University Hospital Aintree Research Articles

Journal of Diabetes NEWS

<i>Journal of Diabetes</i> NEWS

Early and late mortality in hospitalised patients with raised cardiac troponin T

AimsCardiac troponins are measured in acute coronary syndrome (ACS) and other conditions. The authors investigate the prognostic significance of cardiac troponin T (TnT) test and comorbid medical conditions.MethodsConsecutive patients admitted...

Quality of life in older people with oral cancer

There is a growing elderly population presenting with, and surviving, oral cancer. Making decisions about treatment is complex, and is influenced in part by prognosis and expected outcomes for health-related quality of life (HRQoL). We used the University of Washington Head and Neck Quality of Life scale (UWQoL) to compare HRQoL in patients by age group at a time closest to one year after primary surgery. Survival was analysed using data from the Office for National Statistics. A consecutive series of 1091 patients treated curatively for oral squamous cell carcinoma (SCC) at the regional maxillofacial unit at Aintree University Hospital between 1992 and 2009 were included in the main analysis. UWQoL data for 638 patients were available from about one year after treatment. Older patients (65 years or over) reported better physical and emotional function notably in regard to appearance, speech, saliva (75 years and over), pain, shoulder, mood, and anxiety than younger patients with head and neck cancer treated by operation. In conclusion, older patients seem to cope and adjust well to treatment and this is reflected in their HRQoL scores, which are higher in many domains than those of younger patients with head and neck cancer.

Accuracy of magnetic resonance imaging in diagnosing thyroid cartilage and thyroid gland invasion by squamous cell carcinoma in laryngectomy patients

We examined the accuracy of magnetic resonance imaging in assessing thyroid cartilage and thyroid gland invasion in patients undergoing total laryngectomy for squamous cell carcinoma, by comparing histopathology results with imaging findings. A retrospective study reviewed histology and magnetic resonance scan results for all total laryngectomies performed between 1998-2008 at University Hospital Aintree, Liverpool. Pre-operative magnetic resonance images were reviewed independently by two consultant head and neck radiologists masked to the histology; their opinions were then compared with histology findings. Eighty-one magnetic resonance scans were reviewed. There were 22 laryngectomy patients with histologically verified thyroid cartilage invasion and one patient with thyroid gland invasion. There were 31 patients with apparent radiological thyroid cartilage invasion pre-operatively (with 17 false positives), giving sensitivity, specificity, and positive and negative predictive values of 64, 71, 45 and 84 per cent, respectively. On assessing thyroid gland invasion, there were nine false positive scans and no false negative scans, giving sensitivity, specificity, and positive and negative predictive values of 100, 89, 10 and 100 per cent, respectively. Magnetic resonance scanning over-predicts thyroid cartilage and gland invasion in patients undergoing total laryngectomy. Magnetic resonance scans have limited effectiveness in predicting thyroid cartilage invasion by squamous cell carcinoma in laryngectomy patients.

Survival rates for patients with anaplastic thyroid carcinoma receiving different treatment modalities.

Survival rates for patients with anaplastic thyroid carcinoma receiving different treatment modalities.

Commonly used antiseptic agent, rare cause of anaphylaxis

We report a case of anaphylaxis attributed to the chlorhexidine component of Instillagel, presenting after a urological procedure, leading to him becoming unconscious and hypotensive. Authors: Dr P Williams, Dr A Alkali, Department of Dermatology, University Hospital Aintree, Liverpool. Corresponding Author: Dr P Williams, Department of Dermatology, University Hospital Aintree, Liverpool. E-mail: penster50@hotmail.com Abstract Anaphylaxis to chlorhexidine is […]

S166 The role of clinical, metabolic and cardiac biomarkers in predicting outcome from COPD exacerbations requiring hospital admission: A prospective observational study

IntroductionBaseline hyperglycaemia along with Respiratory Rate has been shown to represent a marker for mortality and failure of Non Invasive Ventilation in COPD exacerbations complicated by decompensated respiratory failure. This...

Implementing Traumatic Cervical Spine Clearance Clinical Practice Guidelines

From the Department of Anaesthesia and Intensive Care (S.J.M.), University Hospital Aintree, Merseyside, United Kingdom; and Department of Anaesthesia and Intensive Care (A.G.), Royal Liverpool University Hospital, Merseyside, United Kingdom. Submitted for publication September 4, 2009. Accepted for publication February 4, 2010. Address for reprints: Simon Jude Mercer, FRCA, Anaesthetic Department, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, United Kingdom; email: [email protected].

