WUTH publication: Personal birth preferences and actual mode of delivery outcomes of obstetricians and gynaecologists in South West England; with comparison to regional and national birth statistics

Citation: European Journal of Obstetrics, gynecology and reproductive biology. 2014 Jul 30
Author: Lightly K, Shaw E, Dailami N, Bisson D
Abstract: OBJECTIVE: To determine personal birth preferences of obstetricians in various clinical scenarios, in particular elective caesarean section for maternal request. To determine actual rates of modes of deliveries amongst the same group. To compare the obstetrician's mode of delivery rates, to the general population.

STUDY DESIGN: Following ethical approval, a piloted online survey link was sent via email to 242 current obstetricians and gynaecologists, (consultants and trainees) in South West England. Mode of delivery results were compared to regional and national population data, using Hospital Episode Statistics and subjected to statistical analysis.
RESULTS: The response rate was 68%. 90% would hypothetically plan a vaginal delivery, 10% would consider a caesarean section in an otherwise uncomplicated primiparous pregnancy. Of the 94/165 (60%) respondents with children (201 children), mode of delivery for the first born child; normal vaginal delivery 48%, caesarean section 26.5% (elective 8.5%, emergency 18%), instrumental 24.5% and vaginal breech 1%. Only one chose an elective caesarean for maternal request. During 2006-2011 obstetricians have the same overall actual modes of birth as the population (p=0.9).
CONCLUSIONS: Ten percent of obstetricians report they would consider requesting caesarean section for themselves/their partner, which is the lowest rate reported within UK studies. However only 1% actually had a caesarean solely for maternal choice. When compared to regional/national statistics obstetricians currently have modes of delivery that are not significantly different than the population and suggests that they choose non interventional delivery if possible.
Copyright © 2014. Published by Elsevier Ireland Ltd.
KEYWORDS: Birth preferences; Mode of delivery; Obstetricians

Link to PubMed record

WUTH publications

The WUTH publications section of the Library Blog, which began in 2012, contains Journal articles authored by Wirral University Teaching Hospital (WUTH) employees which have been indexed in PubMed. This facility has been enhanced and now highlights Journal articles authored by Wirral University Teaching Hospital (WUTH) employees which have been indexed in Medline & EMBASE too.The result of this enhancement is that there has been a large number of articles added in one batch. From this point forward articles will continue to be added individually as they appear in PubMed, Medline or EMBASE.

WUTH publication: Using the hospital anxiety and depression scale in surgical patients

Citation: Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2011, 25(34), 35-41
Author: Pritchard M.J.
Abstract: Patients admitted to hospital to undergo an elective surgical procedure often feel frightened and anxious. Healthcare professionals have a responsibility to ensure that patients are physically and psychologically prepared for surgery. The provision of psychological care may be inadequate as there are few protocols for healthcare professionals to follow in this area. Psychological care should be provided routinely for every surgical patient not only those with cancer, for which psychological care forms part of the overall care package. The use of tools such as the Hospital Anxiety and Depression Scale allow staff to identify and monitor anxiety and depression in patients in a busy pre-operative setting.

WUTH publication: Use of prophylactic antibiotics in gynaecological endoscopy in the UK. Do we need a guideline?

Citation: Gynecological Surgery. 2013, 10, S13
Author: Minas V.; Nahid G.; David R.
Abstract: We conducted a survey which suggests significant variation in clinicians' practice and potential overuse of prophylactic antibiotics in gynaecological endoscopy in the United Kingdom. Introduction: Surgical site infection is a common post-operative complication that can result to increased morbidity, prolonged hospital stay and readmission. Pre-operative antibiotics may prevent such infections. Unnecessary prophylaxis however can be detrimental due to adverse reactions, emergence of resistant bacteria and additional costs. Endoscopic procedures are thought to carry a lowrisk of surgical site contamination and therefore antibiotics may not confer any additional benefit. Many European countries, including the UK, lack relevant guidelines. Material and Methods: The survey was designed using the SurveyMonkey website (www.surveymonkey.com) and emailed to the members of the British Society for Gynaecological Endoscopy (BSGE). The members were asked to select "yes", "no", "unsure" or I do not perform this procedur Results: Seventy nine BSGE members responded to our survey. There is significant variation in
clinicians' practice in intermediate level laparoscopy. One in 8 surgeons administers antibiotics for diagnostic laparoscopy, whereas 1 in10 do so for diagnostic hysteroscopy. Hospitals often lack such guidelines. A national guideline would be welcomed by most responders. Discussion: Antibiotic prophylaxis is over-utilised in gynaecological endoscopy in the UK. Production of relevant national recommendations is likely to benefit both patients and hospitals and will provide coherence in clinical practice. These conclusions are likely to be also applicable to other European countries.

WUTH publication: Use of colchicine for skin conditions

Citation: Pharmaceutical Journal. 2012, 289(7719-7720), 203
Author: Malson G.

WUTH publication: Use of a monofilament fibre debridement pad to treat chronic oedema-related hyperkeratosis

Citation: Wounds UK. 2013, 9(3), 85-88
Author: Pidcock L.; Jones H.
Abstract: Moffat et al (2003) report that 1.33 people in every 1 000 of the UK population have chronic oedema, although the true prevalence is likely to be higher. Chronic oedema is often associated with a range of skin conditions, including hyperkeratosis. This article describes the use of a monofilament fibre debridement pad to reduce hyperkeratosis on the legs of a 57-year-old man with a long-standing history of bilateral lymphovenous oedema. As part of an holistic care programme, the monofilament fibre debridement pad was found to quickly and effectively reduce hyperkeratosis.

WUTH publication: Unplanned conversion of regional anaesthesia (RA) to general anaesthesia (GA) in patients undergoing caesarean section (CS)

Citation: Regional Anesthesia and Pain Medicine. 2013, 38(5 SUPPL. 1), E155
Author: Airey N.; Singaravelu S.; Wankhade K.
Abstract: Purpose/Objective: Aim: Establish the RA to GA conversion rate at our institution and identify risk factors for its occurrence. There is unequivocal evidence that RA is safer than GA for patients undergoing CS and is also the preferred choice for patients. However, there are occasions when RA has to be converted to GA part way though the surgery. Materials and Methods: After seeking institutional audit department approval we conducted a retrospective review to identify all cases of RA to GA conversion in patients undergoing a CS over a 5 year period. Having identified the patients we then conducted a case note review. Outcome measures included; category of CS, time of operation, age of patient and reasons given for conversion. Results: 80 patients were identified as having had a RA to GA conversion. 30 patients having had a spinal initially (conversion rate of 1.08%) and 50 patients had an epidural top-up (9.38%). Of the 30 patients who received a spinal; 10 (0.69%) were elective and 20 (1.51%) had emergency CS. The conversion rate increased out-of-hours (18:00-08:00) for both epidural top-ups (10.25%) and spinals (1.61%). For patients <25 years the rate of conversion for epidural top-ups was 24% compared to 6% for patients >25 years. Conclusions: There is a significantly higher risk of RA to GA conversion in patients having an emergency CS, and those having a CS with an epidural top-up. Younger patients having an epidural top-up appear to be at very high risk of requiring a conversion to GA. These results question the wisdom of topping-up epidurals in patients <25 years.

WUTH publication: Time course variations in the mechanisms by which cerebral oxygen delivery is maintained on exposure to hypoxia/altitude

Citation: High Altitude Medicine and Biology. 2014, 15(1), 21-27
Author: Imray C.; Chan C.; Stubbings A.; Rhodes H.; Patey S.; Wilson M.H.; Bailey D.M.; Wright A.D.
Abstract: Normal cerebral function is dependent upon an adequate and continuous supply of oxygen. This study calculated cerebral blood flow based on assessment of the right middle cerebral artery (MCA) velocity (MCA_Vel) and MCA diameter (MCA_Diam) by trans-cranial Doppler and trans-cranial Duplex in normoxia, during acute exposure to 12% normobaric hypoxia for up to 6 hours, and after 3 days exposure to the equivalent altitude, 4392m, in nine subjects. Mean (SD) MCA_Vel increased both after 6 hours hypoxia from 76.8 (11.4) to 97.2 (17.4) cms/sec (p<0.001), and after 3 days at altitude from 68.1 (7.5) [sea level] to 76.2 (10.2) [4392 m] (p=0.015). MCA_Diam increased from 5.07 (0.6) to 6.1 (0.6) mm (p<0.001) after 6 hours of 12% hypoxia. Calculated mean MCA blood flow increased after 6 hours of 12% hypoxia from 5.0 (0.6) mL/sec to 8.9 (1.2) mL/sec, but there was no difference between sea level and 4392m. Calculated mean cerebral oxygen delivery increased from 72.4 (14.4) to 107 (20.1) mL/sec (p<0.001) after 6 hours of 12% hypoxia and was maintained unchanged at 4392m. An increase in MCA caliber, rather than blood velocity, was a major contributor to increased oxygen delivery accompanying within the first few hours of exposure to acute hypoxia. During more long-term exposure, increases in MCA velocity and a rise in hemoglobin appeared to be the more important mechanisms in maintaining cerebral oxygen delivery. The implication of this observed change in MCA diameter questions the widely held assumption that MCA velocity is a surrogate for flow during acute hypoxic exposure. Copyright 2014, Mary Ann Liebert, Inc. 2014.

WUTH publication: The silent cancer-male breast cancer

Citation: Supportive Care in Cancer. 2013, 21, S69
Author: Pritchard M.J.
Abstract: Breast cancer is considered by the general public as a women's illness. In 2008 some 1.38 million women were diagnosed with breast cancer that's nearly a quarter of all female cancer cases. As health professionals our role is to offer hope and support to both the patient and their family members as they undergo cancer treatment. So when we talk about breast cancer we inevitably talk about women's breast cancer. Issues of gender appear not to be at the forefront of the health professionals mind. Consequently we as health professionals have devoted both time and energy to develop sophisticated support systems to aid the patient's physical and emotional well being. Speciality clinics, access to breast care nurses and of course the option to undergo re-constructive surgery. However what happens to this support mechanism when the patient's gender short circuits this network? What if the cancer suffer is a man? Where does a male breast cancer patient go for support and treatment?. Male breast cancer makes up only 1 % of the total number of
breast cancers worldwide. In the United Kingdom approximately 300 men are diagnosed with breast cancer each year. The aim of this paper is to raise the profile of this particular group of patients who have been diagnosed with this disease.

