scholarly journals Audit on Steroid Replacement in Confirmed or Suspected COVID-19 Patients With Adrenal Insufficiency or Adrenal Suppression in a District General Hospital

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A77-A78
Author(s):  
Aiman Haddad
Keyword(s):  
Adrenal Insufficiency ◽  
General Hospital ◽  
Bolus Injection ◽  
District General Hospital ◽  
Adrenal Suppression ◽  
Oral Steroid ◽  
Addison Disease ◽  
Adequate Dose ◽  
Steroid Dependent

Abstract Aim: In response to new updated guidance from Society For Endocrinology April 2020, this Audit was conduct to assess the adequacy of steroid replacement in confirmed or suspected COVID-19 patients with adrenal insufficiency or adrenal suppression admitted to Bedford District General Hospital. In steroid dependent patients (Addison’s disease, adrenal insufficiency, pituitary steroid insufficiency, use of long term steroids for other conditions - 5mg or more of prednisolone (or equivalent doses) daily for longer than 4 weeks) admitted to hospital very unwell with confirmed or suspected COVID recommendations is to start on Hydrocortisone 100 mg per IV injection followed by continuous IV infusion of 200 mg hydrocortisone/24h (alternatively 50 mg every 6 h per intravenous or IM bolus injection). Method: Retrospect data collection on Patients admitted in May 2020 to Bedford Hospital with suspected or confirmed COVID 19 disease with adrenal insufficiency or on long term steroid use. Those patients should be started on Hydrocortisone 100 mg per IV injection followed by continuous IV infusion of 200 mg hydrocortisone/24h (alternatively 50 mg every 6 h per intravenous or IM bolus injection). Results: In May 2020, 295 patients admitted under the medical team in Bedford Hospital with confirmed or suspected COVID-19. Only 12 patients met the inclusion criteria, one patient with a diagnosis of Addison disease and the remaining 11 patients on long term steroids. None of these patients were managed as per updated guidelines. 6 patients had less than the adequate dose, they were started on prednisolone 30-40mg. 4 patients dose of oral steroids was only doubled, 1 patient received the same dose of oral steroid and the only confirmed Addison had higher dose of hydrocortisone. Moreover, In June 2020, The RECOVERY Outcome trial results showed that Dexamethasone 6mg for 10 days reduces the death by one third in hospitalised patient with severe respiratory complications of COVID-19. Dexamethasone 6mg is 12 times the physiological required steroid dose, this is equivalent to 240mg hydrocortisone, which is adequate for steroid replacement in patients with adrenal insufficiency or suppression. Conclusion: In view of these results and the outcome of the RECOVERY Trial, Local trust guidelines updated, indicated that any patient with Adrenal insufficiency or suppression including those on long term steroids very unwell admitted to the hospital should receive Dexamethasone if requiring oxygen or Hydrocortisone if not requiring oxygen. Recommendation of changes included teaching sessions delivered to doctors, posters on updated guidelines distributed in major areas in hospital and trust guidelines updated on the intranet.

Long-term follow-up of patients who had bronchial carcinoid tumours resected in a district general hospital

Lung Cancer ◽  
2019 ◽  
Vol 127 ◽  
pp. S63-S64
Author(s):  
M. Mccloskey ◽  
C. Yarr ◽  
K. Grant ◽  
M. Doherty ◽  
R. Sharkey ◽  
...  
Keyword(s):  
General Hospital ◽  
District General Hospital ◽  
Bronchial Carcinoid ◽  
Carcinoid Tumours ◽  
Long Term Follow Up

scholarly journals Colonoscopy at a Combined District General Hospital and Specialist Endoscopy Unit: Lessons from 505 Consecutive Examinations

2002 ◽  
Vol 95 (4) ◽  
pp. 194-197 ◽  
Author(s):  
Siwan Thomas-Gibson ◽  
Catherine Thapar ◽  
Syed G Shah ◽  
Brian P Saunders
Keyword(s):  
General Hospital ◽  
District General Hospital ◽  
British Society ◽  
Completion Rates ◽  
Endoscopy Unit ◽  
Pain Scores ◽  
Training And Supervision ◽  
Long Term Follow Up