S1353 Pexact®: Analysis of 319 Procedures Performed at the Digestive Diseases Unit, University Hospital Aintree

Introduction Patients with head and neck cancers can require nutritional support during and after treatment of their cancers. This is commonly done via a gastrostomy. The original “pull though” PEG has an increased risk of tumour implantation at the PEG site. We therefore changed our practice to direct puncture gastrostomy insertion in 2004, using the PEXACT® (fresenius) gastrostomy system, for all head and neck cancer patients. We have previously reported our first year experience of 89 cases. We report our practice since then. Methods All PEXACTS® performed in the unit between November 2005 and November 2009 were identified, using our endoscopy reporting system and from referral register. Further information regarding each patient (readmissions, complications and mortality) was obtained from the hospital patient administration system. Results According to the data available to date, 319 PEXACT® insertions were identified in 317 patients. 79% of patients were male (n=251). Average age was 58 years (18–85 years). 99% (n=316) patients had a head and neck cancer as the indication. Insertion was successful in 99% (n=316) and unsuccessful in 3(0.9%) patients: 2 cases due to poor access and 1 case due to gastric intramucosal haematoma. All patients had prophylactic antibiotics on the ward prior to the procedure. In total six patients died within 30 days (1.9%), 1 within 7 days (0.3%). Of the 30-day deaths, 3 were due to disease progression, one neutropenic sepsis following chemotherapy and two had no record of the cause of death available. Two patients had major procedure related complications (0.6%). On both occasions complications was identified immediately. One of the patients had splenic injury during the procedure and required emergency surgery, the second patient had intra-abdominal haematoma due to laceration of gastric wall which was managed conservatively and resolved spontaneously with good outcome. Ten (3.1%) patients had unplanned admissions within 30 days of their procedure. Four patients were admitted within 7 days (1.3%). Reasons for readmission included displaced or blocked gastrostomy tube n=2 (0.6%), disease progression n=2 (0.6%), gastrostomy site infection n=3 (0.9%) and 1 (0.3%) patient developed an aspiration pneumonia secondary to alcohol excess. There have been no cases of tumour implantation to date. Late displacement of the gastrostomy tube (>30 days after insertion) was common (6.6%). Most were replaced at the bedside. Conclusion PEXACT® is a safe and reliable method of gastrostomy tube placement. Overall, our complication rate has fallen, with only two major procedure related complications during this period. There have been no procedure related deaths. There have been no cases of tumour implantation.

The Physical Function and Social-Emotional Function Subscales of the University of Washington Quality of Life Questionnaire

To perform a factor analysis using the University of Washington Quality of Life Questionnaire version 4 (UW-QOLv4) to establish subscales; to report their normative values and variations for patients by age, sex, extent of disease, and time from treatment; and to estimate clinical effect sizes and potential for use in comparative treatment studies. Retrospective cohort. Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, England. Patients with primary oral and oropharyngeal cancer treated by surgery with or without adjuvant radiotherapy since 1992. A database accumulating since 1995 contains more than 2600 UW-QOLs completed by these patients. A data set of 372 patients without cancer attending 10 general dental practices provided normative data. UW-QOLv4. Factor analysis indicated a 2-factor solution: (1) physical function, involving chewing, swallowing, speech, taste, saliva, and appearance, and (2) social-emotional function, involving anxiety, mood, pain, activity, recreation, and shoulder function. The best scores were for those with less advanced oral cancer tumors not requiring free-flap surgery or adjuvant radiotherapy. Older patients reported better scores, but associations were weak, and no sex differences were found. Significant differences were seen for T category, site, free-flap surgery, and adjuvant radiotherapy (P < .001). Preoperative scores were close to normative values. Patients regain social-emotional deficits by 1 year after surgery but continue with significant deficits in physical function. Comparative studies using these UW-QOL subscales as outcome measures should recruit at least 80 patients per treatment arm to detect moderately sized treatment effects. With the UW-QOLv4, it is appropriate to analyze and report outcomes using the 2 subscales of physical and social-emotional function.

