Burnley General Teaching Hospital

The objective of this study was to add to the limited literature of focal scleral nodule (FSN). This study was a single-center, retrospective, observational case series performed at Manchester Royal Eye Hospital (United Kingdom). Nineteen eyes from 19 patients over a 13-year period (January 2011 to January 2024) were included. The principal observations were taken from patient demographic data, fundal and autofluorescence imaging, and Enhanced Depth Imaging Optical Coherence Tomography imaging. Most patients with FSN were female, with median age of 47 years and median visual acuity of 20/20 Snellen. Focal scleral nodules were yellow, yellow-white, orange, or orange halo in appearance. Median horizontal length of a FSN was 2.02 mm (range 0.34-4.79 mm), and median thickness was 417 µ m (range 272-803 µ m). The choroid above the FSN was thinned in nine and absent in 10 cases. Most FSN appeared hyperautofluorescent on autofluorescence imaging. Extramacular FSN appeared directly inferiorly to the optic disc in seven, inferotemporally in five, superonasally in two, and superotemporally in five cases. Seven patients demonstrated FSN within the macula, and two of these had subretinal fluid. Further investigation revealed that one of these patients with subretinal fluid had polypoidal choroidal vasculopathy at the same area as the FSN. This study analyzed FSN lesions of a medium-sized group over a large timeframe. It provides more data in the literature for an uncommon ophthalmic lesion. Furthermore, the study described the first known case in the literature of FSN with polypoidal choroidal vasculopathy in the same area. This finding highlights a potential new complication of the condition.

Abstract Antisynthetase syndrome is a rare inflammatory muscle disease related to dermatomyositis and polymyositis. Anti-Jo-1 antibodies are the most detected antibodies in antisynthetase syndrome. The main clinical features of antisynthetase syndrome are myositis, polyarthritis, interstitial lung disease, mechanic’s hands and Raynaud phenomenon. A 50-year-old man with a background of inflammatory muscle disease and interstitial lung disease, for which he is under the care of respiratory and rheumatology teams, was referred to the dermatology department by his general practitioner with refractory xerotic dry fissured skin on his fingers and feet. He reported itchy, sore and painful dry, cracked skin on both his hands, mainly on the fingertips. It did not affect the rest of his body. He trialled potent topical steroids and emollients, but his condition did not improve. He was on a reducing course of prednisolone 15 mg daily and on long-term oxygen therapy at home for interstitial lung disease. On clinical examination, he had an eczematous-looking eruption. The appearance of his hands was in keeping with ‘mechanic’s hands’. Together with the underlying diagnosis of interstitial lung disease, a diagnosis of antisynthetase syndrome was suspected. Blood tests revealed a fibrinogen of 5.39 g L−1 [reference interval (RI) 1.50–4.50], lupus creatine kinase of 1591 IU L−1 (RI 40–320), positive antibodies to Ro (SS-A) and positive antibodies to Jo-1. Jo-1 antibodies are found in dermatomyositis or polymyositis. Ro antibodies are associated with Sjogren syndrome (primary or secondary) or systemic lupus erythematosus, and serum may be antinuclear antibody negative. Therefore, we suspected a diagnosis of antisynthetase syndrome. A patch test showed a positive reaction to nickel, which was deemed to be in keeping with antisynthetase syndrome hand eruption, or ‘mechanic’s hands’. The patient was commenced on mycophenolate, a low dose of acitretin 10 mg and emollients and reported a significant improvement in symptoms. Repeat blood tests were scheduled for 3 months, including lipid profile and liver function test, for monitoring purposes. A follow-up was arranged for 12 weeks. He had a background of recurrent hospital attendance with pericardial effusions and chest symptoms and was tested for COVID-19 multiple times. This case demonstrates the importance of multidisciplinary coordination with rheumatology and respiratory colleagues in antisynthetase syndrome.

Colonoscopy is an invasive, endoscopic procedure undertaken to visualise the inner lumen of the colon and is used for a variety of diagnostic purposes. The procedure is increasingly performed by nurse endoscopists. This article provides an overview of the indications and contraindications for colonoscopy and describes various elements of the procedure, including consent, sedation and bowel preparation within the context of the evidence base. The article also discusses patient care before, during and after the procedure.

