University Hospitals Birmingham Research Articles

Age and Frailty Are Independently Associated with Increased Mortality in COVID-19: Results of an International Multi-Centre Study

Introduction: Increased mortality has been demonstrated in older adults with COVID-19, but the effect of frailty has been unclear. Methods: This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty, and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation, and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS), and delirium on risk of increased care requirements on discharge, adjusting for the same variables. Results: Data from 5711 patients from 55 hospitals in 12 countries were included (median age 74, IQR 54 – 83; 55.2% male). The risk of death increased independently with increasing age (>80 vs 18-49: HR 3.57, CI 2.54 – 5.02), frailty (CFS 8 vs 1-3: HR 3.03, CI 2.29 – 4.00) inflammation, renal disease, cardiovascular disease, and cancer, but not delirium. Age, frailty (CFS 7 vs 1-3: OR 7.00, CI 5.27 – 9.32), delirium, dementia, and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. Conclusions: Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.Funding Statement: The Geriatric Medicine Research Collaborative has previously received funding from the British Geriatrics Society for administrative and running costs. No project specific funding was obtained for this research. MW and SR acknowledge support from the NIHR Newcastle Biomedical Research Centre.Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: Local, regional, and national approvals were obtained from all participating sites. In the UK, this study was registered as clinical audit or service evaluation, with approval granted in line with local information governance policies, in line with assessment and guidance by the Health Research Authority. At the lead site (University Hospitals Birmingham NHS Trust) this study was registered as clinical audit (CARMS-15986). In other countries, local principal investigators were responsible for obtaining approvals in line with their local, regional, and national guidelines and recommendations. Only routinely collected data was collected and patient care was not altered by this study. Anonymised data was securely transferred to the Birmingham Centre for Prospective and Observational Studies (BiCOPS), University of Birmingham via REDCap. All sites were required to confirm that approvals were in place prior to being provided with logins; written data sharing agreements were arranged where requested by individual sites.

COVID-19-related intracranial imaging findings: a large single-centre experience

AIMTo describe the neuroradiological changes in patients with coronavirus disease 2019 (COVID-19).MATERIALS AND METHODSA retrospective review was undertaken of 3,403 patients who were confirmed positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and admitted to Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK between 1 March 2020 and 31 May 2020, and who underwent neuroimaging. Abnormal brain imaging was evaluated in detail and various imaging patterns on magnetic resonance imaging MRI were identified.RESULTSOf the 3,403 patients with COVID-19, 167 (4.9%) had neurological signs or symptoms warranting neuroimaging. The most common indications were delirium (44/167, 26%), focal neurology (37/167, 22%), and altered consciousness (34/167, 20%). Neuroimaging showed abnormalities in 23% of patients, with MRI being abnormal in 20 patients and computed tomography (CT) in 18 patients. The most consistent neuroradiological finding was microhaemorrhage with a predilection for the splenium of the corpus callosum (12/20, 60%) followed by acute or subacute infarct (5/20, 25%), watershed white matter hyperintensities (4/20, 20%), and susceptibility changes on susceptibility-weighted imaging (SWI) in the superficial veins (3/20, 15%), acute haemorrhagic necrotising encephalopathy (2/20, 10%), large parenchymal haemorrhage (2/20, 10%), subarachnoid haemorrhage (1/20, 5%), hypoxic–ischaemic changes (1/20, 5%), and acute disseminated encephalomyelitis (ADEM)-like changes (1/20, 5%).CONCLUSIONVarious imaging patterns on MRI were observed including acute haemorrhagic necrotising encephalopathy, white matter hyperintensities, hypoxic-ischaemic changes, ADEM-like changes, and stroke. Microhaemorrhages were the most common findings. Prolonged hypoxaemia, consumption coagulopathy, and endothelial disruption are the likely pathological drivers and reflect disease severity in this patient cohort.

Ethnicity and risk of death in patients hospitalised for COVID-19 infection in the UK: an observational cohort study in an urban catchment area

BackgroundStudies suggest that certain black and Asian minority ethnic groups experience poorer outcomes from COVID-19, but these studies have not provided insight into potential reasons for this. We hypothesised that...