WUTH publication: The epidemiology of general paediatric outpatients referrals: 1988 and 2006

Citation: Child: Care, Health & Development. 2013, 39(1), 44-9
Author: Thompson E; Todd P; Ni Bhrolchain C
Abstract: BACKGROUND: Wirral University Teaching Hospital is a large district general hospital situated on the Wirral peninsula, UK. Because of the district's geographical and demographic characteristics, Wirral is an ideal location for population-based studies. Information on paediatric referrals, case mix and outcomes are scarce. We took advantage of our situation to conduct an epidemiological study of referrals to general paediatrics in Wirral in 1988 and again in 2006. A companion paper examines referrals to community paediatricians in the Department during the same period.METHODS: A prospective observational study of general paediatric outpatient referrals between 1 Feb and 31 May 2006 compared with the same period in 1988, using the same methodology. We included all children under the age of 15 offered a new patient appointment during the study period.RESULTS: The referral rate had increased significantly from 15.5 to 25.7 per thousand children under 15 per annum (P < 0.01; Chi Squared). The most common conditions referred in 2006 were constipation (10.5%) and enuresis (7%) compared with asthma (15%) and heart murmurs (13.8%) in 1988. There were significantly fewer wasted appointments (5% vs. 12%), shorter waiting times (5% vs. 12% waited more than 12 weeks), faster treatment times (25% vs. 14% started treatment after the first appointment) and more discharges (41.2% vs. 30.5%) (all P < 0.01; Chi Squared).CONCLUSIONS: More children were referred to paediatricians in 2006 compares with 1988. Services worked more efficiently, with better attendance, access and time to treatment. We provide information on changes in case mix that is not available elsewhere. This population-based study thus gives a unique insight into changes in referrals to UK general paediatricians. 2011 Blackwell Publishing Ltd.

WUTH publication: The epidemiology of community paediatric outpatient referrals 2006

Citation: Child: Care, Health & Development. 2013, 39(1), 50-4
Author: Thompson E; Ni Bhrolchain C
Abstract: BACKGROUND: Wirral University Teaching Hospital is a large district general hospital situated on the Wirral Peninsula, UK. Because of the district's geographical and demographic characteristics, Wirral is an ideal location for population-based studies. Information on community paediatric referrals, case mix and outcomes is scarce. We took advantage of our situation to conduct an epidemiological study of referrals to community paediatrics in Wirral. A companion paper examines referrals to general paediatricians during the same period.METHODS: A prospective observational study of community paediatric outpatient referrals between 1 February and 31 May 2006 for all children under the age of 15 offered a new patient appointment during the study period. The study was conducted using the same methodology as a previous population-based study of community paediatric outpatients in Northampton, UK in 1998. We compared our results with this previous study.RESULTS: The referral rate was 10.1 per 1000 children under 15 per annum. School nurses and health visitors made nearly half the referrals, with general practitioners referring most of the remainder. Compared with the Northampton study, more children were seen by consultants. Case mix showed a shift towards behavioural and neurodevelopmental disorders, with less general paediatrics. Attention deficit hyperactivity disorder was the commonest disorder seen (28.2%), a significant increase from the previous study (3.4%) (P < 0.01). Autism spectrum disorder showed little change (8.1% vs. 9.6%; NS). The Wirral study showed significantly more follow-up compared with the Northampton.CONCLUSIONS: This population-based study gives a unique insight into the epidemiology of referrals to community paediatricians in the UK in 2006 and how these differ from those recorded in a different UK district in 1998. 2011 Blackwell Publishing Ltd.

WUTH publication: Surgical management of scalp squamous cell carcinoma: Predictive value of tumour thickness and deep marginal clearance for regional recurrence

Citation: International Journal of Oral and Maxillofacial Surgery. 2013, 42(10), 1354
Author: Pinto A.; Raphy P.; Jones C.; Parikh S.A.; Mahdmina A.; Elwazani B.; Ho M.W.
Abstract: Background and objectives: Early detection and good loco-regional control is essential for success in surgical management of cutaneous malignancy. In the scalp, the ability to achieve adequate deep marginal clearance can sometimes offer a challenge due to local anatomy (scalp-calvarium junction). This becomes more relevant with increased tumour thickness/depth of invasion. Methods: Retrospective review of medical records: 115 consecutive patients with histological diagnosis of scalp squamous cell carcinoma who were treated with primary surgery from 2005 to 2012. Data collection: patient demography, surgical pathology, reconstruction of defects, regional recurrence and follow-up duration. Results (main findings): Median age 80.7 years (IQR 76-85.4). Gender distribution: 102 (89%) male and 13 (11%) female. Median follow-up 23.5 months (IQR 8.2-42.3). Overall regional recurrence rate in this cohort was 4.3% (5/115). Forty-six patients (40%) required local flaps and 63 (55%) had skin grafts, to reconstruct the ablative surgical defects. In six patients (5%), the wounds were closed primarily. Tumour differentiation*: 29 well (28%), 56 moderate (55%) and 17 poor (17%). Tumour thickness*: <4mm in 20 (33%) patients and >4mm in 41 (67%) patients; regional recurrence 10% (4/41) vs 0. Deep margin*: <1mm in 33 (30%) patients and >1mmin 76 (70%) patients; regional recurrence rates 12% (4/33) vs 0.01% (1/76).*only patients with
completed dataset included. Conclusions: The overall regional recurrence rate in this cohort was within the 5% risk generally accepted for cutaneous head and neck malignancy. The risk factors identified for development of regional parotid/neck recurrence include tumour thickness >4mm and deep marginal clearance <1 mm. This high risk group of patients should be selected to undergo more intensive follow-up
programme by means of ultrasound surveillance. Although the role of sentinel node biopsy is still unproven, this should be a consideration in the context of a clinical trial.

WUTH publication: Successful pregnancy in a patient with untreated pituitary driven Cushing's disease

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 125
Author: Mohammed R.O.; Mwenechanya S.; Khoo C.
Abstract: Introduction Pregnancy occurring in women with Cushing's syndrome is rare as high cortisol levels make conception unlikely. Pregnancy occurring in pituitary driven Cushing's disease is even rarer with only just over 70 cases described in the English literature. Hypercortisolism is associated with increased maternal morbidity and adverse fetal outcome especially if untreated. We report on a rare case of a successful pregnancy with a live birth in a case of untreated pituitary driven Cushing's disease. Case Report A 38-year-old gravida 5 para 3 woman with Cushing's disease and a 5 mm micro adenoma on MRI was awaiting treatment when she got pregnant. Although she had Cushing's disease for about 5 years she had declined treatment and was poorly controlled and had obesity, osteoporosis causing necrosis of femoral head and recurrent infections on the fat pad at back of neck. She declined surgical and medical management during pregnancy. She persisted with hypercortisolism throughout the pregnancy and clinically worsened with increased obesity, recurrent abscesses in her buffalo hump, worsening back pain from osteoporosis and was wheelchair bound from the necrosis of neck of femur. In spite of the untreated hypercortisolism, the pregnancy progressed to 33 weeks of gestation. She then went into spontaneous labour and had a live vaginal delivery of a male infant. There were no intrapartum or postnatal complications for both mother and baby. Discussion Untreated hypercortisolism is associated with increased maternal morbidity like
hypertension, cardiac failure, gestational diabetes, poor skin healing and recurrent infections as well as poor fetal outcomes like still births and preterm labour. Pregnancy outcome may be improved in patients who have surgery to remove the pituitary tumour. Although medical treatment with cortisol inhibiting drugs like ketoconazole and metyrapone have been reported in pregnancy the results have been conflicting with some
case reports reporting high fetal loss rates. There are very few reported cases in the literature of successful pregnancies in untreated Cushing's disease. Our patient gave birth to a live male infant despite lack of treatment. This case highlights the rare occurrence of a successful pregnancy in Cushing's disease and a favourable outcome with supportive measures only.

WUTH publication: Structural alterations in brainstem of fibromyalgia syndrome patients correlate with sensitivity to mechanical pressure

Citation: NeuroImage: Clinical. 2013, 3, 163-170
Author: Fallon N.; Alghamdi J.; Chiu Y.; Sluming V.; Nurmikko T.; Stancak A.
Abstract: Fibromyalgia syndrome is a chronic pain disorder characterised by widespread pain and tenderness in muscles and deep tissues. Current theories regarding the pathophysiological origins of fibromyalgia syndrome point towards central sensitisation and a decreased capacity of descending nociceptive controls. Morphological alterations to subcortical brain regions may contribute to such pathophysiological mechanisms, and to pain and other symptoms seen in fibromyalgia. Therefore, we evaluated geometric differences in subcortical structures in fibromyalgia patients relative to healthy people using a novel method of shape analysis. Sixteen female fibromyalgia patients and 15 age and sex matched, healthy control subjects underwent high-resolution T1-weighted magnetic resonance image scanning. Data was analysed using shape analysis of 15 subcortical regions and standard voxel-based morphometry analysis. Fibromyalgia syndrome patients, relative to healthy control participants, exhibited alterations to the shape of the left lateral aspect of the lower brainstem (medulla). The mean total volume of the brainstem was also found to be significantly reduced in the patient group compared to healthy control subjects, and this brainstem volume reduction in patient group significantly correlated with clinical manual tender point scale scores. Voxel-based morphometry analysis revealed that patients also demonstrated decreased local grey
matter volumes in the brainstem (pons) and left precuneus, and increased grey matter volumes in bilateral primary somatosensory cortices. Results suggest that the volume reduction and associated geometric shape alterations seen in the brainstem of the patient group may contribute to sensitivity to pressure pain in fibromyalgia syndrome. This finding may be due to structure-related deficiencies in regions subserving descending nociceptive control. 2013 The Authors.

WUTH publication: Standardized definition of contamination and evidence-based target necessary for high-quality blood culture contamination rate audit

Citation: Journal of Hospital Infection. 2013, 83(3), 265-266
Author: Harvey D.J.; Albert S.

WUTH publication: Simple measures to improve inpatient referrals for patients with diabetes foot ulcers to the podiatry diabetes service

Citation: Diabetic Medicine. 2013, 30, 192
Author: Lyons C.; Raza F.; Harris G.; Leong K.S.
Abstract: Aim: It was suspected that inpatient referral rates for diabetes foot ulcers were low and an action plan was implemented following a baseline audit. The aim was to demonstrate the impact of this plan on referral rates. Methods: All inpatients with diabetes were audited on a randomly selected date in March 2012. All patients with diabetes had their feet checked for ulceration. Those with ulceration had the following details recorded: type of and duration of ulcer and if a referral to the diabetes podiatrist or other members of the multidisciplinary team had been made. From this initial baseline audit, the following were implemented: raising awareness of ward nursing staff for diabetes foot ulcers and when to refer, establishing a virtual multidisciplinary team to assist in rapid communication between team members and increasing podiatry inpatient capacity to cope with anticipated increase in demand and reduce the time to podiatry intervention. The audit was repeated in September 2012. Results: The initial audit (March 2012) identified 97 inpatients with diabetes: six (6.1%) had foot ulcers and only one (16.6%) had been referred to podiatry and the diabetes team. In September 2012, there were 126 inpatients with diabetes; 12 (9.5%) had foot ulcers, and patients referred to podiatry had increased significantly (p = 0.043, analysed by Fisher's exact test) to nine (75%). Conclusions: Simple measures to increase awareness on the ward and improve communications
amongst key team members were successful in increasing the number of patients with diabetes foot ulcers referred to podiatry.

