Staff Publication

'getting it right first time' (GIRFT) in the management of COPD (2019)

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Type of publication:
Conference abstract

Author(s):
*Ahmad N.; *Crawford E.; *Srinivasan K.; *Moudgil H.

Citation:
Thorax; Dec 2019; vol. 74

Abstract:
Background GIRFT identifies medicine optimisation to improve efficiencies and cost savings. Reducing prescription of High dose inhaled corticosteroids (HD-ICS) in chronic obstructive pulmonary disease (COPD) helps improve patient care by reducing the incidence of pneumonia. A previous work carried out by this group showed an association between HD-ICS prescriptions and the incidence of pneumonia in COPD patients locally, at the primary care level (Ibrahim J et al,Thorax 2018;73:A114-A115). Following this work, a protected learning time event was held in October 2017 for the region's general practitioners to highlight the local COPD guidelines, role of community respiratory MDT and a protocol for weaning COPD patients from HD-ICS inhalers. Aim Primary aim was to demonstrate an achievement in cost savings from reduction in pneumonia admissions coupled with reduced HD-ICS prescriptions. Hence, we compared the incidence of pneumonia in COPD patients and HD-ICS prescriptions between April-September of 2017 (P1) and 2018 (P2) in the region of Telford and Wrekin clinical commissioning group. Method Data were obtained on all hospital admissions for pneumonia between April-September 2018 with a secondary diagnosis code J44 indicating COPD, from the information desk of the clinical commissioning group. For the purpose of comparison, we had the data from previous year for the same time period. We obtained data on HD-ICS prescriptions from openprescribing.net Results There were 97 pneumonia admissions in P2 v 123 in P1, thereby indicating an absolute reduction of 21%. The total cost of pneumonia admissions in P2 was 337,233 v 463,779 in P1, thereby achieving cost savings of 126,546 over a period of 6 months. There were 300 less HD-ICS prescriptions in the 14 general practices during P2 as compared to P1. 4 practices with the highest proportion of COPD patients, achieved most reductions in HD-ICS prescriptions (reduction by 281 prescriptions) and at the same time accounting for 32 less pneumonia admissions. Conclusion GIRFT objectives can be achieved through engagement with primary care. In this respect, it is important to achieve integration as we have done in our area. Our effort fully supports development of new care models to achieve efficiencies within the local health economy.

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Penicillin allergy in patients being treated for pneumonia-making a case for quality improvement project (2019)

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Type of publication:
Conference abstract

Author(s):
*Mahendiran T.; *Omar M.K.; *Moudgil H.; *Crawford E.; *Srinivasan K.; *Makan A.; *Ahmad N.

Citation:
Thorax; Dec 2019; vol. 74 (Suppl. 2)

Abstract:
Background Penicillin allergy is reported by approximately 10% of the UK population, however only 20% of these actually have a true allergy.1 In addition, a documented penicillin 'allergy' may be associated with a prolonged length of stay (LOS) related to longer duration of treatment, complications and adverse effects related to second-line antibiotic use.2 Aim Our primary aim was to establish a documentation of the type of allergy to Penicillin within a cohort of patients presenting to our hospitals with community acquired pneumonia. Secondary aim was to compare the length of hospital stay, readmission within 30 days, complications and 30-day mortality between patients with and without penicillin allergy. Method We obtained data on all hospital admissions with a coded diagnosis of Pneumonia for the period covering October-December 2017. We divided this cohort into those with and without penicillin allergy; allergy information being obtained from discharge summaries and local pharmacy information system. Microsoft Excel and http://vassarstats.net/was used for statistical evaluation. Results 308 admissions were coded as pneumonia in this period. We excluded 77 admissions due to lack of data. Of the remaining, 187 had no penicillin allergy and 44 were allergic to penicillin. This gives a prevalence of 19% (44/231), which is higher than the reported prevalence above, of which 95% (42/44) did not have the type of allergy mentioned. Allergic group was older with a mean age (SD) 75 (15) v 72 (16) years [p value=0.0005], had more females 69% (31/44) v 41% (77/187) [p value=0.02], same LOS 6 days [p value=0.39], more readmissions 20% (9/44) v 16% (29/187) [p value=0.56], no greater complications 20% (9/44) v 20% (37/187) [p value=0.92] and a higher unadjusted overall mortality 14% (6/44) v 10% (18/187) (p value=0.61) Conclusion Data shows: 1. Poor documentation of the type of allergy to Penicillin. This needs a Quality improvement project as it is likely that most patients may not have a true allergy as shown in previous studies.1 2. Allergic group were older, with more females but the other variables were not statistically significant. We would recommend further research in this area to inform future practice.

