Genotypic and transcriptomic characterisation of a small colony variant of Pseudomonas aeruginosa and its parent strain isolated in a murine model of chronic bacterial colonisation
S C Irvine, H K Bayes and T J Evans
Institute of Infection, Immunology and Inflammation, University of Glasgow, UK
Abstract
Objectives: Small colony variants (SCVs) of Pseudomonas aeruginosa are often isolated in CF that shows a number of changes favouring chronic colonisation. In a murine model of chronic pulmonary colonisation with P. aeruginosa, a phenotypically stable SCV arose during the course of infection. We characterised the genomic and transcriptomic characteristics of the SCV compared to the parent strain, to establish the mechanism behind the switch to the SCV phenotype.
Methods: The SCV arose within three days of colonisation. Genomic and transcriptomic analysis was performed by Illumina sequencing.
Results: The SCV showed a highly stable phenotype on repeated subculture. Analysis showed typical SCV colony morphology with markedly increased biofilm production. Pulsed field gel electrophoresis showed no difference between parent NH strain and the SCV. DNA sequencing revealed few consistent changes between the parent and SCV other than a single nucleotide mutation within the algD gene. Initial RNA-seq transcriptomic analysis suggests differential expression of over 400 genes, almost all upregulated in the SCV, and many involved in adaptations to adverse environments. These included homologues of the Psl locus involved in biofilm formation, a hyperosmolar-induced protein, and EF-Tu, a bacterial ligand for the platelet activating receptor, important in epithelial adhesion.
Conclusion: The heritable change in the SCV responsible for its phenotype remains obscure but may involve epigenetic change which we are investigating with PacBio™ sequencing. The observed upregulated genes give insight into the adaptations required for bacterial survival within the CF lung that could be novel therapeutic targets.
Are single rooms in hospitals an advantage?
W Pasha1 and J Hunter2
1Vale of Leven Hospital, UK
2Gartnavel General Hospital, UK
Abstract
Background: Elderly in-patients are usually cared for in three to six bedded bays and occasionally in single rooms. Newly built wards are largely single rooms. This study explores the preferences of elderly patients and their visitors.
Methods: A cross-section of cognitively sound patients and their visitors in elderly care wards were recruited. They completed an interviewer-assisted questionnaire about their preferences, and the perceived advantages and disadvantages of different room styles.
Results: Seventy patients, (50:20 female:male; mean age 73; range 68–89), and 63 visitors (40:23 female:male; mean age 50; range 20–80) agreed to help. Of the patients, 20 (29%) favoured single rooms, 45 (64%) preferred multi-bedded bays and five (7%) had no preference. Fifty (79%) of visitors favoured single rooms and 13 (21%) preferred multi-bedded bays. Multi-bedded bays were favoured by patients because of better interaction with staff and patients (30 patients), less isolation (17 patients), better staff surveillance and less risk from falls (13 patients).1 Visitors preferred single rooms because of increased privacy (40 visitors), dignity and comfort for their relative (35 visitors), less disruption from other patients (19 visitors), improved control over the patient’s environment (15 visitors) and possibly reduced infection risk (10 visitors).
Conclusions: In this survey, the majority of elderly in-patients preferred multi-bedded bays whereas their relatives thought single rooms might be better for them. Possibly single rooms are seen as an advantage by the healthy but not by the sick.
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Stress echocardiography in a university teaching hospital – a retrospective analysis
AC Cameron1, SMM Jenkins2 and P Sonecki3
1CT2, Western Infirmary Glasgow and University of Glasgow, UK
2Consultant Cardiologist, Glasgow Royal Infirmary, UK
3Consultant Cardiologist, Western Infirmary Glasgow, UK
Abstract
Background: Chest pain is a common presentation in acute medical units. Stress echo is recommended in assessing stable patients with moderate probability of coronary artery disease. Stress echo services are likely to expand and national guidelines recommend regular audit to maintain standards.
Methods: A retrospective analysis of stress echo at the Western Infirmary Glasgow between 11 January 2010 and 2 December 2010 was performed. Low-risk tests were considered negative and moderate or high-risk positive. Short-term follow-up was 12 months after echo and long-term follow-up until 2 December 2012. The combined primary endpoint was obstructive disease at coronary angiography, acute coronary syndrome or cardiac death during short-term follow-up. Sensitivity, specificity, PPV and NPV were calculated against this endpoint. We excluded patients with non-diagnostic tests or if medical management was pursued after a positive test.
Results: We analysed 101 patients (51 males; mean age 62). Seventy-six tests were negative and 14 positive. We excluded 11: medical management was pursued in six and five had non-diagnostic tests. Eleven with a positive test (79%) experienced a primary endpoint during short-term follow-up. None experienced a cardiac event during long-term follow-up and none died. Two with a negative test (3%) experienced a primary end-point during short-term follow-up. Six (8%) experienced a primary endpoint during long-term follow-up and two suffered non-cardiac death. The sensitivity of stress echo was 85%, specificity 96%, PPV 79% and NPV 97%.
Conclusions: Stress echo has a very high negative predictive value and should be considered to assess patients presenting with stable chest pain and moderate probability of coronary artery disease. A negative test confers an excellent short-term prognosis.
Correlation between urinary tetrahydroaldosterone excretion and placental growth factor in normal and pre-eclamptic pregnancy
G Currie1, N Eisele2, H Small1, G Escher2, C Gennari-Moser2, D Carty1, M Mohaupt2 and C Delles1
1Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
2Department of Nephrology and Hypertension, Bern University Hospital, Switzerland
Abstract
Background: Aldosterone levels are elevated in pregnancy but fall despite volume contraction in pre-eclampsia. Vascular endothelial growth factor (VEGF) and soluble fms-like tyrosine kinase 1 (sFlt-1) have been implicated in this phenomenon in vitro and in animal work. Low placental growth factor (PlGF), which is closely linked to VEGF signalling, identifies women at risk of pre-eclampsia between 20 and 35 weeks’ gestation. We aimed to examine these relationships in human subjects in early pregnancy.
Methods: We measured aldosterone and PlGF at gestational week 14–16 in women who had previously taken part in the Proteomics in Pre-eclampsia (PIP) Study, a longitudinal study of 4000 pregnancies investigating biomarkers for early detection of pre-eclampsia. Stored samples were obtained from 48 cases and 48 matched pregnant controls. Urinary tetrahydroaldosterone (THAldo) excretion was measured by gas chromatography–mass spectrometry (GC–MS) and PlGF by enzyme-linked immunosorbent assay (ELISA).
Results: Booking diastolic blood pressure was higher among women who went on to develop pre-eclampsia (72 mmHg, IQR 54–82 cf 70 mmHg, IQR 56–78 by Mann Whitney, p = 0.0452). Urinary THAldo/creatinine ratio was significantly lower among cases than controls (9.22 µg/mmol, IQR 1.41–16.6 cf 15.96 µg/mmol, IQR 2.76–22.61 by t-test, p = 0.024). Whilst the groups did not show any significant difference in early pregnancy PlGF level, we identified a linear relationship between PlGF and THAldo (Spearman’s rank 0.415, p = 0.001).