PTH-050 PEXACT®: analysis of 319 procedures performed at the Digestive Diseases Unit, University Hospital Aintree

<h3>Introduction</h3> Patients with head and neck cancers can require nutritional support during and after treatment of their cancers. This is commonly done via a gastrostomy. The original “pull though” PEG has an increased risk of tumour implantation at the PEG site. We therefore changed our practice to direct puncture gastrostomy insertion in 2004, using the PEXACT® (fresenius) gastrostomy system, for all head and neck cancer patients. We have previously reported our first year experience of 89 cases. We report our practice since then. <h3>Methods</h3> All PEXACTS® performed in the unit between November 2005 and November 2009 were identified, using our endoscopy reporting system and from referral register. Further information regarding each patient (readmissions, complications and mortality) was obtained from the hospital patient administration system. <h3>Results</h3> According to the data available to date, 319 PEXACT® insertions were identified in 317 patients. 79% of patients were male (n=251). Average age was 58 years (18–85 years). 99% (n=316) patients had a head and neck cancer as the indication. Insertion was successful in 99% (n=316) and unsuccessful in 3(0.9%) patients: 2 cases due to poor access and 1 case due to gastric intramucosal haematoma. All patients had prophylactic antibiotics on the ward prior to the procedure. In total six patients died within 30 days (1.9%), 1 within 7 days (0.3%). Of the 30-day deaths, 3 were due to disease progression, one neutropenic sepsis following chemotherapy and two had no record of the cause of death available. Two patients had major procedure related complications (0.6%). On both occasions complications was identified immediately. One of the patients had splenic injury during the procedure and required emergency surgery, the second patient had intra-abdominal haematoma due to laceration of gastric wall which was managed conservatively and resolved spontaneously with good outcome. Ten (3.1%) patients had unplanned admissions within 30 days of their procedure. Four patients were admitted within 7 days (1.3%). Reasons for readmission included displaced or blocked gastrostomy tube n=2 (0.6%), disease progression n=2 (0.6%), gastrostomy site infection n=3 (0.9%) and 1 (0.3%) patient developed an aspiration pneumonia secondary to alcohol excess. There have been no cases of tumour implantation to date. Late displacement of the gastrostomy tube (&gt;30 days after insertion) was common (6.6%). Most were replaced at the bedside. <h3>Conclusion</h3> PEXACT® is a safe and reliable method of gastrostomy tube placement. Overall, our complication rate has fallen, with only two major procedure related complications during this period. There have been no procedure related deaths. There have been no cases of tumour implantation.

Improvement in the care of multiple endocrine neoplasia Type 1 through a regional multidisciplinary clinic

Multiple endocrine neoplasia type 1 (MEN1) is associated with significant morbidity and mortality. Timely detection of MEN1 kindred, together with treatment of associated tumours, results in an improved outcome. We describe how the development of a dedicated multidisciplinary MEN clinic has improved the diagnosis and treatment of MEN1-associated endocrinopathies. A dedicated MEN clinic was developed at Aintree University Hospital, Liverpool in 2002 for patients living in Merseyside, Cheshire and North Wales. The multidisciplinary approach adopted, aimed to improve communication and continuity of care. Patients see all clinicians involved in their care (Consultant Endocrinologist, Paediatrician, Clinical Geneticist and Endocrine Surgeon) simultaneously, allowing for a unified, clear approach and a reduction in unnecessary attendances. The clinicians adopt a proactive approach to tracing the relatives of patients, with the aim of identifying kindred with previously asymptomatic disease. In 2002, 16 patients from 5 families were diagnosed clinically with MEN1. Twenty MEN1-associated endocrinopathies had been diagnosed and 21 surgical procedures had been performed. By the end of 2008, 45 patients from 15 families had been identified, with 83 endocrinopathies diagnosed and 50 surgical procedures performed. Ninety-four known relatives are awaiting screening for MEN1. The successful identification of patients with MEN1 has resulted in an exponential increase in the number of patients attending the clinic. As relatives undergo screening, the diagnosis of MEN is likely to increase. The ever increasing numbers of patients requiring screening, surveillance and treatment has implications in the planning of future service provision.

Leonardo Fabbri: investigating the complexity of COPD

Leonardo Fabbri: investigating the complexity of COPD

Issues of intimacy and sexual dysfunction following major head and neck cancer treatment

Problems with sexuality and intimacy in head and neck cancer are under reported. This study set out to describe patients self-reporting of intimacy and sexual dysfunction following treatment and to explore associations with patient characteristics. Patients treated for primary head and neck squamous cell carcinoma, alive and disease free, were identified from the University Hospital Aintree Head and Neck Cancer database, January 2000 to December 2006. A postal survey with two questions from the European Organisation for Research and Treatment of Cancer Quality of Life questionnaire-Head and Neck 35 (EORTC H&N35) regarding sexuality, a self-designed question about intimacy and the University of Washington quality of life questionnaire Version 4 (UW-QOL v4) was sent to patients in March 2007. There was a 68% response (350/518). One-third of those answering the intimacy and sexuality questions reported substantial problems with sexual interest and enjoyment, and one-quarter reported problems with intimacy. Intimacy problems declined with age from 36% if aged under 55 years to 6% for those 75 years and older. Intimacy and sexuality issues were largely unrelated to site, stage of disease, treatment modality and time since surgery. Gender and having a spouse or partner were related to answering the questions but not to having problems. With one-quarter of responders reporting intimacy problems it is surprising how little information and support regarding intimacy and sexual dysfunction is offered to patients and their carers. There is a need to explore these issues more extensively with further research.

