Queen's Medical Centre Research Articles

OC10.03: MRI assessment of regional fractional moving blood volume within the placenta

R. Deshpande1,2, D. Anblagan4, N. W. Jones1,2, N. Raine-Fenning1, G. Bugg2, P. Mansell3, P. Gowland4, L. Leach3 1School of Clinical Sciences, Division of Human Development, University of Nottingham, Nottingham, United Kingdom; 2Deparment of Obstetrics & Gynecology, Queens Medical Centre, Nottingham, United Kingdom; 3School of Biomedical Sciences, University of Nottingham, Nottingham, United Kingdom; 4Sir Peter Mansfield MRI Centre, University of Nottingham, Nottingham, United Kingdom

Levonorgestrel intra-uterine system as a treatment option for complex endometrial hyperplasia

ObjectiveThe objective of this study was to evaluate the potential treatment of atypical and non-atypical endometrial hyperplasia with the levonorgestrel intrauterine system (LNG-IUS). Study designA prospective observational study was undertaken at Queen's Medical Centre's menstrual disorder clinic between 2001 and 2008. Women presenting with abnormal perimenopausal and postmenopausal bleeding, underwent an endometrial biopsy followed by the insertion of a levonorgestrel intrauterine system (LNG-IUS). The study population comprised of 51 patients. The histology of 32 patients (Group A) showed complex hyperplasia without atypia, and in 19 patients (Group B), biopsy revealed atypical endometrial hyperplasia. These patients chose to be managed conservatively with repeat sampling of the endometrium. ResultsGroup A: 28 (87.5%) patients out of 32 had regression of their endometrial hyperplasia within the first 12 months of follow-up. Three of the patients achieved regression by 24 months increasing regression rate to 96.8% and the remaining one had a hysterectomy due to a rare side effect. Group B: 16 (84.2%) of 19 patients had regression of the atypical hyperplasia after treatment with the intrauterine system within 12 months of treatment. One patient achieved regression of the hyperplasia by 24 months and two patients went on to have surgical management due to persistent atypia and severe atypia respectively. ConclusionThis study contribute further evidence that illustrates that levonorgestrel intrauterine systems have a potential role in patients requiring non-operative management although close follow-up is essential.

Robotic-assisted Roux-en-Y gastric bypass performed in a community hospital setting: the future of bariatric surgery?

Since receiving Food and Drug Administration approval in 2000, surgery utilizing a robot has been successfully performed in numerous procedures including gastric bypass. However, despite the proven safety profile, reported lower complication rates, and technical benefits of robotic surgery, only a few centers in the USA have consistently applied this technology to bariatric surgery. In addition, there are limited studies with relatively small sample sizes comparing robotic-assisted Roux-en-Y gastric bypass (RRYGB) with laparoscopic Roux-en-Y gastric bypass (LRYGB). Through a retrospective analysis of our database, we compared outcomes of RRYGB versus LRYGB in the treatment of morbid obesity. All patients who underwent RRYGB and LRYGB through the Comprehensive Weight Management Program of the Queen's Medical Center (Honolulu, HI) from January 2007 to December 2009 were included. Outcomes data included weight loss, operative times, and hospital length of stay. All complications were reported. 105 patients who underwent RRYGB were compared with 195 patients who received LRYGB. Excess weight loss, estimated blood loss, and length of hospital stay were similar in both groups. There were no mortalities in either group. The RRYGB group experienced a 9.5% complication rate versus 9.7% in LRYGB patients. Operative time was the only statistically significant difference, being approximately 17 min in favor of LRYGB. However, there was a steady decrease in RRYGB operative time with increasing experience. Our study demonstrates a favorable safety profile with nearly equivalent outcomes and some previously unidentified qualitative benefits of the RRYGB approach to bariatric surgery in a community setting. These results are despite our early experience with the robotic surgery platform and confirm noninferiority of RRYGB versus LRYGB. While the RRYGB operative time was longer than LRYGB, the demonstrated decrease in operative time commensurate with increase in operative experience holds tremendous promise for the future.

