (table 1). VIEW INLINE VIEW POPUP Abstract S7 Table 1 Patient and participating hospital characteristics Conclusions AE-ILDs are associated with significant mortality, limited standardised treatment and heterogeneous palliative care provision. Higher PCR scores were associated with increased mortality in AE-ILD and may have utility when prioritising patients for palliative care input and advanced care planning.
  • The STAR care pathway for patients with chronic pain after total knee replacement: four-year follow-up of a randomised controlled trial

    Walsh, David A (BMC Musculoskeletal Disorders, 2023-12)
    Background: The Support and Treatment After Replacement (STAR) care pathway is a clinically important and cost-effective intervention found to improve pain outcomes over one year for people with chronic pain three months after total knee replacement (TKR). We followed up STAR trial participants to evaluate the longer-term clinical- and cost-effectiveness of this care pathway. Methods: Participants who remained enrolled on the trial at one year were contacted by post at a median of four years after randomisation and invited to complete a questionnaire comprising the same outcomes collected during the trial. We captured pain (co-primary outcome using the Brief Pain Inventory (BPI) pain severity and interference scales; scored 0-10, best to worst), function, neuropathic characteristics, emotional aspects of pain, health-related quality of life, and satisfaction. Electronic hospital informatics data on hospital resource use for the period of one to four years post-randomisation were collected from participating hospital sites. The economic evaluation took an National Health Service (NHS) secondary care perspective, with a four-year time horizon. Results: Overall, 226/337 (67%) of participants returned completed follow-up questionnaires, yielding adjusted between-group differences in BPI means of -0.42 (95% confidence interval, CI (-1.07, 0.23); p = 0.20) for pain severity and - 0.64 (95% CI -1.41, 0.12); p = 0.10) for pain interference. Analysis using a multiple imputed data set (n = 337) showed an incremental net monetary benefit in favour of the STAR care pathway of £3,525 (95% CI -£990 to £8,039) at a £20,000/QALY willingness-to-pay threshold, leading to a probability that the intervention was cost-effective of 0.94. Conclusions: The magnitude of the longer-term benefits of the STAR care pathway are uncertain due to attrition of trial participants; however, there is a suggestion of some degree of sustained clinical benefit at four years. The care pathway remained cost-effective at four years.
  • Osteoarthritis pain phenotypes: How best to cut the cake?

    Walsh, David A
    Heterogeneity within clinical populations raises challenges and opportunities for improving treatment. Osteoarthritis (OA) treatments often adhere to the ‘one size fits all’ utilitarian approach, suggesting that everyone will gain the greatest benefit from the same treatment. However, OA is a heterogeneous condition, with multiple pathologies driving different outcomes. No single outcome is necessarily equally important for all people. Increasingly recognized as a disease of the whole joint, OA affects articular cartilage, subchondral bone, and synovium, resulting in a clinical syndrome in which pain is predominant.
  • Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY): protocol of a prospective, multicentre, observational study.

    Downer, Nicola (BMJ Open Respiratory Research, 2023-11)
    Introduction: Recurrence rate following radical therapy for lung cancer remains high, potentially reflecting occult metastatic disease, and better staging tools are required. Minimal pleural effusion (mini-PE) is associated with particularly high recurrence risk and is defined as an ipsilateral pleural collection (<1/3 hemithorax on chest radiograph), which is either too small to safely aspirate fluid for cytology using a needle, or from which fluid cytology is negative. Thoracoscopy (local anaesthetic thoracoscopy (LAT) or video-assisted thoracoscopic surgery (VATS)) is the gold-standard diagnostic test for pleural malignancy in patients with larger symptomatic effusions. Staging by Thoracoscopy in potentially radically treatable Lung Cancer associated with Minimal Pleural Effusion (STRATIFY) will prospectively evaluate thoracoscopic staging in lung cancer associated-mini-PE for the first time. Methods and analysis: STRATIFY is a prospective multicentre observational study. Recruitment opened in January 2020. The primary objective is to determine the prevalence of detectable occult pleural metastases (OPM). Secondary objectives include assessment of technical feasibility and safety, and the impact of thoracoscopy results on treatment plans, overall survival and recurrence free survival. Inclusion criteria are (1) suspected/confirmed stages I-III lung cancer, (2) mini-PE, (3) Performance Status 0-2 (4), radical treatment feasible if OPM excluded, (5) ≥16 years old and (6) informed consent. Exclusion criteria are any metastatic disease or contraindication to the chosen thoracoscopy method (LAT/VATS). All patients have LAT or VATS within 7 (±5) days of registration, with results returned to lung cancer teams for treatment planning. Following an interim analysis, the sample size was reduced from 96 to 50, based on a lower-than-expected OPM rate. An MRI substudy was removed in November 2022 due to pandemic-related site setup/recruitment delays. These also necessitated a no-cost recruitment extension until October 2023.
  • 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.

    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.
  • 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.
  • 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 . . .

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