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Warnapura L.P.C.,Luton and Dunstable University Hospital | Peiris T.M.,Luton and Dunstable University Hospital
Sri Lankan Journal of Anaesthesiology | Year: 2017

Evidence behind rational fluid therapy for sick paediatric and adult patients is sparse. During the last two decades, fluid therapy has become increasingly regulated. The neverending debate about crystalloids versus colloids is continuing and the scientific community still waits the discovery of the ideal intravenous solution. This review focus on analyzing the current evidence behind various practices of fluid management in children and adults. A web based search was carried out using the pubmed. The following key words were used; “Fluid therapy”, “peri-operative fluids”, “tissue oxygenation”, “Intravenous fluids”, “tissue perfusion”. Studies more than 10 years old were excluded. Systemic reviews, randomized trials, meta analyses and novel ideas about fluid resuscitation were filtered out to obtain the best evidence. “Up to date” 2016 was used to formulate factual back ground information. © 2017 Warnapura et al.


Edwards D.S.,Public Health England | Milne L.M.,HPA Bedfordshire and Hertfordshire Health Protection Unit | Morrow K.,HPA Bedfordshire and Hertfordshire Health Protection Unit | Sheridan P.,HPA Bedfordshire and Hertfordshire Health Protection Unit | And 6 more authors.
Epidemiology and Infection | Year: 2014

A foodborne outbreak with 49 cases (22 culture positive for Campylobacter sp.) following a wedding party in the East of England was investigated. A retrospective cohort study identified an association between consumption of chicken liver pté and infection with Campylobacter jejuni/coli. There was a statistically significant association between dose (amount of chicken liver pté eaten) and the risk of disease ['tasted': odds ratio (OR) 1·5, 95% confidence interval (CI) 0·04-∞; 'partly eaten': OR 8·4, 95% CI 1·4-87·5; 'most or all eaten': OR 36·1, 95% CI 3·3-2119). The local authority found evidence that the preparation of chicken livers breached Food Standards Agency's guidelines. This epidemiological investigation established a clear dose-response relationship between consumption of chicken liver pté and the risk of infection with Campylobacter. The continuing need to raise public awareness of the risk to human health posed by undercooked chicken liver is evident. © 2013 Cambridge University Press.


Prasad R.,Queen Mary, University of London | Chan L.F.,Queen Mary, University of London | Hughes C.R.,Queen Mary, University of London | Kaski J.P.,Great Ormond St Hospital for Children | And 7 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2014

Context: Classic ACTH resistance, due to disruption of ACTH signaling, accounts for the majority of cases of familial glucocorticoid deficiency (FGD). Recently FGD cases caused by mutations in the mitochondrial antioxidant, nicotinamide nucleotide transhydrogenase, have highlighted the importance of redox regulation in steroidogenesis. Objective: We hypothesized that other components of mitochondrial antioxidant systems would be good candidates in the etiology of FGD. Design: Whole-exome sequencing was performed on three related patients, and segregation of putative causal variants confirmed by Sanger sequencing of all family members. A TXNRD2-knockdown H295R cell line was created to investigate redox homeostasis. Setting: The study was conducted on patients from three pediatric centers in the United Kingdom. Patients: Seven individuals from a consanguineous Kashmiri kindred, six of whom presented with FGD between 0.1 and 10.8 years, participated in the study. Interventions: There were no interventions. Main Outcome Measure: Identification and functional interrogation of a novel homozygous mutation segregating with the disease trait were measured. Results: A stop gain mutation, p.Y447X in TXNRD2, encoding the mitochondrial selenoprotein thioredoxin reductase 2 (TXNRD2) was identified and segregated with disease in this extended kindred. RT-PCR and Western blotting revealed complete absence of TXNRD2 in patients homozygous for the mutation. TXNRD2 deficiency leads to impaired redox homeostasis in a human adrenocortical cell line. Conclusion: In contrast to the Txnrd2-knockout mouse model, in which embryonic lethality as a consequence of hematopoietic and cardiac defects is described, absence of TXNRD2 in humans leads to glucocorticoid deficiency. This is the first report of a homozygous mutation in any component of the thioredoxin antioxidant system leading to inherited disease in humans. Copyright © 2014 by the Endocrine Society.


