Tuesday, 19 October 2021

WUTH publication: Assessment of anti-factor Xa activity in critically ill COVID-19 patients receiving three different anticoagulation regimens

Citation: SAGE open medicine. 2021 Oct 11, 9, 20503121211049931. eCollection 2021
Author: Mohammed A Hamad, Shereen A Dasuqi, Aamer Aleem, Rasha A Omran, Rakan M AlQahtani, Fahad A Alhammad, Abdulaziz H Alzeer 
Abstract: Introduction: Critically ill COVID-19 patients are at increased risk of thrombosis with an enhanced risk of bleeding. We aimed to explore the role of anti-factor Xa levels in optimizing the high-intensity anticoagulation's safety and efficacy and finding possible associations between D-dimer levels, cytokine storm markers, and COVID-19-induced coagulopathy or thrombophilia.
Methods: Retrospective cohort study conducted on 69 critically ill COVID-19 patients who received three regimens of higher intensity anticoagulation.
Results: Seventeen patients (24.6%) received high-dose enoxaparin prophylaxis, 29 patients (42%) received therapeutic doses of enoxaparin, and 23 patients (33.3%) were on therapeutic unfractionated heparin infusion. Fewer than one-third of the whole cohort (n = 22; 31.8%) achieved the target range of anti-factor Xa. The patients were divided into three subgroups based on anti-factor Xa target status within each anticoagulation regimen; when compared, the only association observed among them was for interleukin-6 levels, which were significantly higher in both the "above the expected range" and "below the expected range" groups compared with the "within the expected range" group (p = 0.009). Major bleeding episodes occurred in 14 (20.3%) patients and were non-significantly more frequent in the "below the expected anti-factor Xa range group" (p = 0.415). Seven patients (10.1%) developed thrombosis. The majority of patients had anti-factor Xa levels below the expected ranges (four patients, 57.1%).
Conclusion: Conventional anti-factor Xa ranges may not be appropriate as a predictive surrogate for bleeding in critically ill COVID-19. The clinical decision to initiate therapeutic anticoagulation preemptively may be individualized according to thrombosis and bleeding risks. Cytokine storm markers, namely, interleukin-6, may play a role in COVID-19-induced coagulopathy or thrombophilia.
Keywords: Anti-factor Xa; COVID-19; anticoagulation; bleeding; intensive care unit; thrombosis. 

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WUTH publication: An Unusual and Rare Metachronous Ipsilateral Ureteric Stump Metastasis Post Radical Nephrectomy

Citation: Cureus. 2021, 13(9), e17727. eCollection 2021 Sep
Author: Ramandeep Chalokia, Chinedum Anosike, Lee Robinson, Catherine Manson, Manal Kumar 
Abstract: We report a case of recurrence of chromophobe renal cell cancer in the ipsilateral ureteric stump eight years later after the primary tumor was excised successfully. Before this detection of the recurrence, the patient had presented with recurrent episodes of hematuria four years after the radical nephrectomy was performed and the investigations were inconclusive. Eventually, the lesion was detected on flexible cystoscopy in the area of the right ureteric orifice protruding in the bladder. Transurethral resection of the tumor surprisingly revealed a chromophobe renal cancer with similar features seen in the primary tumor specimen. The patient underwent robotic-assisted laparoscopic excision of the ureteric stump with a cuff of the bladder and has been recurrence-free for five years on regular surveillance scans. 

Keywords: chromophobe renal cell carcinoma; computed tomography; hematuria; metachronous; ureteric stump metastases. 

