Doncaster Royal Infirmary

ObjectivesChronic heart failure (CHF) restricts daily functioning and quality of life. Anaemia is frequent in CHF and can impair functional outcomes. This research evaluated the effectiveness of anaemia on functional status among Pakistani CHF patients.Materials and MethodsThis cross-sectional study comprised 310 patients aged 18 years and above who attended outpatient clinics and community health centres in Islamabad and Rawalpindi. The structured questionnaire was used to gather data on demographics, self-reported anaemia, and medical history. Functional status was assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Descriptive statistics, chi-square, t-tests, correlation, two-way ANOVA, and multiple regression were analysed.Results239 respondents (77%) were anaemic. The KCCQ-12 scores (30.9 ± 3.9) were lower in anaemic patients (34.1 ± 3.2), and there was an inverse relationship between functional status and anaemia (r = -0.338, p < 0.001). There were significant effects of anaemia (p < 0.001), age (p < 0.001), and both (p < 0.001) in two-way ANOVA, with older anaemic patients more impaired. Regression revealed that anaemia (B = -2.10), age (B = -1.25), female gender (B = -0.95), comorbidities (B = -0.48), and smoking (B = -0.65) were the predictors of poor functional status (p = 0.05).ConclusionsAnaemia is ubiquitous among CHF patients in Pakistan and closely associated with diminished functional capacity, especially in the elderly. Anaemia screening and treatment should be part of CHF management to enhance the quality of life.

Granulomatosis with polyangiitis (GPA) is an uncommon autoimmune anti-neutrophilic cytoplasmic antibody-associated vasculitis. Although it was first recognized nearly a century ago, its etiology is still under investigation. Numerous previous studies have widely suggested that neutrophils play a central role in its pathogenesis. This granulomatous necrotizing inflammation has historically been recognized to commonly affect the ear, nose, throat, lungs, and kidneys; however, other organ involvement, including hepatic involvement, has also been occasionally observed. Some older retrospective case studies have reported fatal outcomes associated with liver involvement due to GPA, highlighting the diagnostic challenges it presents. Hence, we present a case report describing a middle-aged gentleman who presented with persistent constitutional symptoms and continuously deranged liver function tests (LFTs) and was ultimately diagnosed with GPA with hepatic involvement.

Evidence suggests that earlier bowel resection may offer more stable remission in localized luminal terminal ileal (TI) Crohn's disease compared with ongoing medical therapy. Surgery is still considered late in the treatment pathway. The aim of this study was to understand the clinician's perspective on 'early' surgery by qualitatively exploring how clinicians make treatment-related decisions. Semistructured interviews with clinicians across the UK with an interest in inflammatory bowel disease (IBD) were undertaken using videoconferencing (February-November 2022). Inductive thematic analysis of interview transcripts was performed; 10% of the data were double-coded. Data saturation was confirmed before stopping recruitment. Participants included nine consultant surgeons, seven consultant gastroenterologists and seven specialist nurses (n = 23) from secondary care and tertiary referral centres. Five key themes were identified: timing of surgery in practice, barriers to timely surgery, factors influencing decision-making, offering choice and the patient's perspective. A practice of exhausting medical options before considering surgery was commonly described. A lack of IBD specialists (especially surgeons), inadequate opportunities for multidisciplinary teamwork and long waiting lists for surgical clinics and theatre were cited as barriers to timely surgery. According to interviewees, patients prefer medical therapy over surgery; the most dreaded risk is thought to be that of a stoma. This study provides new insights into the barriers to earlier surgery for TI disease. Organizational barriers should be considered when designing local services. Collaborative multidisciplinary teamwork may allow clinicians to consider surgery sooner. A study investigating the patient perspective is warranted.

This chapter focuses on diabetic retinopathy, diabetic kidney disease (DKD) and diabetic neuropathy. Diabetic retinopathy is a microvascular complication of diabetes. The screening programme has been an effective population-level intervention. Since its implementation around 20 years ago, there has been a reduction in the vision impairment due to diabetic eye disease. With the progression of DKD and renal function decline, a number of recognised complications can occur, such as anaemia, mineral bone disorder, metabolic acidosis and fluid retention. The chapter summarises the current tests that are available for the diagnosis of diabetic neuropathy. Diabetic neuropathy lacks a targeted pharmaceutical intervention, underscoring the pivotal role of stringent glycaemic control as a primary management strategy. Additionally, diabetic neuropathy can potentially result in foot ulcers and, in severe cases, may necessitate amputations. In the management of neuropathic pain, pharmacotherapy assumes a prominent role. Concurrently, lifestyle modifications play a crucial role in pain management.

