Author: Jason Curtis

SGLT2 inhibitors - moving on with the evidence (2019)

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Type of publication:
Journal article

Author(s):
*Morris, David

Citation:
Journal of Diabetes Nursing; Jun 2019; vol. 23 (no. 4); p. 1-9

Abstract:
The evidence base on the benefits and risks of using sodium-glucose cotransporter 2 (SGLT2) inhibitors for the management of hyperglycaemia has grown in recent years, with data showing potential cardiovascular and renal benefits, along with safety concerns that warrant cautious use and monitoring in certain users. This article reviews the benefits and difficulties associated with the use of SGLT2 inhibitors in people with type 2 diabetes and, potentially, type 1 diabetes.

Chaperons for child protection medical examinations: A missing link? (2019)

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Type of publication:
Conference abstract

Author(s):
*Saran S.; Ganesh M.; Yousif E.

Citation:
Archives of Disease in Childhood; Jun 2019; vol. 104

Abstract:
Background: Child protection medical examinations should be undertaken in the presence of a chaperone. This as a good practice recommendation is clearly stated in the Child Protection companion. Aim(s): We undertook an audit of Child Protection medical examination reports to see if our practice meets the standards set by RCPCH in Child Protection companion. Method Child protection companion's model report was chosen as the standard to compare our practices. Hospital-based electronic patient records system (clinical portal) was used to review the reports by a single auditor. Twenty-eight reports were randomly selected. These children undertook Child Protection medical examination at a District General Hospital over a period of 14 months from January'2017 to February'2018. Demographics Three-fourth were boys & one-fourth were girls. Fifteen percent were under 1 year old, sixty percent were between 1 & 5 years old and twenty-five percent were over 5 years old. Timeliness Three-fourth of the reports were typed within 72 hours of CP medical examination. Quality All (100%) the reports stated the source of information and recommendations made after assessment. Over three-fourth reports stated informed consent was taken; included a brief introduction of the author and information about the growth centiles. Two-third reports established that child's concerns were recorded. Reference to the evidence-based literature was made in fifteen percent of the reports. Only seven percent of the reports stated use of Chaperones and amendments in the report after peer review meeting. Three percent of the reports stated both the time and date of referral. Recommendations Our audit highlighted that Chaperons is an underused entity in child protection medical examinations. Chaperons are not only supposed to provide assurance to the child and family but also offers clinicians with an extra layer of protection in case of a complaint. Thus we strongly advocate using Chaperon's in all cases of Child Protection Medicals unless declined by the child/family. In that case, this should be clearly documented. There is also a pressing need to improve the quality of overall documentation.

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Targeting dyslipidaemia to prevent cardiovascular disease (2019)

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Type of publication:
Journal article

Author(s):
Viljoen A.; Fuat A.; Takhar A.; Williams S.; *Capps N.

Citation:
Prescriber; Jul 2019; vol. 30 (no. 7); p. 23-26

Abstract:
Dyslipidaemia is a key risk factor for cardiovascular disease, and its identification and treatment is important for both primary and secondary prevention. This article discusses how to screen for dyslipidaemia and optimise lipid-lowering therapy to improve cardiovascular outcomes.

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Cancelled! Cancelled! An audit on cancellation of paediatric surgical cases on the day of surgery in a district general hospital (2019)

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Type of publication:
Conference abstract

Author(s):
Singh M.; *Annadurai S.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 90

