WUTH publication: Neonatal IVC thrombosis in a baby born to an aPL positive mother - a case report

Citation: Lupus. 2023 Jan 23, Online ahead of print
Author: Smriti Ramakrishnan, Azhar Abbas, Natasha Jordan  

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WUTH publication: Prevalence of Potentially Clinically Significant Drug-Drug Interactions With Antiretrovirals Against HIV Over Three Decades: A Systematic Review of the Literature

Citation: Journal of acquired immune deficiency syndromes. 2023, 92(2), 97-105
Author: Daryl Hodge, Eva Maria Hodel, Elen Hughes, Phoebe Hazenberg, Sandra Grañana Castillo, Sara Gibbons, Duolao Wang, Fiona Marra, Catia Marzolini, David Back, Saye Khoo
Abstract: Background: Contemporary first-line antiretrovirals have considerably reduced liability for clinically significant drug-drug interactions (DDI). This systematic review evaluates the prevalence of DDI among people receiving antiretrovirals across 3 decades.
Methods: We searched 3 databases for studies reporting the prevalence of clinically significant DDIs in patients receiving antiretrovirals published between January 1987 and July 2022. Clinically significant DDIs were graded by severity. All data extractions were undertaken by 2 independent reviewers, adjudicated by a third.
Results: Of 21,665 records returned, 13,474 were duplicates. After screening the remaining 13,596 abstracts against inclusion criteria, 122 articles were included for full-text analysis, from which a final list of 34 articles were included for data synthesis. The proportion of patients experiencing a clinically significant DDI did not change over time (P = 0.072). The most frequently reported classes of antiretrovirals involved in DDIs were protease inhibitors and non-nucleoside reverse transcriptase inhibitors; of note, integrase use in the most recent studies was highly variable and ranged between 0% and 89%.
Conclusions: The absolute risk of DDIs has not decreased over the period covered. This is likely related to continued use of older regimens and an ageing cohort of patients. A greater reduction in DDI prevalence can be anticipated with broader uptake of regimens containing unboosted integrase inhibitors or non-nucleoside reverse transcriptase inhibitors.

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WUTH publication: Evaluation of Drain Insertion After Appendicectomy for Complicated Appendicitis: A Systematic Review and Meta-Analysis

Citation: Cureus. 2022, 14(11), e32018
Author: Abduelraheim Abu, Ali Yasen Mohamedahmed, Amin Alamin, Mazin Mohamed, Mohamed Osman, Mohammed Jibreel Mohammed, Hiba Abdalla, Hazim A Eltyeb, Omer Ali, Rifat Mohamad, Safaa Hamid, Shaza Faycal Mirghani, Yousif Hamad, Hussam Khougali Mohamed 
Abstract: This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. A systematic search of PubMed, Cochrane Library and Scopus was conducted, and all studies comparing drain versus no drain after appendicectomy for complicated appendicitis were included. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included. There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36). In conclusion, this meta-analysis has shown that drains have no effect on the development of intra-abdominal collections in complicated appendicitis, but it can significantly increase the risk of postoperative complications such as fistula, surgical site infection (SSI), bowel obstruction, ileus and length of hospital stay.
Keywords: drain insertion; intra-abdominal abscess; intra-abdominal collection; postoperative ileus; ruptured appendicitis.

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WUTH publication: The Validation of Surgical Simulators: A Technical Report on Current Validation Terminology as a Reference for Future Research

Citation: Cureus. 2022, 14(11), e31881
Author: Thomas Hughes, Joseph T Fennelly, Rakesh Patel, Jonathan Baxter 
Abstract: In recent years, surgical trainees have been exposed to a lower volume of operative procedures. In part, this is due to the reduction in working hours and further disruption by the coronavirus disease 2019 pandemic. Much has been done to develop the techniques of surgical skill training outside of the operating theatre. Simulation-based interventions must undergo a process of validation to assess their appropriateness and effectiveness for use in training. The terminology of validation within current literature, however, has not evolved in line with the education community, resulting in varying definitions for the same phrase across domains. This can result in confusion and misinterpretation among researchers and surgeons working within this domain. This technical report describes the "types of validity" definitions used in the traditional framework of surgical simulation literature and the contemporary, unitary framework of validity adopted by educationalist theorists. There is a clear overlap between the traditional "types of validity" and the contemporary, unitary framework. The divergence in the use of those definitions seems, at least partly, influenced by the context of the investigations being conducted. By utilising the contemporary definitions, authors may have struggled to provide the evidence required to justify the use of the multitude of surgical skill simulators developed in the recent past. This report has provided an overview of the current terminology within the validation frameworks and can be used as a reference for future surgical simulation research.
Keywords: simulation education; simulation in medical education; surgical training; terminology; validation.