To assess the contemporary malignancy rate in isolated de novo red patches in the bladder and associated risk factors for better selection of red patch biopsy. Patients from the IDENTIFY dataset; Patients referred to secondary care with suspected urinary tract cancer and found to have isolated de novo red patches on cystoscopy. We reported the unadjusted cancer prevalence in isolated de novo red patches that were biopsied; multivariable logistic regression was used to explore cancer-associated risk factors including age, sex, smoking, type of haematuria, LUTS, UTIs and a suspicious-looking red patch (as reported by the cystoscopist). Sub-analysis of these by clinical role and experience was performed. A total of 1110 patients with isolated de novo red patches were included. 41.5% (n = 461) were biopsied, with a malignancy rate of 12.8% (59/461), which was significantly higher in suspicious versus non-suspicious red patches (19.1% vs. 2.81%, p < 0.01). There was a significant association between bladder cancer and age (OR 1.04, 95% CI 1.01-1.07, p = 0.01), smoking history (OR 2.62, 95% CI 1.09-6.27, p = 0.03) and suspicious-looking patch (OR 6.50, 95% CI 2.47-17.1, p < 0.01). The majority of malignancies were in over 60-year-olds. Malignancy rates in suspicious versus non-suspicious red patches did not differ significantly between clinical roles or experiences.Limitations included subjectivity in classifying a suspicious patch and selection bias as not all patches were biopsied. Many patients still undergo unnecessary biopsies under general anaesthetic for isolated de novo red patches. Clinicians should consider the patient's age, smoking status and how suspicious-looking the patch is, before deciding on surveillance versus biopsy to improve cancer diagnostic yield.

Procalcitonin (PCT) has become essential for differentiating bacterial infections from viral infections and noninfectious causes of inflammation, as most inflammatory markers rise with inflammation without indicating a specific etiology. The significance of PCT was underscored during the COVID-19 pandemic, when many patients exhibited elevated inflammatory markers, complicating decisions regarding antibacterial therapy without PCT levels. However, a rise in PCT cannot always be attributed to a bacterial infection, as it is also a precursor of calcitonin produced in the thyroid gland. We present a case of a 77-year-old female patient with a history of medullary thyroid cancer, which she underwent surgical resection and radiotherapy for in 1980. She also experienced right vocal cord palsy as a side effect of radiotherapy and had stable liver metastases. Her past medical history included hypothyroidism, trigeminal neuralgia, gastroesophageal reflux disease, prediabetes, meningioma, vertebral fracture, osteoporosis, depression, and chronic kidney disease stage 4. The patient had recurrent episodes of aspiration pneumonia and poor swallowing. She presented with progressive dysphagia, and her chest X-ray revealed consolidation, with positive Mycoplasma IgM. At the end of her antibiotic course, there were no residual infective symptoms. Prior to admission, a CT scan of the thorax, abdomen, and pelvis showed bilateral upper zone medial fibrotic changes related to radiation, with no sinister lung lesions. It also revealed a few non-united fractures involving the left-sided ribs posteriorly, while biliary distension and liver and bone disease appeared stable. Interestingly, her PCT levels remained consistently elevated at >100 ng/L throughout her admission, despite normal CRP and white blood cell counts. This case was extensively discussed with the infectious diseases team, who suggested that the elevated PCT levels were likely related to thyroid cancer metastases, which can synthesize PCT. Consequently, PCT would be functionally increased in such circumstances and would be an unreliable marker for infection. Further analysis indicated that the PCT elevation resulted from her stable medullary thyroid cancer liver metastases, which were dormant and not affecting liver function but were secreting PCT. This case illustrates that a patient with medullary thyroid cancer metastases to the liver, who was treated for pneumonia, exhibited persistently high PCT levels despite completing the treatment. Calcitonin levels, checked on one occasion, were also elevated, reinforcing that the rise in PCT was attributed to production from medullary cancer metastatic cells rather than an inflammatory response. In bacterial septicemia, PCT is produced through alternate pathways, either directly or indirectly, and is therefore not related to the rise in calcitonin. Consequently, persistently high PCT levels in the absence of other infection markers should prompt further investigation.