Conclusion: THAldo and PlGF are closely linked in early pregnancy. Given the critical role of THAldo in pregnancy, these data suggest that in women destined to develop pre-eclampsia low THAldo rather than PlGF is causal.
Assessing publication bias in dementia biomarker studies
CA Wilson1, D M Kerr2 and T J Quinn3
1Foundation Trainee, Glasgow Royal Infirmary, UK
2Foundation Trainee, East of Scotland Deanery, UK
3Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
Abstract
Introduction: Biomarkers to predict dementia are a contemporary ‘hot topic’ in psychiatry research. Published papers on biomarkers are usually positive; this could represent test utility of all biomarkers or publication bias. Traditional methods of quantifying publication bias, for example Egger’s plots, are not suited to reviews of diagnostic tests. We describe research outputs presented at scientific meetings and predictors of subsequent full manuscript publication as a potential marker of publication bias.
Methods: We chose three exemplar scientific meetings that represent European, North American and Global conferences with a focus on biomarkers (Clinical Trials in Alzheimer’s Disease; International Conference Alzheimer’s Disease; International Psychogeriatric Association all 2009). Two independent, blinded researchers assessed the conference proceedings and selected all abstracts relating to dementia diagnostics. We recorded basic descriptors and dichotomised results as ‘positive’ or ‘neutral’. We assessed publication status using electronic literature databases and contacting lead authors. We described univariate and multivariate associations with publication status.
Results: From 2257 abstracts, we identified 242 abstracts relating to dementia diagnostics. The majority n = 209 (84%) reported positive results. Univariate associations with publication status included ‘positive’ result (p = 0.042); North American research team (p = 0.047) and ‘diagnostic test’ (p = 0.035) with fewer non-biomarker related diagnostic studies published. On multivariate analysis, no single factor was independently associated with publication.
Conclusions: Our results suggest potential for publication bias in dementia biomarkers studies. However, the modest number of conference abstracts reporting neutral biomarkers results suggests that ‘submission bias’ may have a downstream effect on decision to submit data to meetings.
HIV screening of admissions to infectious disease unit
K Montgomery
FY1, Gartnavel General Hospital, UK
Abstract
Background: Twenty-five per cent of patients with HIV are unaware of their infection. Known HIV prevalence in Greater Glasgow and Clyde is 0.1% (n = 1383). Health Protection Agency guidance (2012): ‘NHS bodies, with a diagnosed HIV prevalence greater than two per 1,000 population of 15-59 years, can implement routine HIV testing’. The infectious diseases unit (Brownlee ward) at Gartnavel General Hospital has adopted this policy. Standard: 80% of patients admitted were to be offered an HIV test.
Methods: Patients admitted over a four-week period (July 2013) were audited. Exclusions: HIV test within six months, known HIV positive. PORTAL software (accessed by clinicians for results) and NGTBIO software (where lab uploads results) were examined. Initial audit revealed standard not met. Following discussion with senior medical staff, the following interventions were introduced: screening policy was discussed with all admitting doctors, blood results sheet was modified to highlight HIV screening, sign was introduced into the doctors’ room. Audit was repeated in October 2013.
Results: Ninety-three patients admitted during initial audit. Mean age 48.5 years (95% CI 44–53). In all, 42% (n = 39) of target population were screened. Audit repeated following intervention: 98 patients admitted. Mean age 52 years (95% CI 48–56). In all, 39% (n = 38) of target population were screened. The standard was not met.
Conclusions: Patients with HIV may present with infection. The Brownlee ward offers the opportunity to screen a high-risk population in a setting where there is ready access to counselling, evaluation and therapy. Further work is required to meet the audit standard.
Early androgen blockade influences longer-term brain metabolism as assessed by magnetic resonance spectroscopy
ME Rodie1, M Welsh2, W Holmes3, SA Wudy4, MF Hartmann4, IM Macrae3 and SF Ahmed1
1Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, UK
2Human Biology, School of Life Sciences, University of Glasgow, UK
3Glasgow Experimental MRI Centre, Institute of Neuroscience and Psychology, University of Glasgow, UK
4Steroid Research and Mass Spectrometry Unit, Center for Child and Adolescent Medicine, Justus Liebig University, Germany
Abstract
Background: Magnetic resonance spectroscopy (MRS) can provide a non-invasive, functional insight into brain metabolism and alterations may predict long-term neurocognitive impairment.
Methods: Male and female Sprague Dawley rats (n = 32, 16) were treated on postnatal days 1–5 with an antiandrogen (flutamide, 50 mg/kg) or corn oil SC and scanned at 6 weeks and 10 weeks of age using a small animal 7 T MRI scanner. MR spectra were acquired from a voxel in the frontal cortex. Serum testosterone (T) was measured by GCMS. The results were analysed with a repeated measures nested general linear model.
Results: Male anogenital distance (AGD) was significantly reduced in the treatment group when compared to controls at both 6 and 10 weeks (p = 0.001, p = 0.02). Serum T was higher in the control and treated males at 10 weeks (median 1.9 ng/ml, 2.05 ng/ml) when compared to the same animals at six weeks (0.56 ng/ml, 0.61 ng/ml, p < 0.001). T levels showed a positive correlation with AGD (p < 0.001). On MR spectral analysis, glucose, glutamine, phosphocholine and myo-inositol levels were higher in the treated males compared to control males (p = 0.05, p = 0.03, p = 0.01, p = 0.01); these levels were similar to those in age-matched female controls (ns). N-acetylaspartylglutamate(NAAG) levels were lower in older animals from all groups (p = 0.05) and glutamine, glutamate and GABA also declined over time (ns).
Conclusions: MRS-based assessment shows that brain metabolites have an age and sex dependency. In addition to undermasculinisation of the male external genitalia, early postnatal androgen blockade alters the pattern of these metabolites. The functional effects of these alterations need further study.
Retrospective case study analysis of the clinical presentation and survival of HIV-positive patients diagnosed with PML within a multi-ethnic cohort
A Ahmed, J Bayley, C Taylor and L Campbell
HIV/GUM Department, Kings College Hospital, UK
Abstract
Background: Progressive multifocal leucoencephalopathy (PML) remains an important AIDS-defining condition associated with high levels of morbidity and mortality. This study describes the presentation, demographics and outcomes of patients diagnosed with PML in a multi-ethnic urban HIV cohort.
Methods: A retrospective case note review was performed from 1 January 2006 to 31 December 2012 collecting demographic information, HIV surrogate markers, cART history and survival outcomes. Inclusion criteria were HIV-positive patients with clinical and radiographic findings consistent with PML.
Results: Eighteen patients were identified with a median age of 38 years. Median CD4 count at diagnosis of PML was 134 cells/mm3 (IQR 5–193), with nadir CD4 109 cells/mm3 (41–168). In all, 44% of the patients were previously undiagnosed with HIV infection, with the remainder being on unplanned cART interruptions at the time of PML diagnosis. Seizures occurred in two (12%) of patients. Of the 18 patients, four (22%) died within six months of diagnosis. In all, 72% of all patients were discharged home.