Urine steroid metabolomics for the differential diagnosis of adrenal incidentalomas in the EURINE-ACT study: a prospective test validation study

SummaryBackgroundCross-sectional imaging regularly results in incidental discovery of adrenal tumours, requiring exclusion of adrenocortical carcinoma (ACC). However, differentiation is hampered by poor specificity of imaging characteristics. We aimed to validate a urine steroid metabolomics approach, using steroid profiling as the diagnostic basis for ACC.MethodsWe did a prospective multicentre study in adult participants (age ≥18 years) with newly diagnosed adrenal masses. We assessed the accuracy of diagnostic imaging strategies based on maximum tumour diameter (≥4 cm vs <4 cm), imaging characteristics (positive vs negative), and urine steroid metabolomics (low, medium, or high risk of ACC), separately and in combination, using a reference standard of histopathology and follow-up investigations. With respect to imaging characteristics, we also assessed the diagnostic utility of increasing the unenhanced CT tumour attenuation threshold from the recommended 10 Hounsfield units (HU) to 20 HU.FindingsOf 2169 participants recruited between Jan 17, 2011, and July 15, 2016, we included 2017 from 14 specialist centres in 11 countries in the final analysis. 98 (4·9%) had histopathologically or clinically and biochemically confirmed ACC. Tumours with diameters of 4 cm or larger were identified in 488 participants (24·2%), including 96 of the 98 with ACC (positive predictive value [PPV] 19·7%, 95% CI 16·2–23·5). For imaging characteristics, increasing the unenhanced CT tumour attenuation threshold to 20 HU from the recommended 10 HU increased specificity for ACC (80·0% [95% CI 77·9–82·0] vs 64·0% [61·4–66.4]) while maintaining sensitivity (99·0% [94·4–100·0] vs 100·0% [96·3–100·0]; PPV 19·7%, 16·3–23·5). A urine steroid metabolomics result indicating high risk of ACC had a PPV of 34·6% (95% CI 28·6–41·0). When the three tests were combined, in the order of tumour diameter, positive imaging characteristics, and urine steroid metabolomics, 106 (5·3%) participants had the result maximum tumour diameter of 4 cm or larger, positive imaging characteristics (with the 20 HU cutoff), and urine steroid metabolomics indicating high risk of ACC, for which the PPV was 76·4% (95% CI 67·2–84·1). 70 (3·5%) were classified as being at moderate risk of ACC and 1841 (91·3%) at low risk (negative predictive value 99·7%, 99·4–100·0).InterpretationAn unenhanced CT tumour attenuation cutoff of 20 HU should replace that of 10 HU for exclusion of ACC. A triple test strategy of tumour diameter, imaging characteristics, and urine steroid metabolomics improves detection of ACC, which could shorten time to surgery for patients with ACC and help to avoid unnecessary surgery in patients with benign tumours.FundingEuropean Commission, UK Medical Research Council, Wellcome Trust, and UK National Institute for Health Research, US National Institutes of Health, the Claire Khan Trust Fund at University Hospitals Birmingham Charities, and the Mayo Clinic Foundation for Medical Education and Research.

Patient and clinician opinions of patient reported outcome measures (PROMs) in the management of patients with rare diseases: a qualitative study

BackgroundRare diseases may be life-threatening or chronically debilitating conditions. Patient care needs are often complex and challenging to coordinate and deliver effectively. Rare diseases and their clinical management may therefore substantially impact on patients’ health-related quality of life (HRQOL). The use of patient-reported outcome measures (PROMs) may complement clinical assessments by elucidating patients’ perspectives on their health status and care priorities. This study explored the opinions of patients and clinicians on the use of PROMs in the management of patients with rare diseases in routine clinical practice.MethodsA total of 15 semi-structured one-to-one interviews were conducted with four patients with primary sclerosing cholangitis (PSC); five renal transplant recipients; and six PSC doctors from University Hospitals Birmingham (UHB) NHS Foundation Trust. A focus group session was also conducted with 10 clinical staff members (doctors, nurses and other allied health professionals from UHB). The suitability and acceptability of the Chronic Liver Disease Questionnaire (CLDQ) and the Short Form 12 (SF12) were assessed by patients with PSC and their doctors while the Paediatric quality of life inventory Transplant Module (PedsQL-TM) and the EuroQoL-5 dimensions (EQ. 5D) were evaluated by the renal transplant recipients and their doctors. The discussions were audio recorded and transcribed verbatim. Coding of the transcripts was done using the Nvivo 11 Plus software. Thematic analysis was conducted to identify the main themes and subthemes.ResultsFour themes were identified, namely: (i) potential benefits of PROMs in the management of rare diseases; (ii) views on selected questionnaires; (iii) practical considerations for implementation; and (iv) potential facilitators and barriers of implementation. Patients and clinicians suggested that the use of ePROMs may facilitate patient-centred care by promoting patient-clinician communication, highlighting aspects of HRQOL that are important to patients and encouraging patient involvement in their care. They also felt that the disease-specific CLDQ and PedsQL-TM were more relevant than the generic SF12 and EQ-5D.ConclusionsPatients with rare diseases often experience impaired HRQOL. The use of an ePROM system may enhance the routine management of patients with rare diseases.

