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Using the T11 vertebra to minimise the CT-KUB scan field.
No full textOBJECTIVES
Computed tomography scans of the kidney, ureters, and bladder (CT-KUB) are crucial in investigating urinary calculi but impart a substantial radiation doses. Radiation can be limited by minimising the scanning field to the necessary area ( from the kidneys to urethra). Before auditing, the superior limit of CT-KUB scans had not been formally clarified at our trust. Consistently ensuring the upper limit of scans is at or below T10 has been shown to be a viable method of performing CT-KUB scans. This study aimed to assess the overscan length of CT-KUB investigations and modify practice accordingly to minimise it. There were two standards that were set for CT-KUB scanning. First, the mean percentage overscan length ( percentage of the scan above the kidneys) should be <15%. Second, all scans should include the superior borders of both kidneys.
METHODS
90 consecutive CT-KUB scans for ureteric calculus were retrospectively investigated using IMPAX software in the first phase of data collection. After these data were analysed, a newly devised protocol using T11 as the superior scan limit was delivered to radiographers in the department. and 105 in the second phase (re-audit). The analysis parameters were: percentage overscan length, distance between diaphragm and upper border of kidneys, vertebral level at which the scan commenced, and whether both kidneys were fully included.
RESULTS
In the first phase, overscan of >15% was present in 94.4% of scans. The mean percentage overscan length was 28.2%. The superior vertebral limit of 59% of scans was at T10 or below and a lower superior vertebral limit correlated with decreasing overscan. 99% of scans fully included both kidneys. In the second phase (3 months later), the mean overscan percentage reduced to 10.6% (standard deviation = 4.4%). Excessive overscan affected 35.2% of scans. The superior vertebral limit of 8% of scans was at T10 or below. 100% of scans fully included both kidneys.
CONCLUSION
Excessive overscanning was due to inconsistent technique in capturing CT-KUB scans. Before this audit, the superior limit of CT-KUB scans had not been formally clarified at our trust. By successfully standardising the process with a reproducible method, the overscan target was comfortably met. Therefore, patient dose was minimised without compromising scan quality.
ADVANCES IN KNOWLEDGE
This audit has successfully shown a feasible standardised protocol for CT-KUB investigations which can be used to minimise overscanning of patients
IFCC Working Group Recommendations for Correction of Bias Caused by Noncommutability of a Certified Reference Material Used in the Calibration Hierarchy of an End-User Measurement Procedure.
No full textEstablishing metrological traceability to an assigned value of a matrix-based certified reference material (CRM) that has been validated to be commutable among available end-user measurement procedures (MPs) is central to producing equivalent results for the measurand in clinical samples (CSs) irrespective of the clinical laboratory MPs used. When a CRM is not commutable with CSs, the bias due to noncommutability will be propagated to the CS results causing incorrect metrological traceability to the CRM and nonequivalent CS results among different MPs. In a commutability assessment, a conclusion that a CRM is commutable or noncommutable for use with a specific MP is made when the difference in bias between the CRM and CSs meets or does not meet a criterion for that specific MP when compared to other MPs. A conclusion regarding commutability or noncommutability requires that the magnitude of the difference in bias observed in the commutability assessment remains unchanged over time. This conclusion requires the CRM to be stable and no substantive changes in the MPs. These conditions should be periodically reverified. If an available CRM is determined to be noncommutable for a specific MP, that CRM can be used in the calibration hierarchy for that MP when an appropriately validated MP-specific correction for the noncommutability bias is included. We describe with examples how a MP-specific correction and its uncertainty can be developed and applied in a calibration hierarchy to achieve metrological traceability of results for CSs to the CRM's assigned value
Rapid implementation of an evidence-based remote triaging system for assessment of suspected referrals and patients with head and neck cancer on follow-up after treatment during the COVID-19 pandemic: Model for international collaboration.
No full textBACKGROUND
Outpatient telemedicine consultations are being adopted to triage patients for head and neck cancer. However, there is currently no established structure to frame this consultation.
METHODS
For suspected referrals with cancer, we adapted the Head and Neck Cancer Risk Calculator (HaNC-RC)-V.2, generated from 10 244 referrals with the following diagnostic efficacy metrics: 85% sensitivity, 98.6% negative predictive value, and area under the curve of 0.89. For follow-up patients, a symptom inventory generated from 5123 follow-up consultations was used. A customized Excel Data Tool was created, trialed across professional groups and made freely available for download at www.entintegrate.co.uk/entuk2wwtt, alongside a user guide, protocol, and registration link for the project. Stakeholder support was obtained from national bodies.
RESULTS
No remote consultations were refused by patients. Preliminary data from 511 triaging episodes at 13 centers show that 77.1% of patients were discharged directly or have had their appointments deferred.
DISCUSSION
Significant reduction in footfall can be achieved using a structured triaging system. Further refinement of HaNC-RC-V.2 is feasible and the authors welcome international collaboration
Does declared surgeon specialist interest influence the outcome of emergency laparotomy?
No full textINTRODUCTION
In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes.
METHODS
Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes.
RESULTS
Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10-5.00; = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay.
CONCLUSION
Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed
Paediatric Inflammatory Multisystem Syndrome: Temporally Associated with SARS-CoV-2 (PIMS-TS): Cardiac Features, Management and Short-Term Outcomes at a UK Tertiary Paediatric Hospital.
