Wexham Park Hospital

Objective: This study aims to review valproic acid (VA) toxicity and treatment at an urban safety-net hospital to determine the timeliness and appropriateness of treatment and outcomes.Methods: We gathered data on 159 patients with the diagnosis of VA toxicity who were admitted to the Detroit Medical Center (USA) from January 2005 to 2015. Patients with known liver disease due to alcohol intake and viral infections were excluded. We extracted the following parameters and compared them: demographic variables, time at presentation, time elapsed between presentation and diagnosis, time elapsed between diagnosis and treatment, time elapsed between treatment and discharge, the total hospital length of stay (LOS), diagnosis, symptoms, treatments given, concomitant medications, and laboratory values. The analysis of all variables was descriptive, and simple correlations were done between dependent and independent variables.Result: A total of 159 patients with VA toxicity were identified. The majority of patients (53% male, 47% female) were African Americans (75%), with the remainder Caucasian (22%) and others (3%). According to our data, one-third (33%) of the total cases comprised patients who had multiple disorders (schizophrenia, depression, bipolar, seizure), 36 (22.6%) had schizophrenia, 34 (21%) had bipolar disorder, 23 (14%) had seizure disorder, 11 (7%) had major depression, and two (1%) were without any previous diagnosis. Data showed that 72 patients (45.3%) were found with altered mental status, 49 (31%) with GI and other CNS symptoms, and 38 (24%) without any symptoms. There were 58 (37%) patients who committed a suicidal attempt, but more than half were asymptomatic (59%) on initial presentation. Disposition included discharge from ED in 22 (15%), admission to psychiatry in 11 (7%), floors in 108 (68%), and ICU in 18 (11%). The mean time from presentation to diagnosis was three hours, with a range of 0.1-10 hrs. Supportive care alone was given to 62 (39%), charcoal to 35 (22%), and pharmacological treatment to 62 (39%). Of those receiving pharmacologic treatment, 47 received only levocarnitine; 15 received lactulose followed by levocarnitine. The average ammonia level at presentation among those who received pharmacologic treatment was 89 ± 63 mcg/dL. Those treated with lactulose (15/62) had an initial ammonia level of 97 ± 62 mcg/dL, which fell to 72 ± 58 mcg/dL at 20 hrs. Once levocarnitine was added, ammonia decreased to 56 ± 25 mcg/dL at 25 hrs. Those who were treated only with levocarnitine had an initial ammonia level of 87 ± 63 mcg/dL, which fell to 64 ± 48 mcg/dL at 14 hrs. Of 159 patients, 44 (28%) had known alcohol abuse. In those who required pharmacologic treatment, the time from diagnosis to appropriate treatment with levocarnitine was 7.8 hrs in alcoholics and 4.3 hrs in patients who were not alcoholics. No patient with elevated alcohol on admission was diagnosed with hepatic encephalopathy on discharge. The average hospital LOS for those who received pharmacologic treatment was 92.4 hrs. Patients who received lactulose had a LOS of 98.9 hrs. The total LOS for those who did not receive lactulose was 90.3 hrs.Conclusion: Early diagnosis of VA toxicity is necessary for timely, effective, high-quality care. Patients who initially received lactulose for hyperammonemia had slower recovery. Recognition of VA toxicity and prompt initiation of levocarnitine are associated with faster recovery and shorter LOS.

Renal trauma is a relatively common clinical entity encompassing a broad range of presentations and etiologies. High-grade renal injuries represent the most severe end of this spectrum and are associated with substantial immediate and long-term morbidity and mortality. Accurate triage and timely management are therefore crucial for optimizing patient outcomes. We report the case of a 26-year-old otherwise healthy male who sustained a Grade V renal injury following a road traffic accident. The injury was identified through a primary trauma survey and was managed conservatively despite clinical indicators favoring operative intervention. Unusual features of this case included presentation with isolated right-sided chest pain, imaging evidence of significant renal hilum disruption with preserved renal function, absence of hematuria or urinary extravasation, and persistent hypotension despite adequate resuscitative and maintenance intravenous fluid therapy in a non-septic patient with stable interval imaging. Remarkably, the patient made a complete recovery under conservative management. This case underscores the criticality of early imaging in detecting occult renal trauma, often first recognized through primary trauma surveys in the emergency department. It highlights the nuanced decision-making process between operative and nonoperative management in high-grade renal injuries, an area where standardized clinical guidelines remain limited. Furthermore, the growing role of interventional radiology in the conservative management of renal trauma is discussed. This report emphasizes the necessity for robust follow-up protocols, including interval imaging, to facilitate early detection of complications and improve long-term outcomes in patients with high-grade renal injuries.

Abstract Aims The NoLap audit was launched in April 2024. Participation at a national level has been sporadic- only 10 centers have been able to identify more than 10 NoLap patients. Wexham Park Hospital (WPH) was identified as a leading center having identified 30 patients to date. Despite this, we were concerned that we had not identified all patients eligible for NoLap. Methods All inpatient death certificates from April 2024 to January 2025 were searched for the terms ‘ischaemia’ and ‘perforation’. A surgical WhatsApp group used for handover was searched for the term ‘NoLap’. Patients identified in these searches were checked for eligibility and if they had been entered onto the NoLap database. Results Seven patients eligible for NoLap were missed. Twelve patients were identified from death certificates, of these, 5 were eligible for NOLap. Two patients were identified from the handover group. Of these 7 patients, 3 had small bowel ischaemia, 1 colonic ischemia, 1 small bowel perforation and 1 colonic perforation. All patients were under the care of the general surgery team. Conclusions Identification of NoLap patients is challenging. Surgical teams appear to struggle to identify cases due to confusion over inclusion criteria and lack of engagement. Regular review of death certificates and handover documents may facilitate identifying NoLap patients.