Conclusion: PML appears to occur most commonly in the third decade of life and at a low CD4 count and high HIV viral load. PML is still an important AIDS-defining condition, as nearly half were previously undiagnosed with HIV infection and are associated with long in-patient admissions. The level of long-term morbidity in this case series was relatively low and mortality of ∼28% within 12 months compares favourably to the ∼35% reported in other studies of PML in the post-HAART era.
Documentation and consent in blood transfusion – a prospective audit on a general surgical unit
CL Rutherford and M Abdelhalim
Department of Surgery, Western Infirmary, UK
Abstract
Background: The decision to transfuse is one that is carried out on a regular basis within surgery. In 2012, there were a reported 1645 incidences relating to blood transfusions across 183 health boards. Of these, nine resulted in death in which transfusion was causal or contributory. Our aim was to assess how well we inform patients of the potential risks associated with blood transfusion.
Methods: We carried out a prospective audit within a University Teaching Hospital Surgical Unit over a four-week period. Our aims were to assess how well we informed patients on transfusions and the associated risks, as well as the completeness of blood prescriptions. Using hospital guidelines we created a proforma with two sections: one designed to evaluate documentation and consent, the other to assess the completeness of blood prescriptions. National minimal requirements include name, DOB and address.
Results: A total of 20 patients were transfused over this period. All prescriptions had the national minimal target achieved. Of these however, only four had documented patient consent, despite 18 having indicated on the blood prescription that this had been recorded. Only three (15%) had a completed prescription.
Conclusion: Detailed documentation, particularly relating to consent in blood transfusions, is of the upmost importance, especially considering the potential associated risks. A transfusion study day, as well as posters and informal sessions with foundation trainees, have since been put in place. We plan to re-audit in one month.
Should all patients with a pre-operative diagnosis of metastatic axillary lymphadenopathy undergo axillary node clearance?
CL Rutherford1, J Mansell1, S Stallard1, JC Doughty1 and L Romics2
1Department of Surgery, Western Infirmary, UK
2Victoria Infirmary, UK
Abstract
Background: Recent studies have suggested that women with early breast cancer and low-volume axillary node involvement identified after sentinel lymph node biopsy require no additional surgical treatment, especially those women receiving breast radiotherapy and systemic treatment. In addition, axillary node clearance can be associated with significant morbidity. We aim to identify factors associated with low-volume axillary node involvement in women with early breast cancer and a pre-operative diagnosis of metastatic axillary disease.
Methods: Consecutive women diagnosed with early breast cancer between 2009 and 2011 with a pre-operative diagnosis of axillary node metastasis based on axillary USS and biopsies were identified from a prospectively collected database. Women who received neo-adjuvant treatment were excluded. Axillary USS reports were reviewed. Chi-squared test analysis was performed.
Results: Of 196 women diagnosed with node-positive breast cancer, 36 (18.3%) were diagnosed pre-operatively by axillary USS and biopsy. Six (16.7%) had one node involved, nine (25%) had two nodes involved, four (11.1%) had three nodes involved and 17 (47.2%) had more than three nodes involved. No pathological variables were significantly associated with increasing nodal involvement. Screen detection was significantly associated with reduced node involvement (1–3 nodes = 12 (80%) vs. 7 (33.3%), p = 0.008). Fifteen (41.7%) women with a pre-operative diagnosis of axillary node metastasis had only 1–2 nodes positive on pathology.
Conclusion: In light of recent evidence, this could represent overtreatment and cause unnecessary morbidity. Additional assessment of the axilla in patients with evidence of axillary node metastasis may improve patient selection for more extensive axillary surgery.
Development of a time-efficient high-intensity intermittent exercise programme to improve endurance capacity, insulin sensitivity and reduce inflammatory cytokines
G Langlands1, J Brock1, C Seaton2 and S Gray2
1School of Medicine and Dentistry, University of Aberdeen, UK
2School of Medical Sciences, University of Aberdeen, UK
Abstract
Background: The study aim was to determine whether a time-efficient high-intensity intermittent exercise (HIIE) programme can improve endurance capactiy, insulin sensitivity (estimated through the HOMA-IR (homeostatic model of assessment – insulin resistance)) and reduce inflammatory interleukin-6 (IL-6) cytokines.
Methods: Fourteen recreationally active male subjects (age: 21.1 ± 2.1 years; VO2max: 41.2 ± 6.7 ml/kg/min) were recruited for an HIIE programme involving six sprint sessions over two weeks. Subjects were randomly assigned to a either a 6 s (n = 7) or 30 s (n = 7) sprint group at the start of the trial. The programmes involved either 8 to 12 ‘all out’ 6 s sprints with 30 s recovery periods between sprints (6 s group), or four to six ‘all out’ 30 s sprints with 4 min recovery periods (30 s group) on a cycle ergometer againist 7.5% of the subject’s body mass.
Results: Endurance capacity increased by 90.8% and 27.4% following the six sprint sessions for 30 s and 6 s groups, respectively (p < 0.025). The increase in endurance time for the 30 s group was greater than the increase for the 6 s group (p < 0.025). No significant results were observed on biochemical analysis where pre- and post-training plasma samples were examined for fasting insulin, glucose, triglycerides and IL-6.
Conclusion: The current study concludes that the 30 s and 6 s HIIE programmes are effective at improving endurance capacity. The 30 s protocol produces significantly greater improvements than the more time efficient 6 s protocol. However, these protocols did not influence insulin resistance or inflammatory cytokines.
Cascade testing for long QT syndrome in Scotland
CE Brown1, D O’Sullivan2, S Tennant2, J Dean2, V Murday3, D Oxnard3, H Hailey2, AC Rankin1, ES Tobias13 and C Delles1
1University of Glasgow, UK
2NHS Grampian, UK
3NHS Greater Glasgow and Clyde, UK
Abstract
Objectives: Long QT syndrome (LQTS) has a prevalence of 1/2000–1/3000 and is characterised by QT interval prolongation on the electrocardiogram (ECG). There is marked variability in phenotype, with symptoms ranging from loss of consciousness (syncope) to life-threatening ventricular arrhythmias and sudden death.
Methods: We sought to evaluate cascade testing for LQTS in Scotland up to 31 May 2013. Cascade testing describes genetic testing offered to close relatives of an index individual (proband) if a mutation has been identified. LQTS testing was established in Aberdeen in 2006 with sequencing of the five commonest LQTS genes. The results are classed as follows: Class 5 – definite pathogenic mutation, Class 4 – likely pathogenic, Class 3 – variant of unknown clinical significance and Class 2 – unlikely pathogenic.
Results: Genetic testing for LQTS in 541 individuals identified 116 (21.4%) LQTS mutation positive (Class 5 and 4) probands. Families of 92 (79%) underwent cascade testing and 426 relatives attended generating 4.6 cascade tests per family. Of the 426 cascade tests, 223 (52.3%) were mutation positive. In comparison, there were 3.3 and 2.8 cascades per family for familial hypercholesterolaemia and BRCA1, respectively. Among mutation-negative LQTS probands, 22 had a Class 3 variant and 57 had a Class 2 variant detected.
