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Renin-angiotensin system blockers during the COVID-19 pandemic: an update for patients with hypertension and chronic kidney disease.
No full textHypertension and chronic kidney disease (CKD) are among the most common comorbidities associated with coronavirus disease 2019 (COVID-19) severity and mortality risk. Renin-angiotensin system (RAS) blockers are cornerstones in the treatment of both hypertension and proteinuric CKD. In the early months of the COVID-19 pandemic, a hypothesis emerged suggesting that the use of RAS blockers may increase susceptibility for COVID-19 infection and disease severity in these populations. This hypothesis was based on the fact that angiotensin-converting enzyme 2 (ACE2), a counter regulatory component of the RAS, acts as the receptor for severe acute respiratory syndrome coronavirus 2 cell entry. Extrapolations from preliminary animal studies led to speculation that upregulation of ACE2 by RAS blockers may increase the risk of COVID-19-related adverse outcomes. However, these hypotheses were not supported by emerging evidence from observational and randomized clinical trials in humans, suggesting no such association. Herein we describe the physiological role of ACE2 as part of the RAS, discuss its central role in COVID-19 infection and present original and updated evidence from human studies on the association between RAS blockade and COVID-19 infection or related outcomes, with a particular focus on hypertension and CKD
Brain network reorganisation and spatial lesion distribution in systemic lupus erythematosus.
No full textOBJECTIVE
This work investigates network organisation of brain structural connectivity in systemic lupus erythematosus (SLE) relative to healthy controls and its putative association with lesion distribution and disease indicators.
METHODS
White matter hyperintensity (WMH) segmentation and connectomics were performed in 47 patients with SLE and 47 healthy age-matched controls from structural and diffusion MRI data. Network nodes were divided into hierarchical tiers based on numbers of connections. Results were compared between patients and controls to assess for differences in brain network organisation. Voxel-based analyses of the spatial distribution of WMH in relation to network measures and SLE disease indicators were conducted.
RESULTS
Despite inter-individual differences in brain network organization observed across the study sample, the connectome networks of SLE patients had larger proportion of connections in the peripheral nodes. SLE patients had statistically larger numbers of links in their networks with generally larger fractional anisotropy weights (i.e. a measure of white matter integrity) and less tendency to aggregate than those of healthy controls. The voxels exhibiting connectomic differences were coincident with WMH clusters, particularly the left hemisphere's intersection between the anterior limb of the internal and external capsules. Moreover, these voxels also associated more strongly with disease indicators.
CONCLUSION
Our results indicate network differences reflective of compensatory reorganization of the neural circuits, reflecting adaptive or extended neuroplasticity in SLE
Clinical and laboratory diagnosis of heritable platelet disorders in adults and children: a British Society for Haematology Guideline.
No full textCT angiograms for lower GI bleeding: the experience of a large UK teaching hospital.
No full textINTRODUCTION
The clinical presentation of lower gastrointestinal bleeding (LGIB) is variable in severity, cause and potential investigations. The British Society of Gastroenterology recently published LGIB guidelines, recommending CT angiography (CT-A) for haemodynamically unstable patients, defined by shock index (SI) greater than 1. The aim of this study was to assess the use and role of CT-A in diagnosing LGIB, by assessing the pickup rate of active LGIB defined by contrast extravasation or 'blush' and to determine any association between positive CT-A with various patient and clinical characteristics.
METHODS
A retrospective analysis was carried out of 4 years of LGIB admissions. Demographics, inpatient observations and use of blood products were acquired. Vital signs nearest the time of CT-A plus abnormal vital signs preceding imaging were used to calculate SI, Age SI, National Early Warning Score 2 (NEWS2) and Standardised Early Warning Score (SEWS). A consultant gastrointestinal radiologist further reviewed all consultant-reported scans.
RESULTS
In total, 930 patients were admitted with LGIB. Median age was 71 years and 51% were male; 179 (19.2%) patients received red blood cell transfusion and 93 patients (10%) underwent CT-A, who were older and were likely to be hypotensive and receive red cell transfusions. Following exclusions, 92 CT-As were included in the analysis. Nine (9.8%) were positive. Univariate analysis showed no association between positive CT-A and any scoring system. A multivariate analysis, including age and gender, showed association between both NEWS2 and SEWS scores with positive CT-A.
