Worcestershire Royal Hospital

Royal College of Surgeons (RCS) have suggested the 'Emergency General Surgery' commissioning guidelines on investigations for acute abdominal pain.We aim to assess adherence of mandatory investigations for acute abdominal pain as per the above guidelines, and encourage improvements on compliance, therefore, improving patient care.Retrospective analysis was conducted on 39 patients in the 1 cycle (1 -8 April 2025), and 39 patients in the 2 cycle (28 May-5 June 2025).The data was collected on Full blood count (FBC), Urea and Electrolytes (U&E), Liver Function Test (LFT), C-reactive Protein (CRP), Amylase/Lipase, Urinalysis, Pregnancy Test, Electrocardiogram (ECG) >50 years old, Glucose.The intervention was a poster circulated within the general surgical team explaining the RCS guidelines, between cycles.In both cycles 79% of the patients were women.The age group commonly encountered in both cycles were 30-39 years old.FBC, U&E, LFT, CRP had 100% compliance in both cycles.The most significant positive change was seen with urinalysis, from 49% to 72%, and pregnancy test from 52% to 74%.8% of patients had glucose checked in the 1 cycle, increasing to 13% post-intervention, with ECG in >50 years old increasing from 18% to 19%.However, Amylase/Lipase being 95% in the 1 cycle dropped down to 72% in the second cycle.Overall, this audit ended up producing a significant improvement in the compliance rates of investigations in acute abdominal pain, therefore, translating to a better patient outcome.

<bold>Background</bold> Severe asthma (SA) care is mostly delivered through specialised centres (SAC), but capacity and accessibility is often limited. Expanding capacity by employing spoke centres coordinated by a SAC (hub-and-spoke model) may increase capacity whilst maintaining quality of care. The objective of this study was to evaluate the effectiveness of delivering biologic treatment via a hub-and spoke model by comparing treatment accessibility and outcomes between the hub and spokes. <bold>Methods</bold> outcomes data on socio-demographics, clinical characteristics, treatment outcomes, and carbon assessments were retrieved from the service registry. Biologic treatment outcomes were compared between hub and spokes using standard statistics. <bold>Results</bold> Analysis included 74 hub and 226 spoke patients. Median age was 52 years [41.0-62.0], 64.7% were female and median baseline exacerbation number was 6.0 [4.0-8.0]. Biologics used were mepoizumab (34.6%), benralizumab (50%), omalizumab (15.4%). After 12 months of biologic treatment 80.3% (hub: 85.1%, spokes: 78.5%) of patients had positive response (≥50% reduction in exacerbations and/or mOCS dose) with similar reduction in median exacerbations [hub 5.0 (4,7) vs spokes 5.0 (4,7), p=0.39]. There was also similar improvement in ACQ-6 and asthma biomarkers. Patients travel (miles) to spoke centres was shorter than to the hub (5.8 [3.2-12.8] v 9.0 [5.0-33.7]; p<0.001), amouting to 34.5% reduction in travel carbon footprint. <bold>Conclusions</bold> delivering SA care via hub-spoke models can provide increased capacity and maintain care quality across centres. Patients treated at spokes had shorter travel journeys and reduced carbon footprint than those travelled to the hub.