Abstract LB-442: The association of HER2/neu overexpression with relapse and poor survival in Native Hawaiian women with breast cancer

Abstract Cross-ethnic comparisons of data from the Hawai'i SEER Cancer Registry show that Native Hawaiian female breast cancer patients have the highest incidence and mortality among all ethnic populations in Hawai'i and Japanese had the lowest mortality. Factors that contribute to this disparity include socioeconomic status, access to healthcare, stage at diagnosis, and tumor biology. Breast cancer is a heterogeneous disease, with multiple subtypes based on histologic type, estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2/neu) expression profiles. This single institution-based retrospective study analyzed data for female patients diagnosed with breast cancer from 2000–2005 and followed through 2007 (n=1488) at the Queen's Medical Center in Honolulu, Hawai'i. This study focused on three major ethnic populations in Hawai'i: Native Hawaiian (n=359), Japanese (n=609) and Caucasian (n=520) women. Information on tumor stage, ER, PR, and HER2/neu expression were obtained from the hospital's cancer registry. Cox regression models of 1) relapse 2) death for breast cancer patients were used to evaluate the association with tumor subtype and ethnicity, adjusting for stage. Survival time was defined as the interval between diagnosis and the endpoint or cessation of follow-up at 2007. We compared the frequency distribution of intrinsic breast cancer subtypes [Luminal A (ER/PR+; HER2/neu−), Luminal B (ER/PR+; HER2/neu+), HER2/neu-positive (ER/PR−, HER2/neu+), and Triple Negative (ER/PR−, HER2/neu−)]. Native Hawaiian women had the lowest prevalence of Lum A subtype (69%) compared to Japanese (76%) and Caucasian women (72%). Native Hawaiian women had a higher prevalence of Lum B (14%) compared to Japanese (6%) and Caucasian (12%) women. Prevalence of Triple Negative and HER2/neu subtypes was similar for the three ethnic groups. There was a difference in survival associated with the intrinsic subtypes for the three ethnic groups. Triple Negative breast cancers were associated with increased risk of death for the Native Hawaiian (HR=2.8, p=0.046) and Japanese (Hazard Ratio (HR)=2.2, p=0.052) women. The HER2/neu-positive subtype was associated with increased risk of death for Native Hawaiian (HR=2.6, p=0.044) and Caucasian (HR = 2.9, p = 0.018) women, but not for the Japanese women. When we examined the outcome of relapse associated with HER2/neu overexpression, we observed Native Hawaiian (HR=3.28) women were more likely to relapse compared to Japanese (HR=1.05) or Caucasian (HR=1.2) women. We identified an association between differences in the prevalence of intrinsic subtypes, relapse and survival levels, and racial/ethnic background. These data illustrate the importance of cross-ethnic studies to increase our understanding of racial/ethnic based differences in breast cancer incidence and mortality in order to reduce disparities. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-442. doi:10.1158/1538-7445.AM2011-LB-442

An ion-selective electrode for the determination of the activity of quaternary ammonium salts in formulated products [proceedings

An Ion-Selective Electrode for the Determination of the Activity of Quaternary Ammonium Salts in Formulated Products Get access S S Davis, S S Davis Pharmacy Department and Medical School, Queen's Medical Centre, Nottingham University, Nottingham NG7 2RD Search for other works by this author on: Oxford Academic Google Scholar O Olejnik O Olejnik Pharmacy Department and Medical School, Queen's Medical Centre, Nottingham University, Nottingham NG7 2RD Search for other works by this author on: Oxford Academic Google Scholar Journal of Pharmacy and Pharmacology, Volume 31, Issue Supplement_1, December 1979, Page 19P, https://doi.org/10.1111/j.2042-7158.1979.tb11567.x Published: 12 April 2011

Ranibizumab: a medical treatment that requires surgical administration

Ranibizumab: a medical treatment that requires surgical administration

Clinical Manual of Emergency Psychiatry

Clinical Manual of Emergency Psychiatry

Clinical Manual of Emergency PsychiatryClinical Manual of Emergency Psychiatry RibaMichelle B.M.D., M.S. RavindranathDivyM.D., M.S. ; Washington, D.C., American Psychiatric Publishing, Inc., 2010, 434 pages, $62

Clinical Manual of Emergency PsychiatryClinical Manual of Emergency Psychiatry RibaMichelle B.M.D., M.S. RavindranathDivyM.D., M.S. ; Washington, D.C., American Psychiatric Publishing, Inc., 2010, 434 pages, $62

Observational study to investigate vertically acquired passive immunity in babies of mothers vaccinated against H1N1v during pregnancy