Nair M.,University of Oxford | Soffer K.,Luton and Dunstable University Hospital | Noor N.,University of Oxford | Knight M.,University of Oxford | Griffiths M.,Luton and Dunstable University Hospital
BMJ Open | Year: 2015

Objective: To conduct a secondary analysis of data from the UK Obstetric Surveillance System (UKOSS) to estimate the rates of specific maternal risks associated with planned vaginal birth after caesarean (VBAC) and elective repeat caesarean section (ERCS). Design: A retrospective cohort analysis using UKOSS data from 4 studies conducted between 2005 and 2012. Setting: All hospitals with consultant-led maternity units in the UK. Population: Pregnant women who had a previous caesarean section. Method: Women who had undergone a previous caesarean section were divided into 2 exposure groups: planned VBAC and ERCS. We calculated the incidence of each of the 4 outcomes of interest with 95% CIs for the 2 exposure groups using proxy denominators (total estimated VBAC and ERCS maternities in a given year). Incidences were compared between groups using χ2 test or Fisher's exact test and risk ratios with 95% CI. Main outcome measures: Severe maternal morbidities: peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation. Results: The risks of all complications examined in both groups were low. The rates of peripartum hysterectomy, severe sepsis, peripartum haemorrhage and failed tracheal intubation were not significantly different between the 2 groups in absolute or relative terms. Conclusions: While the risk of uterine rupture in the VBAC and ERCS groups is well understood, this national study did not demonstrate any other clear differences in the outcomes we examined. The absolute and relative risks of maternal complications were small in both groups. Large epidemiological studies could further help to assess whether the incidence of these rare outcomes would significantly differ between the VBAC and ERCS groups if a larger number of cases were to be examined. In the interim, this study provides important information to help pregnant women in their decision-making process.


El Hamamsy D.,Luton and Dunstable University Hospital | Fayyad A.M.,Luton and Dunstable University Hospital
International Urogynecology Journal and Pelvic Floor Dysfunction | Year: 2015

Introduction and hypothesis: The aim of this study was to assess the incidence of stress urinary incontinence (SUI) following laparoscopic sacrocolpopexy in continent women and its relation to postoperative prolapse stage. Methods: A total of 220 continent women with symptomatic apical prolapse who underwent laparoscopic sacrocolpopexy were prospectively evaluated; 100 women had previous hysterectomy. Patients were followed up at 3 and 12 months after surgery. All subjects completed the King’s Health Questionnaire (KHQ) and Prolapse Quality of Life Questionnaire (P-QOL) and were examined using the Pelvic Organ Prolapse Quantification (POP-Q) system. The primary outcome measure was the number of women who developed new onset moderate/severe SUI at 3 and 12 months postoperatively and its relation to postoperative prolapse stage. Results: At 3 months, 52 women (23.6 %) developed moderate/severe SUI; 27 (12.2 %) had severe SUI. Eleven women (5.0 %) underwent surgery for SUI within 6 months of sacrocolpopexy. All surgery for SUI was in women who had post-hysterectomy sacrocolpopexy. Postoperatively, the vaginal apex (point C) was at stage 0/I in 195 cases (88.6 %). There were no differences in postoperative POP-Q stage of the anterior and apical vaginal walls between continent women and those with SUI (p = 0.45). The posterior vaginal wall was higher in women who developed de novo SUI (p = 0.03). Conclusions: The incidence of SUI following apical prolapse repair is 23.6 %. Subsequent continence procedures were performed in 5.0 % of patients. All were in women who had previous hysterectomy making the risk in this group 11 %. Higher POP-Q stage of the posterior vaginal wall was associated with SUI. © 2015, The International Urogynecological Association.


Barreca M.,Luton and Dunstable University Hospital | Nagliati C.,Luton and Dunstable University Hospital | Jain V.K.,Luton and Dunstable University Hospital | Whitelaw D.E.,Luton and Dunstable University Hospital
Surgery for Obesity and Related Diseases | Year: 2015

Background Management of staple-line leak after laparoscopic sleeve gastrectomy (LSG) remains controversial and matter of debate. Transforming a leak into a controlled fistula by insertion of a T-tube is a viable option. To minimize surgical dissection, and to facilitate identification of the leak site and insertion of the T-tube, we have developed a combined endoscopic-laparoscopic T-tube (ELT-t) insertion technique. Methods Between February 2011 and June 2014, 7 patients presented with staple-line leak and were treated with ELT-t insertion. After laparoscopic dissection of the abscess cavity, a guidewire is passed endoscopically through the leak; a polypectomy snare is anchored to the guidewire and retrieved through the patient mouth. The long arm of a T-tube is eventually secured to the snare and pulled down through the leak. Results All patients were started on oral feeding with the T-tube in place. Serial water-soluble contrast swallows were performed to check for healing, and the T-tube was clamped as soon as no extravasation of contrast was demonstrated. The tube was removed either during the index admission or in the outpatient clinic. The residual fistula closed successfully after T-tube removal in all but one case with a "spiral-shaped" sleeve and functional distal obstruction. This patient was treated with stent. Patients were discharged home after a mean postoperative hospital stay of 53.3 days (range: 15-87 days). Conclusion In our experience, ELT-t is a valid alternative for the treatment of staple-line leak after LSG. It allows minimizing surgical dissection, and appears to be safe and effective. © 2015 American Society for Metabolic and Bariatric Surgery.


