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Why are women considering ovarian tissue cryopreservation to preserve reproductive and hormonal ovarian function? A qualitative study protocol.
No full textINTRODUCTION
Current fertility preservation options available to women are oocyte cryopreservation (egg freezing) or embryo cryopreservation. A newer procedure, ovarian tissue cryopreservation (OTC), has become available in some centres, which offers another option for women and girls considering fertility preservation. These procedures are commonly offered to women about to undergo treatments for cancer. OTC involves removing sections of ovarian tissue and cryopreserving it for future reimplantation, often several years later. OTC offers girls and women who may become infertile with optionality and the possibility of pregnancy. OTC has potential for other applications, including restoring ovarian endocrine function beyond biological menopause. This is not without controversy but has led to some women considering undergoing the procedure for purposes of ovarian hormonal preservation (conservation of ovarian endocrine function). OTC is invasive, involves two surgical procedures with concomitant risks and can be costly. Understanding why women may consider and ultimately undergo OTC is timely, so that evidence-based and women-centred care can be provided.
METHODS
A pragmatic narrative qualitative design will be used. A purposive sample of women aged 18-45 who are considering, or have sought, OTC will be recruited over 1-year period. Potential participants will be approached via a clinic that offers OTC on a private basis or via social media.
ANALYSIS
Participant interviews will be audio and, if consented, video recorded. These will be conducted face-to-face or virtually. The recordings will be transcribed verbatim and analysed using a thematic analysis approach supported by NVivo software.
ETHICS AND DISSEMINATION
Ethical approval has been granted by the Institutional Ethical Review ERN_19-1578A. We expect to disseminate the findings of this study through journal articles, conference presentations and multimedia to public
Comparison of catheters or new arteriovenous fistulas for commencement of haemodialysis in pregnant women with chronic kidney disease: an international observational study.
No full textBACKGROUND
Evidence surrounding vascular access options for commencing dialysis in pregnancy complicated by chronic kidney disease (CKD) is limited. Creation of new arteriovenous fistulas (AVFs) in pregnant women is rare.
METHODS
Retrospective cohort study of approaches to vascular access in pregnancy in centres in Australia, the United Kingdom (UK) and Canada (2002-2018).
RESULTS
Twenty-three women with advanced CKD commenced dialysis in pregnancy (n = 20) or planned to commence (n = 3). Access at dialysis start was a tunnelled catheter (n = 13), temporary catheter (n = 1), AVF created pre-conception but used in pregnancy (n = 3) and AVF created during pregnancy (n = 3). No women commencing dialysis with an AVF required a catheter. No differences in perinatal outcomes were observed comparing AVFs and catheters at dialysis commencement. No AVFs were created in pregnancy in Canadian women. From Australia and the UK, 10 women had a new AVF created in pregnancy, at median gestation 14.5 weeks (IQR 12.5, 20.75). Four women still needed a catheter for dialysis initiation and 3 eventually used the new AVF. Six AVFs were successfully used in pregnancy at median gestation 24 weeks (IQR 22.5, 28.5), 2 were successfully created but not used and 2 had primary failure. No catheter-associated complications were identified except one episode of catheter-related sepsis.
CONCLUSIONS
Catheter-related complications were minimal. In selected women, with sufficient pre-planning, an AVF can be created and successfully used during pregnancy to minimise catheter use if preferred. Pre-conception counselling in advanced CKD should include discussing vascular access options reflecting local expertise and patient preferences
Patient perspective on a novel psychological therapy approach (flash technique) for neurofibromatosis.
No full textThe British Orthopaedic Surgery Surveillance study: Perthes' disease: the epidemiology and two-year outcomes from a prospective cohort in Great Britain.
No full textAIMS
The aim of this study was to evaluate the epidemiology and treatment of Perthes' disease of the hip.
METHODS
This was an anonymized comprehensive cohort study of Perthes' disease, with a nested consented cohort. A total of 143 of 144 hospitals treating children's hip disease in the UK participated over an 18-month period. Cases were cross-checked using a secondary independent reporting network of trainee surgeons to minimize those missing. Clinician-reported outcomes were collected until two years. Patient-reported outcome measures (PROMs) were collected for a subset of participants.
