WUTH publication: Tolerability and Adherence Problems in Patients on a Stable Dose of Methotrexate: Results of a Multicentre Survey

Citation: Musculoskeletal Care. 2016, 14(3), 152-5. Epub 2015 Dec 8
Author: Robinson S, Gibson S, George E, Martin U, Heslop P, Wrightson H, Prowse P, Kalinowski M, Marshall D, Reed M, Adebajo A, Walker D
Abstract:  INTRODUCTION: Methotrexate is commonly used in patients with inflammatory arthritis. The aim of the present study was to ascertain the prevalence of side effects that patients on methotrexate were tolerating and to establish their adherence to the medication.
METHOD: A questionnaire was developed for completion by the healthcare professional with the patient, and piloted in one centre. The questionnaire was then used in six other centres, with the addition of a question about the attractiveness of stopping methotrexate treatment. Efficacy and toxicities were scored for severity on a 10-cm visual analogue scale (VAS). Adherence to the drug was also explored.
RESULTS: The prevalence of 'any side effect' ranged from 57% to 86%. The most frequent side effects were fatigue (53%); nausea (38%); mouth ulcers (23%) and hair loss (23%). Efficacy averaged 6.5 cm on the VAS. Results from the combined survey revealed that toxicity averaged 5.9 cm for fatigue, 4.8 cm for nausea, 4.4 for mouth ulcers, 3.9 cm for hair loss and 5.7 cm for 'other' side effects. 13.5% of patients revealed that they had forgotten to take the drug for an average of two weeks, and 25% for an average of 2.5 weeks in the previous year. Participants were more likely to reveal this to a nurse than a doctor.
CONCLUSION: Patients put up with a considerable number of side effects in order to benefit from methotrexate therapy. Adherence to this drug merits further study. Copyright © 2015 John Wiley & Sons, Ltd.

KEYWORDS: Methotrexate; adherence; side effects; tolerance

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WUTH publication: An Alternative Technique for External Fixation of Traumatic Intra-articular Fractures of Proximal and Middle Phalanx.

Citation: Techniques in hand & upper extremity surgery. 2015, 19(4), 163-167
Author: Kapur, Benjamin; Paniker, Jayanath; Casaletto, John
Abstract: BACKGROUND: Intra-articular fractures of the proximal interphalangeal (PIP) joint are commonly treated with dynamic external fixation. Most commonly used is the Suzuki modification of the pins and rubber traction system (PRTS). There are a few other modifications of the PRTS external fixators. We present an alternative pin external fixator that is simple and effective.
METHODS: Under a suitable anesthesia and image intensification a true lateral view of the head of the proximal phalanx is obtained. A K-wire construct holds the affected digit out to length with the fracture reduced and Jurgan pin-balls hold the construct into position. Under image intensification the whole device is checked to ensure the joint and fracture is reduced and the joint is not over distracted. The PIP joint is also checked to ensure good range of motion. The device was checked in clinic at 1 week with radiographs. The wires are removed at 4 weeks followed by intensive hand physiotherapy.
RESULTS: Over 20 patients with intra-articular fractures of the proximal and middle phalangeal were treated with this technique. In all cases the fracture healed with good joint congruency. All patients achieved good range of motion of the PIP joint but with some restriction of full flexion (mean, 20 degrees). There was no loss of position or pin-site infections. There was good compliance with the treatment.
DISCUSSION: The main advantages of the technique we describe are: (1) the compact design, making it less cumbersome for the patient compared with other PRTS external fixators; (2) it is straightforward to assemble and the device is easy to adjust in clinic if there is any loss of reduction; (3) the pin-balls prevent sharp ends of the wire protruding causing morbidity to the patient; (4) there is less chance of loss of traction compared with traction devices using rubber bands. It is a dynamic device, which allows mobilization of the joints reducing stiffness

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WUTH publication: The introduction of an outpatient hysteroscopic polyp morcellation clinic at a district general hospital

Citation: Gynecological Surgery. 2015, 12(1) SUPPL. 1(S395-S396), 1613-2076
Author: Gillian S.; Alam M.
Abstract:  Background Endometrial polyps are a common hysteroscopic finding when investigating
women with abnormal uterine bleeding. They have been found in up to 40% of
symptomatic pre- menopausal women and are associated with menorrhagia, metrorrhagia,
intermenstrual bleeding and subfertility. They are also associated with post- menopausal
bleeding and found in women with malignant tissue changes.(1) In symptomatic women
who undergo polypectomy, it is reported that there is 75%-100% improvement. For
women who are asymptomatic , a polypectomy is recommended for those with risk
factors for endometrial cancer.(2) The introduction of hysteroscopic polyp morcellation
has allowed for a fast, safe and convenient procedure to remove polyps within an
outpatient setting. The use of small scopes, minimal dilatation and little or no local
anaesthetic has impoved the experience for patients and medical staff.(1) At Arrowe Park
Hospital we have introduced polyp morcellation using Hologic Myosure tissue removal
system and Aquilex fluid control system Methods Aim To review the implementation and
outcomes of a Myosure hysteroscopic polypectomy clinic within our outpatient
department performed by consultant and nurse practitioner Method A retrospective data
collection of patients who attended the clinic between September 2014 and May 2015
Results 28 patients were referred to the clinic. 4 patients had not undergone previous
hysteroscopy and were found not to have a polyp, 1 patient refused treatment and was
listed for general anaesthetic. 22 patients had successful polypectomy and 1 patient had
partial polypectomy due to loss of vision. All patients tolerated procedure well and left
clinic within 10 minutes of finishing. There were no complications during or following
polypectomy. 1 histology was reported as atypical hyperplasia, 21 were benign polyps,1
was benign fibroid Conclusions Myosure polypectomy is proving to be a fast, efficient,
safe and well tolerated procedure that is easily performed within an outpatient setting
allowing fast recovery and minimal disruption for patients.