Hyperglycaemia as a predictor of outcome during non-invasive ventilation in decompensated COPD

Rationale:Hyperglycaemia predicts a poor outcome in Intensive Care Unit (ICU) patients. Whether this is true for respiratory failure necessitating non-invasive ventilation (NIV) is not known.Objectives:To determine whether hyperglycaemia within 24...

The inflammation produced by corticosteroid inhalers in the pharynx in asthmatics

To investigate inflammation of the pharyngeal mucosa caused by inhaled corticosteroids. Prospective, cross-sectional, single-blinded study. University Hospital Aintree, Liverpool, UK. Fifty adults were recruited from two local general practices and from general ENT clinics at our University hospital. Patients were allocated to one of four groups according to use of inhaled corticosteroids and the presence of adverse local side effects. Scores achieved on a respiratory symptom questionnaire. Histological markers of inflammation and their correlation with pharyngitis. Statistical modelling included univariate and multivariate analyses, which included multiple linear and logistic regression, and discriminant analysis. The regular use of inhaled corticosteroids predisposed subjects to hoarseness, weakness of voice, sore throat and throat irritation (P < 0.0001). Pharyngitis was significantly different between the groups (P < 0.0001). Furthermore, those not using an inhaled corticosteroid regularly had little or no clinically apparent pharyngitis, whereas those using an inhaled corticosteroid regularly had significantly higher pharyngitis scores (P = 0.0204). Similarly, weakness of voice (P = 0.0234), hoarseness (P < 0.001) and sore throat (P < 0.001) were also more common in those patients that used an inhaled corticosteroid on a regular basis. To our surprise, however, cellular markers of inflammation did not corroborate the appearances of clinical examination. We found that the five most important discriminators, between those that were using inhaled corticosteroid therapy regularly and those that were not, to be intra-epithelial inflammatory cells (scdf -1.2939); age (scdf 0.8389); use of a spacer device (scdf 0.5456); sore throat (scdf 0.4230) and throat irritation (scdf 0.4015). The groups were significantly different (P < 0.0001). The statistical model used, classified 68% of the cases correctly into their respective groups. Inhaled corticosteroids predispose to pharyngitis and an inflammatory infiltrate. However, the clinical diagnosis of pharyngitis does not correlate well with cellular inflammatory infiltrate and is therefore, not a reliable measure of underlying inflammation. We advocate caution in the use of pharyngeal erythema as a measure of underlying inflammation.

Prognostic Variables for Resection of Colorectal Cancer Hepatic Metastases: An Evolving Paradigm

Anton J. Bilchik, California Oncology Research Institute and David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA Graeme Poston, Royal Liverpool and Aintree University Hospitals, Liverpool, United Kingdom Rene Adam, Assistance Publique—Hopitaux de Paris Hopital Paul Brousse, Universite Paris Sud, Paris, France Michael A. Choti, Johns Hopkins School of Medicine, Baltimore, MD

Acoustic Analysis in Asthmatics and the Influence of Inhaled Corticosteroid Therapy

The impact of sustained inhaled corticosteroid (ICS) therapy on the larynx and pharynx was assessed using a prospective, cross-sectional, and investigator-blinded study conducted at the University Hospital Aintree, Liverpool, UK. Forty-six adults recruited from two local general practices and from general ENT clinics at our University hospital were investigated for the study. Patients were allocated to three groups according to ICS use. Laryngeal effects were measured by correlating the results of a vocal performance questionnaire, a respiratory symptom questionnaire, and measurements obtained by computerized speech analysis. Sustained vowels and connected speech were analyzed in normal and asthmatic subjects. Acoustic analysis was correlated with cellular markers of inflammation after biopsy. Regular ICS users had significantly more pharyngeal inflammation and throat discomfort (P<0.0001). Vocal performance was also worse in this group (P<0.0001). They were more likely to have hoarseness, weakness of voice, aphonia, sore throat, throat irritation, and cough (P<0.0001). All these variables were directly related to one another (P<0.0001). Multiple linear regression analysis showed that jitter was a good objective measure of hoarseness (P<0.05). Regular ICS users were significantly more likely to have abnormal jitter, shimmer, and closed-phase quotient scores (P<0.0001). There was no difference between the groups in the observed parameters of inflammation (P>0.01). A higher pharyngitis score did not correlate with any of the histological markers of inflammation (P>0.01). Local side effects are more common in asthmatics that use ICS regularly. Measures of laryngeal function are significantly worse in regular ICS users. However, histological markers and oropharyngeal redness are not reliable measures of inflammation.

