Post-COVID postural orthostatic tachycardia syndrome (POTS): a new phenomenon.

Background: The impact of COVID-19 has been far-reaching, and the field of neurology is no exception. Due to the long-hauler effect, a variety of chronic health consequences have occurred for some post-COVID patients. A subset of these long-hauler patients experienced symptoms of autonomic dysfunction and tested positive for postural orthostatic tachycardia syndrome (POTS) via autonomic testing. Methods: We conducted a chart review of a convenience sample from patients seen by neurologists at our tertiary care center for suspicion of post-COVID POTS. Patients included in our study had clearly defined POTS based on clinical criteria and positive tilt table test, were 81.25% female, and had an average age of approximately 36. Out of 16 patients, 12 had a confirmed positive COVID test result, with the remaining 4 having strong clinical suspicion for COVID infection. Our analysis examined the most bothersome 3 symptoms affecting each patient per the neurologist's note at their initial visit for post-COVID POTS, clinical presentation, comorbidities, neurological exam findings, autonomic testing results, and COMPASS-31 autonomic questionnaire and PROMIS fatigue survey results. Results: Palpitations (68.75%) and fatigue (62.5%) were the most common of the impactful symptoms reported by patients in their initial Cleveland Clinic neurology visit. The most frequent comorbidities in our sample were chronic migraines (37.5%), irritable bowel syndrome (IBS) (18.75%), and Raynaud's (18.75%). Neurological exam findings and autonomic testing results other than tilt table yielded variable findings without clear trends. Survey results showed substantial autonomic symptom burden (COMPASS-31 autonomic questionnaire average score 44.45) and high levels of fatigue (PROMIS fatigue survey average score 64.64) in post-COVID POTS patients. Conclusion: Our sample of post-COVID POTS patients are similar to the diagnosed POTS general population including in comorbidities and autonomic testing. Fatigue was identified by patients as a common and debilitating symptom. We hope that our study will be an early step toward further investigation of post-COVID POTS with focus on the trends identified in this chart review.

Assessing Mode of Recurrence in Breast Cancer to Identify an Optimised Follow-Up Pathway: 10-Year Institutional Review.

BACKGROUND: Breast cancer surveillance programmes ensure early identification of recurrence which maximises overall survival. Programmes include annual clinical examination and radiological assessment. There remains debate around the value of annual clinical exam in diagnosing recurrent disease/second primaries. The aim was to assess diagnostic modalities for recurrent breast cancer with a focus on evaluating the role of annual clinical examination. PATIENTS AND METHODS: A prospectively maintained database from a symptomatic breast cancer service between 2010-2020 was reviewed. Patients with biopsy-proven recurrence/second breast primary were included. The primary outcome was the diagnostic modality by which recurrences/secondary breast cancers were observed. Diagnostic modalities included (i) self-detection by the patient, (ii) clinical examination by a breast surgeon or (iii) radiological assessment. RESULTS: A total of 233 patients were identified and, following application of exclusion criteria, a total of 140 patients were included. A total of 65/140 (46%) patients were diagnosed clinically, either by self-detection or clinical examination, while 75/140 (54%) were diagnosed radiologically. A total of 59/65 (91%) of patients clinically diagnosed with recurrence presented to the breast clinic after self-detection of an abnormality. Four (6%) patients had cognitive impairment and recurrence was diagnosed by a carer. Two (3%) patients were diagnosed with recurrence by a breast surgeon at clinical examination. The median time to recurrence in all patients was 48 months (range 2-263 months). CONCLUSION: Clinical examination provides little value in diagnosing recurrence (< 5%) and surveillance programmes may benefit from reduced focus on such a modality. Regular radiological assessment and ensuring patients have urgent/easy access to a breast clinic if they develop new symptoms/signs should be the focus of surveillance programmes.

The impact of the COVID-19 pandemic on the provision of endovascular thrombectomy for stroke: an Irish perspective.

