The clinical diagnosis of Achilles tendinopathy: a scoping review

Background Achilles tendinopathy describes the clinical presentation of pain localised to the Achilles tendon and associated loss of function with tendon loading activities. However, clinicians display differing approaches to the diagnosis of Achilles tendinopathy due to inconsistency in the clinical terminology, an evolving understanding of the pathophysiology, and the lack of consensus on clinical tests which could be considered the gold standard for diagnosing Achilles tendinopathy. The primary aim of this scoping review is to provide a method for clinically diagnosing Achilles tendinopathy that aligns with the nine core health domains. Methodology A scoping review was conducted to synthesise available evidence on the clinical diagnosis and clinical outcome measures of Achilles tendinopathy. Extracted data included author, year of publication, participant characteristics, methods for diagnosing Achilles tendinopathy and outcome measures. Results A total of 159 articles were included in this scoping review. The most commonly used subjective measure was self-reported location of pain, while additional measures included pain with tendon loading activity, duration of symptoms and tendon stiffness. The most commonly identified objective clinical test for Achilles tendinopathy was tendon palpation (including pain on palpation, localised tendon thickening or localised swelling). Further objective tests used to assess Achilles tendinopathy included tendon pain during loading activities (single-leg heel raises and hopping) and the Royal London Hospital Test and the Painful Arc Sign. The VISA-A questionnaire as the most commonly used outcome measure to monitor Achilles tendinopathy. However, psychological factors (PES, TKS and PCS) and overall quality of life (SF-12, SF-36 and EQ-5D-5L) were less frequently measured. Conclusions There is significant variation in the methodology and outcome measures used to diagnose Achilles tendinopathy. A method for diagnosing Achilles tendinopathy is proposed, that includes both results from the scoping review and recent recommendations for reporting results in tendinopathy.

Making every drop count: reducing wastage of a novel blood component for transfusion of trauma patients

Recent research demonstrates that transfusing whole blood (WB=red blood cells (RBC)+plasma+platelets) rather than just RBC (which is current National Health Service (NHS) practice) may improve outcomes for major trauma patients. As part of a programme to investigate provision of WB, NHS Blood and Transplant undertook a 2-year feasibility study to supply the Royal London Hospital (RLH) with (group O negative, ‘O neg’) leucodepleted red cell and plasma (LD-RCP) for transfusion of trauma patients with major haemorrhage in prehospital settings.Incidents requiring such prehospital transfusion occur randomly, with very high variation. Availability is critical, but O neg LD-RCP is a scarce resource and has a limited shelf life (14 days) after which it must be disposed of. The consequences of wastage are the opportunity cost of loss of overall treatment capacity across the NHS and reputational damage.The context was this feasibility study, set up to assess deliverability to RLH and subsequent wastage levels. Within this, we conducted a quality improvement project, which aimed to reduce the wastage of LD-RCP to no more than 8% (ie, 1 of the 12 units delivered per week).Over this 2-year period, we reduced wastage from a weekly average of 70%–27%. This was achieved over four improvement cycles. The largest improvement came from moving near-expiry LD-RCP to the emergency department (ED) for use with their trauma patients, with subsequent improvements from embedding use in ED as routine practice, introducing a dedicated LD-RCP delivery schedule (which increased the units ≤2 days old at delivery from 42% to 83%) and aligning this delivery schedule to cover two cycles of peak demand (Fridays and Saturdays).

Inflammatory bowel disease in pregnancy: Developing a multidisciplinary care pathway in East London

Objectives Evaluate the management of pregnant women with inflammatory bowel disease. Method We collected data from maternity records for women with IBD who gave birth at The Royal London Hospital between January 2018 and February 2019. Results Twenty-three pregnancies were identified where 8/23 (35%) women had a peri-conception flare and 7/23 (30%) had a flare during pregnancy. Two women received pre-conception counselling. The obstetric medicine team reviewed a patient on average three times and the gastroenterologists twice, during pregnancy. Nine women (39%) gave birth pre-term. Mean birthweight was lower in the group with active disease at conception compared with those in remission (2173 g vs. 2807 g, p = 0.03). Conclusions Women with IBD should all receive pre-conception counselling to reduce the risk of pregnancy complications. By developing a multidisciplinary care pathway for pregnant women with IBD (which includes a joint obstetric/gastroenterology clinic), this will ensure care is standardised throughout the pregnancy and puerperium.

