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Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts; a comparison of treatment at US and UK Medical Treatment Facilities.
No full textINTRODUCTION
The United States (US) and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed Medical Treatment Facilities (MTF) in support of the military campaigns in Iraq and Afghanistan.
METHODS
The US and UK combat trauma registries were scrutinized for patients with penetrating neck injury (PNI) at deployed coalition MTF between March 2003 and October 2011. A multivariate mixed effects logistic regression model (threshold p< 0.05) was used stratified by MTF location and year of injury. The dependent variable was fatality on leaving Role 3, and independent variables ISS on arrival, nationality, MTF nationality, and presence of head and neck surgeon.
RESULTS
3357/67586 (4.9%) of patients who arrived alive at deployed military MTF were recorded to have sustained neck injuries; of which 2186 (83%) were PNI and the remainder were blunt injuries. When service members KIA were included, the incidence of neck injury rose from 4.9 to 10%. 709/2186 (32%) patients with PNI underwent neck exploration; 555 patients were recorded to have sustained cervical vascular injury, 230/555 (41%) underwent vascular ligation or repair. Where it was recorded, PNI directly contributed to death in 64/228 (28%) of patients. Fatality status was positively associated with ISS on arrival (OR 1.05, 95% CI 1.04 -1.06, p<0.001) and the casualty being a local national (OR 1.74, 95% CI: 1.28-2.38, p<0.001).
CONCLUSIONS
Significant differences in the treatment and survival of casualties with PNI were identified between nations in this study, this may reflect differing cervical protection, management protocols and surgical capability and is worthy of further study. In an era of increasing specialization within surgery, neck exploration remains a skill that must be retained by military surgeons deploying to Role 2 and Role 3 MTF.
LEVEL OF EVIDENCE
Level 3: retrospective study with up to two negative criteria
Reduced Sperm Concentration in a Patient from a Suspected Post-Operative Infection: a case study.
No full textA diagnostic semen analysis should be performed as part of a couple's routine fertility investigations in order to determine sperm quality prior to managing the treatment pathway. The semen analysis report should be considered alongside clinical discussions and a review of both patients' medical history. However, whilst it is part of the standard patient pathway, a regular up-to-date review at each clinical step of a patients' journey is not always performed, which may miss potential clinical changes that could impact the most effective management of the couple. This case study reports the impact on the semen quality of a post-operative infection and hospitalisation of a male patient on a fertility management pathway
The United Kingdom Neuro-Ophthalmology Superheroes Day 2019.
No full textA key theme of the United Kingdom Neuro-ophthalmology Superheroes Day was to address emerging topics in Neuro-Ophthalmology and the meeting included speakers from around the world. Rapid cases introduced topics which included non-arteritic anterior ischaemic optic neuropathy, imaging in optic nerve disorders, paediatric optic neuritis, mitochondrial disorders and idiopathic intracranial hypertension
Post-transplant Monoclonal Gammopathy of Renal Significance: A Case Series.
No full textMonoclonal gammopathy of renal significance (MGRS) is a new concept with evolving evidence for treatment. MGRS in the transplant kidney is a rare cause of renal transplant dysfunction that can lead to graft loss. Most cases of post-transplant MGRS are due to recurrent disease. Clone-specific chemotherapy is required to target the underlying clone, and this may improve graft survival; however, this can be challenging, as most patients are elderly with age-related comorbidities and may have complications associated with increasing immunosuppression. Here, we report 3 cases of renal allograft MGRS, and each case highlights different challenges in the diagnosis and management of this condition
National survey of enhanced recovery after thoracic surgery practice in the United Kingdom and Ireland.
No full textBACKGROUND
Evidence that Enhanced Recovery After Thoracic Surgery (ERAS) improves clinical outcomes is growing. Following the recent publications of the international ERAS guidelines in Thoracic surgery, the aim of this audit was to capture variation and perceived difficulties to ERAS implementation, thus helping its development at a national level.
METHODS
We designed an anonymous online survey and distributed it via email to all 36 centres that perform lung lobectomy surgery in the UK and Ireland. It included 38 closed, open and multiple-choice questions on the core elements of ERAS and took an average of 10 min to complete.
RESULTS
Eighty-two healthcare professionals from 34 out of 36 centres completed the survey; majority were completed by consultant thoracic surgeons (57%). Smoking cessation support varied and only 37% of individuals implemented the recommended period for fluid fasting; 59% screen patients for malnutrition and 60% do not give preoperative carbohydrate loading. The compliance with nerve sparing techniques when a thoracotomy is performed was poor (22%). 66% of respondents apply suction on intercostal drains and although 91% refer all lobectomies for physiotherapeutic assessment, the physiotherapy adjuncts varied across centres. Perceived barriers to implementation were staffing levels, lack of teamwork/consistency, limited resources over weekend and the reduced access to smoking cessation services.
