WUTH publication: The treatment of Penile Carcinoma-In-Situ within a UK supra-regional network

Citation: BJU International. 2014 Jul 25
Author: Lucky M, Murthy K, Rogers B, Jones S, Lau M, Sangar V, Parr N
Abstract: OBJECTIVES: To review outcomes of the treatment of carcinoma in situ of the penis at a large supra-regional penile cancer network, where centralisation has permitted greater experience with treatment outcomes, and suggest treatment strategies. MATERIALS AND METHODS: The network penile cancer database which details presentation, treatment and complications was analysed from 2003-10, identifying patients with CIS, with minimum follow up of 2 years, looking at treatments administered and outcomes. RESULTS: Fifty-seven patients with mean age 61yr (range:34-91yr) were identified. Eighteen were treated by circumcision (CIRC) only, 20 by CIRC and local excision (LE) and 19 by CIRC and 5-flurouracil (5FU). Mean follow up was 3.5yr (2-8). Of those treated by CIRC none subsequently developed CIS on the glans. For those who underwent CIRC+LE, 5/20 developed recurrence requiring further treatment. Of those treated by CIRC+5FU, 14/19 (73.7%) completely responded (CR). Of incomplete responders (IR, n=5), 2 showed focal invasive malignancy at repeat biopsy. One IR underwent glansectomy and 4 grafting. No CR relapsed. Complications of 5FU included significant inflammatory response in 7 (36.8%), with 2 requiring hospital admission and 1 neo-phimosis (5.3%). CONCLUSION: This study suggests that patients undergoing circumcision for isolated CIS and complete responders to 5FU may require only short term follow up, as recurrence is unlikely, whereas longer follow up is required for all other patients. However numbers in this study are small and larger studies are needed to support this. Incomplete response to 5FU dictates immediate re-biopsy as it carries a significant chance of previously undetected invasive disease.

This article is protected by copyright. All rights reserved. KEYWORDS: Penile cancer; carcinoma-in-situ; follow-up

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Healthcare excellence gets boost from free research journal trial

NHS Staff now have access to over 2,500 research and medical journals and 40,000 e-books as part of a country wide free trial. The trial supports the NHS focused recommendations of the government-commissioned Finch report into research article availability.

“A year-long pilot will allow staff working across the NHS in England, Scotland, Wales and Northern Ireland free trial access to some of the most respected medical and scientific journals so they can read for themselves the latest trials and research. This is good news for evidence-based healthcare and will give healthcare professionals the opportunity to weigh up the latest developments in the study of disease.”

 [Source JISC news:  http://www.jisc.ac.uk/news/healthcare-excellence-gets-boost-from-free-research-journal-trial-01-may-2014 ]

The titles can now be found on the NICE Evidence A-Z journals list and as embedded links from search results in the NICE Healthcare databases. Please note; to access content provided by Elsevier, Nature Publishing Group and Springer you must log in with a NHS Open Athens account. Content from AAAS, Annual Reviews, Karger, IOP Publishing, Oxford University Press (OUP), and Royal Society of Chemistry (RSC) is via IP range and can only be accessed via a NHS networked computer.

RSC Publishing has also decided to set up trial access to the Merck Index (access via IP address). The URL for The Merck Index homepage is https://www.rsc.org/merck-index.

·         Springer resources will be available until 31^st October 2013

·         Annual Reviews and OUP until 31^st December 2013

·         Elsevier, Nature, AAAS, Karger, IOP publishing and RSC until 31^st March 2015.

For more information about the titles available or how to create an NHS Open Athens account, contact the Trust Library and Knowledge Service on ext. 8610 or email mcardle.library@nhs.net 

WUTH publication: Two-week referrals for suspected head and neck cancer: two cycles of audit, 10 years apart, in a district general hospital

Citation: The Journal of Laryngology and Otology. 2014 Jul 22:1-5. [epub ahead of print]
Author: Williams C, Byrne R, Holden D, Sherman I, Srinivasan VR
Abstract: Objective: To analyse trends in two-week rule referrals for head and neck cancer over 10 years. Method: Data from two-week referrals received by the Wirral University Hospital NHS Trust between 1 January and 30 June 2012 were compared with similar data from 2002. Results: A total of 357 referrals were received during the 6-month audit period, compared with 149 during the whole of 2002. Cancer pick-up rates were 9 per cent and 5 per cent in the first and second cycles, respectively. Conclusion: The annual number of two-week referrals made to our department increased by over 450 per cent in 10 years, but the resulting cancer pick-up rate fell by nearly 50 per cent. Whilst cancer patients need to be seen quickly, the current system is inefficient in parts. Modifications to the treatment pathway should be considered to improve patient care quality and reduce pressure on ENT departments.

