2016

The UK-PBC risk scores: Derivation and validation of a scoring system for long-term prediction of end-stage liver disease in primary biliary cholangitis (2016)

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Type of publication:
Journal article

Author(s):
Carbone M., Sharp S.J., Flack S., Paximadas D., Spiess K., Adgey C., Griffiths L., Lim R., Trembling P., Williamson K., Wareham N.J., Aldersley M., Bathgate A., Burroughs A.K., Heneghan M.A., Neuberger J.M., Thorburn D., Hirschfield G.M., Cordell H.J., Alexander G.J., Jones D.E.J., Sandford R.N., Mells G.F., Jones D., Kirby J., Hirschfield G., Alexander G., Sandford R., Taylor-Robinson S., Ch'ng C.L., Rahman M., Yapp T., Sturgess R., Healey C., Czajkowski M., Gunasekera A., Gyawali P., Premchand P., Kapur K., Marley R., Foster G., Watson A., Dias A., Subhani J., Harvey R., McCorry R., Ramanaden D., Gasem J., Evans R., Mathialahan T., Shorrock C., Lipscomb G., Southern P., Tibble J., Gorard D., Palegwala A., Dawwas M., Dolwani S., Prince M., Foxton M., Elphick D., Mitchison H., Gooding I., Karmo M., Saksena S., Mendall M., Patel M., Ede R., Austin A., Sayer J., Hankey L., Hovell C., Fisher N., Carter M., Koss K., Piotrowicz A., Grimley C., Neal D., Lim G., Levi S., Ala A., Broad A., Saeed A., Wood G., Brown J., Wilkinson M., Gordon H., Ramage J., Ridpath J., Ngatchu T., Grover B., Shaukat S., Shidrawi R., Abouda G., Ali F., Rees I., Salam I., Narain M., Brown A., Williams S., Grellier L., Banim P., Chilton A., Curtis H., Gess M., Drake I., Davies M., Jones R., McNair A., Srirajaskanthan R., Pitcher M., Sen S., Bird G., Barnardo A., Kitchen P., Yoong K., Chirag O., Sivaramakrishnan N., MacFaul G., Shah A., Evans C., Saha S., Pollock K., Bramley P., Mukhopadhya A., Fraser A., Mills P., Shallcross C., Campbell S., Shepherd A., Dillon J., Rushbrook S., Przemioslo R., Macdonald C., Metcalf J., Shmueli U., Davis A., Naqvi A., Lee T., Ryder S.D., Collier J., Klass H., Ninkovic M., Cramp M., Sharer N., Aspinall R., Goggin P., Ghosh D., Douds A., Hoeroldt B., Booth J., Williams E., Hussaini H., Stableforth W., Ayres R., Marshall E., Mann S., Lombard M., Richardson P., Patanwala I., Maltby J., Brookes M., Mathew R., Vyas S., Singhal S., Gleeson D., Misra S., *Butterworth J., George K., Harding T., Douglass A., Panter S., Shearman J., Bray G., Butcher G., Forton D., Mclindon J., Das D., Cowan M., Whatley G., Mandal A., Gupta H., Sanghi P., Jain S., Pereira S., Prasad G., Watts G., Wright M., Gordon F., Unitt E., Grant A., Delahooke T., Higham A., Brind A., Cox M., Ramakrishnan S., King A., Collins C., Whalley S., Li A., Fraser J., Bell A., Wong V.S., Singhal A., Gee I., Ang Y., Ransford R., Gotto J., Millson C., Bowles J., Harrison M., Galaska R., Kendall J., Whiteman J., Lawlor C., Gray C., Elliott K., Mulvaney-Jones C., Hobson L., Van Duyvenvoorde G., Loftus A., Seward K., Penn R., Maiden J., Damant R., Hails J., Cloudsdale R., Silvestre V., Glenn S., Dungca E., Wheatley N., Doyle H., Kent M., Hamilton C., Braim D., Wooldridge H., Abrahams R., Paton A., Lancaster N., Gibbins A., Hogben K., Desousa P., Muscariu F., Musselwhite J., McKay A., Tan L., Foale C., Brighton J., Flahive K., Nambela E., Townshend P., Ford C., Holder S., Palmer C., Featherstone J., Nasseri M., Sadeghian J., Williams B., Thomas C., Rolls S.-A., Hynes A., Duggan C., Jones S., Crossey M., Stansfield G., MacNicol C., Wilkins J., Wilhelmsen E., Raymode P., Lee H.-J., Durant E., Bishop R., Ncube N., Tripoli S., Casey R., Cowley C., Miller R., Houghton K., Ducker S., Wright F., Bird B., Baxter G., Keggans J., Hughes M., Grieve E., Young K., D. Williams, Ocker K., Hines F., Innes C., Valliani T., Fairlamb H., Thornthwaite S., Eastick A., Tanqueray E., Morrison J., Holbrook B., Browning J., Walker K., Congreave S., Verheyden J., Slininger S., Stafford L., Denise O'Donnell, Ainsworth M., Lord S., Kent L., March L., Dickson C., Simpson D., Longhurst B., Hayes M., Shpuza E., White N., Besley S., Pearson S., Wright A., Jones L., Gunter E., Dewhurst H., Fouracres A., Farrington L., Graves L., Marriott S., Leoni M., Tyrer D., Martin K., Dali-kemmery L., Lambourne V., Green M., Sirdefield D., Amor K., Colley J., Shinder B., Jones J., Mills M., *Carnahan M., Taylor N., Boulton K., Tregonning J., Brown C., Clifford G., Archer E., Hamilton M., Curtis J., Shewan T., Walsh S., Warner K., Netherton K., Mupudzi M., Gunson B., Gitahi J., Gocher D., Batham S., Pateman H., Desmennu S., Conder J., Clement D., Gallagher S., Orpe J., Chan P., Currie L., Lynn O'Donohoe, Oblak M., Morgan L., Quinn M., Amey I., Baird Y., Cotterill D., Cumlat L., Winter L., Greer S., Spurdle K., Allison J., Dyer S., Sweeting H., Kordul J.