CONCLUSION
Centres across the UK are working to develop the ERAS pathway. This survey aids this process by providing insight into "real life" ERAS, increasing exposure of staff to the ESTS- ERAS recommendations and identifying barriers to implementation
English hepatitis C registry data show high response rates to directly acting anti-virals, even if treatment is not completed.
No full textBACKGROUND
In England, choice of hepatitis C therapy is determined by national contracts that change with time, facilitating comparisons between different regimens. England has a diverse population with hepatitis C including large proportions of uncommon viral genotypes.
AIM
To evaluate efficacy of directly acting anti-viral treatments for hepatitis C in England using real-world data from the national treatment registry.
METHODS
Sustained virological response (SVR) rates 12 weeks after treatment completion for patients treated between 2014 and August 2018 who attended for SVR tests were analysed in univariate subgroups using Chi-squared tests. Multivariate models were constructed with clinically relevant variables to determine predictors of SVR and evaluate the impact of treatment regimens.
RESULTS
SVR data were available on 14,603 treated patients. The overall SVR rate was 95.59% [95% CI 95.25%-95.91%]. Multivariable regression modelling in patients with genotype 1 infection showed that the odds of SVR with elbasvir/grazoprevir were higher than for those treated with sofosbuvir/ledipasvir (OR 1.891, 95% CI 1.072-3.336, P = 0.028). For genotype 3, we found no significant difference between any of the treatment regimens. Patients who completed at least one third of the planned treatment duration achieved SVR rates in excess of 80%.
CONCLUSIONS
All of the currently licensed hepatitis C direct-acting anti-viral regimens had similar efficacy (>95%) in an unselected population. Noncompletion of planned treatment duration still resulted in over 80% SVR rates provided that more than one third of treatment was completed
A randomised, placebo-controlled pilot study of a nebulised antitumour necrosis factor receptor-1 domain antibody in patients at risk of postoperative lung injury.
No full textBACKGROUND
Tumour necrosis factor receptor 1 (TNFR1) signalling mediates the cell death and inflammatory effects of TNF-α.
OBJECTIVE
The current clinical trial investigated the effects of a nebulised TNFR1 antagonist (GSK2862277) on signs of lung injury in patients undergoing oesophagectomy.
DESIGN
Randomised double-blind (sponsor unblind), placebo-controlled, parallel group study.
SETTING
Eight secondary care centres, the United Kingdom between April 2015 and June 2017.
PATIENTS
Thirty-three patients undergoing elective transthoracic oesophagectomy.
INTERVENTIONS
Patients randomly received a single nebulised dose (26 mg) of GSK2862277 (n = 17) or placebo (n = 16), given 1 to 5 h before surgery; 14 and 16, respectively competed the study.
MAIN OUTCOME MEASUREMENTS
Physiological and biochemical markers of lung injury, pharmacokinetic and safety endpoints were measured. The primary endpoint was the change from baseline in pulmonary vascular permeability index (PVPI) at completion of surgery, measured using single-indicator transpulmonary thermodilution. Adjusted point estimates and 95% credible intervals (analogous to conventional confidence intervals) were constructed for each treatment using Bayesian statistical models.
RESULTS
The mean change (with 95% credible intervals) from baseline in PVPI on completion of surgery was 0.00 (-0.23, 0.39) in the placebo and 0.00 (-0.24, 0.37) in the GSK2862277 treatment groups. There were no significant treatment-related differences in PaO2/FiO2 or Sequential Organ Failure Assessment score. Levels of free soluble TNFR1, Macrophage Inflammatory Protein-1 alpha and total protein were significantly reduced in the bronchoalveolar lavage fluid of patients treated with GSK2862277 (posterior probability of decrease with GSK2862277 vs. placebo:≥0.977; equivalent to P < 0.05). The frequency of adverse events and serious adverse events were distributed evenly across the two treatment arms.
CONCLUSION
Pre-operative treatment with a single 26 mg inhaled dose of GSK2862277 did not result in significantly lower postoperative alveolar capillary leak or extra vascular lung water. Unexpectedly small increases in transpulmonary thermodilution-measured PVPI and extra vascular lung water index at completion of surgery suggest less postoperative lung injury than historically reported, which may have also compromised a clear assessment of efficacy in this trial. GSK2862277 was well tolerated, resulted in expected lung exposure and reduced biomarkers of lung permeability and inflammation.
TRIAL REGISTRATION
clinicaltrials.gov: NCT02221037