Warwick Hospital

To explore modifications of the 2021 European Resuscitation Council/European Society of Intensive Care Medicine (ERC/ESICM) guideline algorithm for neuroprognostication after cardiac arrest to improve its prognostic accuracy. Post-hoc analysis of four prospective multicentre studies (TTM, TTM2, KORHN and ProNeCA). We raised the Glasgow Coma Scale motor (GCS-M) inclusion threshold at 72h after cardiac arrest from the current GCS-M<4 to GCS-M<6 (all unconscious patients). Secondly, we included good outcome predictors (GCS-M 4-5, neuron-specific enolase<17µg/L, benign electroencephalography patterns≤72h post-arrest and normal magnetic resonance imaging at 72-168h post-arrest) in the algorithm. Functional outcome was assessed dichotomously at six months, including modified Rankin Scale 0-3, Cerebral Performance Category 1-2 or Glasgow Outcome Scale 4-5 (no symptoms to moderate disability) as good outcome. We analysed 3,388 patients, of whom 2,079 had GCS-M<4 at≥72h. Of the 874 patients identified by the 2021 ERC/ESICM poor outcome criteria, 870 had poor functional outcome (specificity: 99.6% [95%CI 99.0-99.9]). Using the GCS-M<6 threshold, 366 more patients entered the algorithm (N=2,445). Seven more patients with poor outcomes were identified, with close to identical specificity. Good outcome predictors thereafter identified 673 patients with potential recovery, of whom 411 (61%) had a good functional outcome at six months. With the updated algorithm, the number of prognosticated patients with an indeterminate prognosis decreased from 1,205/2,079 (58%) to 891/2,445 (36%). Raising the GCS-M inclusion threshold and adding favourable predictors to the 2021 ERC/ESICM prognostication algorithm reduced prognostic uncertainty without increasing falsely pessimistic predictions.

Recurrent miscarriage is a debilitating disorder associated with considerable physical and psychological morbidity. An estimated 50% of first trimester miscarriages remain unexplained. The aim of this study was to provide a personalised framework to guide the expectations of women experiencing recurrent miscarriage, with the ultimate goal of transforming clinical practice. We used real-world data from a UK longitudinal study of 1201 couples attending National Health Service (NHS) miscarriage clinics, with a history of previous miscarriages, comprising medical and obstetric history, results of investigations and pregnancy and neonatal outcome. We developed, parametrised, and validated predictive models for the probability that the next pregnancy is viable and for the time to next pregnancy. Time to next pregnancy separates couples into two groups, a group with subfertility, i.e., delay in conception, and a group with no significant delay in conception. We used Bayesian inference for the latter model.Trial registration number: The prospective data collections were pre-registered ISRCTN17732518; https://doi.org/10.1186/ISRCTN17732518. Predictive models of the time to pregnancy, the probability of the couple being subfertility and the probability of having a viable pregnancy can be parametrised from longitudinal study data. We identified several predictors for such models. In the viable pregnancy model, increased maternal age, higher Body Mass Index (BMI), having Polycystic Ovaries Syndrome (PCOS) and the number of previous miscarriages were associated with reduced odds of viable pregnancy. In contrast, having had previous live births increased the odds of a viable pregnancy. Model validation against a second external dataset gave an Area Under Curve (AUC) of 0.65 (95% Confidence Interval (CI): 0.55, 0.76). Of the 942 women referred to our recurrent miscarriage clinics and followed up over a period of 3 years, 10.7% (101) did not conceive during this time, indicating a potential subfertility problem. In the time to pregnancy model, increased maternal age, higher BMI, and smoking were associated with reduced likelihood of conception. Conversely, taking folic acid supplements and having a history of previous conceptions were associated with increased fertility. In our cohort, 53.4% (577 out of 1080 women) reported a pregnancy within 12 months. Additionally, 22.8% (277 out of 996 women who were followed up over a 2-year period) experienced a first pregnancy event in the second year. The area under the curve (AUC) for predicting pregnancy within 12 months was 0.60 (95% CI: 0.50-0.70) in an external validation using a second dataset. The pregnancy journey can be predicted on a personalised basis by integrating the validated models. We provide a framework for evidence-based management of women with miscarriage, comprising informed decision-making, including optimal referral to fertility services, and a tailored insight into fertility outcomes, thereby guiding expectations and providing psychological support. Tommy's National Centre for Miscarriage Research.

Digital papillary adenocarcinoma (DPA) is a rare adnexal tumour of sweat gland differentiation with metastatic potential, with an incidence of 0.10 per 1,000,000 person years in England. This patient viewpoint shares the journey and perspectives of Mr Haines who was diagnosed with DPA in 2019, fourteen years after initial presentation, and who alongside his family is still living with the uncertainty of his prognosis almost two decades later. By writing this piece, he hopes to be able to reach out to and connect with to others affected by this rare and under-researched cancer.