WUTH publication: Secondary prevention of fragility fractures at Wirral university teaching hospital, Wirral, UK

Citation: European Geriatric Medicine. 2012, 3, S131
Author: Cheema M.; Haque R.; Azad M.
Abstract: Text.- Background.- Nearly 650,000 over the age of 60 attend A&E due to fall each year and over 204,000 are admitted to hospital. Seventy-eight thousand hip fractures are admitted every year with 95% hip fractures secondary to falls. We performed a retrospective study on patients admitted with fragility fractures to ascertain appropriate addition of secondary prevention drugs for fragility fractures. Methods.- We performed a retrospective study on 50 patients in rehabilitation ward who had sustained fragility fractures. We checked for appropriate addition of secondary prevention drugs for fragility fractures according to NICE guidelines. Demographics and clinical data were analysed to assess for correct prescription of medications. We assessed discharge medication for secondary prevention drugs. The study was approved by the Local Research Ethics Committee. No conflicts of interests among authors. Results.- Out of 50 patients, 56% were males and 44% were females. The mean age (SD) was 82 (11). Fourteen percent had a history of previous fractures before admission with hip fracture (43%) being the most common. On admission, 70% had hip fractures, 10% had humeral and 6% had wrist fractures. Sixteen percent were on treatment for osteoporosis before admission. After admission, 80% of patients were started and discharged on secondary prevention medications. Ninety-five percent of patients were started on vitamin D derivatives, 68% bisphosphonates, 85% calcium salts and 5%strontium (bisphosphonate intolerable/contraindicated). However, 20% patients were discharged without secondary prevention treatment. Conclusion.- Eighty percent of patients with fragility fractures were commenced on secondary prevention drugs. Twenty percent were not discharged with secondary prevention. The prescribed drugs were in accordance with the NICE guidelines. Awareness regarding importance of prescribing to patient's accordance with NICE guidelines was performed with regional lectures.

WUTH publication: Screening for type 2 diabetes and population mortality over 10 years

Citation: The Lancet. 2013, 381(9870), 901-902
Author: Nwaneri C.; Bowen-Jones D.; Cooper H.

WUTH publication: Rituximab monotherapy (without cyclophosphamide) in anca associated vasculitis in patients with serumcreatinine above and below 500 mumol/l

Citation: Nephrology Dialysis Transplantation. 2013, 28
Author: Naz N.; Hiremath M.; Banerjee A.; Shah Y.
Abstract: Introduction and Aims: There is limited data on using rituximab (without cyclophosphamide combination) as the primary immunosuppressive agent in ANCA associated vasculitis with serum creatinine > 354 mumol/l. RAVE excluded such patients; in RITUXIVAS patients received at least 2 doses of intravenous cyclophosphamide along with rituximab.We used rituximab as the main immunosuppressive agent (without cyclophosphamide combination) as induction therapy in 32 ANCA associated vasculitis patients including 15 patients with serum creatinine > 354mumol/l. We grouped our patients into a presenting creatinine of higher or less than 500mumol/l. Our aim was to investigate the renal outcome in these two groups in the first year of presentation and to identify rates of infection, relapse, malignancy and mortality between these groups. Methods:We retrospectively assessed new ANCA associated vasculitis with acute renal failure. Patients were grouped into two based on their presenting serum creatinine. Group A with serum creatinine < 500mumol/l and Group B with serum creatinine >500mumol/l. Serum creatinine at 3, 6 and 12 months of presentation was compared with baseline serum creatinine. Incidence of infection, mortality, malignancy and relapse rate was also compared in these 2 groups at their first 12 months of treatment. Results: All patients received IV methyl prednisolone followed by oral prednisolone with rituximab 375 mg m

weekly for 4 weeks. 11 (7 with serum creatinine >500 mumol/ l) also received plasma exchange. Table 1 show a significant improvement in serum creatinine in both groups at 3, 6 and 12 months of presentation. Serum creatinine plateaued at 3 months in Group A but took more than 3 months in Group B suggesting severe ischemia and acute tubular necrosis in group.We also found no statistically significance difference in infection, relapse, mortality and malignancy rate in the 2 groups at their first year of rituximab therapy. Conclusions:We concluded that rituximab was a very effective and well tolerated induction agent without cyclophosphamide combination in ANCA associated vasculitis irrespective of the level of renal failure.

WUTH publication: Refractory hyperemesis gravidarum-a rare presentation of maternal hydrocephalus

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 138
Author: Chong D.M.; Mohammed O.; Mwenechanya S.
Abstract: Introduction Nausea and vomiting is common in pregnancy, affecting about 70% of gravid women up to 20 weeks of gestation. For a minority of the pregnant population, however, the symptoms may be severe and recurrent to cause implications in hydration and nutritional intake where hospital admissions are required. Most admissions are treated with supportive measures and anti-emetics with good reported symptomatic relief. In cases with recurrent admissions and refractory symptoms, further investigations are
required to exclude further organic diseases. We present a case of refractory hyperemesis gravidarum secondary to maternal hydrocephalus. Case A 31-year-old multiparous woman with a singleton pregnancy presented at 10 weeks of gestation with severe vomiting treated as hyperemesis gravidarum. She had two previous uneventful pregnancy and delivery with no significant medical history. Her symptoms were refractory to first line hospital treatments. In addition, the patient reported headaches and diplopia. Further
CT imaging revealed hydrocephalus secondary to aqueduct stenosis. At 11 weeks of gestation, she was transferred to a tertiary neurology specialist centre for endoscopic third ventriculostomy. Despite this, her symptoms worsened post procedure. At 13 weeks of gestation, a right ventriculoperitoneal shunt was inserted. The patient was managed jointly under the obstetricians and neurosurgeons as an outpatient with a plan for elective caesarean section at 39 weeks. However, she presented at 32 weeks of gestation with
confirmed premature prelabour rupture of membranes. With steroids cover, an emergency caesarean section was performed under general anaesthesia with no complications. Conclusion Although hyperemesis gravidarum is not uncommon, recurrent and refractory cases should prompt clinicians to consider other organic causes of vomiting in pregnancy. This is imperative especially in cases with reported associated red flag symptoms. Closer surveillance is recommended in these 'high risk' groups and further detailed research is
required within this field.

WUTH publication: Primary peritoneal carcinoma found at caesarean section, value of routine abdominal examination at caesarean section

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2012, 119, 82-83
Author: Myagerimath R.; Azhar L.; Mwenechanya S.; Gul N.
Abstract: Introduction: Primary peritoneal carcinoma (PPC) is a rare malignancy that predominantly affects postmenopausal women and typically displays multicentric peritoneal and omental involvement. Atypical presentations of primary peritoneal carcinoma have been described in english literature but as far as we are aware no reports of primary peritoneal carcinoma which were picked up at caeserean section have been
published. Here we present a case report in a young asymptomatic woman with suspicious peritoneal lesions at elective caesarean section. Case Report: Thirty-seven years old Para 2 had an elective caesarean section for previous caesarean section. During surgery small peritoneal lesions were noted which were suspicious of endometriosis and biopsy was taken. Biopsy result was suggestive of papillary serous carcinoma of ovary.
CT scan of abdomen and pelvis did not show any abnormality. Following MDT meeting she had a total abdominal hysterectomy and bilateral salpingoophrectomy with pelvic clearance. The histology confirmed Primary peritoneal cancer stage 3b with both ovarian and omental involvement. Subsequently she received chemotherapy. Discussion: The well-documented but rare primary papillary serous peritoneal tumors can present as diagnostic dilemma for both the pathologists and the clinicians as primary peritoneal cancer resembles papillary serous ovarian carcinoma. The sensitivity of CT scans and ultrasound for peritoneal nodules measuring smaller than one cm is approximately 15-30%. Treatment of this malignancy is very similar to that of epithelial ovarian cancer i.e. combination chemotherapy after optimal cytoreductive surgery. The goals of chemotherapy are to induce remission, to prevent complications, and to reduce morbidity.
Different studies quote the 5-year survival rates as 26.5-47%. Conclusion: Direct visualisation of the peritoneal surfaces along with palpation of the abdominal cavity is by far the most sensitive modality for detecting primary peritoneal cancer. Caesarean section is an opportunity for direct visualisation and examination of pelvic organs and peritoneal surface, and any suspicious lesions should be biopsied.

WUTH publication: Prescribing liquid medication: Can the dose be accurately given?

Citation: Archives of Disease in Childhood. 2013, 98(10), 831-832
Author: Morecroft C.W.; Caldwell N.A.; Gill A.

WUTH publication: Predictive value of PSA, PSAD and %free PSA for PCa diagnosis, Gleason score (GS) and cancer volume (CaV) in men undergoing transperineal template guided saturation biopsy (TTSB)

Citation: BJU International. 2012, 109, 17
Author: Ekwueme K.C.; Simpson H.; Zakhour H.D.; Parr N.J.
Abstract: Introduction and Objective: Persistent suspicion of PCa despite negative TRUSB presents a dilemma. TTSB is useful, although expensive and associated with significant morbidity. To improve predictive value of PSA additional serum forms and modifications are reported, but are unreliable in the setting of TRUSB, probably because the technique fails to detect a significant proportion of tumours. We postulated that predictive values should be superior in relationship to TTSB. Patients and Methods: A modified TTSB was performed on 139 patients with persistently elevated PSA despite median of 2 (1-6) negative TRUSB. Prior to TTSB, serum PSA (sPSA), PSAD and %fPSA were documented and evaluated for ability to predict PCa diagnosis, GS and CaV (maximum % core, MPC, aggregate of tumour lengths from positive cores, ATLPC and maximum tumour length, MTL). Results: Median age was 63 (48-85), PSA 10 ng/ml (2-114), prostate volume 44cc (18-90), PSAD 0.21 (0.01-2.99), %fPSA 10 (1-32) and number of cores taken 29 (16-43). 71 were diagnosed with PCa (51%). 343 (17%) of total 2004 cores were positive, Gleason 6 (20%), 7 (60%) and 8-10 (20%). Mean MPC was 51% (1-100), ATLPC 51 mm (1-139) and MTL 5 mm (1-16). PSA, PSAD and %fPSA showed linear correlation (r = 0.44, 0.54 & -0.36 respectively). AUC for PSA (0.81) was superior to sPSA and %fPSA (0.76&0.29). PSAD predicted GS 7-10 (p = 0.004), MPC (p = 0.001), ATLPC (p = 0.002) and MTL (p = 0.001). At cut-off of 0.10, PSAD has sensitivity 96%, avoiding unnecessary biopsy in 20%. %fPSA was unreliable predictor of GS (p = 0.58) and CaV. Conclusions: PSAD reliably predicts PCa diagnosis, high grade and CaV in men undergoing TTSB. PSAD >0.10 has high sensitivity and value in deciding to offer TPSB.

