Queen Elizabeth Hospital Birmingham Research Articles

Health screening clinic to reduce absenteeism and presenteeism among NHS Staff: eTHOS a pilot RCT.

Staff sickness absenteeism and presenteeism (attending work while unwell) incur high costs to the NHS, are associated with adverse patient outcomes and have been exacerbated by the COVID-19 pandemic. The main causes are mental and musculoskeletal ill health with cardiovascular risk factors common. To undertake a feasibility study to inform the design of a definitive randomised controlled trial of the effectiveness and cost effectiveness of a health screening clinic in reducing absenteeism and presenteeism amongst the National Health Service staff. Individually randomised controlled pilot trial of the staff health screening clinic compared with usual care, including qualitative process evaluation. Four United Kingdom National Health Service hospitals from two urban and one rural Trust. Hospital employees who had not previously attended a pilot health screening clinic at Queen Elizabeth Hospital Birmingham. Nurse-led staff health screening clinic with assessment for musculoskeletal health (STarT musculoskeletal; STarT Back), mental health (patient health questionnaire-9; generalised anxiety disorder questionnaire-7) and cardiovascular health (NHS health check if aged ≥ 40, lifestyle check if < 40 years). Screen positives were given advice and/or referral to services according to UK guidelines. The three coprimary outcomes were recruitment, referrals and attendance at referred services. These formed stop/go criteria when considered together. If any of these values fell into the 'amber' zone, then the trial would require modifications to proceed to full trial. If all were 'red', then the trial would be considered unfeasible. Secondary outcomes collected to inform the design of the definitive randomised controlled trial included: generalisability, screening results, individual referrals required/attended, health behaviours, acceptability/feasibility of processes, indication of contamination and costs. Outcomes related to the definitive trial included self-reported and employee records of absenteeism with reasons. Process evaluation included interviews with participants, intervention delivery staff and service providers. Descriptive statistics were presented and framework analysis conducted for qualitative data. Due to the COVID-19 pandemic, outcomes were captured up to 6 months only. Three hundred and fourteen participants were consented (236 randomised), the majority within 4 months. The recruitment rate of 314/3788 (8.3%) invited was lower than anticipated (meeting red for this criteria), but screening identified that 57/118 (48.3%) randomised were eligible for referral to either general practitioner (81%), mental health (18%) and/or physiotherapy services (30%) (green). Early trial closure precluded determination of attendance at referrals, but 31.6% of those eligible reported intending to attend (amber). Fifty-one of the 80 (63.75%) planned qualitative interviews were conducted. Quantitative and qualitative data from the process evaluation indicated that the electronic database-driven screening intervention and data collection were efficient, promoting good fidelity, although needing more personalisation at times. Recruitment and delivery of the full trial would benefit from a longer development period to better understand local context, develop effective strategies for engaging with underserved groups, provide longer training and better integration with referral services. Delivery of the pilot was limited by the impact of COVID-19 with staff redeployment, COVID-research prioritisation and reduced availability of community and in-house referral services. While recruitment was rapid, it did not fully represent ethnic minority groups and truncated follow-up due to funding limitations prevented full assessment of attendance at recommended services and secondary outcomes. There is both a clinical need (evidenced by 48% screened eligible for a referral) and perceived benefit (data from the qualitative interviews) for this National Health Service staff health screening clinic. The three stop/go criteria were red, green and amber; therefore, the Trial Oversight Committee recommended that a full-scale trial should proceed, but with modifications to adapt to local context and adopt processes to engage better with underserved communities. This trial is registered as ISRCTN10237475. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/42/42) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 23. See the NIHR Funding and Awards website for further award information.

1056 Audit of Compliance with Local Guidelines on Opioid and Laxative Co-Prescribing in General Surgery Patients at the Queen Elizabeth Hospital Birmingham

1056 Audit of Compliance with Local Guidelines on Opioid and Laxative Co-Prescribing in General Surgery Patients at the Queen Elizabeth Hospital Birmingham

When is HbA1c useful and what do the numbers mean – do they help or hinder?

