Intensive care unit (ICU) survivors have an increased mortality rate and reduced quality of life associated with post-ICU syndrome: a triad of physical, psychiatric and cognitive decline. Following evidence on the benefits of early rehabilitation, the National Institute of Clinical Excellence (NICE) CG83 guidelines instruct the provision of rehabilitation information to ICU patients before discharge. Only 33% of UK trusts meet these guidelines. The aim of this project was to reach 100% patient and ICU therapist satisfaction with the rehabilitation information given before ICU discharge at Medway Maritime Hospital, within four months. Patient and therapist satisfaction was assessed using questionnaires at baseline and following each Plan-Do-Study-Act (PDSA) cycle. In PDSA1, a generalised rehabilitation information booklet was created and distributed to ICU survivors pre-discharge. For PDSA2, a personalised rehabilitation plan completed by therapists was added. During PDSA3, the booklet was enriched with mental health and speech and language therapy sections. Results showed a shift in patient satisfaction scores, indicating a significant change in the median from 20% at baseline to 87% after PDSA3. This was also reflected in the therapist satisfaction scores, which increased significantly from 60% at baseline to 100%. The introduction of a generalised information booklet, supplemented with a personalised recovery plan, is an effective way of increasing critical care patient and therapist satisfaction with post-discharge rehabilitation information provision. This should translate to greater patient engagement with rehabilitation and improved long-term outcomes. This is ever more pertinent, as the COVID-19 pandemic will exponentially increase the numbers of ICU survivors at risk of long-term morbidity and mortality.
Abstract Aims Methods This systematic review protocol was registered on Prospero (ID: CRD42021239363). Seven online databases were searched for relevant papers, with subsequent abstract and full-text screening by two reviewers. The primary outcome was the technical success of stenting. Pooled rates of successful stenting and related complications were calculated through meta-analysis of proportions performed using random effects. Results 266 papers were collected with 15 studies included for analysis. 290 patients were included with an average age of 68, and a male predominance of 57%. The pooled rate of clinical success was 94.4% (95%CI 90.3 – 96.8%). The pooled rate of technical success was 76.0% (95%CI: 64.9-84.5%). Adverse effects were low; perforation 9% (19.9 – 38.6%), recurrence 28% (19.9 – 38.6%) and stent migration (14.6 – 36.0%). The reporting on long-term outcomes of stenting as a bridge to surgery was vastly variable. Conclusions This study demonstrates SEMS could be clinically effective and safe in benign LBO. We propose the introduction of a widescale database to assess current practice and its clinical application.
Abstract Introduction Patients presenting with large bowel obstruction (LBO) frequently undergo emergency surgery that is associated with significant morbidity. In malignant LBO, endoscopic approaches with placement is a self-expanding metal stent (SEMS), have been proposed to prevent emergency surgery and act as a bridge to an elective procedure—with the intention of avoiding a stoma and reducing morbidity. This systematic review aims to assess the quality and outcomes of data available on the use of SEMS in benign causes of colonic obstruction. Methods This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the protocol was registered on Prospero (ID: CRD42021239363). PUBMED, MEDLINE, HMIC, CINAHL, AMED, EMBASE, APA and Cochrane databases were searched. Studies were assessed for quality utilising the MINORS criteria. Pooled odds ratios with 95% confidence intervals (95% CI) were calculated using random effects models. Results Sixteen studies were included for analysis. 300 patients were included with an average age of 68, and a male predominance of 57%. The quality of the papers included were at risk of bias. The pooled rate of technical success of procedure was 94.4% (95% CI 90.5–96.8%) The pooled rate of clinical success was 77.6% (95% CI: 66.6–85.7%). Adverse effects were low, with perforation 8.8% (4.5–16.6%), recurrence 26.5% (17.2–38.5%) and stent migration 22.5% (14.1–33.8%). Discussion This systematic review demonstrated that SEMS for benign colonic obstruction can be a safe and successful procedure. The utilisation of SEMS in malignant disease as a bridge to surgery has been well documented. Whilst the limitations of the data interpreted are appreciated, we postulate that SEMS could be utilised to decompress patients acutely and allow pre-operative optimisation, leading to a more elective surgery with less subsequent morbidity.