Abstract:
Surgical case cancellation has significant impacts on operating theatre efficiency and the UK loses a substantial amount of money on these cases [1]. A recent prospective study over a 1-week period in an NHS hospital suggested a adult surgical case cancellation rate between 10% and 14% and the majority of these cases were due to non-clinical reasons [2]. It is distressing for the patient and affects outcomes. We undertook an audit regarding cancellation of paediatric surgical cases on the day of surgery at a district general hospital (DGH) to look for various reasons for the cancellations and to evaluate the services. Methods We collected prospective data from the hospital's database regarding cancelled paediatric surgical procedures over a 6-month period from February 2018 to July 2018 in our DGH. Results We found that a total of 70 paediatric surgical cases were cancelled on the day of surgery out of total of 653 paediatric surgical cases, which is an approximately 10% cancellation rate over the 6-month period with a range of cancellations from 7% in May and June to 18% in February. We observed that 76% of the cancellations were of elective cases. We subdivided the reasons for cancellations into organisational, patient, surgical and anaesthetic factors. Among the organisational factors, 23% of cancellations were due to 'unavailable beds'. We observed that 11% of cancellations occurred because patients 'did not attend', 7% of patients were reported as 'sick' and 3% of patients did not follow preoperative fasting instructions. Surgeons cancelled 15% of cases for the reason 'procedure no longer required', whereas anaesthetist 'sickness' was the reason for cancellation in 9% of cases. Discussion Cancellations prolong the waiting list and worsens patient experiences and clinical outcomes. In our audit, we found that the main reasons for cancellations were non-clinical. To improve the surgical reasons for cancellation, we suggest timely rereview of the need for surgery. Although staff allocation is looked at regularly, some cases were cancelled due to the unavailability of staff, which can be improved on. We discussed the idea of seasonal planning of cases. We plan to re-audit with the aim of investigating cancellation rates in elective cases over a 1-year period to also review the cancellation rate during the winter months.

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Peri-operative temperature monitoring (2019)

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Type of publication:
Conference abstract

Author(s):
Clulow C.; *Lewis B.; *Law R.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 71

Abstract:
The maintenance of normothermia during the peri-operative period is important in regulating homeostatic processes during physiological stress. Therefore, temperature monitoring is essential to avoid hypothermia or hyperthermia, which might complicate anaesthesia. Inadvertent peri-operative hypothermia (IPH) can contribute to many complications including coagulopathy, infection, delayed wound healing, increased hospital stay, cardiac events and death [1, 2]. Therefore, reducing the incidence of IPH could minimise the morbidity and mortality associated with this problem. Methods This was a prospective observational audit involving 102 cases. We analysed elective surgical cases coming from the Day Case Unit and the Surgical Admissions Suite from April to June 2018. Data collection was performed by the authors using a proforma based on the National Institute for Health and Care Excellence (NICE) clinical guideline 65 [1], and the Royal College of Anaesthetists audit recipe book [2]. We compared our results to the primary audit conducted in 2016. Results Only 9.8% of patients had a temperature recorded within 1 h of surgery. Less than 5% had a temperature < 36degreeC preoperatively. There was an improvement in prophylactically warming at-risk patients from 39.1% to 70.5%. Warming interventions in operations with duration > 30 min were used in 73% of cases in comparison to 39.2% previously. Temperature was measured every 30 min in only 24.3% of cases and 9.8% of cases left theatre 'cold', but none left recovery with a temperature < 36degreeC. Discussion IPH was reduced from 13.7% to 9.8%. The two factors identified that have the most influence on this is improved prophylactic intra-operative warming of the at-risk population and warming methods being used in operations lasting > 30 min. The suboptimal intraoperative monitoring was disappointing to see, but given few cases left theatre 'cold', it may be assumed that this was due to a deficiency in documentation rather than monitoring.

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A quality improvement project to improve anaesthetic peri-operative documentation through excellence reporting (2019)

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Type of publication:
Conference abstract

Author(s):
*Cunningham D.; *Travis M.; *Leach S.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 27

Abstract:
Incomplete or poor quality peri-operative documentation has both clinical and legal implications. As such, anaesthetic professional bodies issue guidance relating to documentation. It is unclear to what extent this guidance is followed by anaesthetists in our hospital. We aimed to improve the quality of documentation through excellence reporting and to test this methodology as a means of implementing change.
Methods: The completeness of anaesthetic charts (n = 50) are analysed annually over a 1- week period, using a proforma. The proforma highlights details that should be included as part of the peri-operative documentation. Several months prior to collection of the 2018 data, we initiated an excellence reporting project. This involved analysing a sample of charts on alternate weeks over a 12-week period. The five anaesthetists with the most complete charts were issued with a certificate. The anaesthetist with the highest scoring chart won a prize. Results were publicised on posters and presented at monthly governance meetings. If multiple charts scored full marks, judgement was used to determine the winner. Following this intervention period, results from the 2018 annual audit were compared with data from the previous year.
Results: The annual audit requires that the anaesthetic charts be scored on 27 key points outlined in the proforma. In 2018, 13 categories scored greater than 95% completeness with the remaining 14 categories scoring less than 95% completeness. In 2017, 10 categories scored greater than 95% completeness with 17 scoring less than 95%. The 2018 data scored greater than or equal to the 2017 data in 16 categories. In the other 11 categories, the 2017 data scored higher. Legibility is not considered in the annual audit but subjectively appeared to improve over the period of excellence reporting.
Discussion: Through the use of excellence reporting, we have seen some improvement in the completeness and legibility of peri-operative documentation in our hospital. This outcome suggests that excellence reporting is a useful tool for managing positive change. However, both data from 2017 and 2018 did not reveal 100% completeness in all categories, and with the potential legal and clinical ramifications, it is important that we continue to improve anaesthetic documentation.