Background: Glycated haemoglobin (HbA1c) measurement is used for diagnosis, management and remission of type 2 diabetes (T2DM), with measurements comparable worldwide and the World Health Organization listing medical conditions that affect its accuracy. Admission glucose is in the ‘diabetes’ range in 5% of emergency hospital admissions without prior diagnosis, with literature searches indicating inconsistent practice on using HbA1c to confirm diagnosis. As oral glucose tolerance tests (OGTT) were not possible during the COVID-19 pandemic, guidance was issued by the Royal College of Obstetrics and Gynaecology on using HbA1c for gestational diabetes mellitus. Aims: This study explores use of HbA1c at Queen Elizabeth Hospital Birmingham, a large university hospital serving a multi- ethnic adult population. Methods: Information is presented on comparability, clinical audits, research studies and current practice, and is illustrated by case reports. Results: Data from the National Glycohemoglobin Standardization Program show comparability of laboratoryHbA1c and point-of-care testing methods from 1993 to 2023. Although HbA1c was used to diagnose gestational diabetes during the COVID-19 pandemic, hospitals have reverted to OGTT post pandemic. In contrast, HbA1c is now being used to assess T2DM remission. Case reports illustrate these scenarios and highlight the complexity of decision-making when the accuracy of the HbA1c reading is affected by multiple co- morbidities. Conclusions: This wider use of HbA1c includes remission of T2DM but the diagnosis of gestational diabetes has reverted to OGTT post pandemic. A pictorial representation of HbA1c range is presented to aid understanding of this test. It is suitable for diagnosis of diabetes in most people except those with some variant haemoglobins or abnormal red blood cell turnover.

Maxillofacial trauma caused by e-scooters: a retrospective review prior to the extension of the UK scheme

The nationwide extension of the electric scooter (e-scooter) scheme, which began in 2020, aimed to alleviate public transport congestion, to reduce pollution and peak-time road traffic. This retrospective study evaluates the range of e-scooter-related maxillofacial trauma before the recent scheme extension and compares the findings with existing literature on this topic. The Queen Elizabeth Hospital Birmingham, United Kingdom (UK) operates as a Level 1 Regional Major Trauma Centre and serves a population of four million. All patient records between September 2021 to September 2022 were analysed to establish the types of e-scooter-related maxillofacial trauma sustained. A Pearson’s chi-squared test was used to assess for significant associations between variables recorded. Falls accounted for the majority of injuries (44.3%), and soft tissue lacerations were the most common maxillofacial injury (38%). Statistically significant results were measured in the following variables: gender and intoxication status (p = 0.007), helmet status and injuries sustained in maxillofacial and non-maxillofacial regions (p = 0.043), mechanism of injury and injuries sustained in both the maxillofacial and non-maxillofacial regions (p = 0.045). E-scooters are an emerging concern within the UK. Further studies across the UK are required to assess the frequency of e-scooter-related injuries. Such data may prove useful in determining the government's decision on e-scooter use on UK roads.

Assessing growth hormone replacement practice in patients with hypopituitarism in queen elizabeth hospital birmingham

Assessing growth hormone replacement practice in patients with hypopituitarism in queen elizabeth hospital birmingham

Versatility of the double fascicular transfer in reconstruction of elbow flexion paralysis: Intermediate term follow-up and patient-related outcome measures

The use of fascicle transfers in the reconstruction of traumatic brachial plexus injury is well established, but limited evidence is available regarding their use in atraumatic elbow flexion paralysis. This retrospective case review aimed to verify whether median and ulnar fascicle transfers are similarly effective in atraumatic versus traumatic elbow flexion paralysis when measured using the British Medical Research Council (MRC) scale, Brachial plexus Assessment Tool (BrAT) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) scores at long-term follow-up. All median and ulnar fascicle transfer cases performed at the Queen Elizabeth Hospital Birmingham between August 2007 and November 2018 were reviewed to compare the outcomes of transfers performed for traumatic and atraumatic indications. Data on patient demographics, mechanism and nature of injury, date of injury or symptom onset, date of operation, and other nerve transfers performed were collected. Outcome measures collected included the British MRC scale and two patient-reported outcome measures (PROMs), BrAT and SPONEA. In total, 34 patients with 45 median and ulnar fascicle transfers were identified. This included 27 traumatic and seven atraumatic brachial plexus insults. Thirty patients had sufficient follow-up to be included in MRC analysis and 17 patients had sufficient follow-up to be included in PROM analysis. No significant differences were found between traumatic and atraumatic subgroups for median MRC, BrAT, or SPONEA scores. This study suggests that nerve transfers might be considered effective reconstructive options in atraumatic pathology and provides validation for further research on the subject.