Provisional reports from the Intercollegiate British Society of Gastroenterology National Colonoscopy audit show completion rates of 57–77%for the procedure and poor levels of training and supervision. We prospectively audited all aspects of colonoscopy performed at a combined district general hospital and specialist endoscopy unit. Details of referral, examination, endoscopist, complications and follow-up were recorded and patients were sent questionnaires for long-term follow-up. 505 patients (246 male) underwent colonoscopy by 27 different endoscopists. Their median age was 57 years (range 13–92) and 93%were outpatients. 64% patients were symptomatic and 36%were having surveillance or follow-up colonoscopy. The overall caecal intubation rate was 93%, with little difference between surgeons, physicians and experienced trainees (89%, 92%, 94%) and specialist endoscopists (98%). In only one case was an inexperienced trainee (<100 procedures) unsupervised. Pain scores estimated by the endoscopist were well matched with those given by the patient—medians 29 and 26 (maximum 100) respectively. Median satisfaction score was 96 (maximum 100). Polyp pick-up rate was 26.9%and there were 11 new cancers. 16 (3%) minor immediate complications were recorded—5 oversedation, 6 vasovagal attacks, 3 polypectomy haemorrhages and 2 mucosal injuries (neither requiring treatment). 3 patients died within 6 months of follow-up but no death was colonoscopy related. Completion rates in this setting were adequate for all endoscopists studied. Patient satisfaction with the procedure was high and very few immediate or long-term complications were encountered.

scholarly journals Latissimus dorsi myocutaneous reconstruction: a study of long-term outcomes in a district general hospital

2016 ◽  
Vol 98 (8) ◽  
pp. 574-577 ◽  
Author(s):  
C Kallaway ◽  
A Humphreys ◽  
N Laurence ◽  
R Sutton
Keyword(s):  
General Hospital ◽  
Latissimus Dorsi ◽  
Capsular Contracture ◽  
District General Hospital ◽  
Latissimus Dorsi Flap ◽  
Protective Mechanism ◽  
Term Outcome ◽  
Long Term Outcome

INTRODUCTIONThe aim of this study was to evaluate the long-term outcome and durability of both autologous and implant-assisted latissimus dorsi reconstruction in a district general hospital over a 10-year follow-up period.METHODSA prospective cohort study was carried out using a detailed database of all latissimus dorsi flap reconstructions performed by a single consultant surgeon between 2003 and 2013 at the Royal United Hospital, Bath. The long-term outcome following reconstruction was assessed by analysing all episodes of ‘reconstruction-specific’ operations required from 6 months after the initial surgery.RESULTSThe study included 110 patients with latissimus dorsi flap reconstructions, 21 autologous and 95 implant-assisted. Radiotherapy was given to 27 patients with reconstructed flaps. Mean follow-up was 69 months. Further reconstruction-specific surgery was needed in 27 (23%) cases, with 5 of these being post-radiotherapy flaps. Implant-related surgery was the most common reason for further surgery. Complications of the implant itself made up 52% of these cases, chronic sepsis being the most common. The rate of symptomatic capsular contracture requiring further surgery was 4.2%. Of these, one of four patients had undergone radiotherapy.DISCUSSIONIn our institution, latissimus dorsi reconstruction is durable and safe over the long term, with limited need for further substantial intervention to maintain a good outcome from the initial reconstruction. Autologous flaps were less likely to require further surgery over the long term compared with implant-based reconstructions. The low rate of symptomatic capsular contracture may be due to the protective mechanism provided by the extended harvest flap used.

scholarly journals Adrenal Suppression following Low-Dose Topical Clobetasol Propionate

1987 ◽  
Vol 80 (7) ◽  
pp. 422-424 ◽  
Author(s):  
E M Ohman ◽  
S Rogers ◽  
F O Meenan ◽  
T J McKenna
Keyword(s):  
Adrenal Insufficiency ◽  
Hpa Axis ◽  
Low Dose ◽  
Clobetasol Propionate ◽  
Adrenal Suppression ◽  
Systemic Effects ◽  
Topical Steroids ◽  
Adrenal Failure ◽  
Hypothalamic Pituitary Adrenal

The use of topical steroids is associated with adverse systemic effects such as suppression of the hypothalamic-pituitary-adrenal (HPA) axis, and application of more than 50 g per week of clobetasol propionate cream has been shown to cause secondary adrenal failure. We describe 4 patients who used clobetasol propionate cream over a prolonged period; 3 patients used less than 50 g per week (7.5, 25 and 30 g per week) and yet all developed secondary adrenal failure for up to 4 months after cessation of therapy. Adrenal insufficiency following prolonged use of clobetasol propionate in moderate dosages may therefore be more common than previously recognized. It is suggested that the metyrapone test, which conveniently examines the entire HPA axis, should be employed in patients receiving long-term topical clobetasol propionate cream and that glucocorticoid supplementation should be given during episodes of stress, such as infections and surgery, for up to 4 months after cessation of therapy.