BACKGROUND: The COVID-19 pandemic produced unprecedented challenges to healthcare systems. These challenges were amplified in the setting of endovascular thrombectomy (EVT) for large vessel occlusion strokes given the time-sensitive nature of the procedure. AIMS: To assess the impact of the COVID-19 pandemic on service provision at the primary endovascular stroke centre in Ireland. METHODS: A retrospective review of the National Thrombectomy Service database was performed. All patients undergoing EVT from 1 January to 31 December inclusive of 2019 to 2021 were included. Patient demographics, functional outcomes and endovascular treatment time metrics were recorded. RESULTS: Data from 2019, 2020 and 2021 were extracted. Three hundred seven thrombectomies were performed in 2019 and 2020; this number increased to 327 in 2021. Median time from arrival to groin puncture for thrombectomy was 64 min in 2019, increasing to 65 min in 2020. In 2021, this decreased to 52 min. Median time taken from groin puncture to first perfusion remained stable from 2019 to 2021 years at 20 min. Total duration of emergency thrombectomies reduced from 32 min in 2019 to 27 min in 2020. This increased to 29 min in 2021. CONCLUSIONS: Despite the myriad of challenges presented by the pandemic, service provision at the primary Irish ESC, and the referring hospitals, has proven to be robust. Procedural time metrics were maintained whilst the expected reduction in number of EVTs performed did not materialise, there actually being a significant increase in number of EVTs performed in the pandemic's second year.

Management and outcomes of military penetrating neck injuries: An eleven-year retrospective case note review.

INTRODUCTION: Penetrating Neck Injuries (PNIs) affected 3.2% of trauma patients attending US and UK deployed medical treatment facilities (MTFs) during the Iraq and Afghanistan conflicts. Injured military personnel requiring aeromedical evacuation for such injuries were managed at the Royal Centre for Defence Medicine (RCDM), Birmingham, UK. The aim of this paper was to review the management of PNI in both deployed MTFs and when evacuated back to the UK. PATIENTS AND METHODS: A retrospective case note review was performed of all military patients who sustained PNI whilst on deployment overseas, and who were subsequently evacuated to RCDM between March 2003 and December 2014. RESULTS: Forty casualties who sustained PNI were identified, of which 28/40 (70%) sustained injury from explosive fragmentation, and 11/40 (28%) from gunshot wounds. Hard signs of PNI were present in 3/40 (7.5%) patients, soft signs in 14/40 (35%), no signs in 12/40 (30%), and unknown signs in 11/40 (28%) patients. Computed tomography angiography (CTA) was used in 39/40 (98%) patients, and was effective at ruling out significant injury, with 100% (29/29) of casualties with a negative CTA not developing vascular or aerodigestive injury. There were 9/29 (31%) patients who had surgical neck exploration despite both a negative CTA and absence of hard signs of PNI. There were 12/40 (30%) patients who required operative intervention at RCDM. CONCLUSION: UK military surgeons in Role 3 MTFs had a low threshold for surgical exploration, even in the absence of CT findings or hard signs. This was likely due to the high-energy mechanisms responsible for military PNI, in addition to the limited availability of equipment and clinical expertise in visualising the larynx.

An 8-year, single-centre experience of primary image-guided insertion of 'button' gastrostomy catheters: Technical and clinical results.

INTRODUCTION: 'Button' gastrostomy insertion is traditionally a two-step procedure with an initial longer gastrostomy tube inserted followed by placement of the shorter 'button' gastrostomy in 6 weeks when the track is mature. The aim of this study is to assess whether the placement of a Button gastrostomy de novo is a safe and effective method of radiologically inserted gastrostomy (RIG) insertion. METHODS: Using our Picture Archive and Communication System (PACS) and electronic patient charts we identified all patients who underwent primary 'button' gastrostomy over an 8-year period with at least a 1-year follow-up period. We evaluated technical success rate, indications for insertion, major and minor complications, 30-day mortality and the number of exchanges performed. RESULTS: Overall, 482 patients underwent a primary button RIG insertion during this period with an overall success rate of 97.1%. Indications for RIG insertion included neurological and neurosurgical disorders 236 (48.9%), head and neck malignancy 182 (37.8%), oesophageal malignancy 27 (5.6%) and other indications in 37 (7.7%). The mean age was 59.55 years (range 18-88 years) with 290 men (60.2%) and 192 women (39.8%). Major complications were recorded in 0.8% and minor complications in 1.7%. A 30-day mortality of 1% was identified (five patients), mortality was directly related to the RIG insertion in one patient (0.2%). A total of 65 exchanges/replacements took place over this period of time, with 33 (50.1%) due to 'inadvertent removal'. CONCLUSION: Primary button RIG insertion is a procedure that has a high success rate and low morbidity and mortality. We believe it is a safe and effective alternative to deliver enteral nutrition.