Nicotinamide Adenine Dinucleotide Metabolome Is Functionally Depressed in Patients Undergoing Liver Transplantation for Alcohol‐Related Liver Disease

Nicotinamide adenine dinucleotide (NAD+) and related coenzymes play critical roles in liver function. Although hepatic alcohol metabolism depresses NAD+, current understanding of the NAD+ metabolome in alcohol‐related liver disease (ArLD) is based on animal models. We used human liver samples to quantify the NAD+ metabolome in ArLD with samples obtained at the time of liver transplantation or resection at University Hospitals Birmingham National Health Service Foundation Trust. The severity of steatohepatitis in liver from patients with ArLD was assessed with standard liver function tests and histology. NAD‐targeted quantitative metabolomic analysis of liver tissue was performed by liquid chromatography–tandem mass spectrometry. Seventy‐two human liver specimens were analyzed, including 43 with ArLD. The NAD+ metabolome differed significantly between different types of liver disease (two‐way analysis of variance [ANOVA], P = 0.001). ArLD liver tissue showed markedly depressed concentrations of NAD+ (432 μM vs. 616 μM in normal liver) and precursor molecules nicotinic acid and nicotinamide riboside. There was a significant overall difference in the NAD+ metabolome between ArLD samples with and without steatohepatitis (two‐way ANOVA, P = 0.018). After correcting for multiple comparisons, a significant difference for individual components of the metabolome was observed for the concentration of NAD+ (mean, 462 μM vs. 322 μM; P < 0.01 in nonsevere vs. severe alcoholic steatohepatitis, respectively). NAD+ concentration was inversely related to serum bilirubin concentration (r 2 = −0.127; P = 0.04) and positively correlated with myeloperoxidase activity (r 2 = 0.31; P = 0.003). The concentration of NAD+ and its precursor molecules are significantly reduced in ArLD and are associated with disease activity. Conclusion: Liver samples from people with ArLD show depressed NAD+ and precursor levels as well as depressed myeloperoxidase activity.

P139: Uptake of Cyclin Dependant Kinase 4/6 inhibitors (CDKi) - A retrospective audit at University Hospital Birmingham trust (UHB) (audit approval number: Carms15507)

Introduction: Since 2017, NICE has approved the first line use of Cyclin Dependent Kinase 4/6 Inhibitors (CDKis) for hormone receptor positive and HER2 negative locally advanced (LABC) or metastatic breast cancer (MBC). Uptake amongst units is variable. CDKis are currently only licensed in conjunction with an aromatase inhibitor or Fulvestrant. Alternative treatments include endocrine monotherapy and/or chemotherapy. This retrospective audit aims to quantify the uptake of CDKis at University Hospital Birmingham (UHB) Trust, and assess variations, if any, compared to the expected uptake of 60% determined by NICE.

Ethnicity and Risk of Death in Patients Hospitalised for COVID-19 Infection: An Observational Cohort Study in an Urban Catchment Area

