Royal Hampshire County Hospital

Abstract Aim Evidence on timing of LC post ERCP for CBD stones is limited. Our aim was to determine the probability of recurrent gallstone events following ERCP ST in patients who did not have LC and to determine the interval from index ERCP at which they occur. Method We analysed ERCP procedures performed between 1/1/2022 and 31/12/2023 in a single DGH. We included patients who had ERCP ST for gallstone disease and did not have LC prior to index ERCP. We followed up patients to the date of LC or until 8/11/2024. Statistical analysis was performed using Welch’s t-test, Fisher’s exact test and chi-squared test. Results 142 patients were included (54% female). For 79 (56%) patients who did not have LC the median follow up was 647 days (131-1039). 17 (12%) suffered from further episodes of gallstone disease. 15 (88%) required hospital admissions. The median length of stay was 9 days (3-22 days). The median time from index ERCP to developing a gallstone complication was 86 days (11-592). Five (29%) developed recurrent gallstone events within 6 weeks. Univariable analyses showed no significant association between recurrence and age (mean 69.0 vs 66.9 years; p = 0.72), gender (p = 1.00), or post-ERCP complications (p = 1.00). Patients who had index ERCP ST for cholangitis had a higher recurrence rate of 21% (p = 0.09). Conclusions The probability of developing gallstone events following ERCP ST was 8% per year. 3.5% of patients suffered from a recurrent event within six weeks. Fit patients should be offered early LC.

The impact of sex-related differences on outcomes following transcatheter aortic valve replacement (TAVR) remains inconclusive. This study investigates sex-related differences in survival and safety outcomes in patients with aortic stenosis undergoing TAVR. We systematically searched PubMed, Embase, Scopus, and Cochrane Library until November 2024. Individual patient data (IPD) were reconstructed from published Kaplan-Meier curves and compared using Cox-proportional hazards model for overall survival and cardiovascular mortality. Pooled risk ratios (RR) for safety outcomes at 30-days and 1 year were estimated using a random-effects model. A total of 48 studies (69 355 women and 65 580 men) were included. Meta-analysis of reconstructed IPD showed that men were at higher risk of all-cause mortality at 5 years [hazard ratio (HR): 1.24, 95% confidence interval (CI): 1.20-1.28, P < 0.001] and cardiovascular mortality at 4 years (HR: 1.34, 95% CI: 1.21-1.49, P < 0.001) compared with women. In random-effects meta-analysis, men faced a higher risk of permanent pacemaker implantation (RR: 1.29, 95% CI: 1.16-1.44, P < 0.001) during the first year. Men experienced a lower risk of stroke (RR: 0.75, 95% CI: 0.64-0.87, P < 0.001) and major vascular complications (RR: 0.58, 95% CI: 0.49-0.69, P < 0.001) at 30 days, and a lower risk of major bleeding (RR: 0.77, 95% CI: 0.70-0.84, P < 0.001) as well as major vascular complications (RR: 0.54, 95% CI: 0.43-0.68, P < 0.001) within the first year. Men demonstrated poorer 5-year overall survival and 4-year cardiovascular survival following TAVR compared with women. Future research with extended follow-up is needed to understand the mechanism underlying sex-specific TAVR outcomes.

IntroductionVenous thromboembolism (VTE) following anterior cruciate ligament (ACL) arthroscopic reconstructions is reported to occur at a rate of 0.5%–2.2%, with very few studies investigating the use of thromboprophylaxis. This study aims to investigate the incidence of VTE post ACL reconstruction surgery while proposing a thromboprophylaxis regimen.MethodsA single-center retrospective cross-sectional observational study was conducted over 8 years and 8 months. The primary outcome was the incidence of symptomatic VTE up to 12 weeks post-operatively. Secondary outcome measures were the rate of major bleeding incidents, wound infections, and delayed wound healing. Enoxaparin 40 mg subcutaneously once daily and thromboembolic deterrent stockings were given to all patients for 14 days post-operatively. Total anesthetic time, total surgical time, and tourniquet time were also recorded. Only patients who underwent arthroscopic ACL reconstruction were included, with all conservatively managed patients being excluded.ResultsA total of 155 patients were identified, and none had a symptomatic VTE up to 12 weeks post-operatively. None of the patients experienced delayed wound healing, wound infections, or major bleeding incidences up to 12 weeks post-operatively. Average total anesthetic time was 145 (±24.8) minutes, average total surgical time was 122 (±25.3) minutes, and average Tourniquet time was 82.1 (±23.8) minutes.ConclusionWe demonstrated a 0% rate of clinically symptomatic VTE without complications such as delayed wound healing or major bleeding incidents. This is the only study proposing a combined regimen of both chemical and mechanical thromboprophylaxis after ACL reconstruction. Further research involving larger groups would be required to assess the effectiveness of this approach and to compare the effectiveness of mechanical and chemical thromboprophylaxis after ACL reconstruction.