RESULTS
Overall, 371 children (396 hips) were newly affected by Perthes' disease arising from 63 hospitals, with a median of two patients (interquartile range 1.0 to 5.5) per hospital. The annual incidence was 2.48 patients (95% confidence interval (CI) 2.20 to 2.76) per 100,000 zero- to 14-year-olds. Of these, 117 hips (36.4%) were treated surgically. There was considerable variation in the treatment strategy, and an optimized decision tree identified joint stiffness and age above eight years as the key determinants for containment surgery. A total of 348 hips (88.5%) had outcomes to two years, of which 227 were in the late reossification stage for which a hip shape outcome (Stulberg grade) was assigned. The independent predictors of a poorer radiological outcome were female sex (odds ratio (OR) 2.27 (95% CI 1.19 to 4.35)), age above six years (OR 2.62 (95% CI (1.30 to 5.28)), and over 50% radiological collapse at inclusion (OR 2.19 (95% CI 0.99 to 4.83)). Surgery had no effect on radiological outcomes (OR 1.03 (95% CI 0.55 to 1.96)). PROMs indicated the marked effect of the disease on the child, which persisted at two years.
CONCLUSION
Despite the frequency of containment surgery, we found no evidence of improved outcomes. There appears to be a sufficient case volume and community equipoise among surgeons to embark on a randomized clinical trial to definitively investigate the effectiveness of containment surgery. Cite this article: 2022;104-B(4):510-518
Developing a simulation-based learning model for acute medical education during COVID-19 pandemic with Simulation via Instant Messaging - Birmingham Advance (SIMBA).
No full textSimulation-based learning (SBL) is well-established in medical education and has gained popularity, particularly during the COVID-19 pandemic when in-person teaching is infeasible. SBL replicates real-life scenarios and provides a fully immersive yet safe learning environment to develop clinical competency. Simulation via Instant Messaging - Birmingham Advance (SIMBA) is an exemplar of SBL, which we previously showed to be effective in endocrinology and diabetes. Previous studies reported the efficacy of SBL in acute medicine. We studied SIMBA as a learning intervention for healthcare professionals interested in acute medicine and defined our aims using the Kirkpatrick model: (i) develop an SBL tool to improve case management; (ii) evaluate experiences and confidence before and after; and (iii) compare efficacy across training levels.Three sessions were conducted, each representing a PDSA cycle (Plan-Do-Study-Act), consisting of four cases and advertised to healthcare professionals at our hospital and social media. Moderators facilitated progression through 25 min simulations and adopted patient and clinical roles as appropriate. Consultants chaired discussion sessions using relevant guidelines. Presimulation and postsimulation questionnaires evaluated self-reported confidence, feedback and intended changes to clinical practice.Improvements were observed in self-reported confidence managing simulated cases across all sessions. Of participants, 93.3% found SIMBA applicable to clinical practice, while 89.3% and 88.0% felt SIMBA aided personal and professional development, respectively. Interestingly, 68.0% preferred SIMBA to traditional teaching methods. Following participant feedback, more challenging cases were included, and we extended the time for simulation and discussion. The transcripts were amended to facilitate more participant-moderator interaction representing clinical practice. In addition, we refined participant recruitment over the three sessions. In cycle 1, we advertised incentives: participation counted towards teaching requirements, certificates and feedback. To rectify the reduction in participants in cycle 2, we implemented new advertisement methods in cycle 3, including on-site posters, reminder emails and recruitment of the defence deanery cohort
Machine learning of COVID-19 clinical data identifies population structures with therapeutic potential.
No full textClinical outcomes for patients with COVID-19 are heterogeneous and there is interest in defining subgroups for prognostic modelling and development of treatment algorithms. We obtained 28 demographic and laboratory variables in patients admitted to hospital with COVID-19. These comprised a training cohort (n= 6099) and two validation cohorts during the first and second waves of the pandemic (n=996; n=1011). Uniform manifold approximation and projection (UMAP) dimension reduction and Gaussian mixture model (GMM) analysis was used to define patient clusters. 29 clusters were defined in the training cohort and associated with markedly different mortality rates which were predictive within confirmation datasets. Deconvolution of clinical features within clusters identified unexpected relationships between variables. Integration of large datasets using UMAP-assisted clustering can therefore identify patient subgroups with prognostic information and uncovers unexpected interactions between clinical variables. This application of machine learning represents a powerful approach for delineating disease pathogenesis and potential therapeutic interventions
ST-segment elevation myocardial infarction with plaque erosion, to stent or not to stent: utility of intracoronary optical coherence tomography (OCT) imaging-a case report.