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WUTH publication: PC.71 Formal chatter makes them "Fatter"! How Introducing a Weekly Nutrition Ward Round (WR) Improves Calorie Intake and Weight Gain in Very Low Birth Weight (VLBW) Infants.

Citation: Archives of disease in childhood. Fetal and neonatal edition. 2014, 99(Suppl 1), A60
Author: Guratsky V, Kalamanathan A, Nielsen M, Eyton-Chong C, Holt S
Abstract: A retrospective audit looking at nutrition, feeding and weight gain in VLBW infants has shown that the introduction of a weekly nutrition WR has increased calorie intake and consequently improved weight gain. Data from 50 VLBW infants was audited against current parenteral and enteral feeding policies on a tertiary neonatal intensive care unit (NICU). Midway through the audit, a weekly nutrition WR (the intervention) was introduced and the pre and post-intervention groups compared. The weekly nutrition WR took place at a separate time to the daily WR. Infants were discussed at the cot-side by a multi-disciplinary team. The WR was led by a neonatal consultant or senior paediatric trainee and attended by a paediatric dietician and members of senior neonatal nursing staff. Other members of medical and nursing staff would also contribute. In the cohort of infants audited after the implementation of the nutrition WR, breast milk fortifier was added at an earlier time point to the milk of infants that had achieved full enteral feeds. Higher calorie intakes (closer to the target of ≥ 110 kCal/Kg/day) were achieved earlier (P < 0.05) after the nutrition WR started. This was associated with improved weight gain, including exceeding birth weight earlier.

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WUTH publication: PC.111 Survey of Sildenafil Use for Treatment of Persistent Pulmonary Hypertension (PPHN) in Tertiary Neonatal Intensive Care Units (NICU) in England and Wales.

Citation: Archives of disease in childhood. Fetal and neonatal edition. 2014, 99(Suppl 1), A74-6
Author: Murphy A, Turnbull C, Nesbitt V, Guratski V, Kamalanathan A
Abstract: INTRODUCTION: Sildenafil is increasingly used to treat PPHN secondary to chronic lung disease in neonates. Severity of PPHN has been linked to increased mortality at two years.(1) There is no national guideline advising clinicians on dosage or weaning schedules for use of Sildenafil in neonates. METHODS: A telephone survey of tertiary level neonatal units in England and Wales (n = 48) was conducted in December 2013 and January 2014. Neonatal consultants were contacted to ensure robust data. In the event a consultant was not available, staffs employed by the unit for at least 24 months (Specialist registrar, Advanced Neonatal Nurse Practitioner (ANNP) or nursing sister) were surveyed. RESULTS: The response rate was 90% (n = 43/48). Sildenafil was used frequently (>5 patients per year) in 12% (n = 5), infrequently, (1-5 patients per year) in 23% (n = 10) and rarely (<1 per year) in 51% (n = 22). Majority of units had used Sildenafil within the last 6 months 49% (n = 21). 60% (n = 26) used Sildenafil only after discussion with Cardiologists, 35% (n = 15) commenced Sildenafil after discussion with neonatal colleagues. No unit had fixed indications for commencement of Sildenafil. Amongst those with a guideline (n = 6); the initial dose varied between 250-300 mcg/kg commenced between 4 and 12 hourly. Guidelines on two units were unclear on rate of increase of Sildenafil. No guideline stipulated weaning/stopping practice. CONCLUSION: Sildenafil is infrequently used in NICU, however only 6 units did not use Sildenafil in the past 24 months. Variability in practice amongst units mirrors the need for a national consensus guideline.

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WUTH publication: PC.121 The Different Presentations and Management of Congenital Cytomegalovirus Infection - A Case Series.