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Friday, 8 October 2021

WUTH publication: Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus

Citation: Obesity Surgery. 2021 Oct 6. Online ahead of print
Author: Mohammad Kermansaravi, Islam Omar, Kamal Mahawar, Shahab Shahabi, Ahmad Bashir, Ashraf Haddad, Alaa Abbass, Syed Imran Abbas, Mujjahid Abbas, Tarek Abouzeid, Faki Akin, Ebrahim Aghajani, Ali Aminian, Mohanad AlAnsari, Syed Tanseer Asghar, Ahmet Ziya Balta, Waleed Bukhari, Mohamad Hayssam Elfawal, Waleed Gado, Khaled Gawdat, Tikfu Gee, Bijan Ghavami, Ramen Goel, Mohammed AlHadad, Bader AlHadhrami, Mohammad AlHaifi, Ali AlHamdani, Ibrahim Hassan, Selim Jalil Illan, Atif Inam, Aiman Ismaeil, Yasser Kayyal, Khaleel Mohammad, Amir Ulhagh Khan, Mousa Khoursheed, Haris Khwaja, K S Kular, Laurent Abram Layani, Maazulhassan, Tarek Mahdy, Mumtaz Maher, Ebrahim Mansoor, Salman Mirza, Muhammad S Niam, Taryel Omarov, Abdolreza Pazouki, Aayed R Alqahtani, Mohamed Qassem, Masoud Rezvani, Karim Sabry, Safauldeen Salim, Asim Shabbir, Mehdi Skalli, Osama Taha, Mohammad Talebpour, Halit Eren Taskin, Mustafa Taskin, Tahir Yunus, Amir Hossein Davarpanah Jazi, Radwan Kassir, Abdelrahman Nimeri 
Abstract: Background: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS.
Methods: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus.
Results: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively.
Conclusion: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.
Keywords: Bariatric surgery; Calorie restriction; Consensus statement; Fasting; Metabolic surgery; Obesity; Ramadan. 

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Monday, 4 October 2021

WUTH publication: Communication skills training through 'role play' in an acute critical care course

Citation: The National Medical Journal of India. 2021, 34(2), 92-94 
Author: Akshay Kumar, Navdeep Sokhal, Richa Aggarwal, Keshav Goyal, Kapil Dev Soni, Rakesh Garg, Sanjeev Bhoi, Ashok Deorari, Ajay Sharma 
Abstract: Background: . Effective patient-doctor communication is a key component of patient-centred care, which is one of the six pillars of quality healthcare delivery. Structured and effective communication skills training for healthcare providers is the need of hour in medical education. We assessed the efficacy of role play and simulation in developing communication skills. 
Methods: . As a key component of an acute critical care course (ACCC), communication skills are taught using role play models and simulation. Live feedback is critical in learning during this course as per the principles of adult learning (andragogy). Quantitative and qualitative data were collected to assess the efficacy of ACCC. 
Results: . The 19th ACCC was introduced to interns at the All India Institute of Medical Sciences, New Delhi in December 2018. The teaching methodology and objective-oriented structured training in ACCC were much appreciated for training in human factors with emphasis on communication. A positive response was obtained from the candidates 3 weeks after they completed the course to assess whether interns are able to make use of this training in their day-to-day clinical practice amounting to a reliable evidence level of Kirkpatrick's 'return of investment'. 
Conclusion: . The use of 'role play' to teach communication skills is effective and superior to lecture-based teaching. Further structured and interactive programmes in communication skills training will improve patient care, relatives' satisfaction and the image of medical profession. 

Friday, 24 September 2021

WUTH publication: Is the use of augmented reality-assisted surgery beneficial in urological education? A systematic review

Citation: Current Urology. 2021, 15(3), 148-52. Epub 2021 Aug 17
Author: Ibraheem Alrishan Alzouebi, Sanad Saad, Tom Farmer, Sophie Green 
Abstract: Background: Google Glass is an optical head-mounted display that has been used in multiple medical and surgical settings to enhance delivery of education and training. This systematic review focuses solely on the use of this technology in urology operating theaters for the purpose of surgical education.
Materials and methods: A systematic search strategy was employed using EMBASE (1996-2019), Medline (1946-2019) and PubMed. Search terms included optical head-mounted displays, Google Glass and urological surgical training. Use of this technology in a nonurological setting, nonteaching sessions, case reports, reviews, editorials, abstracts, and articles not in English were rejected. Three studies were identified following the exclusion criteria.
Results: All 3 studies received positive feedback from trainees regarding this technology in relation to enhanced surgical education. In addition, in all studies the trainees felt the technology had a place for educational training in the future. All studies described disadvantages to the technology as well including battery life, comfort, and cost.
Conclusions: Studies describe a big potential for Google Glass and similar head-mounted devices for the role of surgical training in urology, however, larger studies looking at more varied operations can help reinforce this viewpoint.
Keywords: Augmented reality; Education; Google glass; Head mounted display; Surgical training; Urology.