Abstract Introduction Laparoscopy is the gold-standard approach to elective abdominal surgery. Nevertheless, its application to abdominal trauma, including the treatment of haemoperitoneum, has been historically challenged by links to missed injuries. The European Association for Endoscopic Surgery does not clearly recommend therapeutic laparoscopy in trauma, despite the recognised potential benefits, in light of the scarcity and poor standardisation of available evidence. Case description A 68-year old male, presented with worsening shortness of breath and ascites. He was in type-2 respiratory and renal failure on a background of decompensated heart failure. He was admitted to the ITU for circulatory and ventilatory support and underwent ascitic drainage, removed on day 2. On day 3, the patient became peritonitic, exhibited a haemoglobin drop and went into class 2 haemorrhagic shock. A CT-abdomen showed moderate haemorrhagic ascites. An emergency laparoscopy was undertaken, which revealed active bleeding from the left lower abdominal wall. Haemostasis was achieved with ligation and electrocautery of the deep inferior epigastric perforators. Post-operatively, the patient showed a sustained clinical improvement. On day 4 he was stepped down to the ward and on day 10 discharged without further complications. Discussion Therapeutic laparoscopy is efficacious and safe in selected cases of intra-abdominal trauma, as revealed by emerging literature. The haemodynamic stability of the patient is not always a pre-requisite, and the patient's preoperative comorbidities can be key in deciding in favour of laparoscopy. We underline the following important conditions for success: an experienced surgeon, a systematic approach, suitable equipment and short time to surgery.
This editorial explores how technology has helped clinicians during the COVID-19 pandemic, from patient care to education, the changes that have been made and the numerous exciting possibilities of where technology can amalgamate with health care.
Abstract Background With the rise in day case surgery, there has been an increase in both nurse-led discharge and patient turnover. Patients recovering from anaesthesia frequently retain less, therefore information delivered to patients regarding post-operative recovery is sometimes lost or forgotten. The aim of this quality improvement project was to improve both the quality of information and the patient satisfaction with the information provided to them upon discharge following laparoscopic cholecystectomy. Methods Patient satisfaction was assessed using questionnaires at baseline and following each Plan- Do-Study-Act (PDSA) cycle. In PDSA 1, a generic discharge summary delivering standard post-operative instructions, was distributed to patients on discharge. For PDSA 2, a detailed leaflet, encompassing information requested by previously surveyed patients, entitled “going home after your gall-bladder surgery” was provided in addition to the discharge summaries. Results At baseline we found all patients were receiving some sort of discharge information after laparoscopic cholecystectomy. Key information such as wound care, dietary advice and expected pain, was frequently missed. We found that patients were not satisfied, with an average reported satisfaction of 55%. After PDSA 1 patient satisfaction rose to 66%. However,the generic discharge summary missed advice for patients going home with drains and driving advice. With introduction of the detailed leaflet, patient reported satisfaction reached 100%. Conclusions Introducing detailed discharge leaflets improved the patient satisfaction with the information they received on discharge. We anticipate this will in turn reduce patient concerns and need to seek further medical attention. Similar leaflets can be distributed for day case operations such as hernias. This serves as a useful measure to aid patient recovery at home and supports a high turnover day case surgery list.
Abstract Introduction Living kidney transplantation from donors bearing no genetic or emotional relationship with the recipient, is known as unspecified kidney donation (UKD). UKD can create multiple living donor transplantation opportunities and shorten the national waiting list for cadaveric organs. Consequently, the UK Living Donor Kidney Transplantation 2020 Strategy, has prioritised maximising UKDs. The Internet has an established role in raising awareness, offering support, and potentially influencing the decision for or against UKD. This is the first study assessing the quality and readability of online material related to UKD. Method Google was used to search for the following terms: ‘kidney donation’ and one of ‘unspecified’, ‘altruistic’, ‘non-directed’, ‘anonymous’ or ‘good Samaritan’ as well as ‘giving or donating a kidney to a stranger’. Two independent assessors reviewed the top 100 websites and assessed their quality using the Journal of the American Medical Association (JAMA) criteria, the DISCERN instrument and HONcode (Health on the Net Code) certification. Readability was assessed using the Flesch Reading Ease (FRE), Flesch-Kincaid Grade (FKG) and Simple Measure of Gobbledygook (SMOG) scores. Results Only 6% of websites displayed a HONcode stamp. The mean (± SD) JAMA and DISCERN scores of 1.96 (±1.00) and 32.34 (±11.19) respectively, indicate poor quality. The mean (± SD) FRE, FKG and SMOG scores of 52.92 (±13.62), 10.60 (±2.72) and 9.64 (±2.22), respectively, reveal poor readability. Conclusions Transplant centres and medical organisations should prioritise improving the standards of online material on UKD. This enables informed and ethical decision-making when attempting to expand the living donor pool.