Conclusion: Cascade testing for LQTS in Scotland successfully identifies cases where a pathogenic mutation has been found in the proband. More family members are coming forward for cascade testing in LQTS in comparison with some other conditions tested by the same laboratory.
Comprehensive dobutamine stress MRI versus dobutamine stress echocardiography in the assessment of patients with left bundle branch block and suspected coronary artery disease
I Mordi, T Stanton, D Carrick, J McClure, K Oldroyd, C Berry and N Tzemos
Department of Cardiology, Golden Jubilee National Hospital, UK
Abstract
Background: Non-invasive diagnosis of CAD in patients with pre-existent LBBB is difficult, with SPECT and stress echocardiography both having limitations. We hypothesised that a comprehensive dobutamine stress CMR examination (DSCMR) be more accurate than dobutamine stress echo (DSE), thus potentially reducing the number of unnecessary invasive coronary angiograms.
Methods: We prospectively evaluated 82 consecutive patients with LBBB referred to our cardiology clinic for investigation of suspected CAD. All 82 patients underwent DSE, DSCMR and invasive coronary angiography (ICA) within 14 days. We compared the diagnostic accuracy of DSE, CMR cine imaging and the additive value of first-pass perfusion and late gadolinium enhancement.
Results: CMR cine imaging (regional wall motion abnormalities) had a higher specificity, negative predictive value (NPV) and overall diagnostic accuracy than DSE (87.5% vs. 72.9%; 80.8% vs. 67.3%; 80.4% vs. 72.0%, respectively) though sensitivity was the same (72.0%). The addition of first-pass stress perfusion and late gadolinium enhancement (scar) further improved diagnostic confidence (sensitivity 82.4%; specificity 95.8%; positive predictive value 93.3%; NPV 88.5% and diagnostic accuracy 90.2%).
Conclusions: DSCMR is a safe procedure and has greater diagnostic accuracy than DSE in assessing patients with suspected CAD and LBBB. A comprehensive examination with the addition of perfusion and LGE to CMR cine imaging significantly boosted specificity and sensitivity making DSCMR a reliable alternative to ICA in this group of patients.
The use of bilateral free superior gluteal artery perforator flaps for immediate unilateral breast reconstruction
C Jones, S Lidder and A Jevani
Southern General Hospital, UK
Abstract
Introduction: The use of autologus tissue for breast reconstruction is recognised as the gold standard, with free Transverse Rectus Abdominis Myocutaneous or Deep Inferior Epigastric Perforator flaps most commonly used. Several alternatives have been described when abdominal tissue is not a viable option. We present a case report for the use of bilateral free Superior Gluteal Artery Perforator flaps (S-GAP) for immediate unilateral breast reconstruction.
Method: Two 8 × 20 cm S-GAP flaps were raised. The artery of the first flap was in a T-junction pattern. An end-to-end anastomosis was performed between one of the branches of the T-junction and the internal mammary artery. The remaining branch was anastomosed in an end-to-end fashion with the second flap’s artery. The flaps were inset obliquely. The superior flap was de-epithelialised apart from a small skin paddle to be used for future nipple reconstruction. The upper pole of the inferior flap was de-epithelialised and a strip of skin left at the inferior portion to aid with infra-mammary fold creation. Results: At six months both symmetry and volume were preserved, with minimal and symmetrical donor site morbidity.
Conclusion: The double S-GAP flap is a useful alternative in patients who are not candidates for abdominal flaps.
Urinary steroid profiling by gas-chromatography mass-spectrometry is not helpful in the diagnosis of Cushing’s syndrome
E Johns1, D Shapiro2, F McManus1 and EM Freel1
1BHF GCRC, University of Glasgow, UK
2Department of Biochemistry, Glasgow Royal Infirmary, UK
Abstract
Introduction: The diagnosis of Cushing’s syndrome (CS) can be challenging and there is no single gold standard diagnostic test. Endocrinologists rely on a combination of plasma cortisol (before and after dexamethasone), midnight salivary cortisol and urinary free cortisol (UFC) to make the diagnosis. Assessment of urinary corticosteroids and their metabolites, measured by gas chromatography: mass spectrometry (GC:MS), provides a comprehensive picture of corticosteroid production, metabolism and excretion and so this may be a helpful additional diagnostic tool in CS.
Methods: We retrospectively examined the urinary steroid profiles assessed before and after a low-dose dexamethasone suppression test of 23 patients referred to our unit for further evaluation of possible CS. Patients were labelled as CS (n = 10) or non-CS (n = 13) by a consultant endocrinologist on the basis of clinical suspicion, UFC and post-dexamethasone plasma cortisol.
Results: Patients with CS demonstrated elevation only of glucocorticoid metabolites (tetrahydrocortisol (THF)/tetrahydrocortisone (THE)/allo THF/cortol and cortolone) with no significant suppression by dexamethasone. There was no difference in baseline steroid pattern between ACTH (n = 6) and non-ACTH (n = 4) dependent CS. All urinary metabolites were within normal range in non-CS patients; glucocorticoids and mineralocorticoids (not androgens) were significantly suppressed after dexamethasone (p < 0.03 in all cases). The only significant difference in urinary steroids between these groups was elevated post-dexamethasone glucocorticoid metabolites in CS subjects (p < 0.03). Plasma cortisol correlated strongly with urinary total cortisol after dexamethasone suppression in both patient cohorts (p < 0.01 in both groups).
Conclusions: Urinary steroid profiling using GC–MS provides no diagnostic advantage over conventional dexamethasone suppression testing ± UFC in CS and should not be routinely performed in this setting. Whether it may help in subtype differentiation of CS requires further investigation. Currently, its use should remain limited to biochemical phenotyping of adrenal adenomas.
Describing quality of life in thyroid outpatients
S Mathur1, J Fortune2, D Carty1, F McManus1, R Drummond1 and T Quinn3
1Department of Endocrinology, Glasgow Royal Infirmary, UK
2Medical School, University of Glasgow, UK
3Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
Abstract
Background: Measuring health-related quality of life (HR-QOL) is an increasingly important metric for research and practice. The ThyPRO is a self-completion, HR-QOL questionnaire designed for use with non-malignant thyroid conditions. ThyPRO quantifies QOL using 84 items across 13 domains (examples: fatigue; mood; appearance). ThyPRO is used as a trial endpoint in multi-centre clinical trials; however, data in an unselected ‘real world’ clinical setting are lacking. We describe patterns and predictors of QOL for patients at a University Hospital outpatient clinic.
Methods: We assessed sequential attendees at the East Glasgow thyroid clinic, over two epochs (July–August 2012 and 2013) excluding those with a cancer diagnosis. A copy of ThyPRO was given to patients at clinic reception and collected after the consultation. We dichotomised the ThyPRO summary data on overall QOL and described univariate and multivariate associations of overall QOL with clinical, demographic details and individual ThyPRO domains.