A randomised, parallel-group, double-blind, placebo-controlled multicentre study with health economic and nested qualitative studies to determine if mifepristone (Mifegyne®, Exelgyn, Paris, France) plus misoprostol is superior to misoprostol alone for the resolution of missed miscarriage. Women diagnosed with missed miscarriage in the first 14 weeks of pregnancy were randomly assigned (1 : 1 ratio) to receive 200 mg of oral mifepristone or matched placebo, followed by 800 μg of misoprostol 2 days later. A web-based randomisation system allocated the women to the two groups, with minimisation for age, body mass index, parity, gestational age, amount of bleeding and randomising centre. The primary outcome was failure to pass the gestational sac within 7 days after randomisation. The prespecified key secondary outcome was requirement for surgery to resolve the miscarriage. A within-trial cost-effectiveness study and a nested qualitative study were also conducted. Women who completed the trial protocol were purposively approached to take part in an interview to explore their satisfaction with and the acceptability of medical management of missed miscarriage. A total of 711 women, from 28 hospitals in the UK, were randomised to receive either mifepristone plus misoprostol (357 women) or placebo plus misoprostol (354 women). The follow-up rate for the primary outcome was 98% (696 out of 711 women). The risk of failure to pass the gestational sac within 7 days was 17% (59 out of 348 women) in the mifepristone plus misoprostol group, compared with 24% (82 out of 348 women) in the placebo plus misoprostol group (risk ratio 0.73, 95% confidence interval 0.54 to 0.98; p = 0.04). Surgical intervention to resolve the miscarriage was needed in 17% (62 out of 355 women) in the mifepristone plus misoprostol group, compared with 25% (87 out of 353 women) in the placebo plus misoprostol group (risk ratio 0.70, 95% confidence interval 0.52 to 0.94; p = 0.02). There was no evidence of a difference in the incidence of adverse events between the two groups. A total of 42 women, 19 in the mifepristone plus misoprostol group and 23 in the placebo plus misoprostol group, took part in an interview. Women appeared to have a preference for active management of their miscarriage. Overall, when women experienced care that supported their psychological well-being throughout the care pathway, and information was delivered in a skilled and sensitive manner such that women felt informed and in control, they were more likely to express satisfaction with medical management. The use of mifepristone and misoprostol showed an absolute effect difference of 6.6% (95% confidence interval 0.7% to 12.5%). The average cost per woman was lower in the mifepristone plus misoprostol group, with a cost saving of £182 (95% confidence interval £26 to £338). Therefore, the use of mifepristone and misoprostol for the medical management of a missed miscarriage dominated the use of misoprostol alone. The results from this trial are not generalisable to women diagnosed with incomplete miscarriage and the study does not allow for a comparison with expectant or surgical management of miscarriage. Future work should use existing data to assess and rank the relative clinical effectiveness and safety profiles for all methods of management of miscarriage. Our trial showed that pre-treatment with mifepristone followed by misoprostol resulted in a higher rate of resolution of missed miscarriage than misoprostol treatment alone. Women were largely satisfied with medical management of missed miscarriage and would choose it again. The mifepristone and misoprostol intervention was shown to be cost-effective in comparison to misoprostol alone. Current Controlled Trials ISRCTN17405024. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 68. See the NIHR Journals Library website for further project information.

Abstract Aim (1) To investigate the recurrence rate of periocular primary basal cell carcinoma (pBCC) in Burnley General Teaching Hospital (BGTH). (2) To compare the recurrence rate of periocular pBCC in our centre with the standards published by the British Association of Dermatologists (BAD). Method A retrospective cohort study was carried out. Inclusion criterion was all patients undergoing surgical excision of periocular pBCC in BGTH between January 2011 to December 2016. Electronic records were reviewed, and the recurrence rate locally was then calculated and compared with the 2% stated in the BAD guidelines [1]. Results A total of 197 cases met the audit inclusion criteria over the period of 5 years at BGTH. All of them completed 5 years of follow-up. The mean age of the selected population was 75.7 years (SD 12.77). Male:female ratio was 104:93. Only one case was identified as recurrent primary BCC, which makes the recurrence rate of this audit 0.5% (1/197). Conclusions This audit confirmed that the recurrence rate of periocular pBCC after margin section control achieved the standard set by BAD guidelines. The reason might be that reconstruction is performed after the confirmation of marginal clearance. Although the recommended treatment for pBCC is MMS, it is not available in every centre. However, patients need to wait at least one week for the reconstruction after margin section control. The limitation of this audit includes the data of the size and anatomical site were incomplete for all patients due to inconsistent histology reports.

BackgroundCardiac rehabilitation (CR) is an effective complex intervention for people with coronary heart disease (CHD) which promotes healthy lifestyles, improves quality of life and reduces risk factors. Only 50% of UK eligible patients participate in CR, of which 5.3% have a comorbidity of stroke. Literature has identified parallels in aetiology and risk factors of CHD and stroke. Alongside emerging literature on the benefits of CR for stroke patients, this prompted this study to investigate CR uptake in people with comorbidity of stroke. MethodsPatients entered into the National Audit of Cardiac Rehabilitation (NACR) between 1st Jan 2013 and 30th Jan 2019 were included. Analysis included patient- and service-level characteristics identifying factors associated with uptake of CR by people with comorbid stroke using hierarchical logistic regression. Results6,342 patients were included in the final analysis. This subpopulation was comparable with the wider CR and stroke populations. Main patient-level factors included age, ethnicity, deprivation and having a partner. Main service-level factors were presence of a multi-disciplinary team (MDT) and staff hours per patient. ConclusionPatient and service-level factors contributed to the likelihood of a cardiac patient with comorbid stroke attending CR. The patient-level variables are consistent with wider literature on uptake, suggesting different models of delivery need to be explored to meet the population needs. CR programmes with a more comprehensive and well-resourced MDT are more likely to succeed in increasing the patient attendance with comorbidity of stroke. This highlights inequity of provision and requires strategies to overcome and influencing uptake.