Cases of COVID-19 and associated hospitalizations are rising again, and we are at the start of a "second wave". As we prepare for the second wave, we must reflect on what we have learned from the first and how we are going to effectively manage rheumatology patients going forward. Rheumatology patients were thought to be at a higher risk of contracting COVID-19 due to their disease and associated immunosuppressive treatments. In March, the British Society of Rheumatology developed a risk stratification tool to identify patients who were to shield during the height of the pandemic.1 Shielding precautions included staying home or within 2 m of other individuals when in public. Patients deemed to be at high risk were those on high-dose corticosteroids, cyclophosphamide and 2 immunosuppressive agents. Although shielding can reduce the risk of contracting COVID-19 we must also consider the psychosocial impact it has. Shielding renders patients to extreme isolation and rheumatology patients are already at higher risk of mental health disorders due to the challenges and chronicity of their disease. Superimposed social restrictions make them even more vulnerable to loneliness, depression and anxiety.2 In addition, denying them access to gyms and swimming pools which is a key part of managing arthritis, can cause exacerbation of symptoms. Another vital part of management are immunosuppressant drugs. When the pandemic began there was a theoretical risk that these drugs could increase the risk of developing severe COVID-19. Therefore, there was a hesitation in the rheumatology community to initiate disease-modifying antirheumatic drugs (DMARDs) in newly diagnosed rheumatic patients. However, since the start of the pandemic now pathophysiology of COVID-19 has come to light. It is thought the virus drives a "cytokine storm" leading to a hyper-inflammable state observed in conditions such as rheumatoid arthritis and lupus.3 It is therefore postulated that some of the immunosuppressive therapies used to treat rheumatic conditions are protective against COVID-19.4 An observational study demonstrated that rheumatic patients did not have a higher risk of contracting COVID-19 and they did not suffer a more aggressive illness than the general population. Rather, outcome is more dependent on age and co-morbidities.5 A case series revealed that baseline use of biologic therapy does not lead to worse outcomes compared to the general population.6 More recently, the RECOVERY trial in the United Kingdom has demonstrated that the use of steroid dexamethasone, reduces 28-day mortality in COVID-19 patients with an oxygen requirement.7 The interleukin (IL)-6 inhibitor tocilizumab has shown some benefit in observational studies in reducing mortality and invasive ventilation and is currently part of RECOVERY trial phase 2. Cumulative evidence so far suggests there may be a role for tocilizumab in controlling the cytokine storm induced by COVID-19 and it can have a protective factor in the rheumatoid cohort, but research is still ongoing, and the definite effect of tocilizumab is still yet to be determined. Furthermore, cohort studies in France have shown that anakinra, an IL-1 receptor antagonist, reduces the need for invasive ventilation in COVID-19 patients.8 Barcitinib, a Janus-activated kinase inhibitor and canakinumab, a monoclonal antibody of IL-1B have been shown to improve oxygenation in severe COVID-19 infection.9, 10 There is a wealth of data suggesting that immunosuppressive therapy may be influential in downregulating the cytokine storm and in turn be protective against severe infection. Early aggressive treatment of inflammatory conditions, especially rheumatoid arthritis, leads to a better long-term prognosis and having untreated overt inflammation can itself cause immunocompromise.11 Current practice involves discussing the risks and benefits of starting DMARDs with patients and if they are agreeable then to favor drugs that have a shorter half-life such as hydroxychloroquine or sulfasalazine.12 For biologics, guidelines suggest switching from intravenous to subcutaneous or oral where possible to reduce hospital attendance. Additionally, they advise patients who have suspected or confirmed COVID-19, to continue hydroxychloroquine and sulfasalazine but suspend all other DMARDs.13 However, for COVID-free patients who are already established on DMARDs, stopping treatment abruptly will lead to a disease flare which will inevitably impact on their function. Therefore, many centers continued therapy for stable patients throughout the first wave. The risk of abruptly stopping DMARDs could cause hospitalization and requirement for high-dose systemic steroids ultimately leading to poorer disease outcomes.14 As COVID-19 cases are rising and lockdown measures are being reintroduced, it is necessary to consider the long-term plan for rheumatology patients based on what we have learned from the first wave. The drawbacks of shielding are extensive and there is no reproducible evidence that rheumatology patients are at increased risk of developing COVID-19. Patient factors such as age, body mass index, ethnicity, gender, and co-morbidities are proven risk factors for poorer outcomes.15 Thus, the previous recommendations of shielding to rheumatic patients who are an extremely heterogeneous cohort is not appropriate. We recommend conducting an individualized risk assessment like