Results: We collected data on 135 patients, n = 17 (13%) males; median age: 49 years (IQR: 40–58); representing a range of diagnoses including Grave’s disease n = 69 (51%), autoimmune hypothyroidism n = 21 (16%) and goitre n = 14 (10%). Seventy-seven (57%) reported QOL affected by thyroid disease. On univariate analysis: age; sex; smoking; free thyroxine and all individual ThyPRO domains were associated with overall QOL (p < 0.05). On logistic regression corrected for multiplicity, only the ‘mood’, ‘activities of daily of living’ and ‘appearance’ ThyPRO domains were significantly associated with QOL (p < 0.001).
Conclusions: Non-malignant thyroid disease impacts on QOL of many clinic patients, independent of clinical aspects of their disease. Important predictors of QOL were mood; physical function and appearance.
Troponin level as a predictor of coronary intervention
K Docherty, S Beggs and A Shaukat
Glasgow Royal Infirmary, UK
Abstract
Introduction: Although Troponin assays have increased the biochemical sensitivity for Non-ST Elevation Acute Coronary Syndrome (NSTE ACS), the causes of elevated Troponin are multiple. In the absence of significant disease at angiography, the diagnosis for many patients undergoing examination for minor Troponin elevations remains unclear retrospectively. We wished to determine whether the level of Troponin rise predicted coronary intervention in NSTE ACS patients.
Methods: We retrospectively analysed all patients referred for coronary angiography from Glasgow Royal Infirmary over the 12 months to 31 December 2012 following initial diagnosis of NSTE ACS. We collected basic demographic data, index event data (including peak Troponin I assay) and the result of angiography (PCI, CABG, medical therapy). We excluded patients in whom data were missing.
Results: A total of 268 patients in whom complete data sets were available were referred for angiography. The population had a median age of 63, comprised 67% males, and exhibited typical risk factors. The median peak Troponin I result was 0.71 ng/ml with an interquartile range of 0.22 to 3.96 ng/ml. Coronary intervention at or following angiography comprised PCI in 47.1% and CABG in 8.7%. The correlation coefficient (Pearson’s r) between the level of peak Troponin I and coronary intervention was 0.053 (very weak).
Conclusions: Based on our cohort, the level of Troponin I elevation in suspected NST ACS does not correlate with the likelihood of coronary intervention at angiography. This holds true at both low and high levels of the assay. The implications of ‘tiny’ Troponin rises may not be tiny.
Medication and supplement use in Scottish professional football
A Mercer1 and W Hillis2
1School of Medicine, University of Glasgow, UK
2Institute of Cardiovascular & Medical Sciences, University of Glasgow, UK
Abstract
Background: The use of NSAIDs and nutritional supplements by elite athletes has attracted attention of the media and professional sports bodies. This study aimed to analyse this use in Scottish professional football.
Methods: This study was conducted in three parts: doping control forms filled in by players between the 2008/2009 season and 2011/2012 season were assessed (n = 586); a questionnaire on medication and supplement use was sent to players (n = 87) and elite club doctors were interviewed regarding prescribing practices within their clubs (n = 6).
Results: The use of both medications and supplements was prevalent across all four seasons. NSAIDs were the most commonly declared medication with use stated on 29.8% of doping control forms. Vitamins and protein powders were the most commonly declared supplements. The results also showed an increasing trend for players taking a number of substances at once and showed older players, those over the age of 26, having a higher prevalence of use when compared to younger players. Club doctors were shown to be strict on prescribing protocols and all stated they dissuade use of supplements.
Conclusions: Use of medications and supplements is prevalent in Scottish professional football. The use of supplements is a particular concern due to lack of scientific evidence for performance benefit and the high risk of contamination. This study highlights the need for further research in this area and for a robust education system to be put in place to provide information for athletes on the benefits and potential risks of use of such substances.
Melanocyte density in the excisional margins of lentigo maligna is greater in lesions with five-year local recurrence
KEL Farquhar1, C Orange2 and C Moyes2
1School of Medicine, University of Glasgow, UK
2Pathology Department, Southern General Hospital, UK
Abstract
Background: Lentigo maligna (LM) is a melanoma in situ, commonly arising on the head and neck. Thirty per cent progress to invasive lentigo maligna melanoma (LMM). Surgical excision with a 5 mm margin is the current consensus recommended treatment but is shown to be insufficient, with local recurrence as high as 20%. Assessing suitable margins is challenging both surgically and histologically. MITF (microphthalmia associated transcription factor) immunohistochemistry allows accurate estimation of melanocyte density. We hypothesised that melanocyte density in excisional margins may be greater in recurrent LM excisions.
Methods: Cases of complete LM excisions were selected from two groups: those that had recurred locally within five years and those that had not. Immunostaining with MITF was performed and melanocyte density for the peripheral 0.5 mm and 1 mm margins microscopically evaluated.
Results: Twenty non-recurrent LM cases and 16 recurrent LM cases were included in the study. In the recurrent group, the average time to recurrence was 2.2 years. In the peripheral 0.5 mm and 1 mm of marginal tissue, there was a statistically significant difference in average melanocyte density between the groups: 40.6% (p = 0.001) and 42.3% (p = 0.001) greater in the recurrent LMs, respectively.
Conclusions: The melanocyte density in the margins of recurrent LMs was significantly higher than in the margins of lesions that did not recur within five years of excision.
Comparison of Type 1 diabetic control before and five years after transfer to adult services: audit of the 2008 cohort from the Royal Hospital of Sick Children, Glasgow
Jessie R Wang12, S Ching Chen1 and Kenneth J Robertson1
1Royal Hospital for Sick Children UK
2School of Medicine, University of Glasgow, UK
Abstract
Background: Within the NHS Greater Glasgow and Clyde (GGC), many children with Type 1 Diabetes Mellitus (T1DM) are looked after at the RHSC until the age of 16 years, after which they are transferred to their local adult diabetes services. This is the first longitudinal audit within the GGC looking at the changes in diabetic control of the patient pre- and post-transfer.
Method: A cohort of 75 patients referred onto the adult diabetes service from RHSC in 2008 was identified, of which 58 patients were eligible for inclusion in the audit. Glycaemic control, assessed by glycated haemoglobin (HbA1c) and complication data at the time of transfer (2008) was collected from the Magistral database, and compared with the latest (2013) results available from the SCI-Diabetes database. Parameters of interest included HbA1c, retinopathy, microalbuminuria and neuropathy.
Results: The average HbA1c value changed from 73 mmol/mol in 2008 to 86 mmol/mol (p < 0.001; paired sample tests). Patients in the extremely high-risk category (of developing complications) increased from 23 (39.7%) to 37 (63%). Background diabetic retinopathy rose from 4 (6.9%) to 19 (32.8%) patients, of which five (8.6%) now have maculopathy. The number of people with microalbuminuria also increased from 0 to 8 (13.8%). Four (6.9%) patients are currently at increased risk of foot ulceration due to impaired sensory nerve function or absent pulses. The average attendance rate also dropped from 3.6 to 2.3 visits per 18 months (p < 0.001; paired sample tests).
