West Suffolk Hospital

Whilst aortic stenosis remains the most prevalent valvular abnormality, the management of asymptomatic severe aortic stenosis remains a clinical challenge. Recently, two randomised-controlled trials (RCTs) - EVOLVED (Early Intervention in Patients With Asymptomatic Severe Aortic Stenosis and Myocardial Fibrosis) and Early TAVR (Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis) - have been published, alongside an extended follow-up from the AVATAR (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) study. In response, we conducted a systematic review of PubMed, Ovid, and Cochrane databases, identifying RCTs up to October 29, 2024, that compared early intervention with conventional management. Four studies met the inclusion criteria, with a combined total of 1427 patients across the trials. Meta-analysis of the primary endpoints across these studies demonstrated a benefit with early intervention (HR=0.50, 95% CI: 0.35-0.73). However, we did not find mortality and cardiac mortality to show significant reductions (HR=0.68, 95% CI: 0.40-1.18 and HR=0.66, 95% CI: 0.33-1.29, respectively). Crucially, stroke outcomes were improved with early intervention (HR=0.60, 95% CI: 0.38-0.95), as were unplanned hospitalizations (HR=0.40, 95% CI: 0.30-0.53). These findings confirm the safety of early intervention and suggest a reduction in stroke incidence, although no significant benefits were observed in overall or cardiac mortality; results which can help to guide shared decision-making with patients and prevent adverse health outcomes.

Phacoemulsification and manual small incision cataract surgery (MSICS) are two widely practised techniques for cataract surgery worldwide. However, their comparative efficacy in terms of postoperative visual acuity (VA) remains debated. This paper is an umbrella review for this topic, which synthesises evidence from systematic reviews and meta-analyses directly comparing VA outcomes between the two techniques.PubMed, Cochrane, Web of Science, and the Excerpta Medica database (Embase) were searched, with 712 results remaining after de-duplication. After screening, six papers underwent full-text review, leaving four systematic reviews/meta-analyses for final inclusion. Inclusion criteria were English-language systematic reviews directly comparing postoperative VA between phacoemulsification and MSICS in adults undergoing cataract surgery. Data extraction focused on uncorrected and best-corrected VA (BCVA) at early (≤1 week), intermediate (six to eight weeks), and late (≥6 months) time points. Methodological quality was assessed using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2).The four included reviews ranged from six to 11 primary studies each, with total sample sizes ranging from 1315 to 76,838 eyes. They were published in the years 2013 and 2015. Across reviews, no statistically significant differences were consistently found in BCVA at any time point. Two reviews reported small early advantages for phacoemulsification in uncorrected VA (UCVA, odds ratios (ORs) of 1.40 and relative risk (RR) of 0.90 for achieving ≥6/9 or ≥6/18, respectively), but these differences were not maintained at later follow-up. Complication profiles were broadly similar. AMSTAR 2 ratings indicated high confidence in the Cochrane review, moderate confidence in two reviews, and low-to-moderate confidence in one review.Evidence from conducted systematic reviews suggests that phacoemulsification and MSICS yield similar postoperative VA outcomes. As such, the choice of technique may be guided more by resource availability, surgeon expertise, and patient-specific considerations.