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Domiciliary NIV (DOMNIV) in a real world setting: A retrospective study in a District General Hospital (2019)

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Type of publication:
Conference abstract

Author(s):
*Craik S.; *Nasir A.; *Ali A.; *Moudgil H.; *Srinivasan K.; *Makan A.; *Crawford E.; *Wilson J.; *John N.; *Ahmad N.

Citation:
Thorax; Dec 2019; vol. 74 (Suppl 2).

Abstract:
Introduction: DomNIV in patients with chronic Type 2 respiratory failure results in improved survival. HOT-HMV study produced encouraging results in patients with COPD treated with home oxygen and DomNIV. [Murphy et al, JAMA, 317(21), 2177-2186] DomNIV usage with or without oxygen has been prevalent in our hospital setting over for 10 years. Objective Our primary aim was to look at the indications for prescription of DomNIV in our local hospital. Our secondary aim was to look at overall unadjusted mortality in this cohort and in particular any relationship with different types of oxygen provision.
Methods: We collected data on all patients who have received DomNIV from 2008-2018 with or without oxygen prescription from our local database. Data on mortality was obtained from our Clinical Portal. We used MS Excel and Vassar stats (http://vassarstats.net/) for statistical analysis.
Results: 105 patients commenced DomNIV; 60% were female with a mean (SD) age of 61 (13) years. Indications were Obesity hypoventilation (OH), Overlap syndrome, COPD, Neuromuscular disease, Bronchiectasis and others. 40% of patients did not receive oxygen with DomNIV (wO2), 36% received long term oxygen therapy (LTOT), 15% received overnight oxygen (OO2) and the rest received PRN oxygen. 43% of patients (N=45) died during the study period, of these 40% (N=18) died within the first 12 months. 29% died with LTOT versus 17% wO2 and 0% with OO2 in the first 12 months. This was statistically significant between LTOT and OO2 groups: RR 0.71 (95% CI 0.58-0.87), and also between wO2 and OO2 groups: RR 0.83 (95% CI 0.72- 0.95).
Conclusion: Majority of patients received DomNIV treatment for OH; 36% (N=38) had received long term oxygen therapy (LTOT) along with DomNIV; Patients receiving overnight oxygen with DomNIV survived longer compared to those who had it as LTOT or who didn't have any oxygen at all.

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The challenge of managing mild to moderate distress in patients with end stage renal disease: results from a multi-centre, mixed methods research study and the implications for renal service organisation (2019)

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Type of publication:
Journal article

Author(s):
Damery, Sarah; Sein, Kim; *Nicholas, Johann ; Baharani, Jyoti; Combes, Gill

Citation:
BMC health services research; Dec 2019; vol. 19 (no. 1); p. 989

Abstract:
BACKGROUND Lower-level emotional and psychological difficulties ('distress') in patients with end stage renal disease (ESRD), can lead to reduced quality of life and poor clinical outcomes. National guidelines mandate provision of emotional and psychological support for renal patients yet little is known about the support that patients may require, or the challenges that staff experience in identifying and responding to patient distress.
METHODS Mixed methods study in renal units at four NHS Trusts in the West Midlands, UK involving cross-sectional surveys of ESRD patients and renal unit staff and semi-structured interviews with 46 purposively-sampled patients and 31 renal unit staff. Interviews explored patients' experience of distress and personal coping strategies, staff attitudes towards patient distress and perceptions of their role, responsibility and capacity.
RESULTS Patient distress was widespread (346/1040; 33.3%), and emotional problems were frequently reported. Younger patients, females, those from black and minority ethnic (BME) groups and patients recently initiating dialysis reported particular support needs. Staff recognised the value of supporting distressed patients, yet support often depended on individual staff members' skills and personal approach. Staff reported difficulties with onward referral to formal counselling and psychology services and a lack of immediate access to less formalised options. There was also a substantial training/skills gap whereby many staff reported lacking the confidence to recognise and respond to patient distress. Staff fell broadly into three groups: 'Enthusiasts' who considered identifying and responding to patient distress as integral to their role; 'Equivocators' who thought that managing distress was part of their role, but who lacked skills and confidence to do this effectively, and 'Avoiders' who did not see managing distress as part of their role and actively avoided the issue with patients.
CONCLUSIONS Embedding the value of emotional support provision into renal unit culture is the key to 'normalising' discussions about distress. Immediately accessible, informal support options should be available, and all renal staff should be offered training to proactively identify and reactively manage patient distress. Emotional support for staff is important to ensure that a greater emphasis on managing patient distress is not associated with an increased incidence of staff burnout.