WUTH publication: Post-operative management of diabetic patients requiring major amputation is more challenging than those having open abdominal aortic aneurysm surgery (AAA)

Citation: International Journal of Surgery. 2013, 11(8), 734-735
Author: Barkat M.; Appleton N.; Chatha R.; Chan C.
Abstract: Aim: In-hospital mortality rates for patients undergoing diabetic foot surgery range from 9% (National Vascular Database) to 17% (Hospital Episode Statistics data). This compares unfavourably with 4% for that of open AAA surgery. Our aim was to evaluate outcomes following major diabetic foot amputations in a district general hospital. Method: A retrospective case note review of consecutive patients undergoing major amputation for diabetic foot complications over a three year period. Results: Between
August 2009 to August 2011, 75 patients underwent major amputations: (50% trans-femoral, 42% trans-tibial and 8% other). Indications included ischaemia (41%), sepsis (40%) or both (19%). 36% developed medical complications postoperatively: (25% chest infection, 8% cardiac failure and 3% urosepsis). Mean post-operative length of stay was 35 days (range 1 - 215). In-hospital mortality rate was 16.3% and at one year was 26.6%. Conclusion: The post-operative management of diabetic patients requiring major amputation is associated with a high medical complication rate. We have shown that worryingly, in-hospital mortality for this group is higher than that for open AAA surgery. Prioritisation at all levels of hospital care is required to deliver improved outcomes.

WUTH publication: Patient acceptability of a locally designed insulin passport card and insulin safety information booklet: A patient survey

Citation: Diabetic Medicine. 2013, 30, 119-120
Author: Hodgkinson R.S.; McFarlane F.M.; Leong K.S.
Abstract: Aims: To determine patient acceptability and usefulness of a hospital designed insulin passport card and the NHS Diabetes insulin safety information booklet. The card was developed to meet local needs for documentation of insulin doses and contact details of the diabetes specialist team, an option not available on the National Patient Safety Agency insulin passport. Method: Using a standard questionnaire, three members of pharmacy interviewed 40 adult outpatients and inpatients on insulin. Verbal consent was obtained from all participants. The results were collated and analysed. Results: In relation to the insulin passport card, 88% thought it useful to record the dose of insulin they take, 93% could read the card, 83% considered it useful to help ensure the safe use of insulin, 78% agreed to complete it themselves, 95% would carry it on their person, 93% would bring it into hospital, 83% would show it to a healthcare professional when issued a
prescription and 78% would show it to a pharmacist when receiving a supply of insulin. In relation to the information booklet, 90% deemed it easy to read, 78% found it helpful, 65% indicated it made them more aware of potential errors with insulin and 50% said they would be more inclined to check the insulin supplied by pharmacists or confirm the dose to be administered by a nurse. Conclusion: The majority of patients were satisfied with the insulin passport card and considered it to be a useful document to help optimise their insulin management. After reading the information booklet patients felt more aware of potential errors with insulin.

WUTH publication: Outpatient fluid and electrolyte management for patients with high output stomas and enterocutaneous fistulae

Citation: International Journal of Surgery. 2013, 11(8), 621
Author: Appleton N.D.; Corris A.; Edwards C.; Kenyon A.; Walsh C.J.
Abstract: Aim: Fluid and electrolyte management for patients with high output stomas/enterocutaneous fistulae is challenging. Historically, their care required repeated admissions to avoid ongoing complications eg, acute renal failure.We report our experience of outpatient management of such patients led by a nutrition support team. Method: A retrospective analysis of a prospectively maintained database was performed.
All patients met their nutrition needs enterally. Patients attend a ward based clinic with facilities for monitoring (weight, fluid balance, diet, PICC line care, bloods, urinary sodium and medication review) and IV hydration and/or magnesium/potassium supplementation. Individual cases are discussed at a weekly nutrition support meeting. Results: Between September 2009 - September 2012, 83 patients attended (male:female
43:40, median age 66, range 18-92). 73 had high output stomas, 11 had enterocutaneous fistulas. Total clinic days attended was 1239 (median 9 range 1-109 days). On 224 visits, IV fluids were administered, of which 95 were given IV magnesium and three, IV potassium. Eleven required admission (admission rate of 1%). Other outcomes were either optimisation for surgery, discharge without surgery or long term monitoring
without inpatient stay. Conclusion: Patients with complex fluid balance and electrolyte needs can be managed successfully in the outpatient setting.

WUTH publication: Non-Hodgkin lymphoma (NHL) in the puerperium - A rare case

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2012, 119, 82
Author: Myagerimath R.; Azhar L.; Mwenechanya S.; Gul N.
Abstract: Introduction: Non-Hodgkin lymphoma (NHL) is rare and infrequently diagnosed in the puerperium. It can present as primary lymph node or extra-nodal disease. Non specific symptoms of this condition can cause a diagnostic dilemma leading to delay in initiation of treatment. We are reporting a case of NHL during peurperium with no similar case reports in the literature. Case Report: A 29 year old nulliparous woman had an emergency caeserean section for fetal distress. The postoperative recovery was uneventful. She presented 5 weeks later feeling generally unwell with night sweats, abdominal pain and a palpable tender abdominal mass in the left para umbilical region measuring 10- 12 cm. Ultrasound revealed 14 x 7 x 12 cm mass anterior to the aorta suggestive of para aortic lymphadenopathy. Subsequent CT scan showed abdominal lymphadenopathy with large nodules anterior to aorta extending into the left flank. The appearance was consistent with lymphoma. Laparoscopic biopsy and histology confirmed diffuse large B cell lymphoma.
Staging bone marrow trephine immunochemistry showed marrow involvement consistent with stage IV disease. She received chemotherapy to which there was good response. Discusssion: Diffuse large B-cell lymphoma are fast growing aggressive tumours but with appropriate diagnosis and prompt treatment, they respond well. Five year survival for treated patients is 30%. NHL in a young woman is a management dilemma regarding ovarian preservation and chemoradiation. But in our case since she had completed her
family we did not consider other fertility preserving techniques. Conclusion: Although abdominal masses are not uncommon findings in the puerperium, NHL should be considered in the differential diagnosis.

WUTH publication: Mortality in type 2 diabetes mellitus: Magnitude of the evidence from a systematic review and meta-analysis

Citation: British Journal of Diabetes and Vascular Disease. 2013, 13(4), 192-207
Author: Nwaneri C.; Cooper H.; Bowen-Jones D.
Abstract: Background: Type 2 diabetes is associated with an increase in age-related mortality. A systematic review and meta-analysis were performed to define the relative risks (RR) of all-cause or cause-specific mortality in type 2 diabetes and to determine gaps in current research. Methods: A comprehensive literature search was undertaken for studies (published 1990-2010) on mortality in type 2 diabetes. The study reports on the measure of mortality as defined by RR for all-cause and cause-specific mortality, heterogeneity,
sensitivity analyses and biases. Results: In total 35 studies (220,689 patients; mean follow-up of 10.7 years) were eligible for inclusion: 33 studies reported increased mortality risks; 24 had full data on 95% confidence intervals (CIs), one study reported no excess mortality in men diagnosed after 65 years whereas three reported increased mortality in similar age groups in both sexes. Meta-analysis showed RR = 1.85 (95% CI
1.79-1.92) for all-cause mortality [men RR=1.57 (95% CI 1.46-1.68); women RR=2.0 (95% CI 1.89-2.12)], RR=1.76 (95% CI 1.66-1.88) for cardiovascular mortality and RR=2.26 (95% CI: 1.7-3.02) for stroke. There was no statistically significant evidence of publication bias. Conclusion: Type 2 diabetes increases mortality approximately two-fold increase and macrovascular disease is the principal cause of death. The Author(s) 2013.

WUTH publication: Metrics for obstetrics: Evidence based targets for clinicians and organisations in preconception and early antenatal care

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 419-420
Author: Adams T.; Cooper J.; Rowlands D.; Bricker L.
Abstract: Objective Maternity services are to be commissioned by clinical commissioning groups in England and their equivalent in the devolved nations. Maternity is no longer to be commissioned by the national commissioning board and as such each clinical commissioning group will need metrics by which services can be measured. We present a series of evidence-based metrics for use in maternity care delivered to women who are considering a pregnancy or who are booking their pregnancy delivered derived from nationally available guidance. The metrics are achievable and are a suitable proxy for quality. They also reflect current national priorities and support the King's Fund Ten priorities for commissioners. The metrics were developed by the NHS Northwest's Birth and Newborn Clinical Pathway Group. A group of experts taken from all parts of maternity services, from commissioners, local authorities, primary care, departments of obstetrics and gynaecology, midwifery and hospital management so can be said to be truly multi-disciplinary. Methods Priority themes for health were identified by the group across areas relevant to maternity services focussing on preconception care and antenatal care. A literature search was performed for guidance that dealt with these priority themes across the different areas. The search extended from national organisations such as NICE to patient organisations such as Diabetes UK. From this search, standards of good care were derived together with over 20 suggested metrics. These were discussed in each area by the group, before being reduced to 10 achievable and clinically relevant standards across the two areas. Metrics to measure achievement against the standards were then derived directly by the group. Measuring overall performance in the two areas was supported by the development of one 'supermetric' for each area. Metrics cover all sspects of care including the place and timing of care and are not all secondary care based. Example of preconception care standard: women with epilepsy planning a pregnancy should take 5 mg folic acid daily. Example of antenatal care standard: pregnant women and their families should understand the importance of good food hygiene, particularly with reference to pregnancy.

WUTH publication: Management of patients with high output stomas and enterocutaneous fistulae: Do proton pump inhibitors really help?

Citation: e-SPEN Journal. 2014, 9(3), e136-e140
Author: Appleton N.D.; Neithercut W.D.; Edwards C.; Duncan M.; Walsh C.J.
Abstract: Background and aims: Patients with high output stomas and enterocutaneous fistulae are prone to fluid and electrolyte abnormalities, particularly dehydration, hyponatraemia and hypomagnesaemia. As well as medication to prolong transit time and aid absorption, proton pump inhibitors (PPIs) have been advocated to reduce gastrointestinal losses. Recent, reports in other clinical areas have linked long-term PPI use to
hypomagnesaemia. We wondered whether PPIs used to reduce stoma losses may paradoxically be aggravating hypomagnesaemia in these patients? Our aim was to audit the effect of stopping PPIs, used solely for reduction of gastrointestinal losses, in a cohort of patients with high stoma losses. Methods: Nine patients (8 high output stomas: 1 enterocutaneous fistula) were regularly attending a dedicated clinic for supervision and management of fluid and electrolytes during October 2012. Stoma outputs, blood and urine results were recorded before and after stopping their PPI. Results: There was a significant reduction in average daily stoma outputs when the PPI was stopped. Before PPI cessation, mean daily stoma volume was 1550mls (SE:147.67) compared to mean of 1344mls after (SE:130.29, t(8)=2.11, p<0.05). Additionally, there was a significant increase in both urinary sodium (mean on PPI=32.6mmol/L, SE:22.7, off PPI=63.8, SE:6.65, t(8)=-4.22, p=0.003) and urinary potassium (mean on PPI=61.9mmol/L, SE:7.21, off PPI=77.8mmol/L, t(8)=-2.33, p=0.05). Mean plasma magnesium across the group was not significantly affected by stopping the PPI, yet some individuals had marked improvements (mean before=0.59mmol/L, SE:0.40 compared to mean after=0.64mmol/L, SE:0.40, t(8)=1.42, p=0.226). Conclusion: Our findings do not support current thinking with regard to PPIs reducing enteric losses in patients with high stoma losses. The PPI effect on hypomagnesaemia in this cohort is uncertain but cessation should be considered in resistant hypomagnesaemia. 2014 European Society for Clinical Nutrition and Metabolism.