A single center observational study of the incidence, frequency and timing of critical care physiotherapy intervention during the COVID-19 pandemic

Introduction The recent COVID-19 pandemic saw many patients admitted to an intensive care setting and requiring mechanical ventilation. The NHS increased their critical care beds which included expanding the amount of staff. Physiotherapists were a key part of this and were required to complete numerous interventions within the COVID critical care setting throughout the pandemic. Our aim was to collect the incidence and frequency of physiotherapy interventions performed during the COVID-19 pandemic in a critical care setting. Method Data was collected across all critical care beds at the Royal London Hospital for an eight-week period between March- April 2020. We retrospectively collected physiotherapy interventions for example, endotracheal suctioning and functional rehabilitation for every patient in the critical care setting. The Chelsea Critical Care Physical Assessment Tool (CPAx) scores were also obtained for patients on ACCU admission and discharge. Results A total of 213 patients were included in the sample, 163 COVID-19 positive and 50 COVID-19 negative. Recorded sessions included secretion management (821), weaning (271), rescue therapy (82) and functional rehab (534) across the eight-week period. The mean CPAx score on admission to ACCU for the entire sample was 9/45 points. On discharge that score had improved to 25/45 points. Conclusion This unique project has enabled us to report on the critical care physiotherapy interventions provided during the COVID 19 pandemic. This interesting data on frequency and timing of interventions may be useful to plan future relocation staffing plans and optimal allocation of care.

Maintenance therapy with infliximab or vedolizumab in inflammatory bowel disease is not associated with increased SARS-CoV-2 seroprevalence: UK experience in the 2020 pandemic

Background There has been great concern amongst clinicians and patients that immunomodulatory treatments for IBD may increase risk of SARS-CoV-2 susceptibility or progression to severe disease. Methods Sera from 640 patients attending for maintenance infliximab or vedolizumab infusions between April and June 2020 at the John Radcliffe Hospital (Oxford, UK) and Royal London Hospital (London, UK) were tested using the Abbott SARS-CoV-2 IgG assay. Demographic and clinical data were collated from electronic patient records and research databases. Results Seropositivity rates of 3.0% (12/404), 7.2% (13/180), and 12.5% (7/56) were found in the Oxford and London adult IBD cohorts and London paediatric IBD cohorts respectively. Seroprevalence rates in the Oxford adult IBD cohort were lower than that seen in non-patient facing health-care workers within the same hospital (7.2%). Seroprevalence rates of the London paediatric IBD cohort were comparable to a contemporary healthy cohort collected at the same hospital (54/396, 13.6%). Conclusions SARS-CoV-2 seropositivity rates are not elevated in patients with IBD receiving maintenance infliximab or vedolizumab infusions. There is no rationale based on these data for elective interruption of maintenance therapy, and we recommend continuation of maintenance therapy. These data do not address the efficacy of vaccination in these patients.

1 Soulful neurology

Born on Merseyside, Andrew Lees qualified in medicine at the Royal London Hospital Medical College in 1970. His neurological training was at University College London Hospitals and the National Hospital for Neurology and Neurosurgery, Queen Square. He also spent 1 year at L’Hopital Salpetriere, Paris. He has achieved international recognition for his work on Parkinson’s disease and abnormal movement disorders. He is an original member of the Highly-Cited Researchers ISI Database with an h-index of 130. Founder member of the international Movement Disorder Society, he was elected President (2004–2006) and co-edited the Movement Disorders Journal between 1995 and 2003. In 2006, he was awarded the Movement Disorders Research Award by the American Academy of Neurology and he was awarded the Association of British Neurologists Medal in 2015.At the age of thirty-two he was appointed to the consultant staff at the National Hospitals, The Middlesex, and Whittington Hospitals and in 1987 was elected a Fellow of the Royal College of Physicians. He was later appointed Professor of Neurology at the National Hospital for Neurology and Neurosurgery, Queen Square and was Director of the Reta Lila Weston Institute for Neurological Studies (1998–2012). He was Clinical Director of the Queen Square Brain Bank for Neurological Disorders (1985–2012) and Director of the Sara Koe PSP Research Centre (2002–2012).He is a Visiting Professor at the University of Liverpool and Queen Mary University of London, and has close collaborations with several Brazilian universities. For his contributions to Brazilian neurology he was elected as an overseas member of the Academia Nacional de Medicina and the Academia Brasileira de Neurologia. He was elected as a Council member of the Academy of Medical Sciences 2012–2015 and appointed as an Expert Adviser for the UK Government National Institute for Health and Care Excellence Centre for Guidelines (2006–2019). He received the Bing Spear Award in 2016 for outstanding contributions towards saner drug policies.He has delivered the Gowers Memorial Lecture at the National Hospital, The Inaugural Lord Brain Memorial Lecture at Bart’s and the Royal London Hospitals and David Marsden Memorial Lecture at the European Federation of Neurological Societies. He was the recipient of Stanley Fahn Lectureship Award at the MDS Dublin 2012, and has been awarded the German Society of Neurology’s 2012 Dingebauer Prize for outstanding scientific attainment in the field of Parkinson’s disease and Neurodegenerative Disorders, the Jay Van Andel award for outstanding research in Parkinson’s disease in 2014, and the Parkinson Canada’s Donald Calne Award and Lectureship for 2017.Through a process of reasoning that left little to the imagination the neurologists at The Royal London Hospital where I trained pulled black swans and zebras from their hats. During my training I was led to understand that it was just a matter of time before all disorders of the brain would be worked out and categorised in terms of anatomical electrical and chemical connections. This rational approach drew me in, and I selected diseases of the nervous system as my specialist subject.My first two neurology chiefs at University College Hospital were inspirational and kind. They warned me that it would take many years to learn how to join up the dots and become proficient at knowing where to look. One of them recommended that I should use textbooks only for reference but that I should read the Sherlock Holmes canon. Over time I came to understand that neurologists and criminal detectives both seek hidden truths and meanings in narrative and that both rely on a rigorous tried and tested method that pays attention to detail. Sherlock Holmes provided a romantic bridge to William Gowers and the serious business of neurology.Clinical research and a curiosity for cures should be an integral part of neurology William Seward Burroughs, who had appeared out of nowhere on the cover of Sergeant Pepper became my unlikely source of inspiration. He introduced me to the idea that nothing happens by chance and that novel scientific discoveries rely heavily on personally distinctive actions. He also helped me to understand that art is a complementary source of truth that enlists inventiveness to transport science beyond the acquisition of fact.