65 Conservative Management of Wound Dehiscence Following Inguinal Lymph Node Dissection Using Topical Metronidazole Gel Compared to Simple Wound Packing - a Cohort Study

Abstract Aim The aim of this study is to determine the effect of simple packing against topical metronidazole in the management of wound dehiscence following inguinal lymph node dissection. Method This is a retrospective cohort study of all adult patients who underwent groin dissection between 2014 and 2020 at the Queen Elizabeth Hospital Birmingham. Patients who had flaps or grafts for wound closure, and those with incomplete follow up records were excluded. Patients who developed wound dehiscence were treated with either topical metronidazole or simple packing and were followed up regularly by specialist wound care nurses. Data was collected from electronic medical records from the date of procedure to the latest follow up and analysed in SPSS. The two groups were compared for the time taken for the wound to heal in days as the primary outcome. Results From the 157 patients that had groin dissection, 76 (48.4%) developed wound dehiscence. Eight of them were still unhealed at the time of data collection. Among the 68 healed patients, 32 (47%) had been treated with metronidazole-soaked packing, and 44 (53%) had received packing without metronidazole. The two groups were comparable in terms of age, sex, indication for groin dissection and wound size. The mean time to healing for patients treated with topical metronidazole was 63.7±40 days, compared to 45 ±24.7 days in the non-metronidazole group. The difference is significant with a p value of 0.02. Conclusions Simple packing of dehisced wounds following groin dissection leads to significantly shorter healing times compared to topical metronidazole.

NHS advice and guidance – improving outpatient flow and patient care in general surgery

IntroductionAdvice and Guidance (A&G) is a digital communication tool that allows primary care physicians to seek advice from secondary care clinicians prior to, or instead of, direct referrals. Its effectiveness in general surgery has not been robustly evaluated. AimsTo analyse the number of A&G e-referrals to General Surgery at the Queen Elizabeth Hospital Birmingham and evaluate the outcomes of these requests including response times and changes to outpatient clinic appointment requirements. MethodsA retrospective analysis of all A&G requests to General Surgery between July 2020 and September 2021. The responses were categorised into 7 different outcomes and the time taken to reply to requests was recorded. An analysis of outpatient appointments (both ‘new’ and ‘follow-up’ appointments) pre- and post-introduction of A&G was performed. ResultsA total of 2244 A&G requests were made during the study period: 61% requests resulted in outpatient clinic appointments; 18% direct organisation of investigations; 10% advice was provided; 8% were redirected to a different specialty. Median time take to reply to a referral was the same day. The proportion of outpatient appointments that were ‘new’ appointments was reduced by 16.3% following introduction of A&G (P < 0.001). ConclusionA&G requests to General Surgery potentially diverts patients away from the outpatient clinic. Responses are rapid. A longer term evaluation of the service is necessary to determine its beneficial and detrimental effects on patients, primary care and secondary care.

OGC P16 What is the prevalence of weight loss in patients undergoing oesophago-gastric surgery and the effect of dietetic intervention pre-op