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Coronary heart disease mortality in severe and non-severe familial hyper-cholesterolaemia : data from the UK Simon Broome FH register (2019)

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Type of publication:
Conference abstract

Author(s):
Humphries S.; Cooper J.; *Capps N.; Durrington P.; Jones B.; McDowell I.; Soran H.; Neil A.

Citation:
Atherosclerosis; Aug 2019; vol. 287

Abstract:
Background and Aims: Background: In 2016 the International Atherosclerosis Society (IAS) proposed that patients with "severe" FH (SFH) should be identified since they might warrant early and more aggressive cholesterol-lowering treatment such as with PCSK9 inhibitors. SFH is diagnosed if LDL-cholesterol (LDLC) >10 mmol/L, or LDLC >8.0 mmol/L plus one high-risk feature, or LDLC >5 mmol/L plus two high-risk features. Here we compare CHD mortality in SFH and non-SFH patients in the UK Simon Broome Register since 1991, when
statin use became routine.
Method(s): 2929 Definite or Possible patients (51% women) aged 20-79 years recruited from 21 UK lipid clinics were followed between 1992-2016. The excess CHD standardised mortality ratio (SMR) compared to the population in England and Wales was calculated (95% Confidence intervals).
Result(s): (67.7%) patients met the SFH definition. Post 1991, the SMR for CHD mortality was significantly (p=0.007) higher for SFH (220(184-261) (34,134 person years, 129 deaths observed, vs 59 expected) compared to non-SFH of 144(98-203) (15,432 person years, 32 observed vs 22 expected). After adjustment for traditional risk factors, the Hazard Ratio for CHD mortality in SFH vs non-SFH was 122 (80-187) p=0.36. Applying UK guidelines for the use of PCSK9i agents, overall ~24% of those in the register are likely to be eligible, but if this were restricted to those with SFH, overall ~16% would qualify.
Conclusion(s): CHD mortality remains elevated in treated FH, especially for SFH, emphasising the importance of optimal lipid-lowering, including the use of novel agents, and management of other risk factors

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Practice pattern variability in the management of acute severe colitis: A UK provider survey (2019)

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Type of publication:
Journal article

Author(s):
Sebastian S.; Lisle J.; Subramanian S.; Dhar A.; Shenoy A.; Limdi J.; *Butterworth J.; Allen P.B.; Samuel S.; Moran G.; Shenderey R.; Parkes G.; Raine T.; Lobo A.J.; Kennedy N.A.

Citation:
Frontline Gastroenterology; Jul 2020; vol. 11 (no. 4); p. 272-279

Abstract:
Introduction: Lack of comparative trial data on dosing regimens of infliximab in patients with acute severe ulcerative colitis (ASUC) failing intravenous corticosteroids has resulted in variability of rescue regimes in ASUC with potential impact on clinical outcomes. We aimed to evaluate practice variability and physician perspectives in decision-making with rescue therapy. Methodology: An internet-based survey of members of the inflammatory bowel disease (IBD) section of the British Society of Gastroenterology was conducted. The survey evaluated provider characteristics and general practice in the setting of ASUC, followed by a vignette with linked questions.
Result(s): The response rate of the survey was 31% (209/682 IBD section members). 134 (78%) reported they would use standard infliximab dose (5 mg/kg) while 37 (22%) favoured a higher front-loading dose of 10 mg/kg citing low albumin, high C-reactive protein as their reason for their preference. IBD specialists chose the higher front-loading dose more often compared with other gastroenterologists (p=0.01) In the specific case vignette, accelerated induction (AI) was favoured by 51% of the respondents while 25% used the standard induction regime and 19% favoured colectomy. IBD specialists more often favoured AI compared with other gastroenterologists (p=0.03) with the main reason being presence of predictors of low infliximab levels (74%). The reasons cited for favouring standard induction (n=57) included lack of evidence for AI (18), their usual practice (11), unlicensed regime (7), and safety concerns (4).
Conclusion(s): There are significant variations in practice in the use of infliximab rescue therapies with an urgent need for development of care pathways to standardise practice.