WUTH publication: Malignant melanoma, a cause for postmenopausal bleeding

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2012, 119, 180
Author: Myagerimath R.; Kubwalo B.; Gul N.
Abstract: Introduction: Melanoma is a tumour of the melanocytes of the skin and mucous membranes. Only 2.5% of cutaneous melanomas metastasise to the female genital tract, the most frequently affected organs being the ovaries. The uterus, mainly the myometrium, is only involved in 10% of cases of genital metastases. The endometrium is less frequently involved 1. Uterine metastases of extra genital malignomas are rarely
presented in literature. Here we are presenting a case of postmenopausal bleeding secondary to metastatic malignant melanoma. Case report: A 58 years old woman presented with postmenopausal bleeding. She had a history of cutaneous melanoma >4 mm excised 2 year earlier followed by brain metastasis treated by craniotomy, excision of right temporal brain metastasis and radiotherapy for 6 months prior to Hysteroscopy
revealed suspicious endometrium and histology reported malignant melanoma. Further imaging ruled out other systemic involvement. After multidisciplinary meeting she was offered palliative laparoscopic hysterectomy BSO, washings and peritoneal biopsy. Histology confirmed metastatic malignant melanoma with positive peritoneal washings. She recovered well without evidence of recurrence and is asymptomatic for more than a year. Discussion: Although genital tract malignancies are a common causes of the postmenopausal bleeding next to atrophic vaginitis, metastatic extra genital malignancies should be considered in a woman with past history of extra genital malignancies. In the index case, palliative surgery was offered for de-bulking and symptom control. Lifetime risk of a woman in the UK developing melanoma is 1 in 117. Melanoma confined to the epidermis is effectively curable and thin lesions carry a >98% 5-year survival rate. However patients with primary tumours of >4 mm thickness have a <50% 5 year survival rate and the median survival for disseminated melanoma is just 7-8 months. The prognosis for patients with advanced visceral metastatic melanoma is particularly poor with a 5-year survival of 5-14% 2. Early diagnosis and appropriate management can improve the survival rate. Conclusion: Abnormal uterine bleeding in patients with a history of malignancy should always alert the physician to consider the diagnosis of metastatic spread to the genital tract.

WUTH publication: Loss of donor responsiveness in T cells exposed to the fish oil derivative eicosapentaenoic acid

Citation: Transplant International. 2013, 26, 47
Author: Archer L.; Regan S.; Khan U.; Najam O.; Yonan N.; Saravanan P.; Fildes J.; Critchley W.
Abstract: Background: CD4+ T cells contribute significantly to allograft rejection and represent a primary target for immunosuppression. The fish oil constituent, eicosapentaenoic acid (EPA) has reported immunomodulatory properties, so we investigated the effect of EPA on T helper cell function and alloresponsiveness. Methods: Gas chromatography was used to determine EPA plasma membrane incorporation. Flow cytometry enumerated CD3+ CD4+ (CD45RA+/ -/RO+/-) T cells. Proteomic analysis of molecules involved in intracellular signalling was performed. The effect of EPA on CD4+ T cell antigen
specificity was determined via rapid CD154 capture and CD45RA/RO phenotyping following donor tissue-recipient CD4+ T cell culture. Results: EPA downregulated CD4+ T cell surface CD45RO expression (p = 0.012) and reduced donor antigen specificity, determined via CD154 analysis (p = 0.008). Cell viability was unaffected (p = 0.495); suggesting EPA acts purely at a functional level. The phosphorylation of intracellular
signalling kinases; STAT2, STAT5, STAT4, STAT1, AMPKalpha2, eNOS, HSP-27, p70- S6Kinase and RSK increased, whilst MEK, ERK, JNK, CREB, STAT3, STAT6 and mTOR decreased. Conclusion: EPA exerts a direct, immunomodulatory effect on CD4+ T cells. Alterations in STAT phosphorylation suggest regulatory T (Treg) cell development, as opposed to TH17. Downregulation of CD45RO, MEK, ERK, JNK and CREB and loss of CD154 following alloantigen exposure indicates EPA impairs T cell
alloresponsiveness. Treg development along with HSP27 and eNOS (assisted by AMPKalpha2) may suppress alloantigen specific T cell activation and induce antiinflammatory mediator release. EPA may represent an important therapeutic strategy to reduce graft rejection and other clinical pathologies.

WUTH publication: Lipoleiomyoma of the ovary-a rare tumour

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 268
Author: Mohammed R.O.; Kubwalo B.; Maurice Y.; Doyle M.
Abstract: Case A 62-year-old woman presented with intermittent lower abdominal pain with no bowel or urinary symptoms. She had a vaginal hysterectomy 25 years previously for prolapse. Pelvic USS showed an 8.5 cm complex pelvic mass posterior to the vaginal vault. Serum tumour markers (CA125 CEA and CA199) were normal. She underwent laparoscopic bilateral salpingo - oophorectomy. Macroscopic examination showed a large ovarian mass weighing 236 g with a rubbery cut surface and intact capsule. Microscopy showed interlacing spindle shaped cells and collagen with the presence of adipose tissue.
Immunochemistry revealed a strong reaction to desminand actin and a diagnosis of a lipoleiomyoma of the ovary was made. Discussion Primary leiomyoma is a rare tumour of the ovary and accounts for 0.5-1% of benign ovarian neoplasms. Lipoleiomyomas are even rarer with only about three cases reported in the English literature. In this case, the ovarian tissue was completely replaced by the tumour and there was no normal ovarian tissue visualised. The presence of smooth muscle cells which was strongly positive for desmin and the presence of fat lobules confirmed the diagnosis of a lipoleiomyoma in this patient. Adipose tumours of the ovary are very rare and mostly benign. Clinically, these tumours are asymptomatic and may cause discomfort when they attain a large size. They are often found in menopausal and post menopausal women. Structurally, lipoleiomyomas are microscopically similar to a leiomyoma with (Figure Presented) varying amounts of adipose tissue which may represent metaplasia. Lipoleiomyomas of the uterus are more common than that of the ovary where they are thought to represent uterine tumour metaplasia within a leiomyoma. Because of its rarity, this condition can pose diagnostic difficulty on clinical and radiological grounds and must be distinguished from more common pathology such as an ovarian fibroma. The presence of adipose tissue might also confuse pathologists. Another important differential is a leiomyosarcoma which its macroscopic appearance and clinical picture may imitate. Care must be taken to distinguish it from a penduculatedsubserosal parasitic fibroid which has lost its uterine attachment and is attached to the ovary. Treatment is surgical excision with an excellent prognosis.

WUTH publication: Laparoscopic subtotal hysterectomy for a 30-week sized uterus. Specimen extraction by open knife morcellation

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 601-602
Author: Minas V.; Chong D.; Aust T.
Abstract: Objectives To demonstrate the challenges and suggest practical tips and techniques when operating laparoscopically and needing to extract a very large specimen. Methods A 45-year-old woman presented with abdominal pressure symptoms arising from a 30-week size fibroid uterus (Figure). A laparoscopic subtotal hysterectomy was planned. Entry to the peritoneal cavity was achieved by direct optical entry through Palmer's point. A 10 mm laparoscope was used through a port placed right below the xiphisternum. Two lateral and an umbilical secondary ports were used. Subtotal hysterectomy and left salpingo-oophorectomy were performed using bipolar forceps, scissors and LigaSure. An Alexis O wound retractor was inserted through a 4 cm transverse suprapubic incision and the specimen was retrieved with open knife morcellation. Results Placement of the laparoscope port subxiphisternally provided a satisfactory view of the large specimen. Use of angled lenses helped significantly with access around the uterus. A subtotal hysterectomy was thus successfully performed laparoscopically. During the procedure it became clear that access to the left ovary was very limited to safely separate it from the uterus and preserve it. Thus, a decision to sacrifice the ovary was taken. The patient had been counselled preoperatively about this eventuality. The challenge of extracting the specimen was tackled by using a wound retractor, commonly used by general and
urologic surgeons, through a 4 cm suprapubic transverse incision. The specimen was retrieved by open morcellation with a scalpel. It weighed 1.6 kg. The patient made uneventful recovery and was discharged home on the third postoperative day. Conclusions Adjustments to usual laparoscopic techniques are required when dealing with a very large specimen. In our case, entry through Palmer's point, placement of the laparoscope port well above the umbilicus, use of angled lenses, use of a surgical wound retractor and
extraction by open knife morcellation made this procedure possible. The patient underwent a laparoscopic operation with a 4 cm suprapubic transverse incision instead of a large midline laparotomy which would normally be required. Open morcellation is a safe alternative when having to extract a large specimen which makes closed morcellation unsafe due to access limitations. On occasion it may be necessary to sacrifice one ovary when undertaking a laparoscopic hysterectomy for a large uterus; therefore the patient should be consented accordingly.

WUTH publication: Laparoscopic hemi hysterectomy with preservation of ovaries, a novel treatment option for Herlyn-Werner-Wunderlinch syndrome

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2012, 119, 205
Author: Myagerimath R.; Gul N.; Rowlands D.J.
Abstract: Introduction: Developmental anomalies of the mullerian duct system represent some of the most fascinating disorders that obstetricians and gynecologists encounter. Incidence rates vary between 0.1% and 3.5%. The Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital anomaly characterised by uterus didelphys with blind hemivagina and ipsilateral renal agenesis. Here we are presenting a case of HWW syndrome with ovarian endometrioma, an uncommon cause of abdominal pain and menstrual discomfort in an adolescent girl. Case report: A 13 year-old girl presented with history of abdominal discomfort and painful periods since menarche. Initial ultrasound pelvis suggested a Dermoid cyst, MRI scan showed a uterus didelphys with normal right horn and grossly distended left vagina. Congenital absence of left kidney and left ureter were reconfirmed on MRI scan. Examination under anaesthesia and laparoscopy confirmed normal right cervix, right hemiuterus, right tube, right ovary with a noncommunicating left hemi uterus, which had caused hematocolpos, hematometra, hematosalphinx, left ovarian endometrioma with adhesions and massive distention of left parametrium. The large parametrial swelling drained one litre of old blood. Following laparoscopic drainage of endometrioma she was treated with GnRH analogues and add back HRT for 3 months. Then she successfully underwent laparoscopic hemi hysterectomy with left salphingectomy and preservation of both ovaries. The upper part of left vagina was left open to reduce the risk of pseudocyst formation. The procedure and post operative recovery were uneventful and she is painfree. Discussion: HWW syndrome usually presents after menarche with progressive pelvic pain during menses secondary to haematocolpos. Awareness is necessary in order to diagnose and treat this disorder
properly before complications occur. Because of the wide variation in clinical presentations, mullerian duct anomalies may be difficult to diagnose. Accurate diagnosis and proper surgical management can be challenging. MRI is the preferred modality for the delineation of uterine malformation. Ipsilateral renal agenesis with a pelvic mass should raise the level of suspicion for HWW syndrome. When renal anomalies are encountered, a screening should also be made for congenital abnormalities of the reproductive tract and vice versa. Conclusion: HWW syndrome is a rare cause of abdominal pain and dysmenorrhoea in an adolescent girl. Accurate diagnosis and proper surgical management can be challenging but laparoscopic hemi hysterectomy with preservation of fertility and ovarian reserve is a possible best treatment option.