WUTH publication: Conversion of abdominal hysterectomy to laparoscopic hysterectomy-the reverse paradigm. 5 year experience of a large UK district teaching hospital between 2010/11 and 2014/15

Citation: Gynecological Surgery. 2015, 12(1) SUPPL. 1(S471), 1613-2076
Author: Rowlands D.; Gul N.; Minas V.; King S.
Abstract: Background The EVALUATE study previously reported that for benign conditions and small moderatety enlarged uteri that vaginal hysterectomy was preferable to abdominal or
laparoscopic hysterectomy. And that laparoscopic hysterectomy is preferable to
abdominal. We have previously reported (RCOG World Congress 2015) that <8% of
hysterectomies performed in our unit in a sample size of 327 of 1258 hysterectomies
performed in our unit between 1/1/2010 and 31/12/14 would have been eligible for the
EVALUATE study. We postulate that this is as a consequence of less invasive treatments
such as endometrial ablation and the Mirena IUS. In the UK, despite evidence, the
majority of hysterectomies are still performed abdominally. We describe the difference
that a cultural attitude to laparoscopic surgery has had in reducing our abdominal
hysterctomy rates to under 10% . Methods Review of all hysterectomies performed at
Wirral University Teaching Hospital 1/1/2010 - 31/12/2010 and 1/1/2014 - 31/12/2014 by
type. There were no exclusions . Hysterectomies performed for ovarian cancer, cervical
cancer and high grade endometrial cancer are performed in the Regional Cancer Centre.
Results Results will show an extremely low abdominal hysterectomy rate which has
further fallen within this 5 year period as a consequence of training and education within
the unit. The unit has an inclusive approach towards safe laparoscopic surgery with an
ethos not to perform abdominal procedures wherever possible. With retirements, new
appointments, and education and traing we present results which we believe are
unparalleled in any other UK large hospital but demonstrate that with commitment
support and education we believe this is possible anywhere. Conclusions Abdominal
hysterectomy is in many cases an unnecessary major operation which can be succesfully
and safely achieved through minimal access surgery in almost all cases

WUTH publication: ANNALS EXPRESS: Validation of Serum Free Light Chain Reference Ranges in Primary Care Patients

Citation: Annals of Clinical Biochemistry. 2015 Nov 13
Author: Galvani L, Flanagan J, Sargazi M, Neithercut WD
Abstract: BACKGROUND: The demand for measurement of serum immunoglobulin free kappa (κ) and lambda (λ) light chains has increased. The κ:λ ratio is used to assist in diagnosis/monitoring of plasma cell disorders. The Binding Site reference range for serum free light chain (FLC) κ:λ ratios of 0.26-1.65 was derived from healthy volunteers. Subsequently a reference range of 0.37-3.1 for patients with chronic kidney disease (CKD) has been proposed. Elevated FLC concentrations and borderline raised FLC ratios also may be found in polyclonal gammopathies and with other non-renal illnesses. This assessment was conducted to validate the established FLC reference ranges in individuals from primary care.
METHOD: A total of 130 samples were identified from routine blood samples collected in primary care for routine biochemistry testing and eGFR calculation.
RESULTS: The median and range of κ:λ ratios found in each eGFR group used for CKD classification was higher than previously described. This was the case for individuals with normal or essentially normal renal function with eGFRs > 90, (0.58-1.76) and eGFR of 60-90 mL/min/1.73m², (0.71-1.93). Individuals with eGFR 15-30, (0.72-4.50) and eGFR <15ml/min/1.73m² (0.71-4.95) also had higher values when compared to the current renal reference range of 0.37-3.10.
CONCLUSIONS: Elevation of FLC-κ:λ ratios may occur in the absence of a reduced renal function shown by a normal eGFR and in the presence of reduced renal function by eGFR when comparing results with the established reference ranges. Explanations include choice of analytical systems or the presence of other concurrent non plasma cell illness

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‘New look’ Evidence Alerts

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WUTH publication: A simple technique to achieve parallel transverse cuts in the scarf osteotomy

Citation: Annals of the Royal College of Surgeons of England. 2015, 97(3), 238-9
Author: Brookes-Fazakerley SD, Platt SR, Jackson GE

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WUTH publication: 'Rain chain' for ankle arthroscopy

Citation: Annals of the Royal College of Surgeons of England 2015, 97(5), 397
Author: Ramavath AL, Geary N

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WUTH publication: Where are we with RSV prophylaxis?

Citation: Archives of Disease in Childhood. Education and practice edition. 2016, 101(1), 38-42
Author: Caldwell NA, Townsend C
Abstract: Respiratory syncytial virus (RSV) is a predictable, seasonal disease with significant morbidity and mortality in children below 24 months. Prophylaxis, which decreases hospitalisation in those most vulnerable to the disease, has been available since 1998. Pharmacological prophylaxis is however, expensive and requires good infrastructure to deliver. It is out of reach for many patients in low-income and middle-income countries where mortality is highest. This article looks at the pathophysiology and risk factors for RSV. It also outlines what agents are currently available for prophylaxis and prevention.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
KEYWORDS: General Paediatrics; Immunisation; Infectious Diseases; Virology

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