2016

Are we following the guidelines to prevent contrast induced acute kidney injury? a clinical audit on patients with chronic kidney disease(CKD) undergoing coronary angiogram (2016)

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Type of publication:
Conference abstract

Author(s):
*Kanthasamy V., *Gill S.

Citation:
Global Heart, June 2016, vol./is. 11/2 SUPPL. 1(e94)

Abstract:
Introduction: Contrast induced acute kidney injury(CI-AKI) is one of the potential risk involved in high risk patients who undergo Coronary Angiography/interventions. As the procedure involved intra-arterial administration of contrast media, it expose the patient directly to the toxic side effects. It classically occurs within 72 hours of receiving the contrast media and usually recovers over the following five days. Its incidence increases significantly among the patients with risk factors and is greatly associated with short and long term mortality. The risk of CI-AKI is has been reported as high as 25% in patients with combination of CKD and diabetes, Cardiac failure, older age and exposure to nephrotoxic agents. Objectives: A clinical audit performed in order to assess the adherence to the NICE guidelines to prevent contrast induced Acute Kidney Injury among CKD patients undergoing diagnostic Coronary Angiogram and to identify the incidence of AKI following the procedure. Methods: A retrospective clinical audit was conducted to cover 6 months from May to October 2014. Data was collected from the cath lab register and patients with chronic kidney disease with eGFR<60 were included in the audit covering both in-patient and outpatient procedures(n=30). Data collection was based on the NICE guidance to look for the adherence of monitoring for renal function pre/post angiogram and considering hydration as preventive measure. Results: 93 % of the patients had two or more risk factors including CKD. All patients had renal function checked prior to the procedure but only 57 %(n=17) had post procedure renal function checked within 1 week and only 53 % were hydrated. 10 out of 17 patients( 59%) showed a decline in renal function. Among them 4 (23%) patients had AKI as per KDIGO criteria (Kidney Disease: Improving Global Outcomes) and of which 3 (75%) were not hydrated pre/post procedure. Renal function did not return to baseline in one of those 4 patients. Conclusion: In overall it was clearly evident that taking preventive measures against CIAKI in CKD patients were overlooked. Our recommendations were to introduce a checklist pre & post procedure for all patients so that high risk patients can be identified, to instruct the GP(on discharge) to re-check the renal functions in 3 days and to re-audit.

Parent experiences of paediatric allergy pathways in the West Midlands Region of the United Kingdom - A qualitative study (2016)

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Type of publication:
Conference abstract

Author(s):
*Diwakar L., Cummins C., Williams L., Sansom H., Kerrigan C., *Rees M., Hackett S., Lilford R., Roberts T.

Citation:
Allergy: European Journal of Allergy and Clinical Immunology, August 2016, vol./is. 71/(577)

Abstract:
Background: Almost all allergy care in the UK is provided by the publicly funded National Health Service (NHS). Services are deficient in most parts of the country at both primary and secondary level, with few regions having appropriate access to trained allergy clinical teams. The problem is especially acute for paediatric allergy services. Method: We are carrying out a qualitative study using in-depth, semi-structured interviews of parents purposively selected from two separate NHS Paediatric allergy clinics. All interviews are being audio-taped and transcribed anonymously. Analysis is by framework approach facilitated by NVivo software. Themes are being identified and alternate theories for findings will be sought using peer panels and literature searches. Interviews will be carried out until data saturation is achieved. Results: Preliminary analysis of 6 completed interviews has revealed a few emerging themes. Access to Primary Care services was variable with some parents expressing frustration at delays in obtaining appointments. Some of the mothers felt aggrieved that their 'gut reactions' regarding the well being of their child were often disregarded by Primary Care Physicians (PCPs). This was perceived strongly as 0being dismissed0 and made the mothers feel frustrated and often helpless with regards to taking care of their children. "I'd come out sometimes and I'd be so frustrated because I felt like, 'You weren't listening'. They just wouldn't listen to me. It was as if – you know, 'You're just an overreacting mom'." (P6) Even when the PCPs did not provide effective treatments, mothers were quite accepting of the treatment when they felt that their views were respected and 'listened to' " that's not eczema cream, so I thought that's not what I was expecting … but I can't really-you know -fault them for trying the different creams."(P7) Referral practices from Primary to Secondary Care also varied significantly with some parents facing frustrating delays with referral. Most of our interviewees found specialist clinics satisfactory, although some expressed discontentment over the usefulness of the consultation and followup processes. Conclusion: Parents experience considerable variation with regards to access, knowledge and attitude of PCPs in the WM region for children with allergies. Experiences with secondary care were largely favourable. In general, parents greatly valued being listened to and taken seriously by their clinicians.