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WUTH publication: Removal of breast implants as primary treatment for autoimmune/inflammatory syndrome induced by adjuvants

Citation: Scandinavian Journal of Rheumatology. 2022, Sep 30, 1-2
Author: S Ramakrishnan, A Abbas, N Jordan 

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WUTH publication: Safety and effectiveness of ustekinumab in elderly Crohn's disease patients

Citation: European Journal of Gastroenterology and Hepatology. 2022, 34(11), 1132-39
Author: Joseph Fiske, Eleanor Liu, Jimmy K Limdi, Thomas E Conley, Tristan Townsend, Mike Davies, Robert Brockwell, Daniyal Baig, Sherif Abdelbadiee, Anastasia Uney, Angela Liaros, Waqas Gaba, Philip J Smith, Paul K Flanagan, Sreedhar Subramanian
Abstract: Objective: Anti-tumour necrosis factor (TNF) agents are associated with increased infection risk among elderly IBD patients, but little is known about non anti-TNF biologics in this cohort. We examined the safety and effectiveness of ustekinumab in elderly Crohn's patients.

Methods: This retrospective multi-centre cohort study included Crohn's patients ≥60-years old who commenced ustekinumab. We recorded Harvey-Bradshaw index (HBI), concomitant steroid therapy, treatment persistence and new infections or malignancies. Primary outcome was serious infections requiring hospitalisation.

Results: Seventy patients were included, with median age of 68 years. 43 (61.4%) had prior anti-TNF exposure, and 15 (21.4%) vedolizumab. Median treatment duration was 12 months, totalling 84 patient-years. Nine serious infections were reported, incidence 106.7/1000 patient-years. Systemic steroids were associated with increased risk of serious infections [odds ratio (OR) 7.83, 95% confidence interval (CI): 1.44-44.32, P = 0.02]. There were 27 "non-serious" infections; 321.4/1000 patient-years. Charlson co-morbidity index (OR 1.49, 95% CI: 1.05-2.12, P = 0.03) and steroid exposure (OR 44.10, 95% CI: 1.75-1112.10, P = 0.02) increased non-serious infection risk (P < 0.05). Mean HBI improved from 8.13 to 4.64 at 6 months and 4.10 at last follow up (P < 0.0001). 12-month treatment persistence was 55.7% (N = 39); 34 (48.6%) were steroid-free.

Conclusion: Ustekinumab was safe and effective in a cohort of elderly Crohn's disease patients. Infections were mostly mild, not resulting in therapy discontinuation. Serious infection risk was comparable to previously reported rates with anti-TNF agents. Steroid exposure was associated with an increased serious infection risk.

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WUTH publication: Pregnancy and neonatal outcomes of COVID-19: The PAN-COVID study

Citation: European Journal of Obstetrics, Gynecology and Reproductive Biology. 2022, 276, 161-7
Author: E Mullins, A Perry, J Banerjee, J Townson, D Grozeva, R Milton, N Kirby, R Playle, T Bourne, C Lees, PAN-COVID Investigators
Abstract: Objective: To assess perinatal outcomes for pregnancies affected by suspected or confirmed SARS-CoV-2 infection.
Methods: Prospective, web-based registry. Pregnant women were invited to participate if they had suspected or confirmed SARS-CoV-2 infection between 1st January 2020 and 31st March 2021 to assess the impact of infection on maternal and perinatal outcomes including miscarriage, stillbirth, fetal growth restriction, pre-term birth and transmission to the infant.
Results: Between April 2020 and March 2021, the study recruited 8239 participants who had suspected or confirmed SARs-CoV-2 infection episodes in pregnancy between January 2020 and March 2021. Maternal death affected 14/8197 (0.2%) participants, 176/8187 (2.2%) of participants required ventilatory support. Pre-eclampsia affected 389/8189 (4.8%) participants, eclampsia was reported in 40/ 8024 (0.5%) of all participants. Stillbirth affected 35/8187 (0.4 %) participants. In participants delivering within 2 weeks of delivery 21/2686 (0.8 %) were affected by stillbirth compared with 8/4596 (0.2 %) delivering ≥ 2 weeks after infection (95 % CI 0.3-1.0). SGA affected 744/7696 (9.3 %) of livebirths, FGR affected 360/8175 (4.4 %) of all pregnancies. Pre-term birth occurred in 922/8066 (11.5%), the majority of these were indicated pre-term births, 220/7987 (2.8%) participants experienced spontaneous pre-term births. Early neonatal deaths affected 11/8050 livebirths. Of all neonates, 80/7993 (1.0%) tested positive for SARS-CoV-2.
Conclusions: Infection was associated with indicated pre-term birth, most commonly for fetal compromise. The overall proportions of women affected by SGA and FGR were not higher than expected, however there was the proportion affected by stillbirth in participants delivering within 2 weeks of infection was significantly higher than those delivering ≥ 2 weeks after infection. We suggest that clinicians' threshold for delivery should be low if there are concerns with fetal movements or fetal heart rate monitoring in the time around infection. The proportion affected by pre-eclampsia amongst participants was not higher than would be expected, although we report a higher than expected proportion affected by eclampsia. There appears to be no effect on birthweight or congenital malformations in women affected by SARS-CoV-2 infection in pregnancy and neonatal infection is uncommon. This study reflects a population with a range of infection severity for SARS-COV-2 in pregnancy, generalisable to whole obstetric populations.
Keywords: COVID; Fetal; Fetal growth restriction; Infection; Neonatal; Perinatal; Pregnancy; SARS-CoV-2; Stillbirth.