Prevalence of pharyngeal and laryngeal complications in adult asthmatics using inhaled corticosteroids

To investigate the prevalence in adults of pharyngeal and laryngeal symptoms associated with the use of inhaled corticosteroids. Prospective, observational and based on a structured, specifically designed postal questionnaire. University Hospital Aintree, Liverpool, UK. The questionnaire was distributed to 190 patients on the basis of current inhaled corticosteroid use. Recruitment was from the databases of two local general practices. Individuals were classified as mild, moderate or severe asthmatics, using the guidelines of the British Thoracic Society. Demographic data, including smoking history, were recorded. The number, type, strength, dosing regime and duration of individual inhaler use were recorded. Specific pharyngeal and laryngeal side effects were enquired about. Co-morbidities and preventive measures were also recorded. Results were analysed using univariate and multivariate statistical tests. There was a 75.8 per cent response rate (144/190 questionnaires); 63 (43.8 per cent) of respondents were male and 81 (56.2 per cent) were female. The majority of our patients were either mild or moderate asthmatics. Longer use of an inhaled corticosteroid predisposed to weak voice (p = 0.0016), hoarseness (p = 0.0001) and throat irritation (p = 0.008). Hoarseness, throat irritation, sore throat and cough were observed much more frequently than anticipated. Severe asthmatics were more likely to use a spacer device compliantly (p = 0.0487; odds ratio 1.53). Side effects were more prevalent as asthma severity worsened (p = 0.0049; odds ratio 1.87). Inhaled corticosteroids cause sore throats, throat irritation, hoarseness and cough. Further research in this area is required in order to elucidate the mechanism of inflammation. Only then can effective preventive measures be introduced and implemented.

Prospective, Randomized Cross-Over Trial to Assess the Ability of a Dry-Powder Inhaler to Reverse the Local Side Effects of Pressurized Metered-Dose Inhalers

Objectives. To determine whether a corticosteroid dry-powder inhaler could reverse the pharyngeal and laryngeal side effects produced by a corticosteroid pressurised metered-dose inhaler. Design. Prospective, randomized, controlled, cross-over, evaluator-blinded study. Setting. University Hospital Aintree, Liverpool, United Kingdom. Patients. Thirty-seven adults recruited over a 12-month period from Ear, Nose and Throat clinics at our University hospital. Patients were randomized into three groups using a computer-generated random number list and sealed opaque envelopes. Main outcome measures. Scores were achieved on respiratory symptom and vocal performance questionnaires. Acoustic analysis was performed followed by a standardized biopsy of the posterior pharyngeal wall. Histological markers of inflammation were correlated with pharyngitis. The data were tested for normality using the Kalmogorov-Smirnov test. The Kruskal-Wallis analysis of variance was used to investigate differences between medians and ranges. The data were further investigated for correlations using the Spearman test. Discriminant analysis was used to examine the effect of the three groups on each variable. Results. Discomfort scores (median and range) were significantly lower after dry-powder inhaler use than with either a spacer or water gargle (p < 0.01). These worsened after restoring pressurized metered-dose inhaler therapy. The reduction in pharyngitis in each of the three groups was not significant. Vocal performance scores improved with dry-powder inhaler use. Jitter, shimmer, and closed-phase quotient scores improved with dry-powder inhaler use (p < 0.01). Shimmer scores deteriorated once the pressurized metered-dose inhaler was restored (p < 0.01). There was no significant difference between the groups in most observed parameters of inflammation (p > 0.01). Conclusion. A dry-powder inhaler may alleviate the local side effects produced by a pressurized metered-dose inhaler. Laryngeal dysfunction appears to be particularly responsive to the absence of propellant. More observational and randomized controlled trials are necessary to examine existing inhalers and specifically, how and why they cause local side effects.