Abstract Aim This re-audit evaluated the proportion of patients requiring overnight stays following laparoscopic cholecystectomy, investigated causes of delayed discharge, and assessed compliance with the Getting It Right First Time (GIRFT) guidelines. It was conducted in Frimley Health NHS Trust as a cross-site comparison between Frimley Park and Wexham Park Hospitals to identify best practices. Updated GIRFT recommendations from September 2022 were adapted into Frimley Health’s local guidelines and evaluated during this audit. The guidelines suggest a 90%-day case rate with standardised surgical techniques, including patient positioning with a slight head-up angle, table rotation towards the surgeon, and intermittent pneumatic compression. Three 5mm ports, one 10mm port, and low-pressure CO₂ insufflation (10mmHg) are recommended. Local anaesthetic (30mls - 0.25% bupivacaine) should be instilled around the liver and gallbladder while avoiding surgical drains. Method This closed-loop audit compared data from the initial cycle (July–October 2023, Frimley Park, n=107) with a second cycle (April–June 2024) across Frimley Park (n=121) and Wexham Park (n=72). Data were retrospectively collected from case notes and operative records. Metrics included day-case rates, guideline compliance, reasons for delayed discharge, and 14-day readmissions. Results Day case rates improved from 45% to 70% at Frimley Park, with pain (30%) and drain monitoring (28%) as common causes of delays. Wexham Park achieved 77.8%, aligning with GIRFT targets. Both sites reported low 14-day readmission rates (9%) and consistent patient safety outcomes. Conclusions This cross-site audit facilitated shared learning and progress. Continued efforts are needed to enhance pain management, patient counselling, and adherence to surgical protocols.

In our tertiary plastic surgery center, patients with wounds that will not be treated surgically, including complex pretibial wounds, that would traditionally have been managed operatively are managed on an outpatient basis in a nurse-led pretibial laceration clinic. We conducted a study to investigate dressing usage and assess correlators with healing time or number of appointments. We collected data regarding dressings used, time to discharge, and number of appointments retrospectively over 14months between 2019 and 2021. We analyzed the data using linear regression and set the significance at p <.05. We accepted 138 patients for review and dressing management including 76 patients who had been discharged from the clinic at the time of data collection. The median age was 80 years (interquartile range [IQR] 14, 73-87). Time to discharge ranged from 0 to 201days (median 24.5, IQR 68.5). The number of appointments ranged from 1 to 19 (median 3, IQR 7.25). Linear regression indicated that the number of different types of dressings used was statistically correlated with time to discharge (R2=0.230, F(1,74)=22.1, p <.005). Similarly, the correlation between the number of dressings used and the number of total appointments was also statistically significant (R2=0.246, F(1,74)=24.1, p <.005). In patients with conservatively managed pretibial lacerations, the total number of different dressings used (as a surrogate marker for wound complexity ) is predictive of the time the patient spends in follow-up and the total number of hospital contacts. These data may be used to help understand when conservatively managed pretibial lacerations may require more intensive intervention.

Abstract Background: Having a person with mental illness in the family invariably leads to stigmatic experiences to the family members. Perceived stigma in caregivers leads to social isolation, psychological distress, and suboptimal functioning. Additionally, perceived stigma among such caregivers is one of the barriers that prevent them from taking appropriate care of their dependents with mental illness. There has been little research in this field in the Indian armed forces population. Objective: The objective of this study was to assess the perceived stigma among caregivers of armed forces personnel suffering from mental illnesses. Methods: The calculated sample size was 139 but in our study period of time (December 1, 2019–February 28, 2020) we received the enough number of patients and we continued our study with 150 study subjects which is enough more than the 139. Hence, the total number of 150 caregivers visiting the psychiatry outpatient department of a tertiary care military hospital in North India along with their mentally ill dependents were included in the study after obtaining valid informed consent. The subjects were interviewed, their sociodemographic data were collected, and stigma scores were assessed on a 15-item Explanatory Model Interview Catalogue (EMIC) Stigma Scale. Results: Total stigma score ranged from 20 to 40 with a median of 31. Caregivers with lower level of education, lower income, rural residency, elder age, and diagnosis of psychosis/substance abuse in dependent were found to have higher scores of perceived stigma. Conclusions: Caregivers of patients with mental illnesses experience significant stigma which needs to be addressed so that they can provide optimum care to their mentally ill dependents. Limitation: As EMIC does not provide any standard cutoff for low or high stigma or to categorize persons as having stigma or not, it was difficult to compare results with other studies that used different tools to assess stigma.

A man in his 80s was undergoing immunotherapy with pembrolizumab, an anti-PD-1 monoclonal antibody, following his diagnosis of adenocarcinoma of primary lung origin. 24 weeks into treatment, the patient reported experiencing loose stools associated with malaise and poor appetite but no further symptoms. This progressed in frequency and a clinical diagnosis of grade 2 immune checkpoint inhibitor colitis was made. Management with oral prednisolone was commenced but symptoms persisted. Common enteric infections had been ruled out, as were coeliac disease and hyperthyroidism. Flexible sigmoidoscopy and colonoscopy results were not in keeping with colitis, having revealed normal looking mucosa. Following this, a faecal elastase level was found to be low. A diagnosis of pembrolizumab-induced pancreatic exocrine insufficiency was made, and stool frequency and consistency swiftly improved following the use of pancreatic enzyme replacement therapy.