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WUTH publication: The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections

Citation: Journal of Wound Care. 2022, 31(8), 683-88
Author: Bradley Pittam, Ruby Chumber, Gaurav Vashisht, Sophie Miller, Christina O'Dowd, Thomas Ledson, Upendram Srinivas-Shankar
Abstract: Objective: People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD.
Method: This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome.
Results: A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment.
Conclusion: HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI.
Declaration of interest: The authors have no conflicts of interest to declare.
Keywords: diabetes; diabetic foot infection; haemodialysis; intravenous antibiotics; vancomycin; vascular complications; wound; wound bed; wound care; wound dressing; wound healing.

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WUTH publication: The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery

Citation: International Journal of Surgery. 2022, 104, 106766. Epub 2022 Jul 13.
Author: Islam Omar, Karl Miller, Brijesh Madhok, Bassem Amr, Rishi Singhal, Yitka Graham, Sjaak Pouwels, Mohammad Abu Hilal, Sandeep Aggarwal, Irfan Ahmed, Ali Aminian, Basil Jaser Ammori, Tan Arulampalam, Altaf Awan, José María Balibrea, Aneel Bhangu, Richard Raymond Brady, Wendy Brown, Manish Chand, Ara Darzi, Talvinder Singh Gill, Ramen Goel, Bussa R Gopinath, Mark van Berge Henegouwen, Jacques M Himpens, David Daniel Kerrigan, Misha Luyer, Christian Macutkiewicz, Julio Mayol, Sanjay Purkayastha, Raul Jacobo Rosenthal, Scott Alan Shikora, Peter Kenneth Small, Neil James Smart, Mark A Taylor, Tehemton E Udwadia, Tim Underwood, Yirupaiahgari Ks Viswanath, Neil Thomas Welch, Steven D Wexner, Michael Samuel James Wilson, Des C Winter, Kamal K Mahawar
Abstract: Background: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.
Methods: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.
Results: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.
Conclusion: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.
Keywords: Ergonomics; Gastrointestinal surgery; Guidelines; Hepatobiliary; Laparoscopic surgery; Minimally invasive; Patient safety; Surgical training.

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WUTH publication: Complications in Device Therapy: Spectrum, Prevalence, and Management

Citation: Current Heart Failure Reports. 2022 Aug 6. Online ahead of print.
Author: J Llewellyn, D Garner, A Rao 
Abstract: Purpose of review: Cardiac implantable electronic device implant numbers are continually increasing due to the expanding indications and ageing population. This review explores the complications associated with device therapy and discusses ways to minimise and manage such complications.
Recent findings: Complications related to device therapy contribute to mortality and morbidity. Recent publications have detailed clear guidelines for appropriate cardiac device selection, as well as consensus documents discussing care quality and optimal implantation techniques. There have also been advances in device technologies that may offer alternative options to patients at high risk of/or already having encountered a complication. Adherence to guidelines, appropriate training, and selection of device, in addition to good surgical technique are key in reducing the burden of complications and improving acceptability of device therapy.
Keywords: Complications; Device therapy; Management.

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