Abstract Background Patients with oesophago-gastric (OG) cancer are one of the highest risk groups for malnutrition. Nutrition plays a vital role in supporting this patient group. NICE guidelines (2018) recommend adults with OG cancer have tailored specialist dietetic support before, during and after radical treatment. Unfortunately the research available suggests there are low rates of preoperative dietetic input in this population, which are associated with poorer outcomes. Methods Data was obtained via informatics looking at patients who had an oesophagectomy or total gastrectomy between the years of March 2018 –2020 and were followed up at the Queen Elizabeth Hospital Birmingham. A sample of 66 patients was taken. Data was collected on the surgery type, weight changes and whether there was any dietetic input before and / or after surgery. Results 79% (52) patients had an oesophagectomy and 21% (14) had a total gastrectomy. Weight loss across all patients post-surgery was apparent post op at 3, 6 and 12 months. Clinically significant weight loss (&amp;gt;10%) was demonstrated at 3 months (27%), 6 months (17%) and 12 months (26%). Unfortunately data was not available for 20% (6 months) and 36% at (12 months). Only 16 (24%) patients were known to a dietitian pre-op. Out of these 8 (50%) had a feeding tube inserted pre-operatively, 7 of the patients used the tube for enteral feeding. 5 (31%) were seen for oral nutrition support and 3 (19%) for food first approach. 100% of patient had a feeding tube inserted following surgery. 100% of patients had been seen by a dietitian post op both as an inpatient and outpatient. The percentage of patients seen by a dietitian prior to surgery that had clinically significant weight loss post-op was less than those that were not seen by a dietitian pre op (ie 19% vs 24% at 6 months respectively). Conclusions Patients that undergo OG surgery experience clinically significant weight loss postoperatively. The data collected highlights that dietetic input pre-op can lead to less weight loss following surgery. Additional dietetic funding and the set up of a pre-treatment clinic would enable more patients to be seen prior to surgery. Further research needs to be done with a larger sample size over a longer time-frame to provide more representative results on the effects of dietetic input both pre and post surgery.

13. The Percutaneous Tracheostomy in Head and Neck Oncology Surgery

Enhanced experience in performing percutaneous dilatational tracheostomies (PDT) during the COVID-19 pandemic resulted in changes to airway management for patients undergoing head and neck reconstructive surgery at Queen Elizabeth Hospital Birmingham. All patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy (ST), unless contraindicated.

What is the prevalence of bile acid malabsorption in neuroendocrine tumour patients (NET) at the Queen Elizabeth Hospital Birmingham

What is the prevalence of bile acid malabsorption in neuroendocrine tumour patients (NET) at the Queen Elizabeth Hospital Birmingham

Avoiding PICC-line extractions: Improvement project on PICC-associated DVTs in oncology

Background: Peripherally inserted central catheter (PICC) lines are used to deliver chemotherapy directly into large veins to prevent phlebitis and extravasation. In the cancer service of Queen Elizabeth Hospital Birmingham we insert around 900 PICC lines a year. The most frequent complication of PICC line is upper arm deep vein thrombosis (DVT), which develops around the line in 4.1% of patients (as per data from our initial audit). Before 2020 the standard practice of managing these DVTs included anticoagulation followed by line extraction and subsequent reinsertion.

Incidence of Gastrointestinal Bleeding After Transesophageal Echocardiography Use in Orthotopic Liver Transplantation.

The risk of upper gastrointestinal bleeding (UGIB) after transesophageal echocardiography (TEE) in patients with high grade esophageal varices (EV) that are undergoing Orthotopic Liver transplantation (OLT) is poorly understood. This was a retrospective single-centre cohort study in all patients that underwent OLT at Queen Elizabeth Hospital Birmingham between September 2016 and September 2018. The primary outcome was to determine the incidence of UGIB in patients that have undergone OLT with EV that received TEE. 401 patients were included in the study, of which 320 (80%) received TEE. The incidence of post-operative UGIB in patients that received TEE was 1.6% (5/320) in the entire cohort: 2.7% (4/149) in patients with no evidence of EV and 0.6% (1/171) in patients with EV. UGIB occurred in 1 patient with grade 2 EV and did not occur in patients with grade 1 or 3 EV. The incidence of UGIB in patients that received TEE was not statistically different to patients that did not: 1.6% (5/320) vs. 3.7% (3/81) p = 0.218. In conclusion, in patients that underwent OLT, intra-operative TEE use was associated with low rates of UGIB, even in cohorts with high grade EV. This suggests that TEE is a relatively safe method of haemodynamic monitoring in patients undergoing OLT.

Reducing neuropathies between the 2020 and 2021 Covid-19 surges in a large UK intensive care unit: A quality improvement project.