Abstract Recent medical advances mean that more people survive critical illnesses and intensive care unit (ICU) admissions. This has led to an uptick in reported physical, cognitive and mental health issues post-ICU (Hiser SL, Fatima A, Ali M et al. Post-intensive care syndrome (PICS): recent updates. J Intensive Care 2023; 11: 23). Despite existing research, dermatological symptoms post-ICU care have been overlooked. This study aims to assess the prevalence and extent of such symptoms in patients 1 month after ICU admission. Local approval was obtained for the study. We enrolled ICU patients admitted for 5 days or longer, or with advanced respiratory issues, from 1 August to 30 November 2023. Telephone interviews were conducted with patients 1 month after ICU admission to assess previous and new dermatological diagnoses or symptoms. If new disease was present, patients were asked about the impact on their quality of life, and if they had sought treatment. Of 148 ICU admissions in a 4-month period, 70 met the study’s criteria. Exclusions were made for patients with primary skin issues (n = 1), deceased or on an end-of-life pathway (n = 25), or still under specialist care (n = 10). Three patients could not be reached. In total, data from 31 patients were included; their ages ranged from 18 to 89 years (mean 61.8, SD 16.9) and 48% were female. Twenty-three patients (74%) experienced dermatological issues post-ICU, including xerosis (n = 8), nonspecific pruritic erythematous rash (n = 5), mouth ulcers (n = 3), hair loss (n = 3), brittle nails (n = 3), cellulitis (n = 2), seborrhoeic dermatitis (n = 2) and pruritus (n = 2). Six patients reported that these caused a significant impact on their daily life (causing low mood, or interrupting sleep or daily activities), while nine reported a moderate impact (causing irritation but not halting usual activities). Nine sought healthcare advice to treat their symptoms, while 10 self-managed with over-the-counter products. Among those with post-ICU dermatological issues, six had a formal chronic dermatology diagnosis, and a further nine reported previous skin problems. The eight patients without post-ICU dermatological symptoms had no formal skin disease diagnoses. Our findings indicate that a notable portion of ICU patients experience skin impairments, and a potential predictor is identified, as 65% of affected patients have a history of chronic skin disorders or symptoms. Dermatological symptoms post-ICU significantly or moderately affected daily life for most individuals, leading them to seek treatment following hospital discharge. Further research is warranted to explore the risk of cutaneous impairment post-ICU, and we propose preventive measures such as prescribing prophylactic emollients to mitigate this risk.

Diagnostic needle arthroscopy offers an alternative imaging modality to magnetic resonance imaging (MRI) for the diagnosis of intra-articular pathology. To compare the accuracy of a needle arthroscopy device (Mi-eye2) versus MRI in identifying intra-articular anatomic abnormalities in the glenohumeral joint, with formal arthroscopy as the gold standard. Cohort study; Level of evidence, 2. A total of 22 patients underwent diagnostic needle arthroscopy of the shoulder, of whom 20 had preoperative MRI scans. A standardized 12-point noninstrumented diagnostic arthroscopy was performed on each patient using the 0° needle arthroscope, followed by a 30°, 4 mm-diameter conventional arthroscope. Intraoperative images were randomized and reviewed by 2 independent blinded fellowship-trained shoulder surgeons for identification of key pathology and anatomic structures. The MRI scans were reviewed by a single musculoskeletal radiologist to identify pathology in the same key areas. For the identification of rotator cuff pathology, needle arthroscopy (sensitivity, 0.75; specificity, 1.00) was superior to MRI (sensitivity, 0.75; specificity, 0.75) with an interobserver reliability (κ) of 0.703. For long head of the biceps pathology, needle arthroscopy (sensitivity, 0.67; specificity, 0.95) was superior to MRI (sensitivity, 0.00; specificity, 0.83). It was less accurate for labral (sensitivity, 0.33; specificity, 0.50; κ = 0.522) and articular cartilage pathology (sensitivity, 0.00; specificity, 0.94; κ = 0.353). The number of anatomic structures that could be clearly identified was 8.35 of 12 (69.58%) for needle arthroscopy versus 10.35 of 12 (86.25%) for standard arthroscopy. Diagnostic needle arthroscopy was found to be more accurate than MRI for the diagnosis of rotator cuff and long head of the biceps pathology but was less accurate for diagnosing labral and cartilage pathology. Although the field of view of a 0° needle arthroscope is not equivalent to a 30° conventional arthroscope, it presents an alternative with potential for use in an outpatient setting.

