Torbay Hospital

Abstract This title details drugs in anaesthesia and intensive care in an A–Z format. The new edition has been improved for exam revision and features diagrams of particular drug structures and comparison tables to aid comparison of differences within a drug class.

Hydatid cyst disease is challenging to treat, and surgery remains curative in the majority of cases. There has been more working done recently on laparoscopic Hydatid cyst disease surgery and comparing the outcomes with the open method. Objectives: To compare the frequency of post-operative outcomes vis. Biliary leakage, post-operative pain, wound infection rate, recurrence of Hydatid cyst disease, and length of hospital stay between open versus laparoscopic surgery in patients with liver Hydatid cyst disease. Methods: This randomized controlled trial was conducted in the Surgical Department of Nishtar Hospital, Multan. 84 patients were enrolled and underwent either laparoscopic or open conservative surgery with external drainage. Outcomes between the two groups in terms of biliary leakage, length of stay, pain, wound infection, and recurrence were compared. Statistical analysis was done using SPSS-25.0. Results: There was no significant difference present between groups in terms of biliary leakage (p=0.33), biliary leak output (p=0.21), and days till leak resolution (p=0.32). Biliary leaks occurred in 16.7% of cases in the open group. Pain scores were significantly lower in the laparoscopic group as compared to the open group (p=0.001). Wound infections occurred in 19% of cases in the open group and 4.8% cases in the laparoscopic group, and were significantly different (p=0.04). 2.4% cases had recurrences in both groups. Conclusions: Biliary leak rates between open and laparoscopic surgery for Hydatid cyst disease are comparable. Open surgery may have greater high-output biliary leaks. Advantages conferred by laparoscopic surgery are shorter length of hospital stay, fewer wound infections, and better pain control.

ObjectivesTo determine whether daily provision of a high protein, high energy meal for 12-weeks to under-nourished older adults living independently in the community can improve physical, physiological, and psychological outcomes. DesignA randomised crossover trial. SettingParticipant homes within a 15-mile radius to meal supplier; Dartmoor Community Kitchen Hub. ParticipantsFifty-six community dwelling older adults (82 ± 7 years, 70% female) were randomised (stratified for baseline mini nutritional assessment (MNA) score and cohabiting or living alone) to receive 12-weeks of meal provision followed by 12-weeks no intervention (meals first group, n = 28), or, 12-weeks without intervention followed by 12-weeks of meal provision intervention (meals second group, n = 28). InterventionA daily high protein and high energy home-delivered meal for 12-weeks. Each meal contained >50% daily protein requirements (0.6 g.kg-1 of the recommended 1.2 g.kg-1.day-1, ∼42 g protein per meal) and >40% daily energy requirements (∼715 kcal). MeasurementsPhysical, physiological and psychological health (including MNA score, body composition, hand grip strength, self-esteem, and depression) were evaluated in participants’ homes before and after each 12-week period (baseline, 12-weeks, and 24-weeks). The effect of meal provision was assessed by t-test then effects were combined using meta-analysis. Retention of any meal provision effect after cessation of meal delivery was quantified as change from the end of the meal intervention versus 12-weeks follow-up via paired t-test. ResultsThe meal intervention significantly increased MNA score with a medium effect size (MNA: pooled Cohen’s D = 0.74, p < 0.001). Energy and protein intake increased significantly during the control period where participants were asked to maintain their habitual diet in the meals second group (energy intake: increase = 252 kcal [95% CI 36 – 487 kcal], t(22) = 2.408, p = 0.025, protein intake: increase = 0.20 g.kg-1 [95% CI 0.04 – 0.357 g.kg-1], t(22) = 2.629, p = 0.015), which confounded the principle of a randomised crossover design analysis. When the control effect in those in the meals second group was removed from the analysis, the effect of the meal provision was much greater (meal provision significantly improved energy and protein intakes (311 kcal D = 0.52 (95% CI 0.22 to 0.82), p < 0.001; 0.24 g.kg-1 D = 0.52 (0.19 to 0.81), p < 0.001, respectively), MNA score (2.6 points D = 1.14 (0.78 to 1.50), p < 0.001), and handgrip strength (1.5 kg D = 0.36 (0.06 to 0.66), p = 0.02), but did not change levels of depression or self-esteem). Twelve weeks after meal removal, the following % of the meal effect was retained: 68% for MNA score, 27% for negative mood score, 15% for daily energy intake, 6% for daily protein intake and 0% for handgrip strength. ConclusionProvision of high protein, high energy meals to community dwelling older adults for 12-weeks improved nutritional status and handgrip strength, indicative of reduced frailty risk. Benefits were not retained upon withdrawal of the intervention, suggesting a need for sustained interventions in this cohort to meet nutritional needs. Home-delivered meals offer a popular, and scalable intervention for community dwelling older adults to prevent malnutrition, promote health and sustain high quality independent living thus reducing the burden of ageing and frailty on health and social care systems.

IntroductionFirst-line antibiotics for disease caused by nontuberculous mycobacteria (NTM) are often poorly effective. Bedaquiline is an attractive therapeutic option. Evidence regarding its clinical efficacy is limited. We report outcomes from the largest UK case series of patients with NTM disease who received bedaquiline.MethodsClinicians in NTM centres were contacted to ascertain whether they had used bedaquiline to treat NTM disease. Inclusion criteria for cases were microbiological confirmation of NTM infection and treatment for NTM disease with bedaquiline. Retrospective chart review was undertaken to collate demographics, investigations, regimens and outcomes.ResultsSeventeen patients (10 female; 7 male; median age decile 45–54 years) across 11 hospitals were identified. The commonest pre-existing lung conditions were bronchiectasis (n=5, 29%) and cystic fibrosis (n=4, 24%). Four individuals (24%) had HIV infection; three of whom had AIDS. Nine (53%) had NTM pulmonary disease, three (18%) single-site extrapulmonary disease and five (29%) disseminated disease. NTM disease occurred most frequently secondary to Mycobacterium abscessus (MAB) (n=8, 47%) and Mycobacterium avium complex (MAC) (n=6, 35%).The commonest indication for bedaquiline was NTM treatment failure (n=13, 76%). The BTS MDR TB CAS recommended bedaquiline in seven cases. Bedaquiline was started a median 18.0 (interquartile range (IQR) 4.3–25.5) months after NTM treatment initiation. Median bedaquiline treatment duration was 7.5 (IQR 5.6–12.0) months.Symptoms completely resolved in five (29%) cases, partially resolved in six (35%) and did not change in two (12%). Complete radiological resolution was observed in three (18%), partial resolution in four (24%) and no radiological change in five (29%). Persistent culture conversion was achieved in four (24%) individuals (three MAC, one MAB). Four (24%) individuals (three MAB, one MAC) failed to culture convert.Adverse events associated with bedaquiline included QTc interval prolongation (n=4, 24%), hepatotoxicity (n=3, 18%) and nausea (n=2, 12%). Four individuals (24%) had no bedaquiline-related side effects. Three deaths that occurred while taking bedaquiline were not attributed to the drug by the treating clinicians.ConclusionsAdding bedaquiline to NTM treatment regimens is associated with variable treatment outcomes. Prospective clinical studies evaluating the efficacy of bedaquiline in this context appear warranted.