CONCLUSION
In our analysis of the typical LGIB population, CT-A has shown relatively low pick up rate of active bleeding. CT-A clearly has a role in the investigation of LGIB, but selection remains challenging
An experience using historical hepatitis C data to Re-Engage: Possibilities and pitfalls during the COVID-19 pandemic.
No full textObjectives
Public Health England (PHE) aims meet the WHO target to eliminate hepatitis C as a public health concern by 2030. One aspect of this strategy is to use historical surveillance data of -HCV positive patients identified by PHE to re-engage with offers of PCR testing and treatment if RNA-positive. Operational Delivery Networks (ODN), who deliver Hepatitis C treatment across 22 regions in England, are responsible for enacting this initiative. This study aims to evaluate the effectiveness of using this data with regional PCR results to re-engage HCV-infected persons in the West Midlands region of England.
Study design
A longitudinal prospective study using historical surveillance data.
Methods
A dataset of historical -HCV positive antibody patients provided to the ODN by PHE was cross-referenced with HCV RNA data from 01/01/1996 to 01/01/2019 from five laboratories across the West Midlands. Letters were sent to the general practitioner and to the patients who were HCV RNA positive to invite them for repeat testing and treatment to achieve cure.
Results
From a dataset of 4540 -HCV antibody results, 31.7% (n=1440) had a PCR result: 48.1% (n=693) were PCR positive for HCV RNA. 693 letters were sent to GPs with responses from 14.2% (n=99). By May 2021, only 212 patient letters were sent (due to significant interruption by the COVID-19 pandemic) and 11.3% (n=24) replied, 17 presented for PCR testing and 4 were found to be viraemic. To date, one patient has achieved cure and three have completed treatment awaiting confirmation of cure.
Conclusion
The use of historical -HCV antibody results can be used to successfully re-engage people into testing and treatment for hepatitis C, albeit with modest gains
Early Results of a Variable-Angle Volar Locking Plate for Distal Radius Fractures: A Bi-centre Study.
No full textPurpose This study examines the clinical, functional and radiological outcomes of distal radius fracture fixation with the Aptus® (Medartis, Pennsylvania) locking plate in order to determine its efficacy and identify notable findings related to treatment variations. Methods This is a retrospective bi-centre study collecting patient details from a district general hospital and a regional hand unit. We assessed 61 consecutive patients with distal radius fractures (Arbeitsgemeinschaft für Osteosynthesefragen (AO) grade A=19, B=9, C=33) fixed using an Aptus® plate with a minimum of six months follow-up. Outcome measures included the DASH (Disabilities of the Arm, Shoulder and Hand) score, wrist range of movement and grip strength, and complications. Radiographs were reviewed to assess restoration of anatomy and union. Results All but two fractures united within six weeks. The mean ranges of movement were only mildly restricted compared to the normal wrist (flexion/extension = 102°; radial/ulna deviation = 53°; pronation/supination = 169°). Mean postoperative grip strength was 23.8 kg, which was comparable to the contralateral side at 31.5 kg. The mean DASH score was 18.2. Seven patients had screws misplaced outside the distal radius although three of these remained asymptomatic. Conclusion Variable-angle locking systems benefit from the flexibility of implant positioning and may allow enhanced inter-fragmentary reduction for accurate fixation of intra-articular fractures
Forklift-related lower limb injuries: a retrospective case series study with patient-reported outcome measures (PROMs).
No full textAIM
Forklift trucks can cause serious lower limb trauma with long-lasting sequelae to patients. The aim of this study was to analyse a case series of patients with forklift-related injuries over 7 years at a level 1 major trauma centre in the UK and present their patient-reported outcome measures (PROMs) with long-term follow-up. To the best of the authors' knowledge, this is the largest case series study in the UK describing forklift injuries.
METHODS
Retrospective case note analysis of 19 patients over 7 years. Data including demographics, injury mechanism, pattern of injury, management, length of hospital stay, number of operations and complications were extracted from the notes. We used 'Enneking score' as a validated tool for PROMs.