Abstract Background and Aims Distal renal tubular acidosis (dRTA) is an uncommon diagnosis, especially in adults, with most cases being secondary to autoimmune conditions. Generally, this is a transient phenomenon, and patients seemed to have maintained adequate potassium levels on discharge. This case report presents a patient with recurrent admissions due to dRTA. Method 41-year-old male presented initially in August 2024 to the emergency department with overuse of ibuprofen due to recurrent pain. On the day of admission he took 64 tablets (without suicidal ideation) due to severe tooth pain. He had been vomiting since February 7–8 times per day. Initial blood tests revealed a microcytic anaemia, a mild kidney injury (baseline Creatinine 73 µmol/L, admission creatinine 108 µmol/L), potassium level of 2.7 mmol/L, anion gap of 10.4, chloride level of 114 mmol/L and bicarbonate level of 14 mmol/L. An OGD was performed showing multiple ulcers and he was started on omeprazole and referred for psychological therapy. He was diagnosed with distal renal tubular acidosis secondary to overuse of NSAIDs and was started on potassium citrate therapy for 6 weeks and discharged home. Readmission in October 2024, the patient returned with vomiting (unable to keep food or fluids down) following 4 days of ibuprofen use for tooth pain. His potassium level was 1.8 mmol/L initially, with significant muscle weakness and a normal ECG. Immediate treatment with 1 liter of sodium chloride 0.9% with 40 mmol of KCl was initiated. Despite 3 liters of the potassium replacement over the night his repeated K was 1.7 mmol/L, 1.8 mmol/L and respectively 2.0 mmol/L. He required ITU admission for high concentrate K replacement. His acidosis resolved, bicarbonate climbed to 22.0 mmol/L and potassium stabilised at 3.9–4.1 mmol/L so he was discharged home on potassium citrate 3 g in 10 mL oral liquid for maintenance after 7 days of admission. The patient had in total three admissions in the space of 8 weeks with similar presentations (vomiting, muscle cramps, generalised weakness, dizziness). Each time he had severe hypokalaemia, acidosis, with low bicarbonate and a mild kidney injury. He received each time sodium chloride with 40 mmol of K and bicarbonate replacement. Results He was given potassium citrate 3 g in 10 mls oral liquid on discharge. It was underlined to patient the importance of discontinuation of ibuprofen and sick day rule. If he is unable to orally tolerate the K citrate then he will need to present to hospital for IV replacement. Conclusion In conclusion, this case highlights the critical impact of ibuprofen overuse, leading to significant complications such as distal renal tubular acidosis. Ibuprofen is widely available over the counter with common side effects well known. We highlight this case of life threatening acquired distal tubular acidosis which persisted despite medication cessation.

To assess the presence and CT features of pulmonary cysts (PCs) in patients with renal neoplasms (RN) as a hallmark of Birt-Hogg-Dubé syndrome (BHDS). Single institution retrospective study of all patients with histological RN between May 2014 and May 2020. Individuals with non-renal neoplasm, nephroblastoma, benign cysts, < 18 years old, or without thoracic CT were excluded. Demographics, history of smoking, pneumothorax and cutaneous fibrofolliculomas/trichodischomas, family history of pneumothorax or RN, and genetic testing were recorded. Number, location, distribution and morphology of PCs were assessed on thoracic CT. Differences between patients with positive (BHD+) and negative (BHD-) genetics were analysed. An independent cohort of 10 BHDS patients was added to calculate the diagnostic accuracy of cyst features. Of 1475 patients with RN, 127 (8.6%) had PCs; 40 underwent genetic testing (median age 56 [49-68], 28 men), and 6/127 (4.7%) individuals tested positive for BHDS. BHD+ had significantly more and larger cysts, affecting more lobes (p < 0.01). Higher prevalence of PCs with a perivascular (100% vs. 37%; p = 0.01) and interlobular septal location (100% vs. 16%; p < 0.001), and perilymphatic distribution (100% vs. 5%; p < 0.001) was found in BHD+. All BHD+ had elliptical, irregular, and variable shape PCs, compared to a lower prevalence of these in BHD- (p < 0.01). Traversing vein sign was more common in BHD+ (83% vs. 24%; p = 0.01). The highest accuracy was achieved for perilymphatic distribution (97%), followed by irregular shape (94%) and interlobular septal location (91%). Specific CT features of PC in patients with RN can be highly indicative of BHDS. Radiologists can play a crucial role in the diagnosis of Birt-Hogg-Dubé syndrome (BHDS) by recognising specific CT features of pulmonary cysts; a diagnosis of BHDS has implications for family testing and timely, life-long screening for renal neoplasm. Birt-Hogg-Dubé syndrome (BHDS) should be considered in patients with renal neoplasms and multiple pulmonary cysts. A lower zone predominant, perilymphatic distribution of pulmonary cysts is a strong indicator of BHDS. Identifying specific CT features of pulmonary cysts can improve recognition of BHDS.