Improving documentation of communication with parents in neonatal unit. A service development experience (2016)

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Type of publication:
Conference abstract

Author(s):
Kasim Aldaleel O., *Welch R.

Citation:
Archives of Disease in Childhood, April 2016, vol./is. 101/(A71-A72)

Abstract:
Introduction Effective communication with parents/patients is essential according to Domain 3 of the General Medical Council's (GMC) Guide for Good Medical Practice. Documentation of communication is crucial for clinical and medicolegal aspects. A local survey in our unit revealed a room for development, when 35.3% only of communication with parents was documented. Aim To improve documentation of communication with parents in the neonatal unit, in line with GMC Good Medical Practice Guide, aiming at 100% documentation of communications with parents. Method A development team was assigned with clear responsibilities and leadership. As part of PDSA (Plan-Do-Study-Act) cycle for improvement, tools were developed as an Act to improve documentation of communication with parents. The developed tools were; making documentation of communication with parents a handover component, making the documentation in the notes a personal responsibility of the doctor who spoke to parents and recording that, creating posters about documenting communication with parents and distributing them in different areas of the department as reminders and having a weekly updated Statistical Process Control chart (SPC chart) clearly visible in the unit. Results A Test of the Change was carried out after 2 months by a review of the last 6 weeks of the SPC Chart. The overall percentage of documented communication with parents was 72.85% (51/70) over 6 weeks period. The first week did not show significant change when 36% (4/11) of communications were documented. However, there was a steady improvement between the second and the fifth weeks, ranging from 71% to 80%, before reaching 92% in the sixth week. That was a positive test of change which was highlighted and implementation of these tools was agreed. High quality documented communications were selected and presented to trainees for learning benefits. Conclusion Having accurate medical records is medicolegally essential. Developing local tools to improve documentation of communication with parents is important when that documentation is sub-optimal. The SPC chart, posters, and communication documentation handing over are effective tools. However, other tools might be effective depending on each unit's needs.

Prevention and control of multiresistant Gram-negative bacteria: recommendations from a Joint Working Party (2016)

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Type of publication:
Journal article

Author(s):
Wilson, A.P.R., Livermore, D.M., Otter, J.A., *Warren, R.E., Jenks, P., Enoch, D.A., Newsholme, W., Oppenheim, B., Leanord, A., McNulty, C., Tanner, G., Bennett, S., Cann, M., Bostock, J., Collins, E., Peckitt, S., Ritchie, L., Fry, C., Hawkey, P.

Citation:
Journal of Hospital Infection, 2016, vol./is. 92/S1-S44

Link to more details or full-text: http://www.journalofhospitalinfection.com/article/S0195-6701(15)00314-X/pdf

Knowledge gaps in the management of familial hypercholesterolaemia. A UK based survey (2016)

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Type of publication:
Journal article

Author(s):
Jonathan Schofield, See Kwok, Michael France, *Nigel Capps, Ruth Eatough, Rahul Yadav, Kausik Ray, Handrean Soran

Citation:
Atherosclerosis (2016) [article in press]