RESULTS
Seventeen men and two women with mean age of 47 years; 20% had bilateral injuries and 34% had multi-level fractures. The mean number of theatre sessions was 5.21, while the mean length of hospital stay was 30.10 days. There was one mortality. Twelve patients (63%) required reconstruction with free tissue transfer, with one flap failure. The mean long-term Enneking percentage score was 57.33%. The mean Enneking score for patients in this study is lower than our institute's score for Gustilo 3B, highlighting the gravity of these injuries.
CONCLUSION
Forklifts can cause grave injuries with massive energy transfer. This study highlights the seriousness of those injuries, thus guiding patient counselling and optimising planning of management
Paediatric major incident triage: UK military tool offers best performance in predicting the need for time-critical major surgical and resuscitative intervention.
No full textBackground
Children are frequently injured during major incidents (MI), including terrorist attacks, conflict and natural disasters. Triage facilitates healthcare resource allocation in order to maximise overall survival. A critical function of MI triage tools is to identify patients needing time-critical major resuscitative and surgical intervention (Priority 1 (P1) status). This study compares the performance of 11 MI triage tools in predicting P1 status in children from the UK Trauma Audit and Research Network (TARN) registry.
Methods
Patients aged <16 years within TARN (January 2008-December 2017) were included. 11 triage tools were applied to patients' first recorded pre-hospital physiology. Patients were retrospectively assigned triage categories (P1, P2, P3, Expectant or Dead) using predefined intervention-based criteria. Tools' performance in <16s were evaluated within four-yearly age subgroups, comparing tool-predicted and intervention-based priority status.
Findings
Amongst 4962 patients, mortality was 1.1% ( = 53); median Injury Severity Score (ISS) was 9 (IQR 9-16). Blunt injuries predominated (94.4%). 1343 (27.1%) met intervention-based criteria for P1, exhibiting greater intensive care requirement (60.2% vs. 8.5%, < 0.01) and ISS (median 17 vs 9, < 0.01) compared with P2 patients. The Battlefield Casualty Drills (BCD) Triage Sieve had greatest sensitivity (75.7%) in predicting P1 status in children <16 years, demonstrating a 38.4-49.8% improvement across all subgroups of children <12 years compared with the UK's current Paediatric Triage Tape (PTT). JumpSTART demonstrated low sensitivity in predicting P1 status in 4 to 8 year olds (35.5%) and 0 to 4 year olds (28.5%), and was outperformed by its adult counterpart START (60.6% and 59.6%).
Interpretation
The BCD Triage Sieve had greatest sensitivity in predicting P1 status in this paediatric trauma registry population: we recommend it replaces the PTT in UK practice. Users of JumpSTART may consider alternative tools. We recommend Lerner's triage category definitions when conducting MI evaluations
One Eye or Two: Statistical Considerations in Ophthalmology With a Focus on Interventional Clinical Trials.
No full textFull-left-full-right split liver transplantation for adult recipients: A systematic review and meta-analysis.
No full textBACKGROUND
Full-left-full-right split liver transplantation (FSLT) for adult recipients, may increase availability of liver grafts, reduce waitlist time, and benefit recipients with below-average body weight. However, FSLT may lead to impaired graft and patient survival. This study aims to assess outcomes after FSLT.
METHODS
Five databases were searched to identify studies concerning FSLT. Incidences of complications, graft- and patient survival were assessed. Discrete data were pooled with random-effect models. Graft and patient survival after FSLT were compared to whole liver transplantation (WLT) according to the inverse variance method.
RESULTS
Vascular complications were reported in 25/273 patients after FSLT (Pooled proportion: 6.9%, 95%CI: 3.1-10.7%, I : 36%). Biliary complications were reported in 84/308 patients after FSLT (Pooled proportion: 25.6%, 95%CI: 19-32%, I : 44%). Pooled proportions of graft and patient survival after 3 years follow-up were 72.8% (95%CI: 67.2-78.5, n=231) and 77.3% (95%CI: 66.7-85.8, n=331), respectively. Compared to WLT, FSLT was associated with increased graft loss (pooled HR: 2.12, 95%CI: 1.24-3.61, P=0.006, n=189) and patient mortality (pooled HR: 1.81, 95%CI: 1.17-2.81, P=0.008, n=289).
CONCLUSION
FSLT was associated with high incidences of vascular and biliary complications. Nevertheless, long-term patient and graft survival appear acceptable and justify transplant benefit in selected patients