Citation:
Hepatology, March 2016, vol./is. 63/3(930-950)

Abstract:
The biochemical response to ursodeoxycholic acid (UDCA)-so-called "treatment response"-strongly predicts long-term outcome in primary biliary cholangitis (PBC). Several long-term prognostic models based solely on the treatment response have been developed that are widely used to risk stratify PBC patients and guide their management. However, they do not take other prognostic variables into account, such as the stage of the liver disease. We sought to improve existing long-term prognostic models of PBC using data from the UK-PBC Research Cohort. We performed Cox's proportional hazards regression analysis of diverse explanatory variables in a derivation cohort of 1,916 UDCA-treated participants. We used nonautomatic backward selection to derive the best-fitting Cox model, from which we derived a multivariable fractional polynomial model. We combined linear predictors and baseline survivor functions in equations to score the risk of a liver transplant or liver-related death occurring within 5, 10, or 15 years. We validated these risk scores in an independent cohort of 1,249 UDCA-treated participants. The best-fitting model consisted of the baseline albumin and platelet count, as well as the bilirubin, transaminases, and alkaline phosphatase, after 12 months of UDCA. In the validation cohort, the 5-, 10-, and 15-year risk scores were highly accurate (areas under the curve: >0.90). Conclusions: The prognosis of PBC patients can be accurately evaluated using the UK-PBC risk scores. They may be used to identify high-risk patients for closer monitoring and second-line therapies, as well as low-risk patients who could potentially be followed up in primary care.

Link to full-text (access available to eligible users via an NHS OpenAthens account)

Current evidence and future perspectives on the effective practice of patientcentered Laboratory Medicine [Italian] Attualita e prospettive sull'efficacia pratica della Medicina di Laboratorio orientata al paziente (2016)

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Type of publication:
Journal article

Author(s):
*Hallworth M.J., Epner P.L., Ebert C., Fantz C.R., Faye S.A., Higgins T.N., Kilpatrick E.S., Li W., Rana S.V., Vanstapel F.