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Subacute carbon monoxide poisoning presenting as vertigo and fluctuating low frequency hearing loss (2018)

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Type of publication:
Journal article

Author(s):
Bethany Seale, *Sajad Ahanger, and *Churunal Hari

Citation:
Journal of Surgical Case Reports 2018 Aug; 2018(8)

Abstract:
It is estimated that up to 25,000 UK residents are exposed to small amounts of carbon monoxide (CO) annually. Symptoms of chronic exposure to CO are vague and non-specific and include dizziness and hearing loss. We describe a case of 38-year-old lady presenting with a 4-month history of vertigo and hearing loss. Initially diagnosed as Meniere’s disease, the patient was investigated and followed up in the clinic. She reported leakage of carbon monoxide from her gas fire identified during a routine safety check. Her symptoms fully resolved after disconnecting the faulty gas fire. A rare cause of fluctuating hearing loss and vertigo is described, and the diagnostic challenges are discussed.

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Diagnosis Across the Spectrum of Progressive Supranuclear Palsy and Corticobasal Syndrome (2019)

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Type of publication:
Journal article

Author(s):
Jabbari E, Holland N, Chelban V, Jones PS, Lamb R, Rawlinson C, Guo T, Costantini AA, Tan MMX, Heslegrave AJ, Roncaroli F, Klein JC, Ansorge O, Allinson KSJ, Jaunmuktane Z, Holton JL, Revesz T, Warner TT, Lees AJ, Zetterberg H, Russell LL, Bocchetta M, Rohrer JD, Williams NM, Grosset DG, Burn DJ, Pavese N, Gerhard A, Kobylecki C, Leigh PN, Church A, Hu MTM, Woodside J, Houlden H, Rowe JB, Morris HR.

Patients at Shrewsbury and Telford Hospital NHS Trust were recruited into this study.

Citation:
JAMA Neurol. 2019 Dec 20 [Epub ahead of print]

Abstract:
IMPORTANCE:
Atypical parkinsonian syndromes (APS), including progressive supranuclear palsy (PSP), corticobasal syndrome (CBS), and multiple system atrophy (MSA), may be difficult to distinguish in early stages and are often misdiagnosed as Parkinson disease (PD). The diagnostic criteria for PSP have been updated to encompass a range of clinical subtypes but have not been prospectively studied.

OBJECTIVE:
To define the distinguishing features of PSP and CBS subtypes and to assess their usefulness in facilitating early diagnosis and separation from PD.

DESIGN, SETTING, PARTICIPANTS:
This cohort study recruited patients with APS and PD from movement disorder clinics across the United Kingdom from September 1, 2015, through December 1, 2018. Patients with APS were stratified into the following groups: those with Richardson syndrome (PSP-RS), PSP-subcortical (including PSP-parkinsonism and progressive gait freezing subtypes), PSP-cortical (including PSP-frontal and PSP-CBS overlap subtypes), MSA-parkinsonism, MSA-cerebellar, CBS-Alzheimer disease (CBS-AD), and CBS-non-AD. Data were analyzed from February 1, through May 1, 2019.

MAIN OUTCOMES AND MEASURES:
Baseline group comparisons used (1) clinical trajectory; (2) cognitive screening scales; (3) serum neurofilament light chain (NF-L) levels; (4) TRIM11, ApoE, and MAPT genotypes; and (5) volumetric magnetic resonance imaging measures.

RESULTS:
A total of 222 patients with APS (101 with PSP, 55 with MSA, 40 with CBS, and 26 indeterminate) were recruited (129 [58.1%] male; mean [SD] age at recruitment, 68.3 [8.7] years). Age-matched control participants (n = 76) and patients with PD (n = 1967) were included for comparison. Concordance between the antemortem clinical and pathologic diagnoses was achieved in 12 of 13 patients with PSP and CBS (92.3%) undergoing postmortem evaluation. Applying the Movement Disorder Society PSP diagnostic criteria almost doubled the number of patients diagnosed with PSP from 58 to 101. Forty-nine of 101 patients with reclassified PSP (48.5%) did not have the classic PSP-RS subtype. Patients in the PSP-subcortical group had a longer diagnostic latency and a more benign clinical trajectory than those in PSP-RS and PSP-cortical groups. The PSP-subcortical group was distinguished from PSP-cortical and PSP-RS groups by cortical volumetric magnetic resonance imaging measures (area under the curve [AUC], 0.84-0.89), cognitive profile (AUC, 0.80-0.83), serum NF-L level (AUC, 0.75-0.83), and TRIM11 rs564309 genotype. Midbrain atrophy was a common feature of all PSP groups. Eight of 17 patients with CBS (47.1%) undergoing cerebrospinal fluid analysis were identified as having the CBS-AD subtype. Patients in the CBS-AD group had a longer diagnostic latency, relatively benign clinical trajectory, greater cognitive impairment, and higher APOE-ε4 allele frequency than those in the CBS-non-AD group (AUC, 0.80-0.87; P < .05). Serum NF-L levels distinguished PD from all PSP and CBS cases combined (AUC, 0.80; P < .05).

