ABSTRACT
Correspondence to Wg Cdr Robert M Barker-Davies, Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre Stanford Hall, Loughborough, LE12 5BR, UK;Robert.barker-davies@nhs.net The Royal Society of Medicine (RSM–Military Medicine Section), Colt Foundation Research & Clinical Innovation Meeting has been at the core of Defence Medical Services (DMS) academic activity since its inception in 2007. Initially, the meeting sought submissions from medical officers, typically undertaking higher degrees, but in recent years the scope of the meeting has been broadened to include all healthcare professional disciplines.1 2 This reflects the strategic directions of both UK Healthcare and the DMS towards greater interdisciplinary healthcare delivery models and integrated research3 in which shared role understanding and supportive team structures have been identified as themes that promote collaborative success in military medical teams.4 The top six s for the Colt Research prize, published here in BMJ Military Health, reflect this diversity as they span several disciplines and both academic and Defence institutions. [...]we heard from Captain Kat Matthews, army physiotherapist and professional triathlete.
ABSTRACT
Objective: Continuous glucose monitoring (CGM) has demonstrated benefits in managing inpatient diabetes. We initiated this prospective pilot study to determine the feasibility and accuracy of CGM in high-risk cardiac surgery patients with diabetes after their transition of care from the intensive care unit(ICU). Methods: Clarke Error Grid(CEG) analysis was used to compare CGM and point-of-care(POC) measurements. Mean absolute relative difference(MARD) of the paired measurements was calculated to assess the accuracy of the CGM for glucose measurements during the first 24 hours on CGM, the remainder of time on the CGM as well as for different chronic kidney disease(CKD) strata. Results: Overall MARD between POC and CGM measurements was 14.80%. MARD for patients without CKD IV and V with eGFR < 20 ml/min/1.73m2 was 12.13%. Overall, 97% of the CGM values were within the no-risk zone of the CEG analysis. For the first 24 hours, a sensitivity analysis of the overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m2 was 15.42% (+/- 14.44) and 12.80% (+/- 7.85) respectively. Beyond the first 24 hours, overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m2 was 14.54% (+/- 13.21) and 11.86% (+/- 7.64) respectively. Discussion/Conclusion: CGM has great promise to optimize inpatient diabetes management in the noncritical care setting and after the transition of care from the ICU with high clinical reliability, accuracy, and superior detection of hypoglycemia. More studies are needed to further assess CGM in patients with advanced CKD.
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Background. TNFα and IFN-γ may synergize to induce cytokine-driven lethal hyperinflammation and immune exhaustion in COVID-19 illness. Methods. To assess TNFα-antagonist therapy, 18 hospitalized adults with hypoxic respiratory failure and COVID-19 pneumonia received single-dose infliximab-abda therapy 5mg/kg intravenously between April and December 2020. The primary endpoint was time to increase in oxygen saturation to fraction of inspired oxygen ratio (SpO2/FiO2) by ≥ 50 compared to baseline and sustained for 48 hours. Secondary endpoints included 28-day mortality, dynamic cytokine profiles (Human Cytokine 48-Plex Discovery Assay), secondary infections, duration of supplemental oxygen support and hospitalization. Hospitalized patients with SARS-COV2 infection and pneumonia that were referred to the infliximab-abda study team for evaluation. Results. Patients were predominantly in critical respiratory failure (15/18, 83%), male (14/18, 78%), above 60 years (median 63 yrs, range 31-80), race-ethnic minorities (13/18, 72%), lymphopenic (13/18, 72%), steroid-treated (17/18, 94%), with a median ferritin of 1953ng/ml. Sixteen patients (89%) met the primary endpoint within a median of 4 days, 15/18 (83%) recovered from respiratory failure, and 14/18 (78%) were discharged in a median of 8 days and were alive at 28-day follow-up. Deaths among three patients ≥ 65 years age with pre-existing lung disease or multiple comorbidities were attributed to secondary lung infections. Mean plasma IP-10 levels declined sharply from 9183 pg/ml to 483 pg/ml at Day 3 and 146 pg/ml at Day 14/discharge. Significant declines in IFN-γ, TNFα, IL-27, IL-6 (baseline above 10pg/ml), CRP and ferritin were specifically observed at Day 3 whereas other cytokines were unaffected. Among 13 lymphopenic patients, six (46%) had resolution of lymphopenia by day 3, and 11 by day 14. CXCR3-ligand (IP-10 and CXCL-9) declines were strongly correlated among patients with lymphopenia reversal (Day 3, Pearson r: 0.98, p-value: 0.0006). following treatment with infliximab-abda. The status of the patient at last follow-up (discharged, alive or dead) is indicated. ECMO: extracorporeal membrane oxygenation Control of inflammatory markers and cytokines following infliximab therapy Values from individuals are connected with solid lines, with deceased individuals indicated in red. Statistics: n=18, paired ratio t-test compared to baseline;∗: P<0.05, ∗∗: P<0.01, ∗∗∗: P<0.001, ∗∗∗∗: P<0.0001, n.s.: not significant. Conclusion. Consistent with a central role of TNFα, the clinical and cytokine data indicate that infliximab-abda may rapidly abrogate pathological inflammatory signaling to facilitate clinical recovery in severe and critical COVID-19. Randomized studies are formally evaluating infliximab therapy in this context. Funding: National Center for Advancing Translational Sciences.
ABSTRACT
Virtual consultations and telemedicine have been an emerging trend in modern medicine, which has seen acceleration in uptake across a wide range of specialties as a result of the COVID-19 pandemic. Following on from previous work by the authors in 2019 examining clinician and patient appetite for virtual consultations in maxillofacial surgery, we sought to evaluate whether there had been a change in attitudes as a result of the pandemic. A clinician survey of the consultants at a large teaching hospital and prospective data collection of virtual consultation outcomes was carried out from the inception of UK government lockdown measures to tackle the pandemic. From 151 consultations, 149 (98.7%) successfully established a working diagnosis and treatment plan and/or concluded an episode of patient care, without the need to convert to a face-to-face encounter between clinician and patient. The total number of consultations (virtual or otherwise) was significantly lower than the same time period the preceding year however (1,223 compared with 465 consultations). All consultants surveyed felt the pandemic had altered their opinion of virtual clinics and their place in maxillofacial surgery but cited a number of issues. Further work is required to understand the driving forces behind staff attitudes and the long-term adoption of telemedicine within the specialty as services return to some sense of normalcy.