BackgroundPeripheral nerve injuries (PNIs) can be acquired by patients in intensive care unit (ICU) who are critically unwell with Covid pneumonitis. Prone position ventilation has been linked to this life‐changing complication.AimTo reduce the occurrence and severity of PNIs for patients with Covid pneumonitis requiring prone positioning whilst sedated and ventilated in ICU.Study DesignThis study is a quality improvement project that evolved over the course of the first two surges of Covid pneumonitis admissions within the ICU at the Queen Elizabeth Hospital Birmingham (Surge 1: March 2020–July 2020, 93 prone ventilation survivors; Surge 2: September 2020–May 2021, 309 prone ventilation survivors). Implementation of updated prone positioning guidelines that aimed to reduce the risk of PNI. This was supplemented by face‐to‐face teaching for ICU professionals. The number of patients who sustained PNI and the severity of such injuries were recorded.ResultsDuring the first surge 21 patients (22.6%) had at least one high grade PNI. During the second surge there were 12 patients (3.9%) sustaining an intermediate or high grade PNI. For PNI patients, there was an increase in the mean proning episodes (6–13) and duration (17.8–18.6 h). This represents an 82% reduction in PNI cases. High grade injuries reduced from 14/21 (66%) to 4/12 (33%).ConclusionsOptimizing the position of patients in the prone position in ICU with Covid pneumonitis may be key in reducing the development of PNI. Changes to pharmacological management may have influenced the results seen in this study.Relevance to Clinical PracticeClinicians working within ICU with acutely unwell patients with Covid pneumonitis should acknowledge the heightened risk of PNI and take relevant steps to reduce the risk of injury acquisition.

TU3.8 Advice and Guidance: an effective communication tool between primary and secondary care in the COVID era?

IntroductionAdvice and Guidance is a digital communication tool that allows primary care physicians to seek advice from secondary care clinicians prior or instead of direct referrals.AimsOur audit aims to analyse the number of Advice and Guidance e-referrals made to General Surgery consultants at the Queen Elizabeth Hospital Birmingham and measure the outcomes of those conversations in order to determine the usefulness and value of the given platform as well as analyse the timescale of the replies.MethodsWe have retrospectively analysed the outcomes of all the referrals to General Surgery made via Advice and Guidance platform between July 2020 and September 2021. The responses were categorised into 7 different outcomes, main ones being “outpatient clinic referral”, “further investigation required”, “advice from a different specialty is needed” and “advice on management only”. Time taken to reply to the referrals was also analysed.ResultsAt total of 2244 referrals were included in this audit. 61% of the referrals were deferred to outpatient clinic for further review, 18% required further investigations, in 10% advice only was given and 8% were referred to a different specialty. Time taken to reply to a referral was 5 days on average.ConclusionsAdvice and Guidance is an appropriate tool that allows direct communication between GPs and General Surgical consultants and is set to reduce the number of unnecessary outpatient clinic referrals made. This in turn reduces pressure on the already stretched secondary care system, especially in the ongoing COVID-19 pandemic.

1074 QUALITY IMPROVEMENT PROJECT AIMED TO REDUCE THE AVERAGE NUMBER OF PATIENTS DEVELOPING CONSTIPATION ON BOURNVILLE WARD IN QEHB

Abstract Introduction Constipation is an overlooked but frequent problem in elderly patients on geriatrics wards. The prevalence in inpatients aged over 65 years is estimated at about 50%.There are many reasons for this: reduced oral intake due to illness, delirium, immobility, and constipating drugs. If constipation is addressed correctly, we can reduce the rate of unpleasant complications and prolonged hospital stay by increasing awareness of non-laxative methods to be advocated initially to avoid worsening poly-pharmacy with side effects. Queen Elizabeth Hospital Birmingham guidelines advocates use of conservative measures. However these methods can be frequently underutilized and cause of constipation rarely considered to treat. We aimed to identify the barriers to our outcome by tackling lack of awareness, utilization of non-laxative method DRE prior to rapid relief. This included teaching sessions, MDT, posters, introducing constipation booklets. Method We used prospective data collection with a standardized questionnaire having a mix of descriptive and quantitative questions based on SMART Aims for the project. This was carried out once a week on alternate beds. Baseline data n44,2ndcycle n44,3rd cycle n43,4thcycle n42.With each cycle we used following interventions to improve constipation prevalence in Bournville ward i.e. individually educate patient/staff during ward rounds, MDT presentations, improve documentation of constipation causes, addition of separate educational posters for staff/patients,identification of at risk patients. Introduced Patient information booklet with documented discussion on hospital online record system. Results Following interventions from 1st-4th cycle inpatient constipation prevalence was reduced by 13%,Increased consideration of cause by 38%, significant increase in education by 65%,Increased use of non-laxative approach by 35%,Increased rates of DRE by 35%,reduced use of x-ray prior to DRE by 8.3%,reductions in complication rate by 9%. Conclusion Despite increased education, cause consideration, utilization of conservative non-laxative approaches, introduction of new constipation booklet in welcome pack to all new patients a small impact was made in reducing inpatient constipation prevalence and associated complications occurring.