Abstract Background Gallbladder cancer is not among the 20 most common cancers in the UK, accounting for less than 1% of all new cancer cases with a peak rate at 85-89 years of age. There is a dominant routine conception among surgeons to send the gallbladder specimen for histopathology even if there is no gross features that raise suspicion for neoplasm. In this study, we are trying to get evidence of the value of routine histopathology analysis of gallbladder specimens after elective and emergency laparoscopic cholecystectomy surgeries in Warwick hospital. Method The record of all the patients who underwent laparoscopic cholecystectomy ( elective, expiated and emergency ) in Warwick hospital in the period between 01/07/2023 – 30/01/2024 ( 7 months) were collected, reviewed and underwent data analysis Results A total of 171 specimens were sent for histo-pathology analysis. Only one patient had low grade dysplasia with no malignant features. No routine follow-up decided for him/her after upper GIT MDT discussion. The incidence rate was 0% of neoplasm and 0.6% of low-grade dysplasia. Conclusion No specimen in the study had suspicious gross features of malignancy. Using a selective system is more logical and economic than the routine sending for histopathology after elective and emergency laparoscopic cholecystectomy if there are no suspicious features in the specimen.

IntroductionReactive arthritis is an inflammatory condition that can occur following an infection, commonly caused by bacterial pathogens such as Streptococcus. Pregnancy introduces unique challenges in managing autoimmune and inflammatory conditions due to the need to balance maternal and foetal health. This case report highlights the diagnosis and management of post-streptococcal reactive arthritis and panniculitis in a 16-week pregnant patient, focusing on the use of steroids and the resulting impact on her gestational diabetesCase descriptionA 25-year-old woman, 16 weeks pregnant with no known comorbidities, presented with bilateral ankle pain and swelling for the last two weeks, preceded by an episode of tonsillitis. Initially, the pain was localised to her right ankle and left wrist, then involved her left ankle. She was treated with antibiotics for presumed cellulitis, and a doppler ultrasound ruled out deep vein thrombosis. Examination revealed swollen, inflamed ankles with limited range of motion due to pain. The rest of the examination was unremarkable. This was her second pregnancy and had no complications in her first pregnancy.Routine investigations were done; her C-reactive protein (CRP) was 126 and erythrocyte sedimentation rate (ESR) was 56, with a normal white cell count. Autoimmune workup, including rheumatoid factor (RF), antinuclear antibodies (ANA), and HLA-B27, was negative, but her anti-streptolysin O (ASO) titer was borderline positive. She was diagnosed with post-streptococcal reactive arthritis. After discussing the risks and benefits of NSAID use in the second trimester, we started her on prednisolone 20 mg with a tapering plan.The patient showed clinical improvement, but upon tapering the steroids to 5 mg daily, she developed well-demarcated erythema with desquamation and epidermal changes over both ankles. The left ankle was tender on the medial side, but the right was non-tender. Her angiotensin-converting enzyme (ACE) levels were negative, and calcium levels were normal. Her steroid dose was increased again to 20 mg with a slow tapering plan.She also developed gestational diabetes mellitus and was started on insulin by the diabetes team. Her foetal scan was reassuring and was under obstetrician.A dermatology team reviewed her and suggested the rash was likely panniculitis, which had improved significantly with steroids, so a biopsy was not performed. With careful management, her symptoms resolved, and she successfully discontinued steroid therapy as planned.DiscussionThis case highlights the complex nature of managing post-streptococcal reactive arthritis and panniculitis in a pregnant patient. The initial presentation with a sore throat and subsequent development of arthritis and panniculitis, along with raised inflammatory markers and a positive ASO titer, strongly suggested reactive arthritis triggered by a recent streptococcal infection. Given the foetal risk from NSAIDs, steroid therapy was chosen for its safety profile in pregnancy. While steroid therapy provided symptomatic relief, it led to gestational diabetes, requiring careful monitoring and adjustment of the patient’s diabetic management.The emergence of panniculitis during steroid tapering added another layer of complexity, necessitating collaboration with dermatology specialists for a revised approach. The dermatological team agreed with the recommendation of slow tapering of steroids, which were crucial in managing this complication. This case highlights the importance of a multidisciplinary approach and close monitoring to ensure optimal outcomes for both the mother and the developing foetus.Key learning points• The diagnosis of post-streptococcal reactive arthritis should be considered in pregnant patients presenting with joint inflammation and a recent history of infection. Prompt recognition and appropriate treatment are essential to prevent long-term joint damage.• Careful monitoring of glycaemic control is crucial when initiating steroid therapy in pregnant patients, as it may lead to uncontrolled diabetes and can cause foetal problems. Close collaboration between obstetric and endocrine specialists is necessary to optimise diabetes management while minimising foetal risks.• Collaboration with dermatology specialists can aid in the management of complications such as panniculitis during steroid tapering in pregnant patients. A multidisciplinary approach ensures comprehensive care and improves outcomes for both the mother and the developing foetus.