Fernando P.M.,Luton and Dunstable University Hospital
Sri Lankan Journal of Anaesthesiology | Year: 2013

The concept of 'Enhanced Recovery' is changing the face of surgical care pathways in western countries, benefiting patients as well as healthcare providers. The improvement in outcomes claimed would be of even greater benefit to developing countries, where resources are harder to come by. However, implementation of such a program in a developing country such as Sri Lanka needs to be preceded by thorough study of the obstacles to early discharge of patients, and the program customised to address problems specific to the local healthcare environment.


Kinns H.,Luton and Dunstable University Hospital | Housley D.,Luton and Dunstable University Hospital | Freedman D.B.,Luton and Dunstable University Hospital
Annals of Clinical Biochemistry | Year: 2013

The term Munchausen syndrome is used to describe the patient who chronically fabricates or induces illness with the sole intention of assuming the patient role. Such persons often have a close association with the medical profession and thus use their knowledge to falsify symptoms and laboratory specimens to mimic disease. Cases of factitious disease have appeared in the literature originating from all medical specialties, and include such rare disorders as phaeochromocytoma and Bartter's syndrome. The laboratory can play a key role in the detection and diagnosis of factitious disorders. Indeed discrepant biochemistry results may provide the first clue to the diagnosis. Laboratory staff should be particularly aware of highly variable test results and extreme abnormalities that are not consistent with the wider biochemical profile, suggesting sample tampering. Factitious disorder should also be included in the clinician's differential diagnosis when disease presentation is unusual or an underlying cause cannot be found. Investigation to exclude or confirm factitious disorder at an early stage can prevent unnecessary testing in the search for increasingly rare diseases. Appropriate analyses may include screening tests for the detection of surreptitious drug administration or replication of a fabricated sample to confirm the method used. In all cases close communication between the clinician and laboratory is essential. This will ensure that appropriate tests are conducted particularly with regard to time critical and repeat tests.


Jablenska L.,Luton and Dunstable University Hospital | Trinidade A.,James Paget University Hospital | Meranagri V.,Luton and Dunstable University Hospital | Kothari P.,Luton and Dunstable University Hospital
Journal of Laryngology and Otology | Year: 2014

Abstract Introduction: Salivary gland pathology in the paediatric population is rare and can present management challenges regarding both investigation and treatment. Method: Case report and review of available literature. Results: A seven-year-old, fit, well girl presented with a two-month history of a painless mass over the left parotid area. Ultrasonography confirmed the presence of a well-defined, 1.5 × 2 cm, predominantly solid lesion with minor internal cystic spaces arising from the superficial part of the gland. Magnetic resonance imaging showed no invasion of the deep lobe or skeletal erosion. Superficial parotidectomy was performed via a facelift incision. Histopathology confirmed a diagnosis of pleomorphic adenoma. Review of the literature emphasised important differences in managing this pathology in the paediatric population when compared with adults. Conclusion: We present the youngest reported case of a pleomorphic adenoma of the parotid gland, detail its management, and discuss the general approach to parotid pathology management in the paediatric population. Copyright © JLO (1984) Limited 2014.


Battersby C.,Imperial College London | Santhakumaran S.,Imperial College London | Birch J.,Luton and Dunstable University Hospital | Modi N.,Imperial College London
Archives of Disease in Childhood: Fetal and Neonatal Edition | Year: 2014

Objective: To evaluate a quality improvement (QI) programme to increase the use of maternal breast milk (MBM) in preterm infants. Design: Interrupted time series analysis. Setting: 17 neonatal units in the East of England (EoE) Perinatal Network; 144 in the rest of the UK Neonatal Collaborative (UKNC). Patients: Infants born ≤32+6 weeks gestation admitted to neonatal care between 2009 and 2012. Intervention: A 'care bundle' to promote MBM in the EoE. Outcomes: Percentage of infants receiving exclusive or any MBM at discharge and care days where any MBM was received. Methods: Data were extracted from the National Neonatal Research Database; outcomes were compared preintervention and postintervention, and in relation to the rest of the UKNC. Results: Exclusive and any MBM use at discharge increased from 26% to 33% and 50% to 57% respectively in the EoE, though there was no evidence of a step or trend change following the introduction of the care bundle. Exclusive MBM use at discharge improved significantly faster in EoE than the rest of the UKNC; 0.22% (95% CI 0.11 to 0.34) increase per month versus 0.05% (95% CI 0.01 to 0.09, p=0.007 for difference). The percentage of infants receiving MBM at discharge and care days where any MBM was received was not significantly different between EoE and the rest of the UKNC. Conclusions: This QI programme was associated with some improvement in MBM use in preterm infants that would not have been evident without the use of routinely recorded national comparator data.

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