Abstract:
Background and aims: Untreated individuals with familial hypercholesterolaemia (FH) are at increased
risk of developing premature cardiovascular disease (CVD). Early diagnosis and treatment can result in a
normal life expectancy. A recent survey commissioned by the European Atherosclerosis Society (EAS)
reported a lack of awareness of FH in the general population.We conducted a survey to assess knowledge
among healthcare professionals involved in the assessment and management of cardiovascular risk and
disease in the United Kingdom.
Methods: A survey designed to assess knowledge of diagnostic criteria, risk assessment, the role of
cascade screening, and management options for patients with FH was distributed to 1000 healthcare
professionals (response rate 44.3%). The same survey was redistributed following attendance at an
educational session on FH.
Results: 151 respondents (40.5%) reported having patients under their care who would meet the diagnostic criteria for FH, but just 61.4% recognized that cardiovascular risk estimation tools cannot be
applied in FH, and only 22.3% understood the relative risk of premature CVD compared to the general
population. Similarly, just 65.9% were aware of recommendations regarding cascade screening.
Conclusions: The prevalence and associated risk of FH continue to be underestimated, and knowledge of
diagnostic criteria and treatment options is suboptimal. These results support the recent Consensus
Statement of the EAS and production of quality standards by the National Institute for Health and Care
Excellence. Further work is required to formulate interventions to improve FH awareness and knowledge, and to determine the effect these interventions have on patient outcomes.

Spedali Degli Innocenti, the Foundling Hospital in Florence, Italy (2016)

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Type of publication:
Journal article

Author(s):
*Summers, Bruce

Citation:
Medical humanities, June 2016, vol. 42, no. 2, p. 141-142

Abstract:
The author reflects on a visit to the Ospedale Degli Innocenti, the former Renaissance foundling hospital in Florence, having escaped from an international clinical conference. He considers the symbolism of the architecture and artwork in relation to its function as a sanctuary for abandoned children.

Predicting and measuring fluid responsiveness with echocardiography (2016)

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Type of publication:
Journal article

Author(s):
*Miller, Ashley, Mandeville, Justin

Citation:
Echo research and practice, June 2016, vol. 3, no. 2, p. G1

Abstract:
Echocardiography is ideally suited to guide fluid resuscitation in critically ill patients. It can be used to assess fluid responsiveness by looking at the left ventricle, aortic outflow, inferior vena cava and right ventricle. Static measurements and dynamic variables based on heart-lung interactions all combine to predict and measure fluid responsiveness and assess response to intravenous fluid resuscitation. Thorough knowledge of these variables, the physiology behind them and the pitfalls in their use allows the echocardiographer to confidently assess these patients and in combination with clinical judgement manage them appropriately.

Link to full text: http://www.echorespract.com/content/3/2/G1.abstract

Gynaecological laparoscopic injuries: a 10-year retrospective review at a District General Hospital NHS Trust (2016)

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Type of publication:
Journal article

Author(s):
*Moores K.L., *Bentick B.

Citation:
Gynecological Surgery, May 2016, vol./is. 13/2(125-130)

Abstract:
Worldwide, increasingly complex surgery is being performed laparoscopically; thus, laparoscopic complication rates may be increasing. Reported risks from all complications of laparoscopic surgery are between 1 and 12.5/1000 cases and serious complications in 1/1000 cases. Accurate complication rates of surgery are difficult to obtain as most data are from retrospective studies and may be incomplete. This paper is a 10-year retrospective review of gynaecological laparoscopic complications from 1 January 2003 to 31 December 2012. Data sources are SEMAHELIX Hospital Database, Gynaecology Complications Register, Clinical Governance Records, Complaints and Legal Cases. Recorded complications were classified as diagnostic, sterilisations and therapeutic laparoscopies. Further classifications are as follows: major complications and type of injury (bowel, urological, vascular, other), minor complications and failed sterilisations. Twenty-nine complications were identified from 5128 laparoscopies; total complication rate is 5.7/1000 procedures. Major complication rates are as follows: diagnostic, 2.2/1000; sterilisations, 3.3/1000; and therapeutic, 3.1/1000, subcategorised into bowel 1.4/1000, urological 0.2/1000 and vascular 1.2/1000. Our total complication rate lies within published national rates. Compared to published standards of major complications, diagnostic laparoscopy and laparoscopic sterilisation rates were comparable. Conversely, our therapeutic laparoscopy complication rate was much lower. The highest complication rate was in the failed sterilisation group; however, this rate is within published sterilisation failure rates. Bowel and vascular complications were comparable; minor complication rates were low in all groups.

