WUTH publication: CNS infection with a history of recurrent epistaxis: Streptococcal meningitis as a first presentation of juvenile nasopharyngeal angiofibroma

Citation: Acute Medicine. 2021, 20(3), 231-33
Author: S Biart, M Shakeshaft, K Joseph 
Abstract: An adolescent male with a history of recurrent epistaxis presented with headache and vomiting. Investigations revealed concurrent meningitis as well as the presence of a subarachnoid haemorrhage. Subsequent imaging identified a Juvenile Nasopharyngeal Angiofibroma; a rare but important cause of meningitis that should be considered in the young adult population. 

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WUTH publication: Focused Acute Medicine Ultrasound (FAMUS): uptake, completion and barriers to accreditation after two years

Citation: Acute Medicine. 2021, 20(3), 187-92 
Author: J Russell, M Dachsel, A Gilmore, R Matsa, N Smallwood
Abstract: The Society for Acute Medicine launched their ultrasound accreditation in September 2016, involving a practical course alongside completion of scanning competencies. Candidates require a registered supervisor to oversee their training. We present here the results of a survey of attendees of practical courses approximately 2 years after launch. The majority of respondents were Consultants or trainees within AIM. Fourteen of 76 (18.4%) respondents had completed the whole accreditation process, whilst 51 (67.1%) had not completed any of the three individual modules. The biggest barriers to accreditation were seen to be lack of supervisors, and lack of dedicated training time. There was good uptake of available online learning resources with good feedback. These results will be used to help develop the training pathway further and widen access to ultrasound training within the specialty and beyond. 

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

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

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

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

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

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

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

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

Citation: The National Medical Journal of India. 2021, 34(2), 92-94 
Author: Akshay Kumar, Navdeep Sokhal, Richa Aggarwal, Keshav Goyal, Kapil Dev Soni, Rakesh Garg, Sanjeev Bhoi, Ashok Deorari, Ajay Sharma 
Abstract: Background: . Effective patient-doctor communication is a key component of patient-centred care, which is one of the six pillars of quality healthcare delivery. Structured and effective communication skills training for healthcare providers is the need of hour in medical education. We assessed the efficacy of role play and simulation in developing communication skills. 

Methods: . As a key component of an acute critical care course (ACCC), communication skills are taught using role play models and simulation. Live feedback is critical in learning during this course as per the principles of adult learning (andragogy). Quantitative and qualitative data were collected to assess the efficacy of ACCC. 

Results: . The 19th ACCC was introduced to interns at the All India Institute of Medical Sciences, New Delhi in December 2018. The teaching methodology and objective-oriented structured training in ACCC were much appreciated for training in human factors with emphasis on communication. A positive response was obtained from the candidates 3 weeks after they completed the course to assess whether interns are able to make use of this training in their day-to-day clinical practice amounting to a reliable evidence level of Kirkpatrick's 'return of investment'. 

Conclusion: . The use of 'role play' to teach communication skills is effective and superior to lecture-based teaching. Further structured and interactive programmes in communication skills training will improve patient care, relatives' satisfaction and the image of medical profession. 

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