An observational study assessing high dose opioid prescribing and associated adrenal insufficiency

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X696641 ◽  
Author(s):  
Sophie Hayhoe ◽  
Simon Rudland ◽  
Damian Morris
Keyword(s):  
Adrenal Insufficiency ◽  
Case Reports ◽  
Serum Cortisol ◽  
Adrenal Suppression ◽  
Endocrine Function ◽  
High Dose ◽  
Opioid Use ◽  
Practice List ◽  
Opioid Dose

BackgroundLong-term opioid use is known to affect endocrine function, with case reports indicating an association with adrenal insufficiency.AimThis study aims to investigate long-term, high-dose opioid use (≥80mg morphine or equivalent per day) at a Suffolk (UK) General Practice and its effect on adrenal function.MethodFrom a practice list of 18,300, retrospective data was collected for patients prescribed high-dose opioids for non-cancer pain for at least three months on current repeat prescription. Patient demographics and prescribing information were collected using SystmOne. Cortisol levels in the high-dose opioid patients, and short synacthen testing if indicated, were performed.ResultsThe 35 identified patients (0.2% of practice list) were predominantly female (77%) ≥70 years old (37%), and taking opioids prescribed for osteoarthritis or back pain (77%). 6% were prescribed >280mg morphine or equivalent per day, with one patient prescribed 705 mg. Routine evaluation for development of adrenal suppression and subsequent management was poor. 31% (11 of 35) had developed symptoms potentially indicative of adrenal insufficiency. One of these patients was among the 21% (7 of 35) with suppressed serum cortisol. Adrenal insufficiency secondary to opioids was confirmed in one patient using short synacthen testing. There was no statistical difference in either opioid dose or months of use for those with or without early morning cortisol suppression.ConclusionThe investigation highlights both the considerable use of high-dose opioids for non-malignant pain and their apparent association with adrenal suppression, demonstrating the need for formal guidelines to aid recognition and diagnosis.

scholarly journals Some Aspects of the Fractured Scaphoid

1981 ◽  
Vol 74 (11) ◽  
pp. 800-803 ◽  
Author(s):  
Tudor L Thomas
Keyword(s):  
General Hospital ◽  
Scaphoid Fracture ◽  
District General Hospital ◽  
Scaphoid Fractures ◽  
Prognostic Assessment ◽  
One Year

Ninety-three patients who presented at a district general hospital in one year with a suspected or actual scaphoid fracture were studied. Certain changes in the accepted management of scaphoid fractures, particularly the radiology of these fractures, are suggested. These changes could result in significant savings of time and money. A new investigation is described which may prove helpful in the long-term prognostic assessment of patients who have suffered a scaphoid fracture.

Repetitive and continuous administration of human corticotropin releasing factor to human subjects

1986 ◽  
Vol 112 (2) ◽  
pp. 157-165 ◽  
Author(s):  
J. Schopohl ◽  
A. Hauer ◽  
T. Kaliebe ◽  
G. K. Stalla ◽  
K. von Werder ◽  
...  
Keyword(s):  
Adrenal Insufficiency ◽  
Bolus Injection ◽  
Human Subjects ◽  
Normal Subjects ◽  
Pituitary Hormones ◽  
Corticotropin Releasing Factor ◽  
Secondary Adrenal Insufficiency ◽  
Continuous Administration ◽  
Pulsatile Administration

Abstract. ACTH secretion was studied in response to repetitive and continuous administration of human corticotropin releasing factor (CRF) in 14 healthy volunteers and 2 patients with secondary adrenal insufficiency. ACTH increases during repetitive CRF administration were within the same range in normal subjects independent of the intervals (60– 180 min) between the CRF pulses (100 μg iv). When CRF was infused continuously (100 μg/h for 3 h) after an initial CRF bolus injection (100 μg iv), ACTH and cortisol remained elevated during the infusion at a nearly constant level (ACTH: 60 ± 5 pg/ml; cortisol: 21.2 ± 1 μg/dl; x̄ ± se). A second CRF bolus injection at the end of the infusion did not lead to a significant further increase of ACTH and cortisol levels. This shows that there is no desensitisation or depletion of a ready releasable pool, as it is observed with other pituitary hormones after releasing hormone stimulation. Pulsatile administration of CRF in 2 patients with secondary adrenal insufficiency due to previous cortisol or glucocorticoid excess, respectively, revealed a blunted response to the first pulse which became normal after the following pulses. The latter could not be sustained until the next morning without CRF given overnight. These findings point to a hypothalamic defect being the cause of hypocortisolism after long-term cortisol suppression.

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