To report real-world outcomes for high-risk non-muscle-invasive bladder cancer (HRNMIBC), including bacillus Calmette-Guérin (BCG) and radical cystectomy (RC), as randomised comparisons of these have not been possible. We detail consecutive participants screened for the BRAVO randomised controlled trial comparing RC with BCG (International Standard Randomised Controlled Trial Number [ISRCTN]12509361). Patients were prospectively registered and case-note review used for outcomes. The primary outcome was overall survival. Secondary outcomes included recurrence, progression, metastasis, and bladder cancer-specific survival. A total of 193 patients were screened, including 106 (54.9%) who received BCG, 43 (22.3%) primary RC, 37 (19.2%) 'other' treatment and seven (3.6%) hyperthermic intravesical mitomycin C. All-cause death occurred in 55 (28.5%) patients at median (interquartile range [IQR]) of 29.0 (19.5-42.0) months. In multivariable analysis, overall mortality was more common in older patients (hazard ratio [HR] 2.63, 95% confidence interval [CI] 1.35-5.13; Cox P = 0.004 for age >70 years), those recruited from district hospitals (HR 0.53, 95% CI 0.3-0.95; P = 0.032) and those who did not undergo RC as their first treatment (HR 2.16, 95% CI 1.17-3.99; P = 0.014). In all, 17 (8.8%) patients died from bladder cancer (BC) at median (IQR) of 22.5 (19-36.25) months. In multivariable analysis, BC-specific mortality was more common in older patients (HR 4.87, 95% CI 1.1-21.6; P = 0.037) and those with Tis/T1 disease (HR 2.26, 95% CI 1.23-4.16; P = 0.008) but did not vary with initial treatment. Patients with HRNMIBC are at high-risk of mortality. Those choosing RC as their initial treatment have lower risks of mortality than others, although this may reflect fitness and selection.

Abstract Introduction Early identification and management of all contributory factors is vital in the management of delirium. Delay in investigation can lead to morbidity, mortality, longer length of stay or inappropriate discharge from hospital. We carried out a Quality Improvement project looking to ensure all patients with delirium had appropriate blood tests taken in the Emergency Department (ED). Methods For the first cycle, 25 patients &amp;gt;65 years admitted through ED in December 2022 and January 2023 with delirium were identified based on medical clerking and post take ward round diagnosis. Patients who had a cause for confusion which was clearly known, for example sepsis, were excluded. Data analysis revealed the percentage of patients who had their calcium and CRP bloods checked within 12 hours of admission was only 20% and 76%, respectively. We introduced a simple change: adding bone profile and CRP to the ‘confusion button’ on the ICE electronic requesting and reporting system. A second cycle of data collection was completed for a further 25 patients admitted with delirium between June and July 2023 to measure the effectiveness of the implemented change. Results From our initial analysis, only 20% of patients aged &amp;gt;65 years presenting with delirium had their calcium and 76% of patients had their CRP checked within 12 hours of admission. Following our intervention, we found that 88% of patients had their calcium and 96% of patients had their CRP checked within 12 hours of admission. Conclusion The amendment of the ‘confusion screen’ button, on the ICE requesting system in the hospital, resulted in a significant increase in the number of patents having appropriate blood tests within 12 hours of admission.

The urinary bladder undergoes morphological and functional changes in patients with symptomatic benign prostatic enlargement (BPE). These detrusor changes reflect chronically increased intravesical pressure as a result of outlet obstruction. This study aims to determine the relationship between the Pre- and Post-op detrusor wall thickness (DWT), international prostate symptom score (IPSS), and duration of lower urinary tract symptoms (LUTS) in patients who had open simple prostatectomy (OSP). This was a prospective study of a cohort of patients who had OSP for symptomatic BPE. The IPSS and symptom duration for each patient were noted. Each patient also had an abdominal ultrasound scan with a measurement of their DWT. Retropubic OSP was done for each patient. The detrusor wall thickness was also measured 12 weeks after the prostatectomy. Fifty-two patients completed the study; the mean age was 66.37 ± 8.09 years. The median pre-operative IPSS was 28 (IQR = 13.75), and the median duration of symptoms was 24 months (IQR = 37 months). The mean pre-operative DWT was 4.41 ± 1.38mm, while the mean post-operative DWT was 2.16 ± 0.98mm. The preoperative IPSS (p = 0.833) and duration of symptoms (p = 0.375) did not significantly correlate with the pre-operative DWT. There was a significant reduction in the mean DWT (p < 0.001) and IPSS (p < 0.001) following prostatectomy. DWT appears not to be significantly influenced by the severity or duration of LUTS. However, it reduced significantly following OSP with corresponding improvement in urinary symptoms.