Abstract Background Tofacitinib, filgotinib and upadacitinib are JAK inhibitors (JAKi) that are licensed for treatment in moderate to severe ulcerative colitis (UC). Whilst these drugs have demonstrated efficacy against placebo, there is no head-to-head data. This study aims to compare the clinical efficacy between these drugs. Methods This is a multi-centred, retrospective cohort study with data collected from January 2018 to June 2024. Patients with UC were recruited on their first JAKi, irrespective of previous advanced therapies. Clinical remission (faecal calprotectin (FCP) &amp;lt;250, Mayo £1, UCEIS £1, pMayo £2, SCCAI £2) and response (50% reduction in FCP from baseline, reduction in partial Mayo or UCEIS by 3 or more, or sustained &amp;lt;3) was measured at 3- and 6-months. If a patient stopped taking JAKi, they were considered to have failed both response and remission. Data was non-parametric and outcome measures were compared using Chi-squared tests. Results There was a total of 266 patients included in the final analysis. 70 (26%) were on upadacitinib, 47 (18%) on filgotinib and 149 (56%) on tofacitinib (Table 1). At least 87% (129/149) on tofacitinib had exposure to a previous biologic compared to 80% (56/70) for upadacitinib and 66% (31/47) for filgotinib. At 3-months, clinical response in upadacitinib, filgotinib and tofacitinib was demonstrated in 83%, 74% and 75% patients, respectively and clinical remission was seen in 69%, 64% and 52%, respectively. At 6-months, clinical response was demonstrated in 79%, 65% and 63%, respectively and remission was seen in 75%, 61% and 51%, respectively. Upadacitinib demonstrated significantly higher 3-months remission rate (p=0.019) and 6-months response (p=0.010) and remission rates (p= 0.001) compared to tofacitinib. In the bio-exposed cohorts, upadacitinib demonstrated greater 6-months remission rates (71%) compared to 64% on filgotinib (p=NS) and 52% tofacitinib (p= 0.022). In bio-naïve cohorts (n=50), upadacitinib demonstrated greater 6-months remission rates (93%) compared to 56% on filgotinib (p=0.024) and 50% tofacitinib (p= 0.009). Combining the JAKi, 90% of patients were not on steroids at 3-months and 94% were not on steroids at 6-months. A total of 26 patients had a colectomy at the time of their JAKi, 17 on tofacitinib, 5 on filgotinib and 4 on upadacitinib. Conclusion This study demonstrates that upadacitinib is more likely to achieve 3- and 6-month remission compared to tofacitinib. In a small sub-group of bio-naïve patients Upadacitinib was more likely to achieve 6-month remission compared to filgotinib and tofacitinib. JAKi were associated with minimal adverse events and importantly, the efficacy of JAKi does not appear diminished by prior biologic use.

Injury to the hamate can result in significant functional impairment and a negative impact on quality of life. These injuries, in general, occur very infrequently, and in the setting of an increasingly ageing population and more patients presenting post falls, clinicians are at risk of either misdiagnosing or failing to diagnose patients who sustain hamate fractures. This review finds that hamate fractures can occur through acute trauma or chronic repetitive stress. These injuries are often missed resulting in a delay to management. Common presenting features of hamate fractures include ulnar-sided palmar tenderness and paraesthesia in the ulnar nerve distribution, loss of grip strength and pain on swinging a gripped object. In examination, the hamate "pull test" is a highly sensitive test for hamate fractures. CT scan of the carpal bones is shown to be the gold standard investigation for the diagnosis of such injuries. Initial management of hamate fractures in the United Kingdom is in line with the National Institute of Health and Care Excellence (NICE) guidelines that involves immobilisation with a suitable splint and sling for comfort, adequate analgesia, rest and elevation. Specific management of hamate fractures is divided into conservative and surgical options; however, this review identifies the need for further research into which form of management is superior.

ObjectiveMost patients who have an implantable cardioverter-defibrillator (ICD) implant do not receive life-prolonging therapy from it. Little research has been undertaken to determine which patients benefit the least from ICD therapy. As patients age and accumulate comorbidities, the risk of death increases and the benefit of ICDs diminishes. We sought to evaluate the impact of comorbidity, frailty, functional status on death with no prior appropriate ICD therapy.MethodsA prospective, multicentre, observational study involving 12 English hospitals was undertaken. Patients were eligible for inclusion for the study if they were scheduled to have a de novo, upgrade to or replacement of a transvenous or subcutaneous ICD or cardiac resynchronisation therapy device and defibrillator (CRT-D). Baseline characteristics were collected. Participants were asked to complete a frailty assessment (Fried score) and a functional status questionnaire (EuroQol 5-Dimension 5-Level (EQ-5D-5L)). The Charlson Comorbidity Index was calculated. Patients were prospectively followed up for 2.5 years. The primary outcome was death with no prior appropriate therapy.ResultsIn total, 675 patients were enrolled, mean age 65.7 (IQR 65–75) years. A total of 63 patients (9.5%) died during follow-up, 58 without receiving appropriate ICD therapy. Frailty was present in 86/675 (12.7%) and severe comorbidity in 69/675 (10.2%). Multivariate predictors of death with no appropriate therapy were identified and a risk score comprising frailty, comorbidity, increasing age, estimated glomerular filtration rate and EQ-5D-5L was developed.ConclusionComorbidities, frailty and the EQ-5D-5L score are powerful, independent predictors of death with no prior appropriate therapy in ICD/CRT-D recipients.