No full textBackground
Treating acute myocardial infarction in the setting of insignificant coronary obstruction is an emerging challenge especially with the application of intracoronary imaging like intravascular ultrasound and optical coherence tomography (OCT). The cardiologists dealing with such patients may consider not to stent if there is intracoronary imaging evidence of minimal thrombus without plaque rupture and the vessel appears patent with settling of chest pain and electrocardiogram (ECG) changes.
Case summary
A 47-year-old gentleman presented direct to the emergency department after experiencing retrosternal chest pain with an ECG showing hyperacute anterior T waves. He had ongoing chest pain and was therefore brought to the cardiac cath lab on the primary percutaneous coronary intervention (PCI) pathway. The first picture showed that the proximal left anterior descending (LAD) was occluded (TIMI 0 flow) with evidence of large thrombus burden. Pre-dilating with a 2.5 × 15 mm balloon did not change flow. Aspiration with an Export catheter was carried out for several runs. Most of the thrombus was successfully removed; however, some of it did go into the distal LAD but was successfully retrieved with aspiration catheter. The diagonal branch was occluded with thrombus which was wired followed by thrombus aspiration establishing TIMI II flow. The procedure was covered with Eptifibatide boluses and heparin. After thrombectomy, angiographically there was no obvious lesion present within the LAD. Optical coherence tomography confirmed only mild atheroma with a small amount of plaque and minimal thrombus. There was OCT evidence of plaque erosion without any plaque rupture. The area was above 9 mm and we decided not to treat that with a stent. The right coronary artery had an anterior take-off and was unobstructed. In conclusion, the patient had successful primary PCI to LAD with thrombus aspiration and balloon angioplasty only. He was placed on 12 months of dual antiplatelets therapy with Aspirin and Prasugrel.
Discussion
This case highlights the rare presentation of patients with acute myocardial infarction with plaque erosion and the usefulness of OCT in formulating a management plan
Final rinse water quality for flexible endoscopy to minimize the risk of post-endoscopic infection. Report from Healthcare Infection Society Working Party.
No full textOutcomes of temporary mechanical circulatory support in cardiogenic shock due to end-stage heart failure.
No full textBackground
There are few reports of mechanical circulatory support (MCS) in patients with cardiogenic shock (CS) due to end-stage heart failure (ESHF). We evaluated our institutional MCS strategy and compared the outcomes of INTERMACS 1 and 2 patients with CS due to ESHF.
Methods
Retrospective analysis of prospectively collected data (November 2014 to July 2019) from a single centre. ESHF was defined by a diagnosis of HF prior to presentation with CS. Other causes of CS (eg: acute myocardial infarction) were excluded. We compared the clinical course, complications and 90-day survival of patients with CS due to ESHF in INTERMACS profile 1 and 2.
Results
We included 60 consecutive patients with CS due to ESHF Differences in baseline characteristics were consistent with the INTERMACS profiles. The duration of MCS was similar between INTERMACS 1 and 2 patients (14 (10-33) vs 15 (7-23) days, p = 0.439). There was no significant difference in the number of patients with complications that required intervention. Compared to INTERMACS 2, INTERMACS 1 patients had more organ dysfunction on support and significant lower 90-day survival (66% vs 34%, p = 0.016).
Conclusion
Our temporary MCS strategy, including earlier intervention in patients with CS due to ESHF at INTERMACS 2 was associated with less organ dysfunction and better 90-day survival compared to INTERMACS 1 patients
Acute liver failure following paracetamol overdose.
No full textAcute liver failure is a rare syndrome comprising a coagulopathy of liver origin, jaundice and encephalopathy in a patient with no prior history of liver disease. Paracetamol overdose is the leading cause of acute liver failure in the United Kingdom and often presents with extrahepatic organ dysfunction requiring critical care. We present the case of a patient with hyper acute liver failure secondary to paracetamol overdose. Management focused on ensuring the correct diagnosis had been made, administering N-acetyl cysteine, fluid resuscitation and broad spectrum antimicrobials. Early intubation and transfer to a transplant centre were undertaken following development of hepatic encephalopathy. Neuroprotective measures and hypertonic saline were instituted to reduce the risk of intracranial hypertension. High dose haemofiltration was also started to help reduce ammonia levels. Aggressive critical care therapies with specialised input results in good outcomes for patients admitted with paracetamol induced hyper acute liver failure. Liver transplant is reserved for those patients unlikely to survive with medical treatment alone