The primary objective was to determine the proportion of babies who acquired passive immunity to A/H1N1v, born to mothers who accepted vaccination as part of the national vaccination programme while pregnant (during the second and/or third trimesters) against the novel A/H1N1v influenza virus (exposed group) compared with unvaccinated (unexposed) mothers. An observational study at three sites in the UK. The purpose was to determine if mothers immunised against A/H1N1v during the pandemic vaccination period transferred that immunity to their child in utero. Three sites in the UK [Queen's Medical Centre, Nottingham; City Hospital, Nottingham (both forming University Hospitals Nottingham), and Leicester Royal Infirmary (part of University Hospitals Leicester)]. All pregnant women in the second and third trimester presenting at the NHS hospitals above to deliver were eligible to participate in the study. Women were included regardless of age, social class, ethnicity, gravida and parity status, past and current medical history (including current medications), ethnicity, mode of delivery and pregnancy outcome (live/stillbirth). At enrolment, participants provided written consent and completed a questionnaire. At parturition, venous cord blood was obtained for serological antibody analysis. Serological analysis was undertaken by the Respiratory Virus Unit (RVU), Health Protection Agency (HPA) Centre for Infections, London. The primary end point in the study was the serological results of the cord blood samples for immunity to A/H1N1v. Regarding a suitable threshold for the determination of a serological response consistent with clinical protection, this issue is somewhat complex for pandemic influenza. The European Medicines Agency (EMEA) Committee for Human Medicinal Products (CHMP) judges that a haemagglutination inhibition (HI) titre of 1 : 40 is an acceptable threshold. However, this level was set in the context of licensing plain trivalent seasonal vaccine, where a titre of 1 : 40 is but one of several related immunogenicity criteria, and supported by paired sera capable of demonstrating a fourfold rise in antibody titre in response to vaccination. The current study mainly investigated the effects of an AS03-adjuvanted monovalent vaccine, and it was not possible to obtain paired sera where the initial sample was taken before vaccination (in vaccinated subjects). Of possibly greater relevance is the fact that it has been established from the study of early outbreaks of pandemic influenza in secondary schools in the UK (HPA, unpublished observations) that an HI antibody titre of 1 : 32 seems to be the threshold for a humoral response to 'wild-type' A/H1N1v infection. On that basis, a threshold of 1 : 32 is at least as appropriate as one of 1 : 40, especially in unvaccinated individuals. Given the difficulties that would accrue by applying thresholds of 1 : 32 in unvaccinated patients and 1 : 40 in vaccinated patients, we have therefore applied a threshold of 1 : 32 and 1 : 40, to increase the robustness of our findings. Differences arising are described. A microneutralisation (MN) titre of 1 : 40 may be also used, although it is not part of the CHMP criteria for vaccine licensure. Nonetheless, we utilised this analysis as a secondary end point, based on a conservative threshold of 1 : 60. Reverse cumulative distribution percentage curves for haemagglutinin dilution and MN titres demonstrate background immunity in babies of unvaccinated mothers of 25%-30%. Humoral immunity in babies of vaccinated mothers was present in 80% of the group. The difference in positive immunity between the babies of unvaccinated and vaccinated mothers was statistically significant (chi-squared test, p < 0.001). Our findings reveal a highly significant difference in HI titres between babies born to mothers vaccinated with pandemic-specific vaccine against A/H1N1v during the 2009-10 pandemic period. The subjects recruited were comparable from a baseline perspective and thus do not represent different groups that otherwise could have introduced bias into the study. Continued circulation of 2009 A/H1N1-like viruses is uncertain, but is possible as seasonal influenza in years to come. It is possible that future seasonal waves may display increased virulence. Given the adverse outcomes experienced for a small proportion of pregnant women during the influenza pandemic of 2009-10, this study provides useful evidence to support vaccination in pregnancy to protect both the mother and baby. The National Institute for Health Research Health Technology Assessment programme.

Successful strategies to improve RN retention and patient outcomes in a large medical centre in Hawaii

The purpose of this paper is to describe an assessment of a major retention initiative implemented at The Queen's Medical Center in Honolulu, Hawaii, in response to the nursing workforce shortage in the state. After tracking the situation for several years, nursing leadership at the medical centre critically analysed their registered nurse retention data. The retention rate among new nurses in their first year of employment was only 55·97%. A training programme was initiated to improve registered nurse retention and patient care outcomes with external funding from the US Health Resources and Services Administration. New nurses were supported via additional training and clinical coaches beyond the basic orientation period. Leadership skills of nurse managers were expanded to strengthen their role in retention of new nurses. Four inpatient nursing units became Magnet Pilot Units to demonstrate progress towards achievement of Magnet standards and improvement of patient outcomes. From 2005-2009, first-year-registered nurse retention improved from 55·97-68·20%; registered nurse vacancy rate decreased from 11·26-2·19%; patient satisfaction increased from 84·6-87·8%; registered nurse satisfaction-autonomy improved from 43·55-49·29; registered nurse satisfaction-decision-making went from 41·13-47·97%; and nosocomial decubitus ulcer rate decreased from 15·3-6·7% in the intensive care units. Dedicated resources and targeted activities can make a difference in outcomes for both nurses and patients. Keys to success included engaging staff, having high expectations coupled with high support, providing data to unit-level staff to measure improvements emphasising renewed accountability and maintaining the focus on quality patient care. When the goal is to provide the highest level of quality patient care, professional development of staff and managers is important to meet performance expectations and achieve target clinical goals. Improving registered nurse retention and vacancy rates while also improving patient outcomes had significant human resource and financial benefits for the organisation and contributed to achieving Magnet Recognition.