Citation: Archives of Disease in Childhood. Fetal and neonatal edition. 2014, 99(Suppl 1), A78
Author: Murphy A, Nesbitt V, Babarao S, Kamalnathan A
Abstract: INTRODUCTION: Congenital Cytomegalovirus (CCMV) infection is the most common intrauterine infection. We present three cases of babies and compare their symptoms and subsequent management. Treatment of CMV is with antivirals. The aim is to avoid end-organ damage. We highlight the difficulties in recognising and managing CCMV which is refactory to first line treatment. We identify the issues of differentiating between CCMV complications and side-effects of antivirals. RESULTS: All babies were diagnosed postnatally, from day 2-42 of life. One baby was diagnosed due to symmetrical intrauterine growth retardation, another following tests for petechiae/thrombocytopenia. The last baby was diagnosed following a clinical decline; thought to be infection. Babies were treated with platelet transfusions (average of 1 unit/week). All three babies received an eight week treatment of ganciclovir; with viral loads subsequently falling. One of the babies deteriorated a fortnight after the end of ganciclovir with increased viral loads. Second-line antiviral (Foscarnet) was commenced. Signs of bone marrow suppression were found during treatment, it was unclear whether this was secondary to resurgent CCMV or Foscarnet. End organ damage was evident in two of the three patients; both have a 'moderate' degree of unilateral hearing loss, one of these two has changes on MRI scan consistent with polymicrogyria. CONCLUSION: CCMV infection has a varied presentation and can be resistant to first line antiviral agents. Little literature exists in use of Foscarnet in the neonatal cohort and difficulties in identifying causes of complications makes management difficult.

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WUTH publication: PTH-006 Current Performance Of Ercp In The Clearance Of Bile Duct Stones In Uk Centres - Working Towards Robust Key Performance Indicators.

Citation: Gut. 2014, 63(Suppl 1), A210
Author: Wadsworth C, Dwyer L, Paranandi B, Philips N, Mahmood S, Krishnan B, Taylor T, Seward E, Wilson P, Singhal A, Williams E, Westaby D, Webster G, Sturgess R, UK Multicentre ERCP Study Group
Abstract: INTRODUCTION: Choledocholithiasis is the commonest indication for endoscopic retrograde cholangiopancreatography (ERCP). ERCP carries substantial risk of complication when compared to other endoscopic modalities. The identification of key performance indicators (KPIs) in colonoscopy practice and implementation of related standards has driven quality assurance in the UK and elsewhere. The failure to establish similar contemporary, meaningful and measurable KPIs in ERCP has hampered the development of national standards. We aimed to quantify current performance in a potential new endoscopic KPI: the complete clearance of CBD stones at first ERCP. METHODS: Seven centres participated - four secondary and three tertiary HPB units. All patients undergoing first ERCP for confirmed or suspected choledocholithiasis over a twelve month period were included and data were analysed on an intention to treat basis. The primary endpoint was complete clearance of bile duct stones. Failure to clear stones was defined as i) persisting stones reported ii) placement of biliary endoprosthesis, even if considered precautionary. Secondary endpoints were CBD cannulation, successful biliary decompression and complications. Outcomes were analysed by unit and by consultant clinician performing the procedure. RESULTS: 1178 patients were included in the study. 20 consultant endoscopists carried out or supervised the procedures. Overall, deep biliary cannulation was achieved in 1074/1178 (91%, range for seven units 82-96%). Complete bile duct clearance at first ERCP was achieved in 861/1178 (73%, 65-81%). gutjnl;63/Suppl_1/A210-a/T1T1T1 Abstract PTH-006 Table 1 Unit 1(o) GSD cases (n) Cannulated (n) Cannulated (%) Complete (n) Complete (%) T 154 135 88 100 65 U 323 308 95 263 81 V 129 115 89 98 76 W 211 202 96 149 71 X 134 110 82 89 66 Y 133 118 89 95 71 Z 94 86 92 67 71 Total 1178 1074 91 861 73 CONCLUSION: We investigated the outcome of 1178 ERCP procedures, representing real-life practice in the UK. Duct clearance was possible at first ERCP in almost three quarters of patients. There were significant differences in performance between units and individual operators. The reasons for this are not fully elucidated. The primary endpoint of this study has strengths as a potential KPI. It is clearly defined, measurable on an intention to treat basis and is strongly focused on patient outcome. In addition, it quantifies performance in the commonest indication for ERCP, stone extraction, which is undertaken in all ERCP units. DISCLOSURE OF INTEREST: None Declared.

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WUTH publication: PTH-058 A Centres Experience Of Setting Up A New Bowel Cancer Screening Centre And Preparing For Bowel Scope.