Addition of docetaxel, zoledronic acid, or both to first-line long-term hormone therapy in prostate cancer (STAMPEDE): Survival results from an adaptive, multiarm, multistage, platform randomised controlled trial (2016)

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Type of publication:
Journal article

Author(s):
James N.D., Sydes M.R., Clarke N.W., Mason M.D., Dearnaley D.P., Spears M.R., Ritchie A.W.S., Parker C.C., Russell J.M., Attard G., De Bono J., Cross W., Jones R.J., Thalmann G., Amos C., Matheson D., Millman R., Alzouebi M., Beesley S., Birtle A.J., Brock S., Cathomas R., Chakraborti P., Chowdhury S., Cook A., Elliott T., Gale J., Gibbs S., Graham J.D., Hetherington J., Hughes R., Laing R., McKinna F., McLaren D.B., O'Sullivan J.M., Parikh O., Peedell C., Protheroe A., Robinson A.J., *Srihari N., Srinivasan R., Staffurth J., Sundar S., Tolan S., Tsang D., Wagstaff J., Parmar M.K.B.

Citation:
The Lancet, March 2016, vol./is. 387/10024(1163-1177)

Abstract:
Background
Long-term hormone therapy has been the standard of care for advanced prostate cancer since the 1940s. STAMPEDE is a randomised controlled trial using a multiarm, multistage platform design. It recruits men with high-risk, locally advanced, metastatic or recurrent prostate cancer who are starting first-line long-term hormone therapy. We report primary survival results for three research comparisons testing the addition of zoledronic acid, docetaxel, or their combination to standard of care versus standard of care alone.
Methods
Standard of care was hormone therapy for at least 2 years; radiotherapy was encouraged for men with N0M0 disease to November, 2011, then mandated; radiotherapy was optional for men with node-positive non-metastatic (N+M0) disease. Stratified randomisation (via minimisation) allocated men 2:1:1:1 to standard of care only (SOC-only; control), standard of care plus zoledronic acid (SOC + ZA), standard of care plus docetaxel (SOC + Doc), or standard of care with both zoledronic acid and docetaxel (SOC + ZA + Doc). Zoledronic acid (4 mg) was given for six 3-weekly cycles, then 4-weekly until 2 years, and docetaxel (75 mg/m<sup>2</sup>) for six 3-weekly cycles with prednisolone 10 mg daily. There was no blinding to treatment allocation. The primary outcome measure was overall survival. Pairwise comparisons of research versus control had 90% power at 2.5% one-sided alpha for hazard ratio (HR) 0.75, requiring roughly 400 control arm deaths. Statistical analyses were undertaken with standard log-rank-type methods for time-to-event data, with hazard ratios (HRs) and 95% CIs derived from adjusted Cox models. This trial is registered at ClinicalTrials.gov (NCT00268476) and ControlledTrials.com (ISRCTN78818544).
Findings
2962 men were randomly assigned to four groups between Oct 5, 2005, and March 31, 2013. Median age was 65 years (IQR 60-71). 1817 (61%) men had M+ disease, 448 (15%) had N+/X M0, and 697 (24%) had N0M0. 165 (6%) men were previously treated with local therapy, and median prostate-specific antigen was 65 ng/mL (IQR 23-184). Median follow-up was 43 months (IQR 30-60). There were 415 deaths in the control group (347 [84%] prostate cancer). Median overall survival was 71 months (IQR 32 to not reached) for SOC-only, not reached (32 to not reached) for SOC + ZA (HR 0.94, 95% CI 0.79-1.11; p=0.450), 81 months (41 to not reached) for SOC + Doc (0.78, 0.66-0.93; p=0.006), and 76 months (39 to not reached) for SOC + ZA + Doc (0.82, 0.69-0.97; p=0.022). There was no evidence of heterogeneity in treatment effect (for any of the treatments) across prespecified subsets. Grade 3-5 adverse events were reported for 399 (32%) patients receiving SOC, 197 (32%) receiving SOC + ZA, 288 (52%) receiving SOC + Doc, and 269 (52%) receiving SOC + ZA + Doc.
Interpretation
Zoledronic acid showed no evidence of survival improvement and should not be part of standard of care for this population. Docetaxel chemotherapy, given at the time of long-term hormone therapy initiation, showed evidence of improved survival accompanied by an increase in adverse events. Docetaxel treatment should become part of standard of care for adequately fit men commencing long-term hormone therapy.
Funding
Cancer Research UK, Medical Research Council, Novartis, Sanofi-Aventis, Pfizer, Janssen, Astellas, NIHR Clinical Research Network, Swiss Group for Clinical Cancer Research.