Fibrin glue for the treatment of fistulae in ano – a method worth sticking to?

The current evidence for fibrin glue as a treatment for anal fistulae is mixed. This study reviews the experience of fibrin glue as a treatment for anal fistulae in a single tertiary referral centre and attempts to identify factors related to failure of therapy and the length of follow-up required. Patients with fistulae in ano that were treated with fibrin glue between February 2004 and August 2008 were analysed. All procedures were performed by two colorectal consultants based at the Queens Medical Centre, Nottingham. All patients were followed-up to assess the outcome of this treatment. Forty patients (21 male, 19 female) with a mean age of 46.5 years were studied. The mean duration of symptoms prior to presentation was 39 months (range 4-240 months). Presenting symptoms included perianal discharge (72.5%), perianal abscess (57.5%), pain (12.5%), PR bleeding (7.5%), itching (5%) and urgency (2.5%). Patients had a minimum of two follow-up appointments and the median follow-up period was 5.2 months (range 1-16 months). Following MRI and operative assessment, 28 (70%) of the 40 fistulae were considered complex (high trans-sphincteric, extra-sphincteric, pouch-vaginal). Patients who had inflammatory bowel disease were classified as simple tracts but all failed to heal (three patients). Twenty of the complex fistulae failed to heal. Three patients who had repeat application of glue for their complex fistulae failed to heal on follow-up. Of the remaining 12 patients who had simple fistulae in ano, five (41.7%) healed completely. There were no complications such as abscess, related to treatment. All patients who were asymptomatic at 3 months did not develop any further recurrence. Fibrin glue is a simple treatment strategy, preserves sphincter function with minimal adverse side effects. It should therefore be considered as possible first line treatment in simple fistulae but it is less likely to be successful in complex or those fistulae associated with inflammatory bowel disease. Repeat gluing is unlikely to be successful. Fistulae that have failed to heal by 3 months will need further treatment.

Anaesthetists' and surgeons' attitudes towards informed consent in the UK: an observational study

BackgroundThe attitudes of patients' to consent have changed over the years, but there has been little systematic study of the attitudes of anaesthetists and surgeons in this process. We aimed to describe observations made on the attitudes of medical professionals working in the UK to issues surrounding informed consent.MethodA questionnaire made up of 35 statements addressing the process of consent for anaesthesia and surgery was distributed to randomly selected anaesthetists and surgeons in Queen's Medical Centre (Nottingham), Royal Sussex County Hospital (Brighton) and Eastbourne District General Hospital (Eastbourne) during 2007. Participants were asked to what extent they agreed with statements regarding consent.ResultsOf 234 questionnaires distributed, 63% were returned. Of the respondents 79% agreed that the main purpose of the consent process is to respect patient autonomy. While 55% of the examined cohort agreed that the consent process maybe inappropriate as patients do not usually remember all the information given to them. Furthermore, 84% of the participants agreed that what the procedure aims to achieve should be explained to the patient during the consent process. While of the participants, over 70% agreed that major risks of incidence greater than 1/100 should be disclosed to the patient as part of the consent process.ConclusionsThe majority of respondents appear to hold attitudes in standing with current guidelines on informed consent however there was still a significant minority who held more paternalistic views to the consent process bringing into question the need for further training in the area.

Reallocation of Foundation Programme Doctors From Teams to Wards Reduces Mortality From Proximal Femoral Fracture

Reallocation of Foundation Programme Doctors From Teams to Wards Reduces Mortality From Proximal Femoral Fracture

The Influence of Junctional Competence on Primary Saphenous Reflux

The Influence of Junctional Competence on Primary Saphenous Reflux

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

The Lymph Node Yield of Neck Dissections – Is There a Difference Between Consultant Surgeons and Specialist Registrars?

Should critical care patients receive or remain on treatment with antiplatelet drugs?*

Division of Anaesthesia; Division of Cardiovascular Medicine; School of Clinical Sciences; University of Nottingham; Queens Medical Centre; Nottingham, UK The authors have not disclosed any potential conflicts of interest.