Citation: Gut. 2014, 63(Suppl 1), A234
Author: Taggart N, Batterton J, Mcguinness D, Fitzgerald G, Morton B, Otoole P, Subrumanian S, Haslam N, Oates B, Sarkar S
Abstract: INTRODUCTION: The population served by the Merseyside and North Cheshire Programme was 1.7 million based at University Hospitals Aintree was asked to split because of the imminent introduction of Bowel scope. Authorisation for forming of new centre at the Royal Liverpool Hospital (RLH) by central office was granted in the summer 2013 and implementation was required by February 2014. METHODS: The Liverpool and Wirral Bowel screening centre (LandW BSC) was formed with a 45% share of the in the population. The service was designed with the aim to run the FOBT service and then introduce the Bowel Scope (BS) as second wave for the serving population of 802,000. RESULTS: Workforce: The current workforce at the Royal Liverpool (RLH) included 4x BCSP screening colonoscopists of which one became Clinical Director of the centre. The endoscopy service manager supportive for the nursing and operational aspects and the Endoscopy Admin manager supported the administration aspect. There was full managerial backing by the directorate manager. In addition, programme manager, Lead SSP, 3x New SSPs, 4x admin staff were appointed. Collaborations and Engagement: The logistical issues and training of the new SSPs and Admin staff was heavily facilitated by the current Merseyside and Cheshire programme. Engagement and support also included the National Team, CCG, Local QA team and Screening and Immunisation Regional Team. Implementation group representation from all parties. A business was supported by the trust board. The strong collaboration was made with the team from Arrowe Park Hospital (APH). BowelScope: Stategically, new urology centre had spare capacity for 8 lists to include some evenings and weekends sessions at Broadgreen Hospital was identified as good access site for Liverpool. For the Wirral site, APH was identified as the site to deliver bowelscope and for the population would require 4 lists. Eight endoscopists were further identified (6 nurse endoscopists, 1 Fellow and 1 radiographer-also programme manager) as needing accreditation for bowelscope. All mentees were assigned a mentor (3 BCSP colonoscopists) and put on the pre-accreditation course at RLH. Exams were planned over 3, UKdays for all the endoscopists in April 2014. Prior to the exam, all endoscopists, had 2 flexi lists booked with their mentors at RLH as well as ad-hoc sessions to help with MCQ. Outcome: The LandW BCSC got approval by national office in Jan 2014 with a go live date in Feb to take over FOBT service. Bowelscope is planned for September 2014. CONCLUSION: The setting up of a new centre in such a short period of time was extremely challenging but successful due to good team work, planning and collaboration. DISCLOSURE OF INTEREST: None Declared.

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WUTH publication: PTU-012 Development Of Standards For Delivery Of Training In Gastroenterology: Defining Quality And Providing Accurate Assessment Of Units.

Citation: Gut. 2014, 63(Suppl 1), A42
Author: Britton E, Sarkar S, Flanagan P
Abstract: INTRODUCTION: Training in Gastroenterology is currently defined by the JRCPTB curriculum. Whilst some guidance is provided on composition of clinical sessions its main focus is on overall training structure and expected clinical competencies and knowledge levels. Delivery of training is commonly arranged locally but there are currently no defined standards to describe the expected structure and standard of training within hospital placements. Consequently quality of training can be extremely variable. For the first time we present comprehensive standards detailing the delivery of high quality training in Gastroenterology. METHODS: Aims To develop and validate standards for delivery of training in Gastroenterology. Methods Standards were developed by consensus opinion by trainees and consultants including those with relevant subspecialist interests. Refinement of the standards was achieved by further peer review and pilot studies. In all there were 10 domains (inpatients, outpatients, endoscopy, HPB, IBD, luminal, nutrition, GIM, education, teaching) each with 5 possible grades (unacceptable, minimum, average, good, excellent). All points within the lowest grade had to be achieved before higher grade could be awarded. All units were then assessed against the standards with completion of the form by consensus trainee opinion. Overall assessment of individual units was also performed by consensus opinion and using a likert scale. RESULTS: 9 hospitals were assessed and significant variations in training quality were identified with large variation in overall grade attainment (range 22-94%). Overall grade and% grade attainment correlated accurately with overall consensus opinion on the relative strengths of units. Poorly performing units were reliably identified and relative strengths of units highlighted. Likert scale assessment was shown to be unreliable with consistently high scores across all units even when overall assessment was poor. CONCLUSION: Formal standards define how to deliver high quality training, allow objective assessment of units and highlight specific deficiencies in training enabling targeted improvement in delivery. The standards were more reliable than existing methods of assessment. These standards hold the potential to significantly improve training in Gastroenterology in the UK. DISCLOSURE OF INTEREST: E. Britton: None Declared, S. Sarkar: None Declared, P. Flanagan Grant/research support from: Awarded a Shire innovation fund for SpRs.