WUTH publication: Lack of effect of 8 weeks atorvastatin on microvascular endothelial function in patients with systemic sclerosis

Citation: Rheumatology (Oxford, England). 2010, 49(5), 990-996
Author: Sadik H.Y.; Moore T.L.; Vail A.; Murray A.; Anderson M.; Blann A.; Herrick A.L.
Abstract: The aim of this study was to test the hypothesis that statin therapy confers benefit on the microvasculature, including improving endothelial function, in patients with SSc. This was a randomized, parallel group, double-blind study, with assessments at baseline, 4 and 8 weeks. Thirty-six patients were randomly assigned to receive 8 weeks treatment with atorvastatin 20 mg/day or placebo. The primary end-point was endothelial-dependent vasodilation, as assessed by response to iontophoresis with acetylcholine chloride (ACh) as measured by laser Doppler imaging. Secondary end-points included endothelial-independent vasodilation, microvascular structure as assessed by videocapillaroscopy, von Willebrand factor, high-sensitivity CRP and plasma cholesterol. Eighteen patients were randomly assigned to atorvastatin and 18 to placebo. Eight weeks treatment resulted in no statistically significant differences in any of the outcome measures (other than cholesterol) between atorvastatin and placebo groups. The median area under the curve for ACh iontophoresis at baseline was 1569 perfusion units (PU).time in the atorvastatin group and 1450 PU.time in the placebo group, and at 8 weeks 2146 and 1822 PU.time, respectively. Mean difference (95% CI) at 8 weeks was 355 (-835, 1544) PU.time. Atorvastatin 20 mg/day, given for 8 weeks, was not associated with changes in microvascular function or structure. The large variation in outcome scores means that it is not possible to rule out an effect on the basis of this trial. Future studies should be of longer duration and include patients with early disease who are unlikely to have irreversible structural vascular disease. EudraCT, https://eudract.emea.europa.eu/, 2005-003775-21.

WUTH publication: Juxta CURES: An innovative method of providing compression for leg ulcer management

Citation: Wounds UK. 2014, 10(1), 64-70
Author: Lawrence G.
Abstract: Many patients with leg ulcers require compression therapy to help heal the wound, but often, patients find their treatment challenging and difficult to tolerate. Since the 1990s, the mainstay of treatment in the UK has been compression bandaging of one sort or another, alternatively, ulcer kits comprising of compression hosiery are an added choice. This article describes three case studies in which a leg ulcer compression system called Juxta CURES (medi UK) has been successfully used to provide therapeutic compression on patients for whom compression bandages or hosiery were found to be unsuitable, not
tolerated, or did not fit in with their lifestyle.

WUTH publication: Is possum a valid risk assessment model for predicting outcomes of major urological surgery?

Citation: International Journal of Surgery. 2013, 11(8), 724-725
Author: Farrell A.; Stephenson R.
Abstract: Introduction/Aim: NHS requirements for transparency and accountability in surgical outcomes require accurate and fair means of measuring performance. Crude mortality/morbidity rates may discriminate against surgeons operating on more complex cases. Risk prediction models such as POSSUM may enable post-operative outcomes to be viewed objectively. This audit aimed to determine whether POSSUM/P-POSSUM accurately predicts mortality/morbidity in patients undergoing major urological procedures. Methods: We reviewed POSSUM/P-POSSUM scores of 110 patients undergoing major urological surgery under a single surgeon. Observed and predicted post-operative complications and mortality were compared, measuring significance of differences using Chi-square analysis. Results: The mean P-POSSUM 30 day mortality risk was 4.86%, predicting 5 deaths throughout the sample. Observed mortality was 0(p = 0.0177). The mean POSSUM predicted morbidity risk was 50.96%, meaning we would have expected to observe 56 cases in which complications occurred. Observed morbidity was 43 (39%)(p = 0.0127). Conclusion: Although predictions of both mortality and morbidity were significantly over-estimated, the observed morbidity was proportional to stratified P-POSSUM predictions. Whilst further studies will be required to confirm or refute these findings more generally, the POSSUM and P-POSSUM predicted values
could have value as benchmarks to allow a fairer comparison of performance/safety between urological surgeons/ units.

WUTH publication: Ipsilateral cortical activation in fibromyalgia patients during brushing correlates with symptom severity

Citation: Clinical Neurophysiology. 2013, 124(1), 154-163
Author: Fallon N.; Chiu Y.H.; Li X.; Nurmikko T.J.; Stancak A.
Abstract: Objective: To evaluate cortical activation patterns during mechanical-tactile stimulation in fibromyalgia syndrome (FMS) patients and to correlate cortical activation changes with clinical symptoms. Methods: Nineteen female FMS patients and 18 matched, healthy control subjects underwent EEG examination during brushing stimulation of the right forearm. Participants rated any pain experienced and underwent a manual tender point scale (MTPS) examination. Amplitude changes of cortical rhythms during brushing were analysed in alpha (8-13. Hz) and beta (16-24. Hz) frequency bands. Results: Thirteen patients reported pain during brushing. Independent t-test comparison of event related desynchronisation (ERD) during brushing revealed a cluster of electrodes over ipsilateral (right) central-parietal region which demonstrated ERD in patients only. Clinical MTPS scores correlated with beta-band ERD in this cluster of electrodes. Beamformer analysis revealed a widespread array of source activations in patients, including bilateral insula and primary and secondary somatosensory cortices. Control subject source activations were limited to contralateral (left) hemisphere. Conclusions: Results indicate ipsilateral cortical activations in FMS patients, but not in healthy controls, during brushing. Ipsilateral ERD during brushing is associated with MTPS score suggesting abnormal processing of somatosensory input which may contribute to clinical pain. Significance: Altered functioning in FMS may reflect physiological changes in response to afferent somatosensory information manifesting in chronic pain. 2012 International Federation of Clinical Neurophysiology.

WUTH publication: Induction of abortion following radiofrequency ablation of the endometrium: A case report and search for evidence-based practice

Citation: European Journal of Contraception and Reproductive Health Care. 2014, 19(1), 66-70
Author: Khafizova L.; Minas V.; Alam M.A.
Abstract: Objectives Pregnancy following endometrial ablation is a rare event that carries significant risks to the mother. The majority of women elect to terminate such pregnancies. This brings into question which of the available methods should best be employed and what kinds of problems to anticipate. Case We present a case of a pregnancy following radiofrequency endometrial ablation that was terminated surgically and review the relevant English literature. Conclusions Medical or surgical abortion can be considered as primary methods of terminating a first trimester intrauterine pregnancy following endometrial ablation. The choice will depend on patient preference but also on the available expertise. Cervical stenosis and/or intrauterine adhesions may limit the effectiveness of these methods. In such cases methotrexate is an alternative option,
whereas hysterotomy or hysterectomy should be considered as final options. Counselling patients at the time of endometrial ablation regarding the need for contraception, even after prolonged periods of amenorrhoea is of paramount importance. Laparoscopic or hysteroscopic sterilisation can be offered together with endometrial ablation. 2014 The European Society of Contraception and Reproductive Health.

WUTH publication: Importance of communication skills and adopting a woman centred care approach when setting up a research project: A medical student's perspective

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 68
Author: Higgs C.; Edwards S.; Mwenechanya S.
Abstract: Background After finishing my second year at medical school I spent time with the research midwife at Arrowe Park Hospital while she set up the EMPOWAR study (Efficacy of Metformin in Pregnant Obese Women, A Randomised control Trial). Obesity is a significant problem both in pregnancy and the general population. One issue that needed addressing when recruiting for the study was that obesity can be a difficult and sensitive subject to approach for some women. Focus group approach Before the study was started, approaching women in the clinic waiting areas and asking the following questions aided on finding acceptable ways of discussing the study to women for recruitment: * How they would like obesity to be addressed * Would having multiple glucose tolerance tests (GTT) be an issue? (offering food after the test was requested) * Would they feel embarrassed by staff using callipers for skinfold thickness? Patients come
from diverse backgroun/ds with some not having a home phone or even a home. Mobile phones were therefore preferred mode of communication by most with the teenagers preferring text messaging. Women's perceptions of the study (in the antenatal clinic waiting areas) Will the drug be harmful to my baby like thalidomide? It was very important to make the women aware that metformin use is already well established and safely used in pregnancy. Information leaflets and posters clarified this further. Am I a guinea pig? Making the women feel important was very crucial especially that the study could not go ahead without them and that medicine cannot advance without research. The women were informed that participation was voluntary and that by participating in the study they are potentially benefiting many women in a similar situation in future. Team work between staff It was important to get strong team spirit from the start with everyone involved aware of their roles. A delegation log was thus established from the beginning. E-mail addresses and phone numbers were collected from all involved so they can be kept up-to-date as well as regular reminders at departmental meetings. The research midwife had a lot of administration work in organising this and I found that this was the most time consuming element of the whole set up process. Conclusion This was a very rewarding learning experience for me as I plan to do my intercalating studies. The importance of communication as the key driver to a successful study was obvious.

WUTH publication: Idiopathic massive fetal ascites and mildly elevated middle cerebral artery dopplers: A diagnostic dilemma

Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 137
Author: Chong D.M.; Mwenechanya S.; Bricker L.; Agarwal U.
Abstract: Introduction Fetal ascites is commonly associated with a number of causes; anemia, infection and aneuploidy being among the causes. Idiopathic massive fetal ascites is however very rare with only a few cases reported in the English literature. Case Study We report a case of a 38-year-old multiparous woman with two term deliveries. She was referred at 16 weeks after a screen positive test for Downs syndrome. After counseling she declined karyotyping. A 20 week anomaly scan showed mild ascites and mild pericardial effusion but no structural anomalies. A detailed fetal cardiac scan was normal as was a viral infection screen. Maternal antibody screen was also negative. By 28 weeks the pericardial effusion had resolved but the ascites was massive with no other signs of fetal hydrops. The middle cerebral artery peak systolic velocity (MCA PSV) was elevated at 54 cm/s. The umbilical artery Doppler, fetal growth and liquor volume were normal. Fetal cardiac echo was normal. Amniocentesis was accepted. Karyotype and microarray were normal, viral screen and cystic fibrosis test was negative. Despite the persistence of
massive ascites, serial ultrasound scans showed reassuringly normal growth and umbilical artery dopplers, with MCA PSV stable at 52-54 cm/ s. After the amniocentesis she developed anti -E antibodies with a titre of 1/3 which was too low to cause anemia. At 33 weeks she went into labour with ruptured membranes, she was therefore delivered after a course of steroids. Birthweight was 2575 g with good Apgar scores. Postnatal ultrasound scans showed moderate ascites and cardiac echocardiogram showed small PDA and PFO, likely secondary to prematurity and no other anomalies. HB was normal. The liver, biliary system, bladder, and hepato-portal vascular flow were all normal. The ascites resolved completely by day 7 and the baby was discharged home at day 17 of life. Conclusion Fetuses with isolated ascites, normal karyotype and negative infection screen carry a good prognosis, with spontaneous resolution of the ascites.

