Southend University Hospital is an NHS hospital located in Westcliff-on-Sea, Southend-on-Sea, Essex. It is managed by Mid and South Essex NHS Foundation Trust.
OBJECTIVES:In England, there is a 'hard stop' to weekly tocilizumab (qwTCZ) therapy for GCA; this is currently 12 months but was extended during the COVID-19 pandemic subject to certain criteria for GCA relapse risk. Taking advantage of variation in practice, we aimed to compare outcomes of GCA patients who tapered-TCZ vs those who stopped abruptly (non-taper patients). METHODS:Secondary analysis of an English multicentre service evaluation of relapse after stopping qwTCZ for GCA. Time to relapse was compared between taper and non-taper patients. We examined outcomes according to whether they had been 'adequate responders' during qwTCZ therapy, defined as those in remission and on ≤5 mg prednisolone at qwTCZ cessation, without relapse whilst taking qwTCZ. RESULTS:We analysed 336 patients from 40 centres. Time to relapse after qwTCZ cessation was significantly longer in adequate responders than non-adequate responders (P = 0.0004). 17.0% (57/336) patients tapered to fortnightly TCZ after qwTCZ cessation, for a median of 6 (IQR 2-13) months. For adequate responders, time to relapse whilst taking tapered-dose TCZ was significantly longer compared with those in the non-taper group (P = 0.0231) based on a relatively small number of flares. There was no difference between the taper and non-tapered groups after tapered-TCZ was stopped (P = 0.8346). In contrast, time to relapse for non-adequate responders was similar in taper patients compared with non-taper patients (P = 0.4892). CONCLUSION:Tapering TCZ after qwTCZ cessation delayed relapse only during the tapering period, but only in adequate responders to qwTCZ. No lasting benefit was seen after tapering ended.
OBJECTIVES:This Delphi survey, involving patients, primary and secondary care clinicians, and experts was conducted to evaluate the giant cell arteritis (GCA)-polymyalgia rheumatica (PMR) spectrum disease (GPSD) and its implications. The GPSD concept proposes a unified framework for diagnosis and treatment of overlapping conditions including cranial and extracranial GCA and PMR. The survey included two rounds and addressed six propositions covering disease nomenclature, phenotypes, imaging, stratification and clinical impact. METHODS:Round 1 achieved consensus across all propositions, with over 75% agreement and several items exceeding 90%. Key areas of agreement included recognition of GPSD (92%), the role of imaging in diagnosis and stratification (100%), and the need for multilevel assessment (100%). Round 2 refined and clarified questions, further strengthening consensus, with some items reaching 100% agreement. Internal consistency analysis confirmed the survey's reliability and validity for future use. RESULTS:The GPSD model promotes comprehensive evaluation of all phenotypes regardless of initial presentation. It advocates early specialist involvement, personalized treatment strategies and improved diagnostic tools. Imaging modalities such as ultrasound and PET are essential for detecting subclinical disease, excluding alternative diagnoses, and guiding management, especially when symptoms are ambiguous. Stratified care in PMR addresses diagnostic uncertainty and highlights emerging therapies like cytokine blockade. CONCLUSION:The model supports prospective studies using baseline imaging and stratified treatment arms to monitor disease control and long-term outcomes. By unifying fragmented care pathways and promoting a spectrum-based approach, GPSD has the potential to improve patient outcomes, reduce misdiagnosis and guide more effective therapeutic strategies across related inflammatory conditions.
Purpose Older adults undergoing colorectal cancer surgery frequently have frailty, multimorbidity and social-discharge complexity, and prolonged admission exposes them to hospital-associated disability, deconditioning and delirium. We developed and internally validated a pre-operative machine-learning model to identify those at risk of prolonged postoperative stay. Methods Retrospective single-centre cohort of 197 consecutive patients aged ≥ 65 years assessed in a combined frailty–anaesthesia clinic; 149 were operated with recorded length of stay (LOS). The primary outcome was prolonged stay (LOS > 10 days). Pre-operative predictors included age, Clinical Frailty Scale (CFS), comorbidity, polypharmacy, peri-operative risk scores, and social and operative factors. A gradient-boosted (XGBoost) classifier was evaluated by repeated stratified five-fold cross-validation; exact-LOS regression and illustrative cost scenarios were secondary. Results In cross-validation the classifier achieved an AUROC of 0.75 (95% CI 0.69–0.79); at a screening threshold, sensitivity was 0.66, specificity 0.75 and positive predictive value 0.47 (Brier score 0.16). A single 80/20 split gave a more optimistic AUROC of 0.86 with 100% sensitivity but only 10 test events. The strongest predictors were CFS and NSQIP risk, followed by age and comorbidity; day-level LOS prediction was poor (test R²≤0.06). Of 149 operated patients, 38 (25.5%) had prolonged stay; nationally, a 1-day reduction in 10% of the 20,977 annual resections would save ~ 2,098 bed-days (£1.89–£2.51 million). Conclusion A model using routine pre-operative data identified older colorectal cancer patients at risk of prolonged stay with moderate discrimination; binary classification was more robust than exact-LOS prediction. External validation and prospective evaluation are required before clinical use.
Introduction: As the use of total wrist replacements increases there is an inevitable increase in periprosthetic fractures, as has been observed in other joint replacements. Lower limb arthroplasty surgeons have adopted the Unified Classification System to help classify and manage periprosthetic fractures around hip and knee replacements. In this paper, we demonstrate how the same classification can be used for fractures around wrist replacements.Methods: A retrospective review of prospectively collected data was performed, analysing all periprosthetic fractures treated in four arthroplasty units in two European countries. All fractures were classified using the Unified Classification System and their management and outcome were recorded.Results: Twenty-two periprosthetic fractures were identified. The fractures occurred in 10 females and 12 males, aged between 44 and 84 years. At presentation there were one type A fracture, 18 type B (12 B1, three B2 and three B3), one type C and two type F. Type A fractures and undisplaced type C fractures were successfully managed non-operatively. Undisplaced B1 fractures tended not to heal with non-operative management and progressed to B2 or B3. B1 fractures treated with plate fixation around the implant achieved good results. Type B2 and B3 fractures required revision surgery but, in most cases, resulted in a functioning arthroplasty.Conclusion: We advocate the use of the Unified Classification System to guide management of periprosthetic fractures around Motec implants. Revision surgery is challenging, and we recommend that the more complex B3, and possibly B2, fractures be managed in specialist units.Level Evidence: III