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WUTH publication: PMM.50 A case of small bowel obstruction and ischaemia in second pregnancy after a laparoscopic Roux-en-Y gastric bypass surgery.

Citation: Archives of Disease in Childhood. Fetal and neonatal edition. 2014, 99(Suppl 1), A139.
Author: Palmer C, Shaw E, Adishesh M
Abstract: Obstetricians need to be aware of known complications related to bariatric surgeries and the diagnostic difficulties in pregnancy. We report a rare case of G2P1 28 year old with previous laparoscopic Roux-en-Y gastric bypass surgery. She had an uncomplicated first pregnancy seven months post bariatric surgery following 44 kg weight loss. This resulted in a normal vaginal delivery at term. Eight months later she became pregnant again after a further 15kg loss. From 28/40 she presented with intermittent upper abdominal pain and nausea after eating. At 31/40 she was admitted with US revealing free fluid around the liver and prominent dilated loops of bowel. Rapid clinical deterioration prompted immediate CT scan demonstrating an internal hernia and closed loop bowel obstruction. An emergency caesarean section and laparotomy confirmed a type C Petersen's hernia with subsequent small bowel ischaemia--. (1) An extensive amount of small bowel was resected with the ends temporarily stapled. Following abdominal packing and ITU stabilisation, she returned to theatre within 24 h for reversal of the gastric bypass. Mother and baby recovered well. Petersen's space is created by the boundaries of the transverse mesocolon, the retroperitoneum and the 'Roux limb' mesentery.(1) A Petersen's hernia can arise from any type of gastrojejunostomy, leading to bowel incarceration and obstruction. Decreases in intra-abdominal fat with weight loss cause widening of the mesenteric defects and increased propensity to herniation.(2) Our case demonstrates the subtlety with which such complications can present and highlights to Obstetricians not to be falsely reassured by a previous normal pregnancy.

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WUTH publication: Idiopathic brachial plexus neuritis after laparoscopic treatment of endometriosis: a complication that may mimic position-related brachial plexus injury

Citation: Journal of minimally invasive gynecology. 2013, 20(6), 891-3.
Author: Minas V, Aust T
Abstract: We report the case of a 37-year-old woman who developed idiopathic brachial plexus neuritis, also referred to as Parsonage-Turner syndrome, after laparoscopic excision of endometriosis. The differential diagnosis between this non-position-related neuritis and brachial plexus injury is discussed. The aim of this report was to raise awareness on this distressing postoperative complication.

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WUTH publication: Could failure of the spring ligament complex be the driving force behind the development of the adult flatfoot deformity?

Citation: The Journal of Foot & Ankle Surgery. 2014, 53(2), 152-5
Author: Williams G, Widnall J, Evans P, Platt S
Abstract: We conducted an investigation into the relative associations of magnetic resonance imaging (MRI)-defined pathologic features of the spring ligament and/or tibialis posterior tendon with radiographic evidence of a planovalgus foot position. A total of 161 patient images (MRI and plain radiographs) obtained from the foot and ankle clinic (2008 to 2011) were retrospectively reviewed. All 161 patients (64 male and 97 female; mean age 45.9 years, range 18 to 86) were included in the analysis. Lateral weightbearing radiographs were analyzed for the talo-first metatarsal angle ≥ 5°, calcaneal pitch ≤ 20°, and talocalcaneal angle ≥ 45°. A positive finding for ≥ 1 measurements identified a radiographic planovalgus position of the foot. The radiographic deformity was analyzed against the MRI evidence of either spring ligament or tibialis posterior tendon pathologic features for significance (p < .05). Evidence of a spring ligament abnormality was strongly associated with a planovalgus foot position, reaching high levels of statistical significance in all 3 categories of radiographic deformity (odds ratio 9.2, p < .0001). Abnormalities of the tibialis posterior tendon failed to demonstrate significance, unless grade I changes were excluded, and grade II and III appearances were analyzed in isolation (odds ratio 2.9, p = .04). Although absolute causal relationships were not tested, this investigation has clearly demonstrated that MRI-defined abnormalities of the spring ligament complex are possibly of at least equal importance to tibialis posterior dysfunction for the presence of a moderate to severe radiographic planovalgus foot position.

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