Conclusion: Patient’s glycaemic control appears to deteriorate in the 2008 cohort five years on from transfer to the adult services with significant increase in microvascular complications.
Referrals with suspected OSAS: Potential for improved primary–secondary care interaction
D Murray1*, M Al-Hayali1*, D Cowan2, H Ambler2, D MacFarlane2, E Livingston2 and C Carlin2
1School of Medicine, University of Glasgow, UK
2North Glasgow Sleep Service, Department of Respiratory Medicine, Gartnavel General Hospital and Glasgow Royal Infirmary, UK
*The first two authors contributed equally to the abstract.
Abstract
Introduction: Referral rates to sleep clinics are increasing. Referral quality from primary care is often perceived to be poor. Structured sleep questionnaires are being promoted but there is limited evidence for their value. OSAS diagnosis may be an opportunity for recognition and intervention against cardiovascular risk factors.
Aims and methods: The STOP questionnaire is being promoted for primary care use to screen patients for sleep clinic referral. We had recently identified associations between STOP-BANG scores, adverse lipid profiles, BMI and pre-clinic home sleep study results. Accordingly, we reviewed referral letters, STOP score and statin prescription rates in our study cohort.
Results: Adequate home five-channel sleep study data were available on 131 patients. Snoring and/or witnessed apnoea were frequently documented but otherwise information at referral was suboptimal with only 24% of letters including an Epworth score and 14% including a comment on whether there were driving issues. There was a significantly increased likelihood of a positive sleep study (AHI > 15) if the BMI had been recorded by the referring clinician. Whilst we had found that a STOP-BANG score of <3 can help exclude significant sleep disordered breathing (AHI<5, ROC curve AUC 0.74, p < 0.001, sens 93%), STOP score was not useful for ruling in (AHI>15) or ruling out (AHI<5) sleep disordered breathing (ROC curve AUCs 0.64 and 0.69). Systemic hypertension was prevalent (45%) and despite adverse lipid profiles, 40% of patients with confirmed OSA (AHI>15) were not currently taking a statin.
Conclusions: Referral quality to sleep clinics is suboptimal. Our results suggest that efforts to improve referral quality might improve diagnosis rates, but unfortunately the STOP questionnaire does not look useful in our population. There may be gaps in cardiovascular risk factor management in patients with OSA. All of this could be addressed by enhanced primary–secondary care interaction in sleep services.
A randomised crossover trial of the acute effects of a deep-fried Mars bar on the cerebral vasculature
WG Dunn1 and MR Walters2
1Medical Student, School of Medicine, University of Glasgow, UK
2Professor of Clinical Pharmacology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
Abstract
Background: The deep-fried Mars bar (DFMB) has been cited as ‘a worldwide symbol of all that is wrong with the high-fat, high-sugar Scottish diet’. Dietary factors are likely to contribute to Scotland’s high incidence of cerebrovascular disease. We hypothesised that ingestion of a deep-fried Mars bar would acutely impair cerebrovascular reactivity, which is associated with an increased risk of ischaemic stroke.
Methods: Twenty-four fasted, healthy volunteers on no regular medication (m = 14, f = 10, mean age 21.5 years (SD 1.7)) were randomly assigned to receive a DFMB, then porridge (control), or vice-versa. Breath Holding Index (BHI) was calculated as a surrogate measure of cerebrovascular reactivity by measuring blood flow through the middle cerebral artery, with change in BHI the primary outcome measure.
Results: Ingestion of a DFMB caused a non-significant change in cerebrovascular reactivity of −0.1 units (mean BHI pre-ingestion 1.28 (SD 0.33), post-ingestion 1.18 (SD 0.37), p = 0.19, n = 24). In males only, DFMB ingestion caused a larger change in BHI of −0.21 units, which came close to achieving conventional significance (p = 0.07, n = 14). Porridge elicited no change in cerebrovascular reactivity (mean difference 0.03, p = 0.54, n = 24).
Conclusions: Ingestion of a bolus of sugar and saturated fat in the form of a deep-fried Mars bar caused no overall statistically significant difference in cerebrovascular reactivity, but there was a gender disparity, with a modest decrease in reactivity in males. Impaired cerebrovascular reactivity is associated with increased risk of stroke, and as such ingestion of a deep-fried Mars bar may acutely contribute to cerebral hypoperfusion in males.
Are pre-operative urodynamic studies useful for patients awaiting pelvic organ prolapse surgery?
S Hussain1, K Woods2, L Oliver3 and W Agur4
1Medical Student, School of Medicine, University of Glasgow, UK
2GP Trainee, Glasgow North West, UK
3Urogynaecology Nurse Specialist, University of Glasgow, UK
4Consultant Urogynaecologist, Department of Obstetrics and Gynaecology, Crosshouse Hospital, UK
Abstract
Introduction: The coexistence of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) has been well documented in numerous studies.1–4 The concurrence rate of these two conditions is over 60%3 and over a third of patients who need surgery for either condition require concomitant surgery.3 A urodynamic study (UDS) is performed in patients with POP to ascertain the underlying pathophysiology of urinary incontinence to allow for an appropriate management plan to be devised.5 The aim of this audit was to identify how pre-operative UDS influences the decision for concomitant continence procedure for women who have POP surgery.
Methodology: This was a retrospective study of patients who had POP surgery and underwent preoperative urodynamics. Patients with symptomatic POP (requiring surgery) who also had stress urinary incontinence (SUI) were referred for UDS to determine whether a concomitant continence procedure would be appropriate at the time of the POP surgery.
Results: Thirty-three of the 48 patients (69%) had only a POP repair done despite the fact that nine of these patients were found to have USI on UDS. Of the 48 patients who underwent pre-operative UDS, only six (12%) went on to have a concomitant procedure.
Conclusion: Only 12% of women with combined prolapse symptom requiring surgery and stress urinary incontinence had concomitant procedures. Women awaiting prolapse surgery who are symptomatic of stress urinary incontinence should be fully counselled regarding the potential of a concomitant continence procedure prior to referral for urodynamics.
References
MaherCFeinerBBaesslerK. Surgical management of pelvic organ prolapsed in women (review). Cochrane Library2013; 4: CD004014–CD004014.a-1BaiSWJeonMJKimJY. Relationship between stress urinary incontinence and pelvic organ prolapse. Int Urogynecol J2002; 13: 256–230.a-2HartSRMooreDMiklosJR. Incidence of concomitant surgery for pelvic organ prolapse in patients surgically treated for stress urinary incontinence. J Reprod Med2006; 51: 521–524.a-3a-5NgCSRackleyRRAppellRA. Incidence of concomitant procedures for pelvic organ prolapse and reconstruction in women who undergo surgery for stress urinary incontinence. Urology2001; 57: 911–913.a-4BoschJLHRCardozoLHashimH. Constructing trials to show whether urodynamic studies are necessary in lower urinary tract dysfunction. Neurol Urodyn2011; 30: 735–740.a-6
Test properties of recommended cognitive screening tools for older adults
J Singh1 and TJ Quinn2
1Medical School, University of Glasgow, UK
2Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
Abstract
Background: Routine cognitive assessment of hospitalised older adults is recommended in many guidelines and is an audit standard in NHS England. The Alzheimer’s Society suggests a ‘toolkit’ of cognitive assessments suited to differing healthcare settings. In addition to test accuracy, important properties of a tool are feasibility, acceptability and responsiveness. We assessed properties of the recommended cognitive assessment tools for frail elderly.
