Prospective, multicentre study of screening, investigation and management of hyponatraemia after subarachnoid haemorrhage in the UK and Ireland

Background: Hyponatraemia often occurs after subarachnoid haemorrhage (SAH). However, its clinical significance and optimal management are uncertain. We audited the screening, investigation and management of hyponatraemia after SAH. Methods: We prospectively identified consecutive patients with spontaneous SAH admitted to neurosurgical units in the United Kingdom or Ireland. We reviewed medical records daily from admission to discharge, 21 days or death and extracted all measurements of serum sodium to identify hyponatraemia (<135 mmol/L). Main outcomes were death/dependency at discharge or 21 days and admission duration >10 days. Associations of hyponatraemia with outcome were assessed using logistic regression with adjustment for predictors of outcome after SAH and admission duration. We assessed hyponatraemia-free survival using multivariable Cox regression. Results: 175/407 (43%) patients admitted to 24 neurosurgical units developed hyponatraemia. 5976 serum sodium measurements were made. Serum osmolality, urine osmolality and urine sodium were measured in 30/166 (18%) hyponatraemic patients with complete data. The most frequently target daily fluid intake was >3 L and this did not differ during hyponatraemic or non-hyponatraemic episodes. 26% (n/N=42/164) patients with hyponatraemia received sodium supplementation. 133 (35%) patients were dead or dependent within the study period and 240 (68%) patients had hospital admission for over 10 days. In the multivariable analyses, hyponatraemia was associated with less dependency (adjusted OR (aOR)=0.35 (95% CI 0.17 to 0.69)) but longer admissions (aOR=3.2 (1.8 to 5.7)). World Federation of Neurosurgical Societies grade I–III, modified Fisher 2–4 and posterior circulation aneurysms were associated with greater hazards of hyponatraemia. Conclusions: In this comprehensive multicentre prospective-adjusted analysis of patients with SAH, hyponatraemia was investigated inconsistently and, for most patients, was not associated with changes in management or clinical outcome. This work establishes a basis for the development of evidence-based SAH-specific guidance for targeted screening, investigation and management of high-risk patients to minimise the impact of hyponatraemia on admission duration and to improve consistency of patient care

Ergonomic assessment of the Dix-Hallpike’s test

Abstract Objectives: Numerous tasks carried out in the otolaryngology clinic increase the chances of developing injury among practitioners. To mitigate this, we aim to observe the risk of musculoskeletal injury in practitioners when carrying out common procedures. We observe the performance of the Dix-Hallpike manoeuvre, deducing whether technique has an impact on the likelihood of developing injury. Design: Participants were asked to perform the Dix-Hallpike manoeuvre as they normally would in clinic, on departmental colleagues. Data that was collected included chosen preference of position when carrying out manoeuvre, level of seniority of practitioner and risk of musculoskeletal injury to practitioner. Setting: Simulated outpatient department; St John’s Hospital, Edinburgh. Participants: Otolaryngology consultants and trainees with clinic commitments, having regularly performed the Dix-Hallpike manoeuvre. Main outcome measures: Risk of musculoskeletal injury was measured using the validated Rapid Upper Limb Assessment (RULA) tool. Results: 3 consultants and 7 trainees were included in this study performing on average 4 Dix-Hallpike’s during the study period – totalling 40 attempts. The median RULA score was 4 for the sitting position, compared to 6 for standing (p<0.0001). There was similar statistical significance when consultants and trainees were evaluated separately. Conclusions: A doctor’s wellness is of great importance to facilitate long-term job satisfaction and productivity. It is important to improve conditions for the practitioner in the otology clinic, and one factor is procedural technique. Further work is needed to raise ergonomic awareness amongst otolaryngology surgeons.Nair, Sanjay Govind; Ammari, Tareq; Gohil, Rohit; Bennett, Alex. (2021). Ergonomic assessment of the Dix-Hallpike’s test, [dataset]. University of Edinburgh. College of Medicine & Veterinary Sciences. Department of Otolaryngology. NHS Lothian. https://doi.org/10.7488/ds/2971

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

Background: Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.Methods: This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.Results: A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 percent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 percent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 percent; however, it was 41 per cent in low-to-middle-compared with 19 per cent in very high-HDI countries.Conclusion: Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761)