Children in a disaster: health protection and intervention.

Children are disproportionately affected by disasters. They have greater physiological, psychological and sociological vulnerabilities, often exacerbated by the fact that their unique needs can be overlooked during relief efforts. This article provides an overview of disasters, including how they are categorised, and the factors that need to be considered by military and civilian healthcare teams that respond to them. Information is drawn from a variety of previous disasters, with the effects considered across a range of different populations and communities. The lessons learnt from previous disasters need to inform the ongoing discussions around how to best train and supply both individual healthcare workers and the wider teams that will be expected to respond to future disasters. The importance of role-specific training incorporating caring for children, consideration of paediatric casualties during planning exercises and teaching scenarios, and the requirement for paediatric equipment and medications cannot be overemphasised. While provision of paediatric care may not be the primary role of an individual healthcare worker or their broader team, it still remains their ethical and often legal duty to plan for and deliver care for children when responding to a disaster. This is a paper commissioned as part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

Civilian penetrating neck trauma at a level I trauma centre: A five-year retrospective case note review.

OBJECTIVES: To report the experience of civilian penetrating neck trauma (PNT) at a UK level I trauma centre, propose an initial management algorithm and assess the degree of correlation between clinical signs of injury, operative findings and radiological reports. DESIGN: Retrospective case note review. SETTING: UK level I trauma centre April 2012-November 2017. PARTICIPANTS: Three hundred ten cases of PNT were drawn from electronic patient records. Data were extracted on hard and soft signs of vascular or aerodigestive tract injury, clinical management, radiological imaging and patient outcomes. MAIN OUTCOME MEASURES: Patient demographics, mechanism of injury, morbidity and mortality. The correlation between clinical signs, and radiological reports to internal injury on surgical exploration. RESULTS: Two hundred seventy-one (87.4%) male and 39 (13.6%) female patients with a mean age of 36 years (16-87) were identified. The most common causes of injury were assault 171 (55.2%) and deliberate self-harm 118 (38%). A knife was the most common instrument 240 (77.4%). Past psychiatric history was noted in 119 (38.4%), and 60 (19.4%) were intoxicated. 50% were definitively managed in theatre with a negative exploration rate of 38%, and 50% were managed in ED. Pre-operative radiological reports correlated with operative reports in 62% of cases with venous injury the most common positive and negative finding. Multivariate correlation was r = 0.89, p = 0.045, between hard signs plus positive radiology findings and internal injury on neck exploration. CONCLUSIONS: Management of PNT by clinical and radiological signs is safe and effective, and can be streamlined by a decision-making algorithm as proposed here.

The infrared reflex: a potential new method for congenital cataract screening.

OBJECTIVE: To compare the accuracy of infrared (IR)-reflex assessment using a prototype imaging device to standard non-mydriatic red-reflex screening with direct ophthalmoscope (DO) in the diagnosis of neonatal and childhood cataract. METHODS: The comparison of the techniques was made in two distinct cohorts: in the first, newborns underwent IR and red-reflex testing by a medical student, with results compared to a reference red-reflex examination by an experienced midwife. In the second, an enriched cohort of children attending a specialist paediatric ophthalmology clinic had IR and red-reflex testing by a medical student to reference examination by a paediatric ophthalmologist. The medical students were considered inexperienced screeners due to their limited exposure to ophthalmology. The sensitivity and specificity of the IR and red-reflex assessments in respect to reference examination were calculated. Diagnostic accuracy was compared in Caucasian and non-Caucasian eyes. RESULTS: IR and red-reflex imaging were possible in all 180 neonatal eyes examined. A total of 5% of newborn eyes were found to have embryological remnants in the anterior segment of the eye with IR-reflex imaging which were not detected on reference red-reflex examination. IR-reflex assessment had significantly better sensitivity (100 vs 71%, p < 0.05) and specificity (100 vs 63%, p < 0.01) than red-reflex assessment in the diagnosis of childhood cataract. Red-reflex specificity was particularly poor in non-Caucasian eyes compared to Caucasian eyes (32 vs 72%, p < 0.05). CONCLUSION: This pilot study indicates that IR-reflex imaging has the potential to improve the diagnostic accuracy of eye screening for cataract by inexperienced healthcare staff, particularly in non-Caucasian children.