Methods: We assessed sequential admissions to two Geriatric Acute Assessment Units in Glasgow Royal Infirmary over one month (January 2014). Our test battery was Hodkinson’s abbreviated mental test (AMT); ‘GPCOG’ and Montreal Cognitive Assessment (MoCA). To assess feasibility and acceptability, we recorded time taken to complete assessment and described numbers completing each test as a proportion of total population. We used basic statistics to describe range of scores and numbers ‘test positive’.
Results: Over one-month data, 54 patients were admitted, median age: 83 years (IQR: 80–88), 23 (43%) males, 27 were able to complete the full battery (n = 13 too unwell; n = 7 behavioural disturbance; n = 3 refused testing). Median time for assessment: 24 min (IQR: 12–28). Of test completers, 13 had a previous diagnosis of dementia. For AMT: 27 out of 42 patients completing the test (64%) were screened positive for cognitive impairment; GPCOG: 14/38 (37%) screened positive; MoCA: 29/29 (100%) screened positive.
Conclusions: Routine assessment of all medical admissions using recommended tools may not be feasible and even a short test battery is still associated with substantial administration time. MoCA, at its usual diagnostic threshold, may not be suited to older hospitalised patients.
The accuracy of colonoscopic localisation of colorectal tumours: a prospective, multi-centred observational study
MS Johnstone1 and SJ Moug2
1Medical Student, School of Medicine, University of Glasgow, UK
2Specialist Registrar in General Surgery, West of Scotland Higher Surgical Training Rotation, UK
Abstract
Background: Colonoscopy is the gold standard for colorectal cancer detection and is additionally used to determine tumour location for surgical planning. Despite this, colonoscopic localisation accuracy remains unclear. The primary objective was to establish the accuracy of colonoscopic localisation and to determine how often inaccuracy results in alteration of planned surgical management.
Methods: A prospective, powered, multi-centred observational study recruited 79 patients who underwent pre-arranged colonoscopy where one colorectal lesion was found that required subsequent surgical resection. Patient and colonoscopic factors were recorded. Pre-operative colonoscopic and radiological lesion localisations were compared to intra-operative localisation using pre-defined anatomical regions to determine accuracy, with any change in planned surgical management documented.
Results: Colonoscopy accurately located the colorectal lesion in 64/79 patients (81%): 10 of the 15 inaccurately located patients required no change in surgical management due to the accurate lesion localisation still being within the planned surgical resection; the remaining five patients (6.3%) did require an on-table alteration in surgical management. Pre-operative imaging was unable to identify the primary tumour in 18/78 patients (23.1%), a finding that was more prevalent amongst bowel screener patients compared to those with symptoms (p = 0.003). Of the 60 patients where the lesion could be visualised on pre-operative imaging, the lesion was correctly localised in 53 patients (88.3%).
Conclusions: Colonoscopic lesion localisation was inaccurate in 19.0% of cases and altered on-table patient management in 6.3%. With CT unable to visualise lesions in just under a quarter of cases, pre-operative localisation is heavily reliant on colonoscopy.
Investigating the expression of matrix metalloproteinases and heat shock proteins in postpartum uterine involution
LE Burton1, RS Oldham1, CA Higgins1, RJB Nibbs2, SM Nelson1 and FM Menzies3
1School of Medicine, University of Glasgow, UK
2Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, UK
3Institute of Biomedical and Environmental Health Research, University of the West of Scotland, UK
Abstract
Background: Following labour, the uterus rapidly returns to its pre-pregnancy state in a dynamic process known as postpartum uterine involution. Exact mechanisms underlying labour and postpartum involution are not fully understood but inflammation is understood to play a key role. It has been hypothesised that rather than initiating or propagating labour, inflammation may prime the uterus for extensive postpartum tissue repair and remodelling, in a manner akin to repair in exercising skeletal muscle. Matrix metalloproteinases (MMPs) and heat shock proteins (HSPs) are known to play a role in skeletal muscle remodelling after injury. Little is known about their role in the postpartum myometrium, and this study aims to examine the expression of mRNA for MMPs (MMP2, MMP8, MMP9) and HSPs (HSP70, HSP27, HSP60, HSP90) in the postpartum mouse uterus.
Methods: Uterine tissues of C57BL/6 mice were collected at Day 1 (n = 5), 4 (n = 6) and 7 (n = 5) postpartum. Virgin females (proestrous stage) were used as non-pregnant controls (n = 5). mRNA expression was determined by qRT-PCR. Differences were analysed by Kruskal–Wallis test, followed by Dunn’s Multiple Comparison Test.
Results: A three-fold increase in expression of Hspb1 (HSP27) at Day 7 postpartum (p = 0.04) and Mmp8 at Day 4 postpartum (p = 0.03) compared to non-pregnant samples was found. Expression of all other genes examined remained unchanged throughout the postpartum period.
Conclusion: HSP27 and MMP8 may have a role in postpartum uterine involution. This study provides a foundation for future research into the potential role of these proteins during the physiological process of uterine involution and muscle damage repair and remodelling.
Screening for cognitive impairments in the acute stroke unit: comparing informant and direct testing strategies
F Barlow-Pay1, I Ahmed1 and T J Quinn2
1Medical Student, School of Medicine, University of Glasgow, UK
2Lecturer in Geriatric Medicine, University of Glasgow and ST7 Glasgow Royal Infirmary, UK
Abstract
Introduction: The Guidelines recommend cognitive screening of all stroke survivors. The Montreal Cognitive Assessment (MoCA) is commonly used as a direct cognitive test in stroke, but may not be feasible in the acute stroke setting. An alternative strategy is to question a collateral source on cognitive decline; this approach requires an available informant and may not capture cognitive change caused by the stroke event. We aimed to assess feasibility of cognitive testing using MoCA and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) and describe the relationship between the two tests.
Patients and methods: We assessed sequential stroke admissions to a University Hospital acute stroke unit over a one-month period (June–July 2013). Assessors were two medical students trained in cognitive testing. One of MoCA or IQCODE was assessed by each student so that both tests were performed blinded to each other’s scores. Order of assessment was randomised (coin toss). Assessors noted where impairments prevented completion of testing. We described proportions completing tests as a measure of feasibility; we also compared MoCA and IQCODE using test accuracy and correlation metrics.
