RESUMO
Introduction: Good Surgical Practice from RCS England encourages the use of e-health records and detailed typed operative notes. The Covid- 19 pandemic has led to multi-site operating. ENT operations in our trust were split over three sites including the private sector leading to potential disruption in continuity of patient care. Physical operation notes are difficult to access in emergencies, telephonic clinics or for audit purposes. We aim to have operative notes available on patients' erecords which adhere to RCSEng guidelines. Method: In this QIP, we reviewed all ENT operations over a retrospective one-month period recording percentage of notes uploaded to patient e-record and the number of surgeons in theatre. We created two novel RCSEng compliant e-operative notes with a user guide, generic and tonsillectomy-specific, and prospectively collected data to complete the cycle. Results: 261 patients were included in both study periods. Only 36/ 134(27%) had e-operative pre-intervention improving to 71/127(56%) post-intervention. In the latter period, 76% of operations included a registrar and were more likely to have e-operative notes(72%) compared to when a consultant was operating alone(6%). There was low uptake of our tonsillectomy e-proforma(33%). Conclusions: Our QIP has already proved effective with our templates increasing operative documentation on e-records. Increased use of etemplate was more likely with the presence of a registrar in theatre. Room for improvement remains and we will re-audit after the introduction of further user-friendly operative templates and IT training. This QIP has also revealed additional operative training opportunities of which registrars can take advantage.
RESUMO
Introduction: Primary membranous nephropathy (MN) is most commonly due to phospholipase A2 receptor antibodies (PLA2R Ab). It is unclear whether the COVID-19 vaccine can trigger flares of glomerular diseases such as primary MN. We present a patient with MN and metastatic breast cancer who developed nephrotic syndrome after receiving her second mRNA-1273 COVID-19 vaccine with positive PLA2R Ab by ELISA suggesting MN flare. Case Description: A 62 year old female with history of Stage IIIB T3N3M1 ER/PR positive HER-2 negative metastatic left breast invasive ductal carcinoma, hypertension, hyperlipidemia, and primary MN presented with bilateral leg edema, dyspnea, and proteinuria 2 weeks after COVID-19 vaccination. She had previous proteinuria of 7029 mg/24hr in August 2018 with PLA2R Ab 128 RU/mL in October 2018. She underwent modified radical mastectomy in September 2018 followed by adjuvant chemotherapy in November 2018, after which PLA2R Ab decreased to <2 RU/mL in February 2019 and urine protein/Cr ratio (UPCR) decreased to 1094 mg/g Cr in April 2019. She was diagnosed with metastatic breast cancer and started anastrazole transiently. She received mRNA-1273 COVID-19 vaccines in late January and February 2021. In March 2021, she presented with bilateral leg edema, dyspnea, and bilateral pleural effusions. Urinalysis had >1000 protein, 24hr urine protein 11.2 g, Cr 1.6 mg/dL, and PLA2R Ab 787 RU/mL. Renal biopsy showed immune complex-mediated glomerulopathy with positive PLA2R, consistent with primary MN stage II-III. Glomerular basement membrane deposits were strongly positive for IgG4. Electron microscopy showed numerous subepithelial and occasional intramembranous electron-dense immune-type deposits. She was treated with lisinopril and furosemide followed by rituximab in May 2021. Prior to rituximab PLA2R Ab was 342 RU/mL and UPCR was 8671 mg/g Cr. Discussion: There is insufficient data on the risk of flare after COVID-19 vaccine in glomerular diseases. There have been a few case reports of primary MN and minimal change disease after COVID-19 vaccine as well as MN after influenza vaccine. Our case of primary MN flare after COVID-19 vaccine adds support to a potential association between SARS-CoV-2 antigens and loss of tolerance to the PLA2R antigen. Close follow-up of patients with primary MN and other glomerular diseases after COVID-19 vaccination is warranted.