Background: Studies during the COVID-19 pandemic have suggested patient characteristics with increased risk of death. Most studies have not included populations which reflect an urban UK demographic but emerging case reports have suggested poorer outcomes in certain ethnic groups. It was hypothesised that people from South Asian ethnic groups would be more susceptible to severe manifestations of COVID-19. Methods: Patients with confirmed SARS-CoV-2 infection by positive polymerase chain reaction testing and requiring admission to University Hospitals Birmingham NHS Foundation Trust in Birmingham UK between 10th March 2020 and 17th April 2020 were included. Demographics, ethnicity, baseline co-morbidities, social deprivation index and outcome (death within the censor date) were assessed and Cox regression analysis conducted. Using observed sex-specific age distributions of COVID-19 admissions/deaths and 2011 census data for Birmingham/Solihull, expected numbers of admissions and deaths were estimated and ratios of observed to expected numbers calculated, providing standardised admission ratios (SAR) and standardised mortality ratios (SMR). Results: 2217 patients admitted to UHB with a proven diagnosis of COVID-19 were included. 58.2% were male, 69.5% White and the majority (80.2%) had co-morbidities. 18.5% were of South Asian ethnicity, and these patients were more likely to be younger (median age 61 vs.77), have no co-morbidities (27.8% vs. 16.6%) but a higher prevalence of diabetes mellitus (48.1% vs 28.2%) than White patients. SAR and SMR suggested more admissions and deaths in South Asian patients than would be predicted. These patients were more likely to present with severe disease. South Asian ethnicity was associated with an increased risk of death (Hazard Ratio 1.67 (95%CI 1.34 – 2.10)) after adjusting for age, sex, deprivation and comorbidities. Interpretation: Current evidence suggests those of South Asian ethnicity may be at risk of worse COVID019 outcomes, further studies needs to establish the underlying mechanistic pathways. Funding Statement: HDRUK Hub PIONEER Declaration of Interests: S Gallier, C Mainey, P Nightingale, D McNulty, A Kolesnyk, M Ahmed, H Crothers, F Evison, A Liaqat, L Irshad, M. Harris, T Nabavi, P Cockwell, D Pagano, report no conflicts of interest. S Ballreports funding support from the HDFR-UK, K Reeves reports funding support from the NIHR, E Sapey reports funding support from the MRC, Wellcome Trust, NIHR and British Lung Foundation. K. Nirantharakumar reports funding from MRC, Wellcome Trust, NIHR, Vifor and AstraZeneca. A.K Dennistonreports funding from HDR-UK, Wellcome Trust and Fight for Sight. Ethics Approval Statement: This retrospective cohort study, using prospectively collected data was conducted as part of DECOVID, an HRA and London - City & East Research Ethics Committee approved research database (Ethics number 20/HRA/1689).

P222 Vitamin D in early rheumatoid arthritis

Abstract Background Rheumatoid arthritis (RA) is the commonest chronic inflammatory arthritis, predominantly affecting small/medium joints and associated with extra-articular features. Previous studies have linked RA risk and disease activity with vitamin D-deficiency, but a causal role for vitamin D in RA is still unclear, partly due to heterogeneous study methods and sample populations. Moreover, no studies have focused specifically on vitamin D status (serum levels of 25-hydroxyvitamin D, 25OHD) in early RA, or whether low 25OHD is linked to progression from undifferentiated inflammatory arthritis to RA. Our objectives were therefore (1) to analyse serum 25OHD in early inflammatory arthritis, (2) to compare 25OHD levels with disease activity and fatigue in early RA and (3) to determine whether low serum 25OHD is associated with progression to RA. Methods We analysed 791 patients enrolled in the Birmingham Early Arthritis Cohort from 2013-19 at Sandwell and West Birmingham Hospitals NHS Trust and University Hospitals Birmingham NHS Trust. We collect baseline demographic data, serum 25OHD (ng/ml), and clinical variables including: duration of symptoms, duration of early morning stiffness (EMS), CRP, ESR, anti-CCP antibody status, Rheumatoid factor status, tender and swollen joint counts, DAS28-ESR, DAS28-CRP, Visual Analogue Scale (VAS) pain/fatigue and FACIT scores. Diagnosis was recorded at 0 and 12 months onwards as either RA, psoriatic arthritis (PsA), Undifferentiated Inflammatory Arthritis (UIA; synovitis not meeting other classification/diagnostic criteria), Clinical Suspect Arthralgia (CSA; arthralgia of an inflammatory type without synovitis), or Other. Data were analysed using SPSSv25. Full ethical approval was given for the study (REC12/WM/0258). Results Baseline demographic data were similar between all groups, with a median symptom duration of 16.8-34.0 days. Baseline 25OHD was not significantly different between groups [median, interquartile range (IQR): RA 46.7, 30.0-73.3; PsA 41.2, 30.0-65.0; UIA 51.4, 30.0-72.3; CSA 47.7, 30.3-73.0; Other 37.0, 24.9-55.3]. In the RA group (n = 335), there were no significant differences between 25OHD and any measures of disease activity/fatigue. Finally, we found no association between 25OHD and progression from UIA (n = 121) or CSA (n = 150) to RA (p = 0.554 and p = 0.741 respectively). Conclusion Overall we found no clear association between serum 25OHD and baseline diagnosis, RA disease activity, or progression from UIA/CSA to RA in this large cohort of early RA patients. Limitations of the study include that we were unable to report on levels of vitamin D metabolites which may be more important than total vitamin D. In addition, we were unable to adjust for supplement use/ time of year the sample was taken due to missing data. Future studies into the role of different metabolites of vitamin D in aetiopathogenesis of inflammatory arthritis would provide invaluable insight into the role of vitamin D in inflammatory arthritis better defining the complex role of vitamin D in RA. Disclosures S.R. Harrison: None. G. Jutley: None. D. Li: None. I. Sahbudin: None. A. Filer: None. M. Hewison: None. K. Raza: None.