Results: Of 58 suspected stroke patients, 38 were females; median age: 79 (IQR: 74–85). Median time to assessment: three days (IQR: 2–6). MoCA data were available from 47 (n = 2 refused; n = 9 too unwell), six patients required assistance for completion. Median MoCA: 18.5 (IQR:10–24). Using MoCA threshold of ≤ 26, n = 35 (74%) had cognitive impairment. IQCODE data were available from 33 (n = 1 refused, n = 2 not suitable; n = 22 no informant). Median IQCODE: 3.13 (IQR: 3.00–3.70). Using IQCODE threshold of ≥ 3.5, n = 14 (40%) had cognitive impairment. Data on both IQCODE and MoCA were available for n = 27. There was no correlation between the scales (p = 0.07), accuracy of IQCODE for detecting MoCA-positive cognitive impairment gave sensitivity of 0.50 (95% CI: 0.28–0.72) and specificity 1.00 (95% CI: 0.48–1.00).
Conclusions: Cognitive screening of all acute stroke admissions with MoCA may not be feasible and availability of a suitable informant limits the utility of IQCODE. MoCA and IQCODE seem to measure different constructs (‘snapshot’ cognitive function and pre-stroke cognitive decline, respectively) and should be used to complement each other rather than be used in isolation.
Early warning scores and sepsis bundle care: an audit into the sensitivity and specificity of NEWS and SEWS in cases of sepsis
ADD McFadyen and C Diffin
Medical Student, School of Medicine, University of Glasgow, UK
Abstract
Background: Sepsis is a major cause of death. In 2005, it had the same mortality rate as out-of-hospital myocardial infarctions.1 Key in treating Sepsis is early effective management: first driven by Rivers et al.2: Early Goal Directed Therapy. A new national early warning score, ‘NEWS’, has been implemented across Greater Glasgow and Clyde. This study assessed the appropriateness of using ‘NEWS 5 plus suspicion of infection’ as a trigger for initiating sepsis 6.
Method: Data were collected during a four-week period in the Acute Medical Unit at the Southern General Hospital. At ward rounds each day clinical notes were checked to identify any patient with Sepsis. Patients were then sub-categorised into severe or non-severe sepsis using parameters in the surviving sepsis guidelines.3 The scoring systems were examined by looking at NEWS and SEWS in ED and the maximum NEWS and SEWS score up to the point of review.
Results: A total of 52 patients met the criteria for inclusion. Of these cases, 21 met the criteria for severe sepsis. The average NEWS score of severe sepsis patients was 7.9, the average SEWS score was 4.7. The NEWS score was 19% more sensitive at detecting severe sepsis: triggering a medical response in 19 cases.
Conclusion: NEWS is a more sensitive scoring system for triggering medical intervention in cases of severe sepsis. NEWS score of five is an appropriate trigger in the ED. We believe this could lead to earlier completion of sepsis 6 in severely septic patients with consequent improvements in mortality expected.1–3
References
OsborneTMNguyenHBRiversEP. Emergency medicine and the surviving sepsis campaign: an international approach to managing severe sepsis and septic shock. Ann Emerg Med2005; 46: 228–231.a-7a-10RiversENguyenBHavstadS. Early goal directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med2001; 345: 1368–1377.a-8a-11DellingerRPLevyMMRhodesA. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med J2013; 41: 580–637.a-9a-12
Radiological investigation of unexplained weight loss
J Tan
Medical Student, School of Medicine, University of Glasgow, UK
Abstract
Aims/objectives: To investigate the role of CT in the investigation of unexplained weight loss, to compare diagnostic yield of primary care and secondary care radiological referrals and to establish reasons for discrepancy.
Content: Retrospective study of 440 patients referred to a hospital radiology department for CT from January to December 2012 for investigation of unexplained weight loss, defined as weight loss without other prominent signs/symptoms. We compared diagnostic yield between the different referring departments: general practice (GP), in-patient department(IPD) and out-patient department(OPD). We identified factors responsible for discrepancy in diagnostic yield and re-categorised patients according to the most relevant factor that was identified. We compared diagnostic yield and survival statistics of cancer patients between the new groups. Fisher’s exact test and Peto-Prentice test were used for statistical analysis.
Relevance/impact: To aid establishment of a ‘weight loss’ protocol; to reduce unnecessary CT requests for the investigation of unexplained weight loss.
Outcomes: Seventy-two cancers and four cases of chronic pancreatitis were diagnosed: an overall diagnostic yield of 17.3%. Diagnostic yield between GP (23/47; 49%), IPD(36/144; 25%) and OPD(17/249; 7%) differed significantly (p < 0.01). We identified baseline imaging (radiography/ultrasound) as the most decisive factor and re-categorised patients according to baseline imaging status (abnormal/nil/normal). Diagnostic yield between abnormal (56/132;42%), nil (17/164;10%) and normal (3/144;2%) groups differed significantly; survival times for cancer patients did not differ significantly between groups (p = 0.38).
Discussion: CT is not helpful at detecting non-malignant causes of weight loss. Majority of unnecessary CT referrals are from the hospital out-patient department. CT is not recommended in these patients unless backed by abnormal radiography/ultrasound findings.
Investigating hypoglycaemia awareness in type 1 diabetes during pregnancy
L Vermont1, S Hussain1, SJ Lam2, S Jarvis1, F Cheng2, C Jairam1, B Jones2 and A Dornhorst1
1Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, UK
2Department of Obstetrics and Gynaecology, Imperial College Healthcare NHS Trust, Queen Charlotte’s and Chelsea Hospital, UK
Abstract
Aims: This prospective observational study was aimed to determine the prevalence of impaired awareness of hypoglycaemia (IAH) and frequency of hypoglycaemia in pregnant type 1 diabetes patients.
Methods: IAH was assessed using three validated questionnaires (Clarke, Gold and Pederson). These questionnaires were amalgamated together and incorporated the Edinburgh Hypoglycaemic Score, questions on causes and worry for hypoglycaemia scored on a seven-point Likert scale. Questionnaires, self-monitored blood glucose diaries and Diasend® meter downloads were collected from the pregnant patients every fortnight.
Results: Eight pregnant (baseline mean ± SEM: age 28 ± 1.24 years, duration of diabetes 12.5 ± 3 years, HbA1c 65 ± 7.88 mmol/mol) and 22 matched non-pregnant female (age 30 ± 1.23 years, duration of diabetes 16.32 ± 2 years, HbA1c 70.77 ± 4.26 mmol/mol) type 1 diabetes patients were recruited. In keeping with previous observations, there was increased prevalence of IAH in pregnant patients compared to non-pregnant subjects. There was no significant difference in severe hypoglycaemia or proportion of blood glucose readings below 3.5 mmol/l during pregnancy between IAH and aware patients. Pregnant subjects were significantly more worried about nocturnal hypoglycaemia than daytime hypoglycaemia (p = 0.007). Patients with IAH felt more worried about hypoglycaemia compared to aware patients (p = 0.04). Comparison of blood glucose diaries and meter downloads highlighted underreporting of hypoglycaemic events on diaries.
Conclusions: This report demonstrates increased prevalence of IAH during pregnancy. Further research is required to fully assess whether IAH assessed via questionnaires in clinic can predict higher incidence of hypoglycaemia or severe hypoglycaemia in patients. The findings of this study highlight potential for improved detection of hypoglycaemic episodes using technology.