CONCLUSIONS AND RELEVANCE:
These findings suggest that studies focusing on the PSP-RS subtype are likely to miss a large number of patients with underlying PSP tau pathology. Analysis of cerebrospinal fluid defined a distinct CBS-AD subtype. The PSP and CBS subtypes have distinct characteristics that may enhance their early diagnosis.

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Transcutaneous electrical acupoint stimulation for people with chronic musculoskeletal pain: an exploratory review (2019)

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Type of publication:
Journal article

Author(s):
Ely, S. ; Barlas, P.

Citation:
Physical Therapy Reviews, Dec 2019 Vol. 24(6) p.377-388

Abstract:
Background: Transcutaneous electrical acupoint stimulation (TEAS) is a form of stimulation-induced analgesia with potential as a non-invasive alternative to acupuncture, suitable for self-application. The clinical evidence for TEAS for people with chronic musculoskeletal pain is limited.
Objectives: This exploratory review aimed to evaluate the potential of TEAS as a pain relief option for people with chronic musculoskeletal pain and explore the evidence relating to dose parameters.
Methods: A literature search was conducted using Medline, EMBASE, CINAHL, AMED and the Cochrane Database for studies that used TEAS or specified the use of Transcutaneous electrical nerve stimulation (TENS) over acupuncture points for people with chronic pain. Data relating to the treatment dose parameters was extracted including frequency, intensity, treatment duration and stimulation location, to identify themes and trends with a narrative analysis and review.
Results: The review included 20 studies consisting of 13 randomised controlled trials, four comparative trials and three cross-over studies. Most RCTs indicated some beneficial effect on pain scores, but the overall quality of evidence was low. Most studies applied a TENS device for 20–40 minutes, several times a week similar to an acupuncture treatment protocol. There was no clear evidence that the electrical parameters of frequency and intensity or the choice of acupuncture points had an effect on the outcomes.
Conclusions: People with chronic musculoskeletal pain may achieve pain relief using TEAS but the existing evidence is limited and high quality clinical evidence is required to establish efficacy. Effects appear to be achieved with short applications, several times a week in a protocol similar to those used with acupuncture. It is not clear whether the choice of acupuncture point, stimulation frequency or intensity has an impact on the results. Further investigation of the effect of stimulation duration for both TEAS and TENS is recommended.

Synchronous versus sequential chemo-radiotherapy in patients with early stage breast cancer (SECRAB): A randomised, phase III, trial (2020)

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Type of publication:
Randomised controlled trial

Author(s):
Fernando I.N.; Spooner D.; Latief T.N.; Stevens A.; Bowden S.J.; Herring K.; Ahmed I.; Rea D.W.; Brookes C.L.; Marshall A.; Dunn J.; Grieve R.; Poole C.J.; Churn M.; *Agrawal R.K.; Brunt A.M.; Goodman A.; Canney P.; Ritchie D.; Bishop J.