Citation:
Biochimica Clinica, 2016, vol./is. 40/2(143-153)

Abstract:
Systematic evidence of the contribution made by laboratory medicine to patient outcomes and the overall process of healthcare is difficult to find. An understanding of the value of laboratory medicine, how it can be determined, and the various factors that influence it is vital to ensuring that the service is provided and used optimally. This review summarizes existing evidence supporting the impact of laboratory medicine in healthcare and indicates the gaps in our understanding. It also identifies deficiencies in current utilization, suggests potential solutions, and offers a vision of a future in which laboratory medicine is used optimally to support patient care. To maximize the value of laboratory medicine, work is required in 5 areas: a) improved utilization of existing and new tests; b) definition of new roles for laboratory professionals that are focused on optimizing patient outcomes by adding value at all points of the diagnostic brain-to-brain cycle; c) development of standardized protocols for prospective patient-centered studies of biomarker clinical effectiveness or extraanalytical process effectiveness; d) benchmarking of existing and new tests in specified situations with commonly accepted measures of effectiveness; e) agreed definition and validation of effectiveness measures and use of checklists for articles submitted for publication. Progress in these areas is essential if we are to demonstrate and enhance the value of laboratory medicine and prevent valuable information being lost in meaningless data. This requires effective collaboration with clinicians and a determination to accept patient outcome and patient experience as the primary measure of laboratory effectiveness.

The low-down on fresh gas flows (2016)

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Type of publication:
Conference abstract

Author(s):
*Keogh T., *Elcock D.

Citation:
Anaesthesia, June 2016, vol./is. 71, Supplement 3, p. 26

Abstract:
Inhalational anaesthetic agents are minimally metabolised and mostly exhaled unchanged; using a closed breathing system with CO<inf>2</inf> absorption, reduces waste of volatiles and permits the reduction of fresh gas flow (FGF) to providing only the patient's metabolic requirements [1]. In addition to reducing wastage of volatiles, low FGF benefits the environment and improves cost effectiveness with a potentially advantageous impact on care. We looked at practice in a typical district general hospital (The Royal Shrewsbury Hospital), with the aim of identifying potential cost savings; we surveyed FGF and investigated whether our volatile costs were influenced by use of the relatively expensive sevoflurane. Methods Theatre lists were inspected to identify cases anticipated to last > 60 min, and were then audited by going into theatre and recording data. A maximum of one case was analysed from each list per day so as to avoid bias by targeting a particular anaesthetist and to avoid influences on an individual's practice once they realised they were being surveyed. A range of specialities was audited and data were collected after at least 30 min on table to allow time for the anaesthetist to modify flows. Results Median flow rates (n = 49) were found to be 0.95 l.min<sup>-1</sup> with an interquartile range of between 0.70 l.min<sup>-1</sup> and 1.10 l.min<sup>-1</sup> (Fig. 1). While these are low flows compared with those required by non-circle systems, they are not basal flow rates and therefore an estimated saving of around 50% could be made if typical flows were < 0.5 l.min<sup>-1</sup> (roughly equal to 70 000/pa in the Trust). Based on our pharmacy costs, we estimate equivalent doses of sevoflurane to be roughly 14x the cost of isoflurane, suggesting a saving of up to 93% per case if only the latter were used. However we acknowledge that this is simplistic and may not offset the disadvantages of isoflurane. Discussion We may have underestimated FGF being used; it is probable that people do not use low-flows in the anaesthetic room, at the beginning of cases, or possibly at all in shorter cases. Results have shown a generally responsible use of FGF rates, and perhaps limiting the type of volatiles used would not be as cost-effective as may have been thought, but rather encouraging the use of 'minimal flows'(< 500 ml) may be more promising. The introduction of self-adjusting low FGF on newer anaesthetic machines will also weaken any case for preferring isoflurane on grounds of cost alone – indeed manufacturers may argue the cost of this type of technology is quickly offset by the savings made in volatile costs. We think that rather than trying to reduce costs by limiting use of sevoflurane, there is more to gain by promoting the use of 'minimal flow'. (Figure Presented) .