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WUTH publication: Idiopathic brachial plexus neuritis vs brachial plexus injury following laparoscopy. Can you spot the difference?

Citation: Gynecological Surgery. 2013, 10, S13-S14
Author: Minas V.; Thomas A.
Abstract: We report a case of idiopathic brachial plexus neuritis (IBN) following laparoscopic excision of endometriosis. The differential diagnosis between this non-position-related neuritis and brachial plexus injury is discussed. Introduction: IBN was reported in 1948 by Parsonage and Turner and presents with shoulder girdle pain followed by profound weakness. The syndrome is of unknown aetiology and has been described as a potential post-operative complication. In gynaecology there exists a report of IBN following hysteroscopic surgery. In the post-operative patient the appearance of IBNsymptoms may lead to misdiagnosis as they can be attributed to brachial plexus injury (BPI) due to peri-operative patient positioning. Material and Methods: A 37-year-old woman underwent laparoscopic excision of endometriosis. The operation was performed in Trendelenburg position. The patient's head was kept in a neutral position and her arms were placed straight by her side. She had an initially uneventful r Results: Clinical examination revealed wasting and weakness of the infra-spinatus muscle i.e. likely isolated supra-scapular nerve palsy in keeping with IBN. Magnetic resonance imaging showed atrophy of supra-spinatus and infra-spinatus left shoulder muscles without evidence of nerve compression. Nerve conduction studies confirmed the diagnosis of IBN. Recovery was enhanced with physiotherapy. Discussion: IBNmay complicate laparoscopic gynaecological surgery. It can be transiently debilitating for the patient and
distressing for the surgeon, with potential medico-legal implications if misdiagnosed as BPI. The diagnosis must be based on history, clinical examination, absence of evidence of nerve compression in MRI and confirmation by electromyographic studies.

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WUTH publication: Guideline for the diagnosis and management of myelofibrosis

Citation: British Journal of Haematology. 2012, 158(4), 453-471
Author: Reilly J.T.; Mcmullin M.F.; Beer P.A.; Butt N.; Conneally E.; Duncombe A.; Green A.R.; Michaeel N.G.; Gilleece M.H.; Hall G.W.; Knapper S.; Mead A.; Mesa R.A.; Sekhar M.; Wilkins B.; Harrison C.N.
Abstract: The guideline group regarding the diagnosis and management of myelofibrosis was selected to be representative of UK-based medical experts, together with a contribution from a single expert from the USA. MEDLINE and EMBASE were searched systematically for publications in English from 1966 until August 2011 using a variety of key words. The writing group produced the draft guideline, which was subsequently revised by consensus of the members of the General Haematology and Haemato-oncology Task Forces of the British Committee for Standards in Haematology (BCSH). The guideline was then reviewed by a sounding board of UK haematologists, the BCSH and the British Society for Haematology Committee and comments incorporated where appropriate. The criteria used to state levels and grades of evidence are as outlined in the Procedure for Guidelines commissioned by the BCSH; the 'GRADE' system was used to score strength and quality of evidence. The objective of this guideline is to provide healthcare professionals with clear guidance on the investigation and management of primary myelofibrosis, as well as post-polycythaemic myelofibrosis (post-PV MF) and post-thrombocythemic myelofibrosis (post-ET MF) in both adult and paediatric patients. 2012 Blackwell Publishing Ltd.

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WUTH publication: Falling mortality rates in type 2 diabetes mellitus in the Wirral Peninsula: A longitudinal and retrospective cohort population-based study

Citation: Postgraduate Medical Journal. 2012, 88(1046), 679-683
Author: Nwaneri C.; Bowen-Jones D.; Cooper H.; Chikkaveerappa K.; Afolabi B.A.
Abstract: Objectives: To determine the life expectancy and mortality rates in patients with type 2 diabetes mellitus when compared with the UK general population; to measure the years of life lost. Design: Longitudinal and retrospective cohort study. Setting: The Wirral Peninsula in the northwest of England. Participants: Total of 13 620 patients with type 2 diabetes mellitus on the Wirral Diabetes Register. Main Outcome measure: All-cause mortality, from 1 January 2000 to 31 December 2007. Results: Over the 8-year period of the study, there were a total of 16 692.5 person-years lived and 3888 deaths; 2041 (52.5%) males and 1847 (47.5%) females with corresponding mean ages at death of 75.6+10.3 years and 80.2+10.2 years, respectively. Although prevalence rates increased linearly (from 1.06% in 2000 to 4.39% in 2007) a decrease in mortality rates (from 117 to 46 per 1000 population) in both sexes was observed. This coincided with a progressive fall in cardiovascular risk factors in this population. A survival time curve of life lived until death showed that males had 8.0 years reduction in life span and females' life span was reduced by 9.6 years when compared with UK general population. In both sexes, life expectancy was reduced by between 2 and 11 years dependent on the age of diagnosis, with males showing a greater degree of reduction. Conclusion Type 2 diabetes mellitus is associated with a significant reduction in life expectancy, more markedly in men, and in those diagnosed before age 70 years. However, annual mortality rates have fallen progressively in our population and may contribute to longer survival and life expectancy in future years.

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WUTH publication: Expand your options with an MBA

Citation: Clinical Pharmacist. 2010, 2(6), 221-224
Author: Malson G.

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WUTH publication: Epidermoid cyst of testis: 3 cases of testicular mass with normal tumour markers

Citation: Journal of Pathology. 2013, 231, S43
Author: Azhar U.A.; Seneviratne R.H.
Abstract: Epidermoid cyst is a rare and non-teratomatous benign tumour of the testis. It cannot be differentiated reliably from the far more common malignant testicular mass on a clinical basis. Testicular epidermoid cysts are of two types, occurring through one of two possible lineages proposed; those of monodermal teratoma origin and those of invaginated mesothelial origin. Intratubular germ cell neoplasia is not reported in association with true testicular epidermoid cysts, which are defined, mainly by the absence of scarring and absence of any dermal appendages and sebaceous glands. We here by report three cases of
epidermoid cyst of testis in young boys aged 11, 14 and 18. In all three cases the clinical information on the form mentioned testicular mass with negative tumour markers. The histological examination showed a fibrous cyst capsule lined by well-differentiated squamous epithelium that surrounded a cavity of laminated keratin. Negative immunohistochemistry ruled out intratubular germ cell neoplasia in these cases. The absence of mesodermal and endodermal components distinguished this from dermoid cyst or teratomas. Radical orchiectomy has been extensively carried out earlier but some authors have lately encouraged testis-sparing surgery in adults.

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WUTH publication: Emergency transfer of patients into a neurosurgical intensive care unit

Citation: Anaesthesia. 2012, 67, 40
Author: Cliff D.; Loh N.H.W.
Abstract: High quality transfer of patients with brain injury improves outcome but is potentially hazardous if poorly executed [1]. Transfer to a specialised neurosurgical centre is urgent but priority should be given to thorough resuscitation before setting off. Patients with brain injury should be accompanied by a doctor of appropriate training and experience [1, 2]. Audit is crucial to improving standards of transfer [1]. This audit assessed the grade of doctor performing transfers, factors contributing to delays in arrival and any adverse
events occurring during transit to an ITU in a tertiary neurosurgical centre. Additionally, the quality of record keeping regarding transfer was examined. Methods A retrospective review of records completed by both transferring and receiving teams for every patient transferred into this tertiary neurosurgical intensive care unit between January 2009 and September 2011 was conducted. Results The total number of transfers performed was 519. Where the grade of doctor performing a transfer had been recorded, the distribution was: SHO 131 (42%), SpR 104 (34%), other 75 (24%). Of those transfers performed at night, 32 (52%) were performed by a junior trainee (SHO equivalent). The mean time taken to be ready to start a transfer at the admitting hospital was two hours 27 minutes. Mean time to commence the transfer once the ambulance had arrived was 30 minutes and mean journey time was 39 minutes. If the transfer was listed as 'time critical' and aimed to be completed within one hour, the mean transfer time was two hours 55 minutes. Adverse
events recorded during transfer were; cardiovascular instability (nine incidences), equipment failure (eight), development of new focal neurology (eight), an intubated patient arriving without or with inadequate sedation (eight) and intubated patients being transferred with no end tidal CO2 monitoring (three). Data relating to the identity of the transferring or receiving team was found to be missing frequently (29 incidences). Other
important omissions in record keeping included documentation of drugs given during transfer (12 incidences), vital signs (three), diagnosis (eight) and transfer timings (11). Discussion Substantial numbers of patient transfers are being performed by junior, potentially inexperienced trainees. This includes transfers undertaken at night when less senior assistance is available at both sending and receiving hospitals. Delays in arrival are
largely due to patient treatment in their presenting hospital which is deemed to take priority over an expedient transfer [1,2]. Adverse events are relatively common during transit and include both expected events relating to physiological instability in an acutely unwell patient but also the potentially avoidable issues of equipment failure and poor transfer technique. Logging of data by those transferring patients is often inadequate.

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WUTH publication: Early morning salivary cortisol and cortisone, and adrenal responses to a simplified low-dose short Synacthen test in children with asthma

Citation: Clinical Endocrinology. 2014, 80(3), 376-383
Author: Blair J.; Lancaster G.; Titman A.; Peak M.; Newlands P.; Collingwood C.; Chesters C.; Moorcroft T.; Wallin N.; Hawcutt D.; Gardner C.; Didi M.; Lacy D.; Couriel J.
Abstract: Objective: To examine serum cortisol responses to a simplified low-dose short Synacthen test (LDSST) in children treated with inhaled corticosteroids (ICS) for asthma and to compare these to early morning salivary cortisol (EMSC) and cortisone (EMSCn) levels. Design: Early morning salivary cortisol and EMSCn samples were collected for three consecutive days. On day three, Synacthen 500 ng/1.73 m² was administered intravenously. Samples were collected at 0, 15, 25, 35 min. Results: A total of 269 subjects (160 M: 109 F), median (range) age 10.0 (5.1-15.2) years were studied. Peak cortisol in the LDSST was <500 nmol/l in 101 subjects (37.5%) and <350 nmol/l in 12 subjects (4.5%). Basal cortisol correlated with peak cortisol: r = 0.55, (95% CI: 0.46, 0.63, P < 0.0001). Time at which peak cortisol concentration was achieved was significantly related to the value of peak cortisol (P < 0.0001), with higher cortisol peaks occurring later in the test and lower cortisol peaks occurring earlier. EMSC and EMSCn had no predictive value for the identification of patients with a peak cortisol < 500 nmol/l. EMSCn was superior to EMSC in identifying patients with a peak cortisol < 350 nmol/l: a minimum EMSCn cut-off value of 12.5 nmol/l gave a negative predictive value of 99.2% and positive predictive value of 30.1%. Conclusion: Our data illustrate that basal measures of cortisol are likely to be of value in screening populations for patients at greatest risk of adrenal crisis. EMSCn shows promise as a screening tool for the
identification of patients with severe adrenal insufficiency. 2013 John Wiley & Sons Ltd.