Adult Presentation of X-Linked Retinoschisis: Patient and Physician Perspectives.

This commentary article is co-authored by an adult patient with X-linked retinoschisis and two ophthalmologists affiliated with the University Hospitals Birmingham NHS Foundation Trust. It describes the patient’s experiences of sight loss and the diagnosis and management of X-linked retinoschisis. The treating ophthalmologists then draw upon these experiences and discuss the disease and associated sight loss in a wider context.

P005 Regulators of the guanylate cyclase pathway are potential novel markers of mucosal healing in IBD

Abstract Background Intestinal guanylate cyclase C (GC-C) present in epithelial cells has been shown to have a role in gut homeostasis. The downstream effects of activation of GC-C are due to production of cyclic-GMP. GC-C is encoded by the gene GUCY2C, mutations in which are implicated in Familial Diarrhoea Syndrome and noted as risk factors for Crohn’s disease. GUCY2C and its activator, GUCA2A have been shown to be downregulated in IBD. We hypothesised that regulation of this pathway might be important in remission and response to therapy. Methods Forty-four patients with IBD and 7 patients with polyps (controls) at University Hospitals Birmingham, UK were recruited under ethical consent. Relevant demographic and clinical data were extracted from the hospital EMR. All patients had disease activity recorded on endoscopic examination of mucosa and intestinal biopsies collected for analysis. Mucosal healing was defined as MES = 0 (UC) and SES-CD &amp;lt;6 (CD). Of 44 patients, 14 had matched baseline and 12-week post-biologic therapy assessment and had tissues collected. Intestinal biopsies were analysed by 3’RNA-sequencing using the Illumina Nextseq sequencer. FASTQ files were generated through BaseSpace and reads de-multiplexed, trimmed, aligned, and quantified using the GeneGlobe (Qiagen) workflow. Expression was compared between groups using either Wilcoxon tests or Kruskal–Wallis with Dunn post-hoc analysis as appropriate. Results Expression of Guanylate cyclase activators GUCA2A and GUCA2B in patients who showed mucosal healing was equivalent to controls, but GUCA2A was down-regulated in those with active disease (non-healing) (p = 0.006). The same pattern was observed for transcriptional regulators of GUCY2C, including HNF4A (p = 0.0248) and CDX2 (0.0062). Correspondingly, GUCY2C was reduced in non-healing mucosa, although the difference was not significant (Figure 1). In patients who responded to biologic therapy, both GUCA2A (p = 0.0234) and GUCA2B (p = 0.0117) were increased at follow-up but no change was observed for those who did not respond. Change in GUCY2C expression did not reach statistical significance in either group, although an increase was observed for a large proportion of responders. Conclusion Our findings suggest that regulation of the Guanylate Cyclase pathway may be involved in the restoration of a stable mucosa in IBD and that expression of its regulators may be used to indicate response to treatment.

Acute, non-COVID related medical admissions during the first wave of COVID-19: A retrospective comparison of changing patterns of disease

COVID-19 may have altered the case-mix of non-COVID acute medical admissions. Retrospective analysis of acute medical admissions to University Hospitals Birmingham NHS Foundation Trust, showed that medical admissions decreased in April 2020 compared to April 2019. The proportion of young adults, non-cardiac chest pain, musculoskeletal conditions and self-discharges decreased. The proportion of admissions due to alcohol misuse, psychiatric conditions, overdoses and falls increased. There were a higher number of patients admitted to ICU and greater inpatient mortality but not once COVID diagnoses were excluded. There was a significant change in hospitalised case-mix with conditions potentially reflecting social isolation increasing and diagnoses which rarely require hospital treatment, reducing. This analysis will help inform service planning.