Link to more details or full-text: http://onlinelibrary.wiley.com/doi/10.1111/anae.13519/epdf

Consultants as victims of bullying and undermining: A survey of Royal College of Obstetricians and Gynaecologists consultant experiences (2016)

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Type of publication:
Journal article

Author(s):
Shabazz T., Parry-Smith W., *Oates S., Henderson S., Mountfield J.

Citation:
BMJ Open, June 2016, vol./is. 6/6(no pagination)

Abstract:
Objective: To explore incidents of bullying and undermining among obstetrics and gynaecology (O&G) consultants in the UK, to add another dimension to previous research and assist in providing a more holistic understanding of the problem in medicine. Design: Questionnaire survey. Setting: Royal College of Obstetricians and Gynaecologists (RCOG). Participants: O&G consultant members/fellows of the RCOG working in the UK. Main outcome measures: Measures included a typology of 4 bullying and undermining consequences from major to coping. Results: There was a 28% (664) response rate of whom 44% (229) responded that they had been persistently bullied or undermined. Victims responded that bullying and undermining is carried out by those senior or at least close in the hierarchy. Of the 278 consultants who answered the question on 'frequency of occurrence', 50% stated that bullying and undermining occurs on half, or more, of all encounters with perpetrators and two-thirds reported that it had lasted more than 3 years. The reported impact on professional and personal life spans a wide spectrum from suicidal ideation, depression and sleep disturbance, and a loss of confidence. Over half reported problems that could compromise patient care. When victims were asked if the problem was being addressed, 73% of those that responded stated that it was not. Conclusions: Significant numbers of consultants in O&G in the UK are victims of bullying and undermining behaviour that puts their own health and patient care at risk. New interventions to tackle the problem, rather than its consequences, are required urgently, together with greater commitment to supporting such interventions.

Screening for arteriovenous malformations in hereditary haemorrhagic telangiectasia (2016)

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Type of publication:
Journal article

Author(s):
*Jervis, S, *Skinner, D

Citation:
Journal of Laryngology & Otology, 2016, vol./is. 130/8(734-742)

Abstract:
To determine whether patients with hereditary haemorrhagic telangiectasia were being screened according to international guidelines, and to review recent evidence in order to provide up-to-date guidelines for the initial systemic management of hereditary haemorrhagic telangiectasia.

A retrospective case note analysis was conducted, assessing patients in terms of screening for: genetics, cerebral arteriovenous malformations, pulmonary and hepatic arteriovenous malformations, and gastrointestinal telangiectasia. Databases searched included Medline, the Cumulative Index to Nursing and Allied Health Literature, and Embase.

Screening investigations were most frequently performed for hepatic arteriovenous malformations and least frequently for genetics. Recent data suggest avoiding routine genetic and cerebral arteriovenous malformation screening because of treatment morbidities; performing high-resolution chest computed tomography for pulmonary arteriovenous malformation screening; using capsule endoscopy (if possible) to reduce complications from upper gastrointestinal endoscopy; and omitting routine liver enzyme testing in favour of Doppler ultrasound.

Opportunities for systemic arteriovenous malformation screening are frequently overlooked. This review highlights the need for screening and considers the form in which it should be undertaken.

Prophylactic proton pump inhibitors in femoral neck fracture patients - A life - and cost-saving intervention (2016)

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Type of publication:
Journal article

Author(s):
*Singh, R, Trickett, R, Meyer, Cer, Lewthwaite, S, Ford, D

Citation:
Annals of the Royal College of Surgeons of England, Jul 2016, vol. 98, no. 6, p. 371-375