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WUTH publication: Diagnostic difficulty: Myeloid sarcoma masquerading as pyoderma gangrenosum

Citation: British Journal of Dermatology. 2014, 170(3), e11-e12
Author: Cutts L.; Brown P.
Abstract: Myeloid sarcoma (MS) is an extramedullary solid tumour of myeloid precursor cells, which most commonly occurs in the presence of acute or chronic myeloid leukaemias. Cases where a diagnosis of MS precedes that of the haematological disease are known, and reports have shown that it can infiltrate a variety of sites such as the orbit, lungs and gastrointestinal tract (Klco JM, Welch JS, Nguyen TT et al. State of the art in myeloid sarcoma. Int J Lab Hematol 2011; 33: 555-65). We present the case of a 69-year-old man
with myelodysplastic syndrome (MDS), which was being managed with azacitidine and regular transfusions. The patient presented with a 1- month history of three necrotic leg ulcers. These were initially thought to be pyoderma gangrenosum (PD) and were treated with minocycline, given the increased risk of immunocompromisation. The initial skin biopsy was reported as inconclusive, and the lesions continued to be managed as PD. Four months later, after the ulcers showed no sign of resolution, a repeat biopsy was
performed, which demonstrated a leukaemic skin infiltrate, highly suggestive of MS. Once this diagnosis was confirmed, our patient was admitted for daunorubicin and cytarabine chemotherapy and the appearance of his lesions improved. This case highlights the importance of reinvestigation of skin disease associated with underlying MDS. This is of particular relevance with regards to MS, as cutaneous manifestations can precede the underlying haematological diagnosis. A diagnosis of MS can also indicate a relapse in patients previously treated for acute myeloid leukaemia, and can herald a blastic transformation of MDS that requires more intensive therapy (Campidelli C, Agostinelli C, Stitson R, Pileri SA. Myeloid sarcoma: extramedullary manifestations of myeloid disorder. Am J Clin Pathol 2009; 132: 426-37).

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WUTH publication: "Current performance of ERCP in the clearance of bile duct stones in UK centres-working towards robust key performance indicators"

Citation: Gastrointestinal Endoscopy. 2014, 79(5, SUPPL. 1), AB230
Author: Wadsworth C.A.; Dwyer L.K.; Paranandi B.; Mahmood S.; Johnson G.J.; Chapman M.; Pereira S.P.; Stern N.; Singhal A.; Webster G.; Sturgess R.
Abstract: Background: 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. Aim: To quantify current performance in a potential new endoscopic KPI: the complete clearance of CBD stones at first ERCP. Method: Three centres participated in the study-one secondary and two tertiary HPB units. All patients undergoing first ERCP for confirmed or suspected choledocholithiasis over a twelve month period were included, 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 or supervising the procedure. A range of patient and endoscopist factors were recorded. Results: 592 patients were included in the study. 10 consultant endoscopists carried out or supervised the procedures. Overall, deep biliary cannulation was achieved in 536/592 (91%, range for three units 82-95%, p<0.05). Complete bile duct
clearance at first ERCP was achieved in 447/592 (76%, 66-81%, p<0.05). Endoscopist factors associated with success included larger annual ERCP caseload. Patient factors included low stone burden and normal ampullary anatomy. Clopidogrel use and acute pancreatitis were associated with lower chance of success. Discussion: We investigated the outcome of nearly 600 ERCP procedures, representing real-life practice in UK centres. Duct clearance was possible at first ERCP in three quarters of patients. There were significant differences in performance between units, and between individual clinicians. The reasons for this are not fully elucidated, but there is an association between larger ERCP caseload and success. 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 focussed on patient outcome. In addition, it quantifies performance in the commonest indication for ERCP, stone extraction, which is undertaken in all ERCP units. Although an acceptable success rate cannot be extrapolated from this data, it appears that a rate of O65% should be achievable. A larger study, including further centres, is underway.

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WUTH publication: Corneal protection during general anesthesia for nonocular surgery

Citation: Ocular Surface. 2013, 11(2), 109-118
Author: Grixti A.; Sadri M.; Watts M.T.
Abstract: Corneal abrasion is the most common ophthalmologic complication that occurs during general anesthesia for nonocular surgery. Such abrasions can be caused by a variety of mechanisms and can lead to sightthreatening microbial keratitis and permanent scarring. There is no standard mode of protecting the cornea during general anesthesia for nonocular surgery. Methods described in the literature are not entirely effective and may be associated with unwanted side effects. Taping alone provides protection that is  equivalent or superior to other interventions and has fewer side effects. Petroleum gel is flammable and is best avoided when electrocautery and open oxygen are to be used around the face. Preservativefree eye ointment is preferred, as preservative can cause corneal epithelial sloughing and conjunctival hyperemia. Recently, the application of Geliperm and bio-occlusive dressings has been advocated. Geliperm may be particularly useful during endonasal surgery when continuous perioperative observation of the eye is required. In this article, the literature on the etiology of perioperative corneal abrasions is reviewed and various protection strategies are compared in order to identify the best methods to prevent corneal abrasions during general anesthesia. 2013 Elsevier Inc.

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WUTH publication: Core temperature changes following lower limb tourniquet deflation in patients receiving sub-arachnoid anaesthesia for knee arthroplasty

Citation: Anaesthesia. 2012, 67, 77
Author: Cliff D.; Tierney J.; McGrath C.
Abstract: The detrimental effects of even mild perioperative core hypothermia are well known and wide-ranging, including increased wound infection, cardiac morbidity, blood transfusion requirement and longer hospital stay [1]. Pneumatic tourniquets are commonly used during limb surgery to reduce blood loss and improve the quality of the surgical field. A significant fall in core temperature following limb tourniquet release has been demonstrated in patients undergoing general or epidural anaesthesia, presumably due to redistribution of body heat and efflux of hypothermic blood from the tourniqueted limb[2, 3]. Sub-arachnoid anaesthesia is a commonly used method for lower limb orthopaedic procedures including knee arthroplasty, with beneficial effects including lower incidence of deep vein thrombosis and a potential increased cost effectiveness when compared to general anaesthesia[4]. Methods Having gained approval from the regional ethics committee, and participants' written informed consent, a prospective observational study was conducted. Twenty patients undergoing elective primary unilateral knee arthroplasty with use of a lower limb pneumatic tourniquet under sub-arachnoid anaesthesia and with conscious sedation via a propofol target controlled infusion were recruited. During surgery, core temperature was attempted to be maintained between 36.5 - 37.5 degreeC using warmed intravenous fluid and a forced air warming blanket. At the end of surgery, warming methods were continued and core body temperature was observed at the time of
tourniquet release and then for the following ten minutes. Data was analysed using a multiple dependent samples t-test. Results Mean core temperature at tourniquet deflation was 36.25oC (SD 0.44). Mean maximal core temperature drop was 0.13oC (SD 0.12). Any change in core temperature after tourniquet release was not significant (p= 6.62). Discussion Our study would suggest a potential benefit from use of subarachnoid anaesthesia in avoidance of core hypothermia associated with tourniquet release when compared to epidural or general anaesthesia. A further study with a larger number of patients would be indicated to investigate this.

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WUTH publication: Calculating the prevalence of 1st MTP joint arthritis in the subclinical population using X-ray analysis

Citation: International Journal of Surgery. 2013, 11(8), 670
Author: Cowan C.; Howard N.; Platt S.
Abstract: Osteoarthritis of the 1st metatarsophalangeal joint (MTPJ) is one of the commoner disorders affecting the foot. Despite the presence of many studies looking to correlate the X-ray appearance of established Hallux Rigidus with clinical findings, no population-based studies exist to explore its prevalence in the normal population. Methods: 352 consecutive radiographs were used in adult patients who presented to A&E requiring foot x-ray. These were assessed independently by the 2 authors using the Hattrup and Johnson grading system. Discrepancies were referred to a radiologist for grading. Results: The radiographic prevalence of MTPJ arthritis in our population was 23.6% (23.6% grade 1, 5.7% grade 2 and 1.4% grade 3). (21.1% males vs 25.2% female). Prevalence markedly increased with age and was significantly increased over the age of 60 (RR=4.6, 95% CI 3.2 to 6.5, p<0.0001). Incidence was also significantly higher in females with an overall incidence of 9.5% in males and compared to 23.0% in females (RR = 2.1, 95% CI 1.1 to 3.9, p=0.01). Conclusion: The results of this study suggest the incidence of the disease significantly increases over the age of sixty and is significantly more common in females (ratio 2:1) as has previously been reported in the literature.

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WUTH publication: Audit on the anaesthetic antenatal clinic, how obesity is impacting our service, with comparison across merseyside

Citation: Anaesthesia. 2013, 68, 9
Author: Davies J.E.; Frias-Jimenez C.
Abstract: The prevalence of obesity in pregnancy is increasing, and is a significant risk factor for anaesthetic related maternal mortality [1]. The CMACE/RCOG guidelines recommend that pregnant women with a booking BMI >40 have a consultation with an obstetric anaesthetist to enable potential difficulties to be identified and formation of a management plan [2]. Methods All letters from the anaesthetic antenatal clinic for 2010 were retrospectively reviewed and data collected on: reason for referral, coexisting medical problems, and BMI. Information on anaesthetic involvement during delivery in those seen with morbid obesity was collected using computer records and the theatre logbook. A telephone satisfaction survey was done on 10% of patients. To compare our clinic with the surrounding hospitals in Merseyside, similar data was collected from 4 district general hospitals (DGH) and the tertiary obstetric unit. Results The anaesthetic
antenatal clinic at WUTH saw 211 patients in 2010, which corresponds to 6% of the obstetric population in our area; this is higher in comparison to surrounding units (2.9-4.6%). A much greater proportion of referrals were due to obesity at our clinic (74%), compared to surrounding hospitals where rates were between 40-58%, despite similar BMI thresholds for clinic referral. All of the hospitals in the area with the exception of one DGH had a threshold for referral set at BMI 40 or below. The average BMI of those referred for obesity was 40-44, which was similar throughout the region. Coexisting medical conditions were present in 74 (47%) of those referred for obesity, the commonest being asthma and diabetes. Anaesthetic involvement in labour occurred in 59 (53%) of the obese referrals, of which 30% had an epidural. The telephone satisfaction survey revealed that 90% found the consultation helpful with 76% feeling more confident about delivery afterwards. Failure to attend rates ranged across the region between 7-20%. Discussion WUTH has 3544 deliveries annually, and serves an area with wide health inequalities; life expectancy for women in the most deprived areas of the Wirral is 9.7 years lower in comparison to the least deprived [3]. This data suggests there is a greater proportion of obesity in the obstetric population in Wirral compared to
surrounding units in Merseyside. A re audit is planned to monitor the changes within the clinic, if obesity rates continue to rise this will impact on the number of clinic sessions required. With 53% of morbid obese parturients having anaesthetic involvement in labour, and rising obesity rates nationwide, there is a significant impact on obstetric and anaesthetic services.

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