Assessing Univentricular Function in Adult Fontan Using 3D Echocardiography

<b>Objective:</b> To determine the accuracy of assessing univentricular function in adult Fontan patients using three-dimensional (3D) volumetric echocardiography. <b>Design:</b> A prospective observational study in an adult Fontan patient cohort. <b>Setting:</b> University Hospitals Birmingham, NHS Foundation Trust. <b>Patients:</b> 26 patients were enrolled in the study all aged over 18 years, possessing the Fontan anatomy, with no contraindications to Cardiac Magnetic Resonance (CMR) imaging and in sinus rhythm. <b>Intervention:</b> All patients underwent transthoracic echocardiography using a Philips EPIQ 7 and X5-1 transducer. End diastolic volume (EDV), end systolic volume (ESV), stroke volume (SV) and ejection fraction (EF) were obtained using two dimensional (2D) and 3D acquisitions. CMR was performed within 3 months according to standard protocols. <b>Outcome Measures:</b> The agreement and correlation between 2D, 3D and CMR derived parameters were determined by Bland and Altman analysis and Pearson’s correlation coefficient method. The inter-observer variability was also assessed for all three modalities. <b>Results:</b> 3D volumetric acquisitions of the single ventricle were feasible in 18/26 (69%) patients. 3D volumes strongly correlated with CMR but with a systematic bias to underestimation: EDV r = 0.66, bias = –47.1 (–109.6 to 15.2); ESV r = 0.82, bias = – 19.4 (–59.9 to 21.1); EF r = 0.73, –1.56 (–18.8 to 15.7) and SV r = 0.32, –27.7 (– 70.2 to 14.7). Inter-observer variability was lowest with CMR, when compared to echocardiographic techniques. The inter-observer variability for 3D when compared with 2D echocardiography was lower across all parameters except EDV. <b>Conclusions:</b> 3D volumes correlate strongly with CMR and may be used for serial assessment of univentricular function. However, 3D volumes on echo are not interchangeable with CMR due to systematic underestimation of volume.

108 - Durvalumab for stage III non-small cell lung cancer (NSCLC): early access programme (EAP) in University Hospitals Birmingham (UHB), UK

108 - Durvalumab for stage III non-small cell lung cancer (NSCLC): early access programme (EAP) in University Hospitals Birmingham (UHB), UK

93 - Management of stage III non-small cell lung cancer (NSCLC); outcomes from University Hospitals Birmingham NHS Foundation Trust (UHB)

93 - Management of stage III non-small cell lung cancer (NSCLC); outcomes from University Hospitals Birmingham NHS Foundation Trust (UHB)

Myocardial characterization in pre-dialysis chronic kidney disease: a study of prevalence, patterns and outcomes

BackgroundLate gadolinium enhancement (LGE) using cardiac magnetic resonance (CMR) characterizes myocardial disease and predicts an adverse cardiovascular (CV) prognosis. Myocardial abnormalities, are present in early chronic kidney disease (CKD). To date there are no data defining prevalence, pattern and clinical implications of LGE-CMR in CKD.MethodsPatients with pre-dialysis CKD (stage 2–5) attending specialist renal clinics at University Hospital Birmingham (UK) who underwent gadolinium enhanced CMR (1.5 T) between 2005 and 2017 were included. The patterns and presence (LGEpos) / absence (LGEneg) of LGE were assessed by two blinded observers. Association between LGE and CV outcomes were assessed.ResultsIn total, 159 patients received gadolinium (male 61%, mean age 55 years, mean left ventricular ejection fraction 69%, left ventricular hypertrophy 5%) with a median follow up period of 3.8 years [1.04–11.59]. LGEpos was present in 55 (34%) subjects; the patterns were: right ventricular insertion point n = 28 (51%), mid wall n = 18 (33%), sub-endocardial n = 5 (9%) and sub-epicardial n = 4 (7%). There were no differences in left ventricular structural or functional parameters with LGEpos. There were 12 adverse CV outcomes over follow up; 7 of 55 with LGEpos and 5 of 104 LGEneg. LGEpos was not predicted by age, gender, glomerular filtration rate or electrocardiographic abnormalities.ConclusionsIn a selected cohort of subjects with moderate CKD but low CV risk, LGE was present in approximately a third of patients. LGE was not associated with adverse CV outcomes. Further studies in high risk CKD cohorts are required to assess the role of LGE with multiplicative risk factors.