Abstract:
Introduction Acute gastrointestinal stress ulceration is a common and serious complication of trauma. Prophylactic proton pump inhibitors (PPIs) or histamine receptor antagonists have been used in poly-trauma, burns and head and spinal injuries, as well as on intensive care units, for the prevention of acute gastric stress ulcers. Methods We prospectively studied the use of prophylactic PPIs in with femoral neck fracture patients, gathering data on all acute gastric ulcer complications, including coffee-ground vomiting, malena and haematemesis. We then implemented a treatment protocol in which all patients were given prophylactic PPIs, again prospectively collecting all data. Results Five hundred and fifteen patients were included. Prior to prophylactic PPI, 15% of patients developed gastric stress ulcer complications, with 3% requiring acute intervention with oesophagogastroduodenoscopy (OGD), 5% requiring transfusions and 4% experiencing surgical delays. All patients had delayed discharges. Following PPI implementation, no patients developed gastric stress ulcer complications. Conclusions Femoral neck fracture patients create a substantial workload for orthopaedic units. The increasingly elderly population often have comorbidities, and concomitantly use medications with gastrointestinal side effects. This, combined with the stress of a fracture and preoperative starvation periods increases the risk of gastric ulcers. Here, the use of prophylactic PPIs statistically reduced the incidence of gastric stress ulcers in patients with femoral neck fractures, resulting in fewer surgical delays, reduced length of hospital stay and reduced stress ulcer-related mortality.

Vestibular Mast Cell Density in Vulvodynia: A Case-Controlled Study (2016)

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Type of publication:
Journal article

Author(s):
*Papoutsis, Dimitrios, Haefner, Hope K, Crum, Christopher P, Opipari, Anthony W, Reed, Barbara D

Citation:
Journal of lower genital tract disease, Jul 2016, vol. 20, no. 3, p. 275-279

Abstract:
To identify whether mast cell densities in vulvar biopsies from the vestibule are associated with vulvodynia. We enrolled 100 women aged 19 to 59 years with confirmed vulvodynia cases, 100 racially matched controls, and 100 black control women. All had vulvar biopsies performed at the 7 o'clock position of the vestibule, which were then immunostained to detect c-KIT protein. The numbers of c-KIT positive mast cells per ×400 magnification field were manually counted, and t tests and logistic regression were used to assess the association with case-control status. Of the biopsies, 235 were adequate samples for c-KIT testing for mast cells. The mast cell density was substantially lower in black control women (13.9 ± 10.9) in comparison to white control women (22.5 ± 13.2 p < 0.001): hence the analysis was confined to white cases and racially matched control women. Compared with racially matched controls, cases were younger, more likely to be married, and reported a higher household income. The average number of mast cells per ×400 magnification field overall was 19.1 ± 13.2 (range, 0-62). There was no difference in the mast cell count between racially matched cases (22.4 ± 13.9 per ×400 field) and controls (22.5 ± 13.2) in either the univariate or multivariable analyses. Within the group of cases, there was no difference in mast cell density based on the presence or absence of a variety of urogenital symptoms. No difference in mast cell density in biopsies of the vestibule was found between white cases and racially matched controls. Black control women have a lower mast cell density compared with white control women.

Suicidal ideation during pregnancy in British Pakistani women (2016)

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Type of publication:
Conference abstract

Author(s):
*Sharif A., Gire N., Tomenson B., Chaudhry N., Husain M.

Citation:
European Psychiatry, March 2016, vol./is. 33/(S272-S273)

Abstract:
Introduction Suicide is a major public health problem and one of the common causes of maternal mortality. Rates of suicide and self-harm are higher in British South Asian women compared to the majority white population. Suicidal Ideation (SI) is a significant risk factor associated with self-harm and suicide. Objective To explore the prevalence and risk factors of SI in British Pakistani women. Aim To identify risk factors associated with SI, in order to inform future preventive strategies. Method This is a secondary analysis of a larger study which looked at depression during pregnancy and infant outcomes. Par ticipants who consented (women aged 18 or over, in their third pregnancy trimester) were initially assessed for maternal depression using the Edinburgh Post-Natal Depression Scale (EPDS), with one of the questions on the EPDS being on SI. Participants who met the study criteria, were further assessed regarding sociodemographic factors, perceived social support, social adversity and isolation. Results The rate of SI in this group of women was 8.1%, with baseline interview results suggesting that women with SI being significantly more likely to be aged 20 or less, have experience of severe life events and being less likely to have social support. Conclusion This area of research is key to understanding SI in British Pakistani women, to better develop culturally sensitive interventions for use within this group.