Background Thyroid autoantibodies, specifically thyroid peroxidase antibodies, have been associated with miscarriage and pre-term birth in women with a normal thyroid function. Small randomised controlled trials have found that treatment with levothyroxine may reduce such adverse outcomes in pregnancy. Objectives The Thyroid AntiBodies and LEvoThyroxine (TABLET) trial was conducted to explore the effects of levothyroxine in euthyroid women with thyroid peroxidase antibodies. A concurrent mechanistic study was conducted to examine the effect of levothyroxine on immune responses. Design This was a randomised, double-blind, placebo-controlled, multicentre study. Setting The TABLET trial was conducted in 49 hospitals across the UK between 2011 and 2016. Participants Euthyroid women who tested positive for thyroid peroxidase antibodies, were aged between 16 and 41 years and were trying to conceive either naturally or through assisted conception were eligible. Intervention Participants were randomised to levothyroxine at a dose of 50 µg daily or placebo. The intervention was commenced preconception and continued until the end of a pregnancy. Women were given a 12-month period to conceive from randomisation. Main outcome measures The primary outcome was live birth at ≥ 34 completed weeks of gestation. The secondary outcomes included miscarriage at < 24 weeks; clinical pregnancy at 7 weeks; ongoing pregnancy at 12 weeks; gestation at delivery; birthweight; appearance, pulse, grimace, activity and respiration (Apgar) scores; congenital abnormalities; and neonatal survival at 28 days of life. Methods Participants were randomised in a 1 : 1 ratio. Minimisation was implemented for age (< 35 or ≥ 35 years), number of previous miscarriages (0, 1 or 2, ≥ 3), infertility treatment (yes/no) and baseline thyroid-stimulating hormone concentration (≤ 2.5 or > 2.5 mlU/l) to achieve balanced trial arms. Women were followed up every 3 months while trying to conceive to check thyroid function and general well-being, and, once pregnant, were seen each trimester: 6–8 weeks, 16–18 weeks and 28 weeks. Any abnormal thyroid results were managed in line with clinical guidance at the time. Results Of the 19,556 women screened, 1420 women were eligible and 952 were randomised to receive levothyroxine (n = 476) or placebo (n = 476). Six women from each arm either were lost to follow-up or withdrew from the trial. A total 540 women became pregnant: 266 in the levothyroxine arm and 274 in the placebo arm. The live birth rate was 37% (176/470) in the levothyroxine group and 38% (178/470) in the placebo group, translating to a relative risk of 0.97 (95% confidence interval 0.83 to 1.14; p = 0.74) and an absolute risk difference of –0.4% (95% confidence interval –6.6% to 5.8%). A subset of 49 trial participants (26 in the levothyroxine arm and 23 in the placebo arm) were recruited to assess changes in their serum chemocytokine concentrations. Treatment with levothyroxine resulted in some changes in chemocytokine concentrations in the non-pregnant state and in early pregnancy, but these had no association with clinical outcome. Conclusions Levothyroxine therapy in a dose of 50 µg per day does not improve live birth rate in euthyroid women with thyroid peroxidase antibodies. Limitations Titration of the levothyroxine dose based on thyroid-stimulating hormone/thyroid peroxidase concentrations was not explored. Future work Future research could explore the efficacy of levothyroxine administered for the treatment of subclinical hypothyroidism. Trial registration Current Controlled Trials ISRCTN15948785 and EudraCT 2011-000719-19. Funding This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership.

Objectives: The aim of this study is to assess the risk of venous thromboembolism (VTE) in surgical patients. Study Design: An Observational Study. Setting: 4 Tertiary Hospitals in Faisalabad city. Period: 6 months from July 2015 to December 2015. Material & Methods: Clinical data sheets of surgical in patients of 4 teaching hospitals in Faisalabad city were retrospectively reviewed. Caprini assessment model (CAM) was used for VTE risk assessment and the patients were classified into very high risk (VHR), high risk (HR), moderate risk (MR) and low risk (LR) groups. The data was collected on an Excel spread sheet and statistical analysis was done using SPSS version 17. Chi square test was carried out to assess the association of VTE risk with age, gender, BMI and surgical units. Results: We identified a total of 256 patients from July 2015 to December 2015. The median age was 42 years. 118 (46%) patients were male and 138 (54%) were female. 106 (41.4%) patients were VHR and 124 (48.4%) patients were HR for VTE according to CAM. Nineteen (7.4%) patients were MR and only 7 (2.7%) patients were LR. Higher age and male gender were found to be significantly associated with the high risk for VTE (p<0.001). Conclusion: Our study shows that the postoperative surgical patients are at higher risk of developing VTE. There is statistically significant association between increasing age and male gender with risk of VTE in this group of patients.

Amyloidosis of the eyelid is uncommon and is typically associated with systemic associations. In contrast, amyloidosis of the conjunctiva is often localised with no other associations. We present a rare case of a 92-year-old gentleman with both cutaneous lid lesions and conjunctival amyloid with no systemic involvement. Biopsy demonstrated the hallmarks of amyloid and treatment has remained conservative. He remains at the department to be monitored for secondary glaucoma.