Surgical Correction of Carcinoid Heart Disease Improves Liver Function and 5-Hydroxyindoleacetic Acid Levels.

IntroductionCarcinoid heart disease (CHD) is a consequence of neuroendocrine tumors releasing 5-hydroxytryptamine (5-HT) into the systemic circulation, affecting right heart valves, causing fibrosis, and eventually right heart failure. The aim of this study was to determine the effect of valve-replacement on kidney function, liver function, and 5-hydroxyindoleacetic acid (5-HIAA) levels.MethodsA Retrospective study of 17 patients with CHD who had undergone heart-valve replacement surgery between 2010 and 2019, from the Queen Elizabeth Hospital Birmingham. 5-HIAA levels, liver, and kidney function were measured in addition to hepatic inferior vena cava (IVC) diameter and its relationship to carcinoid symptoms.ResultsEleven patients were male and six were female. At time of surgery, average age was 66.6 ± 8.1 years and average BMI was 25.8 ± 5.5 Kg/cm2. Three out of 17 patients had one valve replaced, 13/17 had two replaced (tricuspid and pulmonary), and 1/17 had three replaced (tricuspid, pulmonary and aortic). There was a 31% average decline in 5-HIAA [799.8 (343.6–1078.0) to 555.3 (275.8–817.9), p = 0.011], a 35% decline in bilirubin [20 (16–29) to 13 (10–19), p = < 0.001], and a 15% reduction in the short and long axes of the IVC after valve-replacement surgery [20.0 (18.0–25.0) and 36.5 (29.0–39.8) to 17.0 (14.5–19.3) and 31.0 (26.5–34.3) respectively, p = < 0.001 and 0.002 respectively].ConclusionValve replacement surgery improves 5-HIAA levels alongside improved liver function and hepatic IVC diameter. These findings are consistent with resolution of congestive hepatopathy, and therefore enhanced clearance of 5-HIAA. This suggests that valve-replacement surgery can indirectly have beneficial outcomes on hepatic function and is also associated with a drop in the circulating levels of tumor derived serotonin.

Feasibility, Efficacy, and Safety of Percutaneous Muscle Biopsies in Patients With Chronic Liver Disease.

IntroductionSarcopenia is present in many chronic disease states including decompensated end stage liver disease (ESLD) and non-cirrhotic non-alcoholic fatty liver disease (NAFLD). Sarcopenia in ESLD can negatively impact quality of life and increase mortality. Despite this, very little is understood about the mechanisms of sarcopenia in these conditions. One key reason for this is the reluctance to undertake percutaneous muscle biopsies due to the perceived increased risks. ESLD can induce thrombocytopaenia and coagulopathy which significantly increases the risk of bleeding. In addition, patients with either NAFLD or ESLD often have co-morbidities that would require additional care and risk assessment. Thus, the aim of this study was to establish an effective and safe protocol for the implementation of percutaneous muscle biopsies in patients with NAFLD and ESLD.MethodsA total of 47 patients with ESLD and 9 patients with non-cirrhotic NAFLD were recruited from the Liver Unit, Queen Elizabeth Hospital (Birmingham, United Kingdom). A total of 71 percutaneous vastus lateralis biopsies were attempted over two study visits. A vigorous safety screening occurred prior to and during each visit and a strict protocol was followed to mitigate against complications and risk.ResultsA total of 85% of patients consented to the muscle biopsy at either visit (48/56). A total of 9% of consented biopsies could not occur due to medical considerations, including high international normalised ratio (INR) (n = 3) and the use of aspirin (n = 4). Muscle tissue was obtained from 90% of attempts, with a mean average yield (wet weight tissue) of 98.1 ± 52.9 mg.ConclusionPercutaneous muscle biopsies are both feasible and yield sufficient tissue in an ESLD population. The procedure is effective for obtaining muscle tissue whilst also safe, with only one adverse event. This study provides evidence for the successful use of muscle biopsies in this population, even in consideration of disease specific complications, medications, and comorbidities.