the one undertaken for hospital staff to identify who is at high risk and would benefit from additional protective measures. Those with multiple risk factors along with immunosuppressive therapy are likely to be at higher risk than stable patients on DMARDs alone. We agree with recent recommendations that vulnerable patients at high risk (over 65 years, medical co-morbidities as well as rheumatic disease) should not shield in this "second wave" but will mostly benefit from taking particular caution: reducing the number of social interactions, working from home where possible and limiting the use of public transport. Local rheumatology centers should strive to identify and appropriately advise these patients. We suggest for lower risk rheumatic patients to follow government guidance with the general population and continue with their medication. The mode in which we deliver care has drastically changed since the pandemic. Although the majority of new referrals are seen face-to-face following strict social distancing guidelines and utilizing appropriate personal protective equipment, some new patients are reviewed virtually. History and investigations may be all that's needed to reach a diagnosis or create a management plan for certain conditions for example, those referred for osteoporosis, fibromyalgia, or ankylosing spondylitis (AS) where the main bulk of information is obtained from history. Examination is still important and should not become obsolete, but it adds value only when objective assessment of joints are needed, for example those referred for inflammatory arthritis. Therefore, a triage system to differentiate who will benefit from a face-to-face review will be helpful as the pandemic continues. Follow up of existing patients has largely become virtual over the last 4 months. Data on patient experience have been analyzed in our center and there has been an overwhelming amount of positive feedback. Patients feel safer staying at home but still appreciate the opportunity to speak to their rheumatologist. They feel that virtual appointments are less stressful with no commuting, parking or waiting and therefore a lot of patients are happy to continue virtual clinics for the foreseeable future and even after the pandemic. We acknowledge that there are drawbacks to virtual clinics such as the patient feeling lonely and lack of interaction, there are also fewer support group meetings which can all make the patient feel isolated. Virtual clinics also rely on patients to carry out their own disease activity assessment; some can be reliably done such as the Bath AS Disease Activity Index but measures such as the Disease Activity Score of 28 joints will be difficult for patients to do accurately, but they can give some idea on the extent of disease severity and whether a remote consultation is suitable. Although patients seem to have a good experience with virtual consultations, the effect on clinical outcome is not yet known, whether they experience any adverse effects or suboptimal care will require a longitudinal study. Virtual consultations can take away from the holistic approach to care that a face-to-face review provides but weighing up the risks and benefits and as the pandemic continues, we feel it puts more onus on patients to manage their condition and provide a safer review of patients. In addition, we observed that many drug monitoring blood tests took place in the community with primary care following up results. We have not seen any detriment from this and believe that stable patients can safely increase blood to from 3-monthly to 6-monthly.12
Abstract Introduction Roux-en-Y Gastric bypass (REYGB) amounts for a third of surgical bariatric interventions. Small bowel obstruction (SBO) is a long-term complication in REYGB and can be caused by intussusception of bowel, in approximately 0.5% of procedures. Intussusception in REYBG is mostly attributed to dysmotility. This report demonstrates a rare case of intussusception in REYGB secondary to a benign polyp. Case description A 45 year old female, three years post REYGB, presented to A&E with acute, extreme upper abdominal pain, with three days absolute constipation. She was tender on examination with normal blood tests. CT scan demonstrated small bowel intussusception. Initial concerns were of intussusception of the jejuno-jejunostomy anastomosis causing SBO. She had an exploratory laparotomy, which confirmed intussusception, however this was 20cm distal to the jejuno-jejunostomy. Bowel was gently reduced, and deemed viable. On thorough run-through, a small segment at the transition point, was considered abnormal on palpation. This region was resected and a 1x1cm intraluminal polyp was identified as the causative lead point. The patient did well postoperatively. Discussion Small bowel intussusception in adults is typically attributed to pathological lead point, such as benign or malignant lesions. Intussusception in REYBG is a rare but well-documented cause of intestinal obstruction, usually attributed to dysmotility, secondary to ectopic pacemaker cells particularly around anastomoses. In this case, the intussusception was caused by an unusual pathology separate from the jejuno-jejunal anastomosis. We recommend thorough examination of all adjacent bowel to exclude lesions, in this case a polyp, which could result in recurrence.
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