Neurological update: non-motor symptoms in atypical parkinsonian syndromes

Among people with Parkinson’s disease (PD), non-motor symptoms (NMS) are a well-recognised cause of significant morbidity and poor quality of life. Yet, it is only more recently that NMS have been recognised to affect the lives of patients with atypical parkinsonian syndromes in a similar fashion. The aim of this article is to highlight and compare the relative prevalence of NMS among patients with atypical parkinsonian syndromes in the published literature, which largely remain underreported and unaddressed in routine clinical practice. All NMS that are recognised to occur in PD are also found to commonly occur in atypical parkinsonian syndromes. In particular, excessive daytime sleepiness is more prevalent among atypical parkinsonian syndromes (94.3%) compared to PD (33.9%) or normal controls (10.5%) (p < 0.001). Urinary dysfunction (not limited to urinary incontinence) is not only found to occur in MSA (79.7%) and PD (79.9%), but has also been reported in nearly half of the patients with PSP (49.3%), DLB (42%) and CBD (53.8%) (p < 0.001). Apathy is significantly more common among the atypical parkinsonian syndromes [PSP (56%), MSA (48%), DLB (44%), CBD (43%)] compared to PD (35%) (p = 0.029). Early recognition and addressing of NMS among atypical parkinsonian syndromes may help improve the holistic patient care provided and may encompass a range of conservative and pharmacotherapeutic treatments to address these symptoms

Delivery of urethral sphincter botulinum toxin injections for treating urinary retention during the COVID19 pandemic

Aims: Urethral sphincter botulinum toxin injections is an alternative treatment for urinary retention in women with Fowler’s syndrome and when access to health services were curtailed during the Covid19 pandemic, we continued to offer treatment to prevent increased demand on catheter services due to a recurrence of urinary retention. We describe our experience delivering safe and timely treatment during this period of lockdowns and restricted access to healthcare. // Methods: We retrospectively reviewed the records of all women with Fowler’s syndrome treated with transperineal urethral sphincter botulinum toxin injection between 23rd March 2020 and 31st December 2021 in a tertiary university hospital and clinical outcomes were recorded. // Results: 15 women (mean age 35.6 ± 10.1 years) received 100U OnabotulinumtoxinA injected into the external urethral sphincter as an out-patient procedure adopting hospital infection control guidelines. 41 injections were administered in total, and 8 (53%) patients received more than 1 injection (median 2 injections/patient, median inter-injection interval 108.5 days). 10 (66.7%) patients reported improvements in urinary symptoms across 31/41 (75.6%) of injections. Side effects were reported after 21.4% of injections which were mild and transient. No patients developed Covid19 within 4 weeks of the hospital visit. // Conclusion: Real-world data shows that transperineal urethral sphincter botulinum toxin injections could be continued safely and effectively during the Covid19 pandemic. This essential outpatient service played an important role in treatment and quality of life for women with Fowler’s syndrome, and avoided an additional burden on the NHS at the time of a health crisis

Acute appendiceal abscess and atraumatic splenic rupture: A case of dual pathology

Introduction: Atraumatic splenic rupture is a rare surgical emergency that is often attributed to neoplastic or infectious causes. Rarely, it has been identified to also occur in the setting of an acute severe sepsis and in cases of pelvic or splenic abscess formation post-appendicectomy. However, to our knowledge, the co-presentation of acute appendiceal abscess and splenic rupture has not been previously described. Presentation of case: We present the case of a 67-year old male with decompensating haemorrhagic shock secondary to atraumatic splenic rupture on a background of an inadequately treated complicated appendicitis originally managed as diverticulitis with antibiotics in the community. Intra-operatively, in addition to a de-gloved, ruptured spleen; an acutely inflamed appendiceal abscess was also identified. A concomitant splenectomy, washout and appendicectomy and was therefore performed. Histopathological examination revealed a normal spleen with a stripped capsular layer. Mucosal ulceration, transmural inflammation and serositis of the appendix appeared to be consistent with acute appendicitis. Discussion: Our case demonstrates how inadequately treated sepsis may predispose to an acute presentation of splenic rupture with associated haemorrhagic shock; which may initially be interpreted as septic shock. However, we demonstrate how insults such as sepsis and haemorrhagic shock may co-exist warranting careful consideration of possible dual pathologies in complex presentations which may be life-threatening. Conclusion: While the causal relationship between acute appendicitis and atraumatic spontaneous splenic rupture remains unclear, our case considers and highlights the importance of considering dual pathology in patients presenting in the acute setting

Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT.

BACKGROUND Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI. OBJECTIVE To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds. DESIGN Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved. SETTING Usual NHS care. PARTICIPANTS Patients undergoing elective/non-elective abdominal surgery, including caesarean section. INTERVENTIONS Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'. MAIN OUTCOME MEASURES Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers. DATA SOURCES Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals. RESULTS Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple,  = 133; glue,  = 129; no dressing,  = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments. LIMITATIONS Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres. CONCLUSIONS A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks. TRIAL REGISTRATION Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1)