An audit on the surgical management of patients with asymptomatic primary hyperparathyroidism (PHPT) at University Hospital Birmingham

An audit on the surgical management of patients with asymptomatic primary hyperparathyroidism (PHPT) at University Hospital Birmingham

Predicting Postoperative Lung Function Following Lung Cancer Resection: A Systematic Review and Meta-analysis

BackgroundLung resection remains the gold standard treatment for early stage lung cancer; prediction of postoperative lung function is a key selection criterion for surgery with the aim of determining risk of postoperative dyspnoea. We aimed to identify the different prediction techniques used, and compare their accuracy. MethodsA systematic review and meta-analysis sought to synthesise studies conducted that assess prediction of postoperative lung function up to 18/02/2018 (n = 135). PROBAST was used to assess risk of bias in studies, 17 studies were judged to be at low risk of bias. FindingsMeta-analysis revealed CT volume and density measurement to be the most accurate (mean difference 71 ml) and precise (standard deviation 207 ml) of the reported techniques used for predicting FEV1; evidence for predicting gas transfer was lacking. InterpretationThe evidence suggests using CT volume and density is the preferred technique in the prediction of postoperative FEV1. Further studies are required to ensure that the methods and thresholds we propose are linked to patient reported outcomes. FundingSalary support for NKO, RM, PN, BN, and AMT was provided by University Hospitals Birmingham NHS Foundation Trust.

Obesity in acute alcoholic hepatitis increases morbidity and mortality.

BackgroundAlcohol and obesity synergise to increase the risk of liver-related mortality. We examined the influence of adiposity on clinical outcomes in alcoholic hepatitis (AH) and the underlying inflammatory crosstalk between adipose tissue (AT) and the liver.MethodsA cohort of 233 patients with AH from the UK and USA provided data to analyse the effects of obesity in AH. Body mass index was corrected for the severity of ascites, termed cBMI. Inflammatory and metabolic profiling was undertaken by proteome analysis of human serum samples. The effect of alcohol on adipose tissue and CXCL11 expression was studied in 3 T3-derived adipocytes and in mice using the high-fat diet-plus-binge ethanol model.FindingsObesity was common amongst patients with AH, seen in 19% of individuals. Obesity (HR 2.22, 95%CI 1.1–4.3, p = .022) and underweight (HR 2.38, 1.00–5.6, p = .049) were independently associated with mortality at 3 months. Proteome analysis demonstrated multiple metabolic and inflammatory factors differentially expressed in obese AH verse lean AH, with CXCL11 being the most elevated factor in obese AH. In vitro analysis of cultured adipocytes and in vivo analysis of mouse models showed that alcohol induced CXCL11 expression in AT, but not in liver.InterpretationObesity is common in AH and associated with a greater than two-fold increase in short-term mortality. Obese AH is associated with a different inflammatory phenotype, with the greatest elevation in CXCL11. These data confirm that adiposity is clinically important in acute alcohol-related liver disease and illustrate the adipose-liver inflammatory axis in AH.FundThis work was supported in part by an EASL Sheila Sherlock Physician Scientist Fellowship. The funder played no role in gathering or analysing data or writing the manuscript. This paper presents independent research supported by the NIHR Birmingham Biomedical Research Centre at the University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Review of a medical illustration department’s data processing system to confirm general data protection regulation (GDPR) compliance

This article reviews the clinical photography and video data processing and storage arrangements of the Medical Illustration Department (MID) at the Queen Elizabeth Hospital Birmingham National Health Service (NHS) Foundation Trust (QEHB), part of the University Hospitals Birmingham (UHB) NHS Foundation Trust umbrella group. This review suggests that the department’s current workflow and technical processing solution satisfies the requirements of the general data protection regulation (GDPR). At the time of writing, there were no additional financial costs or technical skills required for implementing GDPR regulations but this could change in future data processing systems. There are significant potential costs for non-compliance with GDPR. Brexit is unlikely to have any effect on complying with GDPR requirements. The GDPR gives the public the right to access information and be informed of how and why it is processed. It is recommended that improved administrative processing capability to accommodate this requirement should be included in future data processing designs. At the QEHB informed consent for use of photographs and videos is currently adequate to satisfy the common law of confidence.