BackgroundDue to the insidious onset and non-specific nature of axial spondyloarthritis (AxSpA), there is often a significant delay to diagnosis. The average delay to diagnosis in the UK is 8.5 years [1]. This is associated with several adverse sequalae including poor disease-related quality of life and worse overall health outomes [2,3]. In addition, there are substantial health-economic costs associated with this. Recent modelling data in the UK, commissioned by the National Axial Spondylarthritis Society (NASS), demonstrated the average financial cost of this delay to be £196,000 (221,000 Euros) per person affected [1]. There is a focus on reducing diagnostic delay for patients with AxSpA.The SCAN (South Central Axial Spondylarthritis Network) is a network of NHS (National Health Service) Rheumatology departments in hospitals across south-central UK. The group comprises of; doctors, nurses and physiotherapists. SCAN has a working interest in service development.ObjectivesThe SCAN group carried out a service evaluation to establish the average delay to diagnosis for patients with AxSpA across our region. Data was gathered from a total of 7 hospitals within the SCAN region. We also aimed to assess the degree of variability across the 7 different hospitals. The baseline data will be used to support potential implementation of service development initiatives, which in turn, will aim to ultimately reduce the delay to diagnosis for patients with AxSpA across the SCAN region.MethodsRetrospective patient data was collected from 7 different hospitals within the SCAN network area. Data was gathered on 5-10 sequential cases of newly diagnosed AxSpA at each hospital. A total of 65 cases were included in our dataset. Data was collected on; date of symptom onset, date of diagnosis, age and gender.ResultsChart 1 summarises our main findings across the 7 different hospitals.Chart 1.Based on our representative sample from our region, the overall average (mean) delay to diagnosis in the SCAN area hospitals is 4.6 years. This is new data.The average age of the patients was 37 years old and 70% of the patients were male. The range for delay to diagnosis across the 65 cases was from 1 month to 30 years.The observed variability between the hospitals may be related to sample size, differences within local referral systems or reflective of areas where primary care education has been undertaken.Whilst acknowledging the relatively modest size of the sample, this regional multicentre dataset has allowed us to importantly establish what our average delay to diagnosis is for patients within the SCAN region. This valuable information will provide support for planning and implementation of further regional service improvements.ConclusionOur data suggests the delay to diagnosis within our region is significantly shorter than the national average (4.6 years versus national average 8.5 years). However, this delay remains unacceptably long and is likely to be associated with worse disease-related quality of life and a wider detrimental socio-economic impact.The SCAN group will consider introducing changes to the referral processes (e.g., an agreed single referral proforma with local education). We may also aim to replicate any successful local arrangements in place at those hospitals with the shortest delay to diagnosis.We aim to re-evaluate the delay to diagnosis across the SCAN region in 12-36 months where we are optimistic of demonstrating further progress with reducing diagnostic delay for our patients with AxSpA.

ObjectiveThe training of interventional cardiologists (ICs), non-interventional cardiologists (NICs) and cardiac surgeons (CSs) differs, and this may be reflected in their interpretation of invasive coronary angiography (ICA) and management plan. Availability of systematic coronary physiology might result in more homogeneous interpretation and management strategy compared with ICA alone.Methods150 coronary angiograms from patients with stable chest pain were presented independently to three NICs, three ICs and three CSs. By consensus, each group graded (1) coronary disease severity and (2) management plan, using options: (a) optimal medical therapy alone, (b) percutaneous coronary intervention, (c) coronary artery bypass graft or (d) more investigation required. Each group was then provided with fractional flow reserve (FFR) from all major vessels and asked to repeat the analysis.ResultsThere was only ‘fair’ level of agreement of management plan among ICs, NICs and CSs (kappa 0.351, 95% CI 0.295–0.408, p<0.001) based on ICA alone (complete agreement in 35% of cases), which almost doubled to ‘good’ level (kappa 0.635, 95% CI 0.572–0.697, p<0.001) when comprehensive FFR was available (complete agreement in 66% of cases). Overall, the consensus management plan changed in 36.7%, 52% and 37.3% of cases for ICs, NICs and CSs, respectively, when FFR data were available.ConclusionsCompared with ICA alone, the availability of systematic FFR of all major coronary arteries produced a significantly more concordant interpretation and more homogeneous management plan among IC, NIC and CS specialists. Comprehensive physiological assessment may be of value in routine care for Heart Team decision-making.Trial registration numberNCT01070771.