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Thursday, 16 September 2021

WUTH publication: Establishing the phenotypic spectrum of ZTTK syndrome by analysis of 52 individuals with variants in SON

Citation: European Journal of Human Genetics. 2021 Sep 15. Online ahead of print
Author: Alexander J M Dingemans, Kim M G Truijen, Jung-Hyun Kim, Zahide Alaçam, Laurence Faivre, Kathleen M Collins, Erica H Gerkes, Mieke van Haelst, Ingrid M B H van de Laar, Kristin Lindstrom, Mathilde Nizon, James Pauling, Edyta Heropolitańska-Pliszka, Astrid S Plomp, Caroline Racine, Rani Sachdev, Margje Sinnema, Jon Skranes, Hermine E Veenstra-Knol, Eline A Verberne, Anneke T Vulto-van Silfhout, Marlon E F Wilsterman, Eun-Young Erin Ahn, Bert B A de Vries, Lisenka E L M Vissers 
Abstract: Zhu-Tokita-Takenouchi-Kim (ZTTK) syndrome, an intellectual disability syndrome first described in 2016, is caused by heterozygous loss-of-function variants in SON. Its encoded protein promotes pre-mRNA splicing of many genes essential for development. Whereas individual phenotypic traits have previously been linked to erroneous splicing of SON target genes, the phenotypic spectrum and the pathogenicity of missense variants have not been further evaluated. We present the phenotypic abnormalities in 52 individuals, including 17 individuals who have not been reported before. In total, loss-of-function variants were detected in 49 individuals (de novo in 47, inheritance unknown in 2), and in 3, a missense variant was observed (2 de novo, 1 inheritance unknown). Phenotypic abnormalities, systematically collected and analyzed in Human Phenotype Ontology, were found in all organ systems. Significant inter-individual phenotypic variability was observed, even in individuals with the same recurrent variant (n = 13). SON haploinsufficiency was previously shown to lead to downregulation of downstream genes, contributing to specific phenotypic features. Similar functional analysis for one missense variant, however, suggests a different mechanism than for heterozygous loss-of-function. Although small in numbers and while pathogenicity of these variants is not certain, these data allow for speculation whether de novo missense variants cause ZTTK syndrome via another mechanism, or a separate overlapping syndrome. In conclusion, heterozygous loss-of-function variants in SON define a recognizable syndrome, ZTTK, associated with a broad, severe phenotypic spectrum, characterized by a large inter-individual variability. These observations provide essential information for affected individuals, parents, and healthcare professionals to ensure appropriate clinical management. 

Tuesday, 7 September 2021

WUTH publication: Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures

Citation: The International Journal of Risk & Safety in Medicine. 2021 Aug 23. Online ahead of print.  
Author: Ahmed T Hafez, Islam Omar, Balaji Purushothaman, Yusuf Michla, Kamal Mahawar 
Abstract: Background: Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties.
Objective: The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England.
Method: We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes.
Results: We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest "wrong implants" (n = 94; 45.63% and n = 91; 44.17% respectively). There were 197 "Wrong-site surgery" incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. There were 18 (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each.
Conclusion: We identified 47 different themes of NE specific to orthopaedic surgery. Awareness of these themes would help in their prevention. Site marking can be challenging in the presence of cast and on operating on the digits and spine. Addition of a Real-time intra-operative implant scan to the National Joint Registry can avoid wrong implant selection while Fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.
Keywords: Orthopaedic surgery; medical claims; medical errors; never events; patient safety. 