SUN-306 The Interaction Between Thiazide-Associated Hyponatremia and Acute Illness in Hospitalised Patients

Thiazide diuretics, widely used in the management of hypertension, are associated with a five times greater risk of hyponatremia (serum Na <135mmol/L) than in the general population. Hyponatremia in hospitalised patients warrants special consideration since it is associated with increased morbidity and mortality. The aim of this study was to describe the clinical characteristics and outcomes in acutely ill medical patients with thiazide-associated hyponatremia (TAH). We performed a retrospective, case control study examining all acute, unselected medical admissions, over a six week period, to The Royal London Hospital. Cases were defined as adults admitted to hospital with TAH (hyponatremia and a history of being prescribed thiazide diuretic pre-admission). Each case was matched by age, gender and degree of hyponatremia to a similar control - admitted with hyponatremia and no pre-admission exposure to thiazide (non-TAH). Clinical characteristics and treatment outcomes were compared between TAH and non-TAH cohorts. A total of 1,341 consecutive acute medical admissions (49.7% men) were evaluated. Hyponatremia was detected in 240 (17.9%) admissions. Median (±SD) length of stay was longer among patients with hyponatremia compared to normonatremic patients (5.0±12.4 versus 3.0±9.2 days; p=<0.0001). In-hospital mortality was higher in the hyponatremic group (8.8% versus 4.4% p=0.005). Twenty-two cases (11 men) of TAH accounted for 9.2% of patients with hyponatremia. Median age 64±14 years was similar to other patients with hyponatremia 68±20 years. The median admission serum sodium for TAH cases was 131.5 mmol/L (IQR 126.8 - 134) with a discharge serum sodium of 136.5 mmol/L (IQR 133.8 - 139.3). When compared to matched controls, patients with TAH had similar presenting symptoms - most commonly confusion, headache and dizziness. Length of stay among TAH cases was similar to controls; 5.5±5.1 versus 4.0±3.7 days; p=0.24. Mortality (10%) was the same in both groups. Thiazide was withdrawn during admission in 14 (64%) cases. In conclusion, acute, clinical outcomes for hospitalised patients with TAH are similar to those with comparable degrees of hyponatremia due to other causes.

Developing an alemtuzumab infusion unit for patients with multiple sclerosis

Treating multiple sclerosis (MS) with alemtuzumab involves multiple dosing cycles and long-term safety monitoring. With the NHS being under increasing financial pressure, there is the potential for gaps to form between national guidelines for MS treatment and service provision, making it difficult for patients with MS who are eligible to receive treatments like alemtuzumab. In this article, we share our experiences of setting up an alemtuzumab infusion unit at The Royal London Hospital. We created a collaborative partnership with industry, based on the mutual goal of optimising access to alemtuzumab for all eligible patients who would like to receive it. This agreement involved the provision of additional nursing support and a roaming phlebotomy service by Sanofi Genzyme (formerly Genzyme), and careful planning of the hospital's support requirements on a month-by-month basis. The success of the partnership has been reflected by the complete clearance of the patient waiting list for alemtuzumab.