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Infliximab induction regimes in steroid refractory acute severe colitis: A multi-centre retrospective cohort study with propensity score analysis (2019)

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Type of publication:
Conference abstract

Author(s):
Sebastian S.; Myers S.; Syed N.; Argyriou K.; Samuel S.; Moran G.; Martin G.; Allen P.B.; *Los L.; *Butterworth J.; Fiske J.; Limdy J.; Ranjan R.; Dhar A.; Cooper B.; Shenoy A.H.; Patel N.; Subramanian S.; Goodoory V.; Shaikh F.; Shenderey R.; Ching H.L.; Lobo A.; Jayasooriya N.; Parkes G.; Brooks J.; Raine T.

Citation:
Journal of Crohn's and Colitis; Mar 2019; vol. 13

Abstract:
Background: While infliximab is used as rescue therapy for steroid refractory acute severe colitis (ASUC),
between 30 and 40% of patients do not respond and undergo colectomy. Accelerated induction regimes of
infliximab have been proposed to improve response rates. We aimed to evaluate colectomy rates in steroid
refractory ASUC patients receiving standard induction (SI) vs. accelerated induction (AI) of infliximab.
Method(s): Data collected on hospitalised patients receiving rescue therapy for steroid refractory ASUC. The choice of rescue therapy was at the discretion of the treating clinician. Accelerated induction (AI) was defined as receiving second dose of infliximab within 8 days of first rescue therapy or receiving front loading dose of 10 mg/kg. Our primary outcome was the short-term (in-patient, 30 days and 90 days) colectomy rate. Secondary outcomes were 12-month colectomy rates, length of hospital stay (LOS), and complication rates. We used a propensity score analysis with optimal calliper matching using a priori defined high-risk covariates at the start of rescue therapy (albumin, CRP, CRP-albumin ratio, haemoglobin nadir and pancolitis) to reduce potential provider selection bias.
Result(s): A total of 131 patients receiving infliximab rescue therapy were included, of whom 102 patients
received SI and 29 received AI. There was no difference in age, duration of diagnosis, age at rescue therapy,
Montreal class or use of steroids, 5ASAs or thiopurines prior to index admission. In the unmatched overall
cohort, there was no difference in colectomy during index admission (13% vs. 20%, p = 0.26), 30-day colectomy (18% vs. 20%, p = 0.45), 90-day colectomy (20% vs. 24%, p = 0.38) or 6 month colectomy (25% vs. 27%, p = 0.49). The LOS was shorter in the SI group (14.87 +/- 8.1 days vs. 19.31 +/- 5.8 days, p = 0.007). In patients who underwent colectomy, there were no differences in complications or serious infection rates. In the propensity score-matched cohort of 52 patients, there was no difference in overall colectomy rates between SI and AI groups (57% vs. 31%, p = 0.09), but the index admission colectomy (53% vs. 23%, p = 0.045) and 30-day colectomy (57% vs. 27%, p = 0.048) rates were higher in those receiving SI. There was no significant difference in LOS between SI and AI groups (23.6 +/- 4.3 vs. 18.2 +/- 7.1 days, p = 0.09) or in overall complication and infection rates but there was a mortality in AI group.
Conclusion(s): In this retrospective cohort study, there was no difference in overall colectomy rates in ASUC patients receiving different induction dosing regimens of infliximab. However, using propensity score matching, the short-term colectomy rates appear to be better in those receiving accelerated induction regime. A prospective study to confirm findings is planned.

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