Link to more details or full-text: http://www.sciencedirect.com/science/article/pii/S0140673615010375

Breast reconstruction changes coping mechanisms in breast cancer survivorship (2016)

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Type of publication:
Conference abstract

Author(s):
*Lake B., *Fuller H.R., *Rastall S., *Usman T.

Citation:
Cancer Research, February 2016, vol./is. 76/4 SUPPL. 1(no pagination)

Abstract:
Introduction
Cancer survivorship is the process of living through and beyond cancer; a key part is how a patient copes with their diagnosis. Breast cancer is the most common malignancy of women worldwide and is known to be a severe stressor. Research has determined that the coping strategies used by women with breast cancer are vital to adjustment to their disease. Immediate breast reconstruction at the time of mastectomy with preservation of the breast form has been shown to be a positive influence on breast cancer patients however there are currently no studies to show whether breast reconstruction changes mechanisms of coping for such patients. The aim of this study, therefore, was to conduct a prospective cohort study to determine whether immediate breast reconstruction following mastectomy changes the way women with breast cancer cope with their diagnosis, compared to those who have mastectomy alone.
Method
A standardised questionnaire, the Brief Cope Scale was sent to two cohorts of patients who had a mastectomy and immediate reconstruction or mastectomy alone over an 11 year period 2003 to 2014 in Shropshire, England. It is a 28-point item with a four point Likert scale, which measures 14 different coping mechanisms: self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning humour, acceptance, religion and self-blame. The inclusion criteria for this study was all woman who had mastectomy with immediate breast reconstruction in Shropshire between 2003 and 2014 for either Ductal carcinoma in situ (DCIS) or breast cancer which was node negative (cohort 1). The principle exclusion criteria were: men, node positive cancer, prophylactic mastectomy and breast reconstruction. Each index patient was matched for year of diagnosis, adjuvant therapy and age to woman who had mastectomy alone for DCIS or breast cancer which was node negative (cohort 2). An anonymous questionnaire was sent out to all patients identified who were still living, with a reminder letter at six weeks.
Results
Questionnaires were sent to a total of 234 patients; 117 patients in each cohort. Preliminary results indicate a response rate of 46%, with 60 responses from reconstruction cohort and 48 from mastectomy. The mean age was 50, with range 29 to 70 for reconstruction cohort, and the mean age of mastectomy cohort was 52, with range 32 to 70. Common coping styles for the reconstruction cohort were acceptance, active coping and use of emotional support. Common coping styles for mastectomy cohort were acceptance, use of emotional support and positive reframing. Significantly more patients from the reconstruction cohort coped by active coping (T value 1.88 at P value 0.02). Significantly less patients coped by active venting in reconstructive cohort compared to mastectomy cohort; (T value 1.91 at P value 0.03).
Conclusion
Breast reconstruction alters coping mechanisms in breast cancer patients allowing less venting coping style and more active coping. Understanding how breast surgery changes coping mechanisms allows clinicians to understand cancer survivorship in breast cancer patients and helps to provide needed support.