Impact of neoadjuvant chemotherapy on nodal regression and survival in oesophageal adenocarcinoma

BackgroundThe prognostic value of lymph node regression (LNR) following neoadjuvant chemotherapy (nCT) for oesophageal and gastro-oeosphageal adenocarcinoma remains unclear. This study aimed to characterise the long-term survival outcomes of LNR in patients having resectional surgery after nCT. MethodsThis study included patients undergoing oesophagectomy or extended total gastrectomy for oesophageal and junctional tumours (Siewert types 1,2,3) at the Queen Elizabeth Hospital Birmingham from 2012 to 2018. Lymph nodes retrieved at surgery were examined for evidence of a response to chemotherapy. Patients were classified as lymph node-negative (either negative nodes with no evidence of previous tumour involvement or negative with evidence of complete regression) or positive with either partial or no response. ResultsThis study identified 183 patients who received nCT, of which 71% (130/183) had positive lymph nodes. Of these 130 patients, 44% (57/130) had a lymph node response and 56% (73/130) did not. The remaining 53 patients (29.0%) had negative lymph nodes with no evidence of tumour. Lymph node responders had a significant survival benefit compared to patients without lymph node response, but shorter than those with negative lymph nodes (median: 27 vs 18 vs NR months, p < 0·001). On multivariable analysis, lymph node responders had an improved overall (Hazard ratio (HR): 0.86, 95% CI: 0.80–0.92, p < 0.001) and recurrence-free (HR: 0.90, 95% CI: 0.82–0.98, p = 0.030) survival. ConclusionLymph node regression is an important prognostic factor, warranting closer evaluation over primary tumour response to help with planning further adjuvant therapy in these patients.

The clinical profile and associated mortality in people with and without diabetes with Coronavirus disease 2019 on admission to acute hospital services.

IntroductionTo assess if in adults with COVID‐19, whether those with diabetes and complications (DM+C) present with a more severe clinical profile and if that relates to increased mortality, compared to those with diabetes with no complications (DM‐NC) and those without diabetes.MethodsService‐level data was used from 996 adults with laboratory confirmed COVID‐19 who presented to the Queen Elizabeth Hospital Birmingham, UK, from March to June 2020. All individuals were categorized into DM+C, DM‐NC, and non‐diabetes groups. Physiological and laboratory measurements in the first 5 days after admission were collated and compared among groups. Cox proportional hazards regression models were used to evaluate associations between diabetes status and the risk of mortality.ResultsAmong the 996 individuals, 104 (10.4%) were DM+C, 295 (29.6%) DM‐NC and 597 (59.9%) non‐diabetes. There were 309 (31.0%) in‐hospital deaths documented, 40 (4.0% of total cohort) were DM+C, 99 (9.9%) DM‐NC and 170 (17.0%) non‐diabetes. Individuals with DM+C were more likely to present with high anion gap/metabolic acidosis, features of renal impairment, and low albumin/lymphocyte count than those with DM‐NC or those without diabetes. There was no significant difference in mortality rates among the groups: compared to individuals without diabetes, the adjusted HRs were 1.39 (95% CI 0.95–2.03, p = 0.093) and 1.18 (95% CI 0.90–1.54, p = 0.226) in DM+C and DM‐C, respectively.ConclusionsThose with COVID‐19 and DM+C presented with a more severe clinical and biochemical profile, but this did not associate with increased mortality in this study.