West Heath Hospital

Renin-angiotensin-aldosterone system inhibitor (RAASi) therapies are a cornerstone of guideline-directed medical therapy in the management of cardiorenal disease, including chronic kidney disease and heart failure. Management guidelines state that these therapies should be prescribed at the maximum licensed or tolerated dose in order to prevent disease progression and adverse events. However, both cardiorenal disease and RAASi therapies increase the risk of hyperkalaemia. When hyperkalaemia occurs, clinicians often down-titrate or discontinue these important RAASi therapies, leaving patients at risk of adverse cardiorenal outcomes. Eleven cardiorenal experts considered how hyperkalaemia can act as a barrier to optimised RAASi therapy in patients with cardiorenal disease and how these issues could be mitigated. Four key areas of suboptimal and variable clinical practice were identified: optimisation of RAASi therapy; definition and management of acute hyperkalaemia; secondary to primary care communications; and patient education. In this podcast article, two of the experts discuss the clinical challenges and principles of optimal care for each of the four areas identified. The experts agreed that hyperkalaemia should be considered a predictable and manageable condition, requiring a pre-emptive and long-term approach. When hyperkalaemia occurs, down-titrating or discontinuing RAASi therapy should be a last resort, after all other management approaches have been employed. Healthcare professionals in secondary and primary care must communicate and collaborate to ensure effective, consistent management of patients with cardiorenal disease. Finally, patients should be educated to understand their cardiorenal disease and its management and the importance of optimal RAASi therapy. Supplementary file1 (MP4 173853 KB).

Objectives: Anterior tibial tendon (ATT) pathologies, though infrequent, can significantly impact patient morbidity. This study aims to describe the cross-sectional area (CSA) of ATT on magnetic resonance imaging (MRI). Materials and Methods: A retrospective study was done on 50 consecutive patients with normal ATT who underwent ankle MRI. The CSA measurements of the ATT with the extensor hallucis longus tendon (EHLT) were measured by one consultant radiologist and one radiology fellow with one repeating measurement after a period of two weeks. Results: Patients were categorized into four age groups: <20, 20-40, 40-60, and >60 years. The average CSA ratio between ATT and EHLT was found to be 1.64, 1.63, 1.64, and 1.67, respectively, for each age group. Conclusion: These findings provide quantitative insights into the correlation between ATT and EHLT CSAs across different age brackets in normal population. These can aid in the diagnosis of pathologies of ATT, such as tendinopathy and tear.

Abstract Penile fractures are the traumatic rupture of the tunica albuginea encasing the corpora cavernosum. We reviewed long-term sexual and urinary outcomes following penile fracture repair. We performed a multicentre retrospective analysis with data from three metropolitan Australian hospital services over a 10-year period. Operative reports were reviewed and patients with intraoperatively confirmed fractures were included. Patients were contacted to complete a survey, composed of validated questionnaires including the International Index of Erectile Function-5 (IIEF-5) and International Prostate Symptom Score (IPSS). We analysed perioperative data against questionnaire responses. 55 patients were identified with penile fractures. 21 patients completed questionnaire follow-up. The median age was 44.8 years; the median time to follow-up was 4.0 years; 95.5% (20) of these cases occurred during sexual intercourse. The median IIEF-5 was 23 (no erectile dysfunction) and median IPSS was 5 (mildly symptomatic). Seven patients (33.3%) suffered bilateral cavernosal injury and eight (38.1%) suffered urethral injury. No significant relationships were found between injury factors and erectile or urinary function. We found promising outcomes for long-term erectile and urinary function. Study limitations include sample size and subjective outcome measurements. To completely define the relationship between injury factors and outcomes, larger cohorts will need to be analysed.

Variations in anatomy of the tendons and ligaments are not uncommon and cause a diagnostic dilemma. We describe a novel ligament encountered in the ankle extending from posterior inferior tibiofibular ligament to calcaneum. Awareness of normal variant is essential during evaluation of a study.

BackgroundPrimary care has played a central role in the community response to the coronavirus disease-19 (COVID-19) pandemic. The use of the National Early Warning Score 2 (NEWS2) has been advocated as a tool to guide escalation decisions in the community. The performance of this tool applied in this context is unclear.AimTo evaluate the process of escalation of care to the hospital within a primary care assessment centre (PCAC) designed to assess patients with suspected COVID-19 in the community.Design and settingA retrospective service evaluation of all adult patients assessed between 30 March and 22 April 2020 within a COVID-19 primary care assessment centre within Sandwell West Birmingham CCG.MethodA database of patient demographics, healthcare interactions and physiological observations was constructed. NEWS2 and CRB65 scores were calculated retrospectively. The proportion of patients escalated was within risk groups defined by NHSE guidelines in place during the evaluation period was determined.ResultsA total of 150 patients were identified. Following assessment 13.3% (n = 20) patients were deemed to require escalation. The proportion of patients escalated with a NEWS2 greater than or equal to 3 was 46.9% (95% CI 30.8–63.6%). The proportion of patients escalated to secondary care using NHSE defined risk thresholds was 0% in the green group, 22% (n = 4) in the amber group, and 81.3% (n = 13) in the red group.ConclusionClinical decisions to escalate care to the hospital did not follow initial guidance written for the COVID-19 outbreak but were demonstrated to be safe.

Globally, leaders require strategies to sustain the performance and well-being of themselves and their teams while managing and adapting to uncertainty, workplace turbulence, and high job demands. This study evaluates the Resilience at Work Leader 180 Scale assessing leader behaviors that either promote or detract from resilience in others. Study participants comprised Australian pharmacy employees (N = 80) in two groups made up of the senior leadership team (n = 10) and their direct report employees (n = 70). A mixed-methods design was employed using a directed content analysis. Results indicate that the Resilience at Work Leader 180 Scale provides insight into leader behaviors that foster or detract from employee resilience. This scale is of value to researchers and organizations interested in a measure of leader resilience.

To examine occurrence of severe adverse fetal outcomes (SAO), including fetal loss and major congenital malformations (MCMs), in pregnant women with epilepsy (PWWE) vs healthy pregnant women (HPW). The Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study is an NIH-funded, prospective, observational, multicenter investigation of pregnancy outcomes for both mother and child, which enrolled women December 2012 through January 2016. The 351 PWWE had 365 conceptions, and 105 HPW had 109 conceptions. SAOs occurred more often in PWWE (7.9%) vs HPW (1.9%) (p = 0.025) with odds ratio (OR) 4.45 (95% confidence intervals [CI] 1.04-19.01). There were no significant differences for fetal loss (2.8% vs 0%, p = 0.126) or MCMs (5.2% vs 1.9%, p = 0.185; OR 2.86, 95% CI 0.65-12.53) individually. No fetal losses in PWWE appeared to be related to acute seizures. Outcomes were not affected by periconceptional folate, unplanned/unwanted pregnancies, prior maternal pregnancy history, or antiepileptic drug (AED) blood levels, except for an AED level effect for fetal loss that appeared to be due to polytherapy. Combined maternal or paternal family history of MCM was marginally associated with increased SAOs (p = 0.046). The findings provide additional information on risks of SAOs in PWWE, assessing effects of both AED levels and periconceptional folate. Group differences in average enrollment gestational age could have affected fetal loss results. Analyses are limited by small sample sizes as the MONEAD study was not powered for these secondary outcomes. The large majority of pregnancies in women with epilepsy do not have SOAs.