Introduction Orthopaedic surgery frequently involves the use of intra-operative radiographs, commonly taken with surgeons standing in close proximity to the X-ray machine. Radiation training and appropriate radiation protection minimise the harm that surgeons can face from ionising radiation. This study evaluates the current state of radiation training and protective equipment available to orthopaedic surgeons in the East of England. Methods A digital questionnaire on Google Forms (Google LLC, Mountain View, CA, USA) was disseminated to regional orthopaedic surgeons between October 2022 and January 2023. Results Of the 75 respondents, 49% were consultants and 51% were trainees at various stages. Regarding training and risk assessment, 62% of surgeons lacked radiation protection training, 45% of female trainees didn't undergo radiation risk assessments during pregnancy, and none did while breastfeeding. Concerning radiation protection, all respondents inadvertently X-rayed their hands; lead gloves and glasses were scarce, and X-ray gowns were in poor condition and in a limited range of sizes. Most surgeons were unwilling to purchase their own dosimeters, lead gowns, thyroid guards, and lead glasses, despite their limited availability, inadequate size range, and poor condition. No significant differences were observed between consultant and registrar responses. Conclusion The study reveals inadequate training and mitigation against radiation exposure in orthopaedics. The lack of radiation training prompted its inclusion in this year's trainee inductions. The shortage of proper radiation protective equipment exposes surgeons to radiation risks. Orthopaedic surgeons should not have to choose between workplace health and safety and affordability. Greater financial support and investment in radiation protection should be prioritised to minimise radiation-induced harm. We aim to raise awareness and encourage key decision-makers to address this critical issue.

<h3>Background</h3> Following acute stroke, long-term secondary prevention is typically the responsibility of primary care. However, discharge summaries communicating with GPs are normally completed by junior doctors often lacking expertise in stroke medicine. Following an incident highlighted though clinical governance, we started a QIP to improve this communication. <h3>Methods</h3> Our QIP, based at a DGH HASU, used Model for Improvement methodology, completing 4 PDSA cycles between February 2022 and June 2023. We targeted inclusion of selected critical information on 80% of discharge summaries. Progress was measured via audit of discharge summaries. Change ideas implemented included an EPR template (Cerner Millenium), task automation, handover and educational interventions. <h3>Results</h3> Descriptive information concerning patients’ strokes was adequately communicated, improving post intervention (75% to 85% of discharge summaries). Initially, secondary prevention information was included sporadically (39%). By cycle 4, this improved to 74% (p&lt;0.005), approaching 90% when the template was used. <h3>Conclusion</h3> While narrowly missing our target, our QIP demonstrated large improvements in the completeness of communication with GPs and patients. This improvement was primarily delivered through improved utilisation of often neglected aspects of EPR functionality. This makes our results widely applicable to stroke units seeking to improve this critical step in the patient journey.

This review paper explores the synergistic effects of obesity, hypertension (HTN), and hyperlipidemia on cardiovascular health by integrating pathophysiological and clinical perspectives. Obesity, characterized by excessive body fat, HTN, defined by elevated blood pressure, and hyperlipidemia, indicated by high blood lipid levels, are globally prevalent conditions that significantly increase the risk of cardiovascular diseases (CVDs). The interplay between these conditions exacerbates cardiovascular risk through mechanisms such as chronic inflammation, insulin resistance, endothelial dysfunction, arterial stiffness, and atherogenesis. This review synthesizes epidemiological evidence and highlights the prevalence and co-occurrence of these conditions, with an emphasis on their combined impact on cardiovascular health. The literature search encompassed various databases, and data extraction included key study characteristics and outcomes. The findings underscore the importance of integrated management strategies, involving lifestyle interventions, pharmacological treatments, and regular monitoring, to mitigate the heightened cardiovascular risk posed by these conditions. In addition, the various public health implications are addressed, advocating for community-based interventions and policy changes. Future research directions may include exploring novel therapeutic approaches, personalized medicine strategies, and longitudinal studies to enhance the understanding and management of the synergistic effects of obesity, HTN, and hyperlipidemia on cardiovascular health.