Cardiovascular risk assessment in psychiatric inpatient setting (2016)

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Type of publication:
Conference abstract

Author(s):
*Dahmer E., *Lokunarangoda N.C., Romain K., Kumar M.

Citation:
European Psychiatry, March 2016, vol./is. 33/(S281)

Abstract:
Objectives To assess the general cardiac health of inpatients in acute psychiatric units and to evaluate the practice of ECG use in this setting. Aims Overall cardiac risk is assessed using QRISK2. Clinically significant ECG abnormality detection by psychiatric teams are compared with same by cardiologist. Methods Ten percent of patients (n = 113) admitted to five acute psychiatric wards during a period of 13 months across three hospital sites, covering a population of 1.1 million, were randomly selected. Electronic health care records were used to collect all data, in the form of typed entries and scanned notes. An experienced cardiologist, blind to the psychiatrist assessments, performed ECG analysis. The QRISK2 online calculator was used to calculate 10-year cardiovascular risk as recommended by NIHR, UK. Results A score of 10% or more indicates a need for further intervention to lower risk.13.5% of patients had a QRISK2 score of 10-20%, 5.2% had a score of 20-30%, and 1 patient had a QRISK2 score > 30%. In total, 19.7% had a QRISK2 of 10% or greater. A total of 2.9% had prolonged QTC interval (> 440 ms), with 2.9% having a borderline QTC (421-440). A total of 34.3% of ECGs were identified by the ward doctors as abnormal, with action being taken on 41.6% of these abnormal ECGs. Cardiologist analysis identified 57.1% of ECGs with abnormalities of potential clinical significance. Conclusions One in five patients admitted to psychiatry wards have poor cardiac health requiring interventions. Though QTC interval prolongation is rare, half of patients may have abnormal ECGs that require further analysis.

Diagnostic yield of biliary brushing cytology: A single centre study (2016)

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Type of publication:
Conference abstract

Author(s):
*Wasimi M., Azam A.S., Abdullah P., Muzaffar S.

Citation:
Journal of Pathology, March 2016, vol. 238, Supplement 1, p.S19

Abstract:
Introduction: Biliary brushing cytology is a commonly used technique for the diagnosis of extra hepatic biliary and pancreatic malignancy. Despite a high specificity, the sensitivity remains low and variable. British Society of Gastroenterology guidelines recommend cytological analysis of brushing taken from the biliary structure to support diagnosis of malignancy in suspected individuals. We report here a single center experience of diagnostic yield of cytological specimens of biliary brushings. Objectives: (a) To determine the percentage of biliary brushing cytology cases with positive, negative, false positive and false negative results. (b) To determine the positive and negative predictive value of this test in our centre. (c) To see the correlation between cytological, radiological and clinical findings. Methodology: This is a retrospective data analysis of all biliary brushing cytology cases reported over three years from Jan 2012 to Jan 2014. The data was obtained from cytology reports and findings were correlated with the radiological diagnosis, outcome from the MDT meetings and subsequent follow up from the clinic letters. Results: A total of 34 biliary brushing cytology cases were reported between 2012 to 2014. Among them 22 were men and 12 were women. Average age was 69 years (Range 24-92 years). Out of 34, 15 cases (44%) showed presence of malignant cells and all these were true positives with underlying pancreatic and biliary malignancy. Among the remaining 19 cases, 10 cases were true negatives and 9 cases were false negatives. In our cohort, the specificity of biliary brushing cytology was 100% and sensitivity was 63%. The positive predictive value 100% and negative predictive value 53%. Conclusion: Biliary brushing cytology in conjunction with radiological investigation and serology is a useful technique in patients with suspected pancreato-biliary malignancy. Our results are comparable to studies done in other centres. To be re-audited.

Link to more details or full-text: http://onlinelibrary.wiley.com/doi/10.1002/path.4705/epdf