Citation:
Radiotherapy and Oncology; 2020; Vol 24; p. 52-61

Abstract:
Background: The optimal sequence of adjuvant chemotherapy and radiotherapy for breast cancer is unknown. SECRAB assesses whether local control can be improved without increased toxicity.
Method(s): SECRAB was a prospective, open-label, multi-centre, phase III trial comparing synchronous to sequential chemo-radiotherapy, conducted in 48 UK centres. Patients with invasive, early stage breast cancer were eligible. Randomisation (performed using random permuted block assignment) was stratified by centre, axillary surgery, chemotherapy, and radiotherapy boost. Permitted chemotherapy regimens included CMF and anthracycline-CMF. Synchronous radiotherapy was administered between cycles two and three for CMF or five and six for anthracycline-CMF. Sequential radiotherapy was delivered on chemotherapy completion. Radiotherapy schedules included 40 Gy/15F over three weeks, and 50 Gy/25F over five weeks. The primary outcome was local recurrence at five and ten years, defined as time to local recurrence, and analysed by intention to treat. ClinicalTrials.gov NCT00003893.
Finding(s): Between 02-July-1998 and 25-March-2004, 2297 patients were recruited (1150 synchronous and 1146 sequential). Baseline characteristics were balanced. With 10.2 years median follow-up, the ten-year local recurrence rates were 4.6% and 7.1% in the synchronous and sequential arms respectively (hazard ratio (HR) 0.62; 95% confidence interval (CI): 0.43-0.90; p = 0.012). In a planned sub-group analysis of anthracycline-CMF, the ten-year local recurrence rates difference were 3.5% versus 6.7% respectively (HR 0.48 95% CI: 0.26-0.88; p = 0.018). There was no significant difference in overall or disease-free survival. 24% of patients on the synchronous arm suffered moderate/severe acute skin reactions compared to 15% on the sequential arm (p < 0.0001). There were no significant differences in late adverse effects apart from telangiectasia (p = 0.03). Interpretation(s): Synchronous chemo-radiotherapy significantly improved local recurrence rates. This was delivered with an acceptable increase in acute toxicity. The greatest benefit of synchronous chemo-radiation was in patients treated with anthracycline-CMF.

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Use of recombinant parathyroid hormone in treatment of bisphosphonate related osteonecrosis leading to spontaneous healing (2019)

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Type of publication:
Conference abstract

Author(s):
*Chundoo S.; *Pilkington R.; *Bhatia S.; *Garton M.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)

Abstract:
Introduction: Case presentation of 61 year old female patient who developed BRONJ (bisphosphonate related osteonecrosis of the jaw) and a pathological triple fracture of the anterior mandible. She had underlying vitamin D deficiency and secondary hypoparathyroidism. She also suffers from anca positive rheumatoid arthritis and is under the active care of rheumatology.
Method(s): Patient was treated with conservative measures which failed to give a good quality of life outcome. Under special license, with involvement from rheumatology, the patient was started on monthly injections of recombinant parathyroid hormone (teriparatide).
Result(s): Over 12-18 months, the serial radiographs reveal bony union of all fracture sites. Patient now has good quality of life and patient is back on disease modifying drugs to control their active rheumatoid arthritis.
Conclusions/Clinical Relevance: Novel approach to using teriparatide for patients with end-stage BRONJ. License of the drug as well as current NICE guidelines for its use and patient specific requirements such as fragility fracture risks age and DEXA scores are also discussed. The action of the drug on osteoblastic formation and bone turnover is discussed. This will help practitioners have another agent to add to their treatment options in treating the effects of BRONJ.

A technical note describing the use of a carotid artery bypass graft in the management of head and neck cancer with carotid artery involvement and review of literature (2019)

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Type of publication:
Conference abstract

Author(s):
*Hamps C.; *Pilkington R.; *Merriman C.; *Thomas S.; *Bhatia S.

Citation:
British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)

Abstract:
Introduction Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon but often catastrophic complication of head and neck cancer when arterial wall integrity is compromised,
particularly where surgical procedures and radiotherapy are involved. Rupture occurs most commonly in the common carotid artery in proximity to the furcation, often within 10-40 days post surgery. Methods We present the use of a great saphenous vein carotid artery bypass graft in the management of a 47-year-old woman with recurrent squamous cell carcinoma (T2 N1 M0 RO V1) utilizing the Pruitt F3 carotid shunt system to minimize cerebral perfusion compromise. We explore pre and post-operative surgical considerations including suggested graft-monitoring protocols. Results The body of evidence supporting the use of carotid bypass grafts is limited. Despite data paucity, case series are available demonstrating variable mortality. A systematic review of PubMed was conducted revealing three English language case series. One series reported a 2-year survival of 82% with carotid sacrifice and autogenous venous graft where distant metastatic disease is absent. 96% of patients experienced no neurologic sequela whilst 3.9% suffered CVA post-operatively. Our own patient remains free of neurologic symptoms and graft patency has been confirmed at 3 months. Clinical Relevance Tumour resection involving in the carotid artery presents an array of surgical management possibilities including tumour shaving, artery ligation or resection. The long-term survival of carotid bypass graft is unknown and reported complications vary, it remains a promising technique in the prevention of carotid blowout syndrome.