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Thursday, 2 September 2021

WUTH publication: Prevalence of Falls in Patients Presenting to an Ophthalmic Outpatients Department- A Surveillance Study

Citation: The Biritsh and Irish Orthoptic Journal. 2021, 17(1), 134-41
Author: Jignasa Mehta, Karen Knowles, Erin Wilson 
Abstract: Introduction: Approximately 1 in 3 adults aged 65 and over experience a fall each year. Poor vision is an identified risk factor. The aim of this cross-sectional public health surveillance audit was to determine the prevalence of falls experienced in the previous 12 months by adult patients presenting to an ophthalmology department.
Methods: A short questionnaire was given to consecutive patients attending an ophthalmology department at two trusts in the North West to determine whether they had experienced a fall in the previous 12 months, whether they had suffered a fracture, their eye condition and the type of glasses worn.
Results: Data was collected for 585 patients (mean age: 69 years, SD: 13.8). Falls in the previous 12 months were reported by 96 (16.4%) patients, and a significant proportion of these were aged 60 years and over (82%, p < 0.0001, one-sample binomial test). Half of the respondents were unaware of their eye health condition for which they were attending the department. Glaucoma was the most prevalent condition in those who had experienced a fall (43%). A significant proportion of the individuals who reported a fall wore single-vision glasses (43%, p < 0.0001, one-sample chi-square test).
Conclusion: In an ophthalmology outpatient department, the proportion of older adults who experienced a fall in the previous 12 months was lower than the reported prevalence in the general population. There is a need for health literacy to educate patients about their eye condition, the potential effects on their visual function and, consequently, managing falls risk.
Keywords: Falls; Ophthalmic conditions; Vision.

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Tuesday, 31 August 2021

WUTH publication: Targeted atrial fibrillation (AF) detection in COVID-19 vaccination clinics

Citation: European Heart Journal. 2021 Aug 27, qcab061. Online ahead of print.
Author: Gary A Ford, David Hargroves, Deb Lowe, Nicholas Hicks, Gregory Y H Lip, Guy Rooney, Hannah Oatley 

Thursday, 19 August 2021

WUTH publication: The prevalence of oropharyngeal squamous cell carcinoma in patients admitted with symptoms of peritonsillar abscess or cellulitis: a retrospective multicentre study

Citation: Clinical Otolaryngology. 2021 Aug 18
Author: Andrew S Lau, Kristijonas Milinis, Mila Roode, Stephen P Williams, Colette Cook, Hussein Walijee, Matthew Zammit, Richard Siau, Hannah Emerson, Rosanna Wright, Thomas Hampton 
Abstract: Objectives: Anecdotal evidence suggests that oropharyngeal squamous cell carcinoma (OPSCC) should be suspected in patients presenting with symptoms of peritonsillar abscess (PTA) or cellulitis (PTC). The aim of this study was to estimate the prevalence of OPSCC in patients presenting with symptoms of PTA/PTC. 
Method, setting and participants: We retrospectively identified all adults with a coded diagnosis of PTA or PTC who presented between 2012-2016 inclusive, across six ENT units in Merseyside. Records were compared to that of the centralised regional head and neck cancer database. The clinical records of a subset of patients were reviewed for the purposes of data validation. 
Results: A total of 1975 patients with PTA/PTC were identified. Three patients were subsequently diagnosed with OPSCC. None of the three actually had an objective underlying diagnosis of PTA/PTC on the same side. The prevalence of OPSCC in patients admitted with symptoms of PTA/PTC was 0.15%, or approximately 1:650 admissions. The records of 510 patients who presented over a one-year period (2016) were reviewed in even greater detail. There were 298 patients with PTA (59.4%), 151 with PTC (29.1%) and 61 had an alternative diagnosis (11.9%). High risk features (age ≥40, tonsillar asymmetry or tonsillar lesion) were present in 106 patients (24%). Urgent follow up was expedited for 77 patients (73%). 
Conclusion: This study estimates the risk of OPSCC in patients with peritonsillar symptoms. The prevalence is low, even in a region with a relatively heavy disease burden. Clinicians should, however, retain a high level of suspicion in patients with persistent symptoms. 
Keywords: Peritonsillar abscess; oropharyngeal; peritonsillar cellulitis; risk analysis; squamous cell carcinoma; tonsil.