Objectives: Sacral chordoma (SC) is a rare, aggressive tumor with a high recurrence rate and originates from notochordal remnants.SC is difficult to differentiate with its non-specific symptoms such as lower back pain.Surgical treatment and radiotherapy are first-line treatments.Resection with wide margins is vital for the prevention of recurrence. Materials and Methods:Nine patients diagnosed with SC between January 2014 and December 2021 were retrospectively analyzed.All adult patients with SC were included in the study.Pediatric population was excluded from the study.Pathology, radiology and surgical records of the patients' were used.Mean age was 53.2.Results: Two out of 9 patients died during follow-up and 5 patients had local recurrence.No metastasis was observed. Conclusion:Current evidence shows that surgical treatment is necessary for SC's treatment.Radiotherapy is also an important aspect of the treatment.Existing evidence should be meta-analyzed for a better understanding of SC's treatment and outcomes.

Introduction The prevalence of bilateral hip arthritis continues to rise. With the dramatic change in the practice of modern-day arthroplasty with standard operating protocols and guidelines in place to reduce the incidence of surgical site infection and peri-operative thromboembolic events, simultaneous bilateral total hip replacement (THR) has been considered a viable option to reduce morbidity. The efficacy of simultaneous bilateral THR with regardto patient outcomes and complications has been debated. The aim of this study was to assess and compare the functional outcomes, radiological outcomes, and complications following bilateral simultaneous THR with the existing literature. Methods We conducted a retrospective study of 28 patients who underwent simultaneous bilateral THRby a single surgeon at a district general hospital in the United Kingdom between 2010 and 2019. All the patients in the study were operated on via the posterior approach to the hip and received uncemented implants. Data on blood loss and hospital stay were collected from the hospital records. The radiological outcomes were studied from the post-operative radiographs. The patient-reported outcomes were measured via a telephone session at an average follow-up of 7.8 years. Results Our results noted a statistically significant drop in haemoglobin after the procedure from a mean of 13.5 g/dl to 9.05 g/dl (t: -15.84, p < 0.00001). The average blood loss was 643 ml +/- 330 ml (200-1850 ml). Nine patients (32.1%) required blood transfusions and a total of 21 units were transfused. The mean duration of stay in the hospital was 6.7 days (three to 20 days). There were no intra-operative/immediate/early post-operative complications. The revision rate was 1.7%, as one patient had a revision of the femoral component following a peri-prosthetic fracture. The mean visual analogue scale painscore was 1.51 +/- 0.58 (1-3). The mean Oxford Hip Score improved from 19.5 (12-28) pre-operatively to 44.3 (37-48) post-operatively at the time of the study (t: -21.88945; p < 0.00001), with the difference being statistically significant using a paired t-test. From the series, 14 (50%) patients were found to have limb length discrepancies. The mean limb length discrepancy was found to be 2.3 mm (0-16 mm). In 13 of the 28 patients (46.4%), the global hip offset was equal on both sides.In two patients, the difference in the global hip offset was more than 10 mm. Conclusion We reported good patient-reported functional outcomes with simultaneous bilateral THR with a low complication rate. Despite the lack of opportunity to template the second hip, the limb length and global hip offset can be restored after a simultaneous bilateral THR.