No full textChildren were relatively spared during COVID-19 pandemic. However, the recently reported hyperinflammatory syndrome with overlapping features of Kawasaki disease and toxic shock syndrome-"Paediatric Inflammatory Multisystem Syndrome-temporally associated with SARS-CoV-2" (PIMS-TS) has caused concern. We describe cardiac findings and short-term outcomes in children with PIMS-TS at a tertiary children's hospital. Single-center observational study of children with PIMS-TS from 10th April to 9th May 2020. Data on ECG and echocardiogram were retrospectively analyzed along with demographics, clinical features and blood parameters. Fifteen children with median age of 8.8 (IQR 6.4-11.2) years were included, all were from African/Afro-Caribbean, South Asian, Mixed or other minority ethnic groups. All showed raised inflammatory/cardiac markers (CRP, ferritin, Troponin I, CK and pro-BNP). Transient valve regurgitation was present in 10 patients (67%). Left Ventricular ejection fraction was reduced in 12 (80%), fractional shortening in 8 (53%) with resolution in all but 2. Fourteen (93%) had coronary artery abnormalities, with normalization in 6. ECG abnormalities were present in 9 (60%) which normalized in 6 by discharge. Ten (67%) needed inotropes and/or vasopressors. None needed extracorporeal life support. Improvement in cardiac biochemical markers was closely followed by improvement in ECG/echocardiogram. All patients were discharged alive and twelve (80%) have been reviewed since. Our entire cohort with PIMS-TS had cardiac involvement and this degree of involvement is significantly more than other published series and emphasizes the need for specialist cardiac review. We believe that our multi-disciplinary team approach was crucial for the good short-term outcomes
Therapeutic Mammoplasty and Dermal Flap: A Novel Hybrid Approach for Chest Wall Reconstruction.
No full textBreast reduction techniques in management of breast cancer have been described since 1980 mainly to resect a large tumor in large breasts. Driven by the demand for more aesthetically acceptable results without compromising oncological safety, these oncoplastic approaches have become more popular. In addition, the utilization of redundant lower pole dermal flap has been a widely practiced tool in the armamentarium of implant-based breast reconstruction in patients with large ptotic breasts. The authors advocate a novel hybrid technique utilizing both therapeutic mammoplasty and lower breast pole dermal flap to provide coverage for anterior chest wall defect posttumor resection in patients with large or ptotic breasts.
Methods
A retrospective review was conducted on patients who underwent chest wall resection and reconstruction using therapeutic mammoplasty and dermal flap to provide soft tissue coverage in the period between 2012 and 2018. Patient's demographics, clinicopathological, radiological, operative details, postoperative morbidity, and follow-up data were recorded.
Results
Nine patients with chondrosarcoma (7/9) and giant cell tumor (2/9) were managed with a mean age 44.1 years (range 28-73). Complete oncological resection was achieved in all patients followed by rigid/nonrigid skeletal reconstructions. All procedures were completed successfully with no nipple areolar complex (NAC) necrosis or prosthesis failure experienced during the follow-up period (range 12-72 months). Excellent functional and aesthetic outcomes were reported in all patients.
Conclusion
The authors' results demonstrate that this technique could be safely planned for soft tissue coverage postchest wall resection with superior aesthetic and durable outcomes
Getting health services right for 16-25 year-olds.
No full textThe 2019 NHS England Long Term Plan set out the ambition to work across the 0-25 age range to support children and young people as they make the transition to early adulthood. Within this broad age bracket, how do we ensure we get health services right for 16-25 year-olds including the transfer to adult services? In this paper, we explore the evidence supporting youth-friendly and developmentally appropriate healthcare approaches and what these mean in practice for young people and healthcare professionals. Examples from primary and secondary care, as well as the perspectives of a young person, illustrate the challenges and solutions
New testosterone 2% gel using Ferring Advanced Skin Technology (FAST), for the treatment of testosterone deficiency in men, with a novel applicator.
No full textINTRODUCTION
Testosterone deficiency (TD) is an increasing problem that can affect a man's physical and psychological health, and quality of life. Testosterone replacement therapy (TRT), combined with weight reduction, lifestyle advice, and the treatment of co-morbidities, is the treatment of choice in men who are not concerned about fertility. However, there remains an unmet need in this therapeutic area, relating to factors such as inconvenient or painful administration, fluctuations in testosterone levels, supra-physiologic testosterone levels, poor tolerability, and secondary safety issues, which may be associated with the current TRT options. Advances in transdermal delivery systems have resulted in the development of a new 2% transdermal testosterone gel, that may offer some additional features over the other currently available TRTs.
AREAS COVERED
We performed a comprehensive review of the published and gray literature to identify randomized studies and non-randomized studies (NRS) involving adult men receiving treatment for low testosterone levels.
EXPERT OPINION
Topical gels are often the most convenient first-line treatment for testosterone deficiency, but options are important as patient preference is more important than virtually any other clinical area of medicine. The chosen therapy must be convenient to use and reach reliable therapeutic levels to effectively and consistently relieve symptoms. Testavan, a new 2% testosterone gel, goes some way to achieving these goals