Abstract B111: Differential expression of c-Met/HGF axis and epithelial-mesenchymal transition (EMT)-related gene markers between primary colorectal carcinomas and liver metastases in primary tissue, isolated cell types and in vivo

Abstract Introduction: EMT is frequently activated in a subset of tumor cells during disease progression. EMT is described as downregulation of E-cadherin with a corresponding upregulation of mesenchymal markers such as Vimentin. EMT is linked to carcinoma progression stemming from increased tumor cell motility, growth, survival, and invasion. The c-Met receptor and MACC1 (metastasis-associated in colon cancer-1) are often upregulated in CRC metastases, have been associated with increased metastasis, and represent potential drug targets. Here we assessed the expression of genes associated with EMT in human CRCs and liver metastases (LMs), in epithelial cells isolated from primary tissues and in mouse passaged primary tumor xenografts. Methods: Human primary CRC (n = 11) and LM (n = 21) samples, along with matched normal tissues, were obtained under full ethical approval from the Queen's Medical Centre, Nottingham, UK. Real-time quantitative PCR was used to determine expression levels of EMT-related markers (growth factors, transcriptional repressors, mesenchymal markers) relative to the housekeeping gene hypoxanthine-guanine phosphoribosyltransferase, from (i) primary tissues, (ii) epithelial cells and fibroblasts isolated from disaggregated primary tissues using cell type-specific antibodies bound to magnetic beads, (iii) primary tumor tissues subcutaneously passaged in nude mice. A student's t-test was used for statistical analyses. Results: MACC1 and c-Met were significantly upregulated, whereas E-cadherin was significantly downregulated, in CRC and LM primary tissues compared to normal colonic mucosa, indicating that EMT had occurred. In LMs, hepatocyte growth factor (HGF), Snail, Slug, Twist, Vimentin, TGFβ1, and matrix metalloproteinase 9 were also significantly upregulated (P &amp;lt;0.05), whereas expression of Zeb1, s100a4, and MMP2 were not altered. Gene expression profiles from isolated epithelial cells and fibroblasts showed that hgf, vimentin, and TGFβ1 were predominantly expressed by mesenchymal cells, whereas c-met, e-cadherin, and snail expression were predominantly epithelial. In xenograft tumor tissues, hgf and vimentin expression was lost within the first passage, whereas e-cadherin and c-met expression was maintained, indicating that human stroma was rapidly replaced. Conclusions: Phenotypic markers consistent with EMT were significantly increased in LMs compared to CRCs, and Snail, Twist, Vimentin, TGFβ1, and MMP9 provide the best markers for LM. In CRCs and LMs, paracrine signalling of HGF (mesenchymal) to the c-Met receptor (epithelial) is likely to occur, and this signalling pathway appears to be lost during growth of the primary tumor in nude mice. This has important implications in therapy studies targeting the HGF-MACC1-cMet axis. Citation Information: Mol Cancer Ther 2009;8(12 Suppl):B111.

Effective teamwork in trauma management

The emergency department (ED) education team at the Queen's Medical Centre, Nottingham, has developed a process to promote effective teamwork in major trauma management. To introduce this process to ED staff, the team developed a multiprofessional education and training programme. This article describes the development process, explains how and why it was undertaken, and provides details of the education and training programme. It also highlights the challenges met by the education team during implementation.

Age variations of melatonin level and its hormesis; implications for AIS and osteoporosis

Address: 1Department of Trauma and Orthopaedics, Tzanio General Hospital NHS, Tzani and Afendouli, 18536, Piraeus, Greece, 2Department of Trauma and Orthopaedics, Thriasio General Hospital NHS, G, Gennimata Av, 19600, Magoula, Attica, Greece and 3The Centre for Spinal Studies & Surgery, Nottingham University Hospitals Trust, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK, D. Bernardou 31 Brilissia, Attica, 15235, Greece

The Norman Capener Travelling Fellowship in complex spinal oncological surgery

I had been working as a consultant spine surgeon in Oxford (Nuffield Orthopaedic Centre and the John Radcliffe Hospitals) for approximately one year when I was given the opportunity to lead the spinal oncology department at the internationally known AOSpine centre of excellence in England, the Queens Medical Centre, Nottingham. Before starting my new post, I decided to embark on a travelling fellowship in complex spinal oncological surgery under the leadership of Professor Ziya Gokaslan at the Johns Hopkins Hospital, Baltimore, which is the number one ranked hospital in the US.