2019

Follow up chest radiograph in community acquired pneumonia (CAP)-are we meeting the standards? (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Zeb M.S.; *Hamze H.; *Ali A.; *Annabel M.; *Ahmad N.; *Moudgil H.; *Ibrahim J.; *Srinivasan K.S.; *Crawford E.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2019; vol. 199 (no. 9)

Abstract:
Introduction and objectives CAP accounts for 29,000 deaths per annum in the UK with In-patient mortality of 17.7% [1]. In older population (>65years) associated malignancy is 9.1%. Current guidelines [2] recommend chest radiograph (CXR) follow up 6 weeks after CAP in high risk patients. We aimed to audit our follow up practice with a view to service improvement for early detection of malignancy and complications from CAP. Methods Patients were identified via retrospective review of local database of patients recorded as "CAP" on discharge from 02/01/2017 to 01/31/2018. CXR reports were reviewed using patient archives communication system for radiology and clinical portal. Results 97 patients were identified with discharge diagnoses recorded as "CAP". We excluded patients below 50 years of age (n=7), those without radiographic pneumonia (n= 26), CXR not reported (as patient deceased) (n=2) and patients with CAP who died within 6 weeks of presentation (n=25, mean age 83 years; this included inpatients as well as those died post discharge from hospital). Patients included (n=37). Mean age 74 years. Female patients (n=19, 50.1%). 14 (37.8%) patients had follow up CXR. One of these showed incomplete resolution with no further follow up or investigation arranged. Three patients were considered not suitable for follow up in view of their co-morbidities. 20/37 (58%) patients didn't have appropriate follow up arranged. Conclusion(s): Our results underestimated CAP incidence at secondary level based on the discharge diagnosis of CAP. Mortality in this cohort was high signifying the severity of pneumonia, particularly with increasing age. There was one unresolved consolidation with no lung cancers diagnosed implying small sample size as a limitation in our study. Nevertheless 26 (27%) of patients had clinical diagnosis of CAP with no radiographic evidence. There was heterogeneity in the follow up CXR arrangements with patients shared between hospital specialists and primary care. For improvement we need to ensure appropriate follow up CXR (streamlined by staff education), radiology reports (highlighting the need for repeat CXR) and virtual clinics are arranged.

Link to full-text [no password required]

The multidisciplinary team (MDT) management of chronic obstructive pulmonary disease in the community (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Ali A.; *Khan T.; *Ahmed J.; *Sesan A.; *Moudgil H.; *Makan A.; *Nawaid A.; *Ibrahim J.; *Crawford E.; *Srinivasan K.S.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2019; vol. 199 (no. 9)

Abstract:
Introduction: Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized by progressive airflow limitation that is not fully reversible. It encompasses chronic bronchitis and emphysema. This condition is both treatable and preventable. The incidence of COPD in the UK is estimated to be 3 million out of which 900,000 are diagnosed and 2 million remain undiagnosed. Acute exacerbation of COPD is one of the most common causes of emergency hospital admissions with 115,000 admissions per year with a mortality rate of 12 deaths during hospital stay and 6 dying within 90 days of admission.1&2 In the current state of increased healthcare costs related to hospital admissions, there is a service need to manage patients with long-term conditions in the community through development of specialist teams. The multidisciplinary community team consists of specialist nurses, doctors, therapists and community matrons who deliver services through community clinics, domiciliary visits, pulmonary rehabilitation and MDT meetings[3]. Studies have shown the benefits of promoting self-management and providing care closer to home in terms of reducing unnecessary primary care contacts as well as hospital admissions; thereby reducing mortality [4]. Aim The primary aim was to evaluate the role of MDT in reducing or preventing hospital admissions and secondary aim was to look at overall mortality in this cohort. Method(s): This was a retrospective study looking at the clinical notes and MDT letters for all patients with COPD (with post bronchodilator FEV1 of <70%) discussed in a local MDT meeting at a District General Hospital in the UK. Data on mortality and hospital admissions was obtained from our Clinical Portal, which is an electronic patient information system. Result(s): 151 patients were discussed at the local MDT meeting. 55.6% of females (graph 1) with a mean age of 72 years. After discussion at MDT, the number of hospital admissions were either reduced or remained the same in 65% (n= 98) but only 28% (n=42) of patients had more admissions. Data was not available for 9 patients. 64% (n=96) patients are alive 3 years from the discussion at the MDT meeting. Conclusion(s): Our study suggests that, the approach of community based MDT management of patients with COPD has got the advantage of reducing the healthcare expenditure on this cohort of patients, with no negative effect on mortality. As such, we propose these services to be funded in the near future.

Top research priorities for preterm birth: Results of a prioritisation partnership between people affected by preterm birth and healthcare professionals (2019)

Posted on by

Type of publication:
Journal article

Author(s):
Oliver S.; Uhm S.; Duley L.; Crowe S.; David A.L.; James C.P.; Chivers Z.; Gyte G.; Gale C.; Turner M.; Chambers B.; Dowling I.; McNeill J.; Alderdice F.; Shennan A.; *Deshpande S.

Citation:
BMC Pregnancy and Childbirth; Dec 2019; vol. 19 (no. 1) 528

Abstract:
Background: We report a process to identify and prioritise research questions in preterm birth that are most important to people affected by preterm birth and healthcare practitioners in the United Kingdom and Republic of Ireland. Method(s): Using consensus development methods established by the James Lind Alliance, unanswered research questions were identified using an online survey, a paper survey distributed in NHS preterm birth clinics and neonatal units, and through searching published systematic reviews and guidelines. Prioritisation of these questions was by online voting, with paper copies at the same NHS clinics and units, followed by a decision-making workshop of people affected by preterm birth and healthcare professionals. Result(s): Overall 26 organisations participated. Three hundred and eighty six people responded to the survey, and 636 systematic reviews and 12 clinical guidelines were inspected for research recommendations. From this, a list of 122 uncertainties about the effects of treatment was collated: 70 from the survey, 28 from systematic reviews, and 24 from guidelines. After removing 18 duplicates, the 104 remaining questions went to a public online vote on the top 10. Five hundred and seven people voted; 231 (45%) people affected by preterm birth, 216 (43%) health professionals, and 55 (11%) affected by preterm birth who were also a health professional. Although the top priority was the same for all types of voter, there was variation in how other questions were ranked. Following review by the Steering Group, the top 30 questions were then taken to the prioritisation workshop. A list of top 15 questions was agreed, but with some clear differences in priorities between people affected by preterm birth and healthcare professionals. Conclusion(s): These research questions prioritised by a partnership process between service users and healthcare professionals should inform the decisions of those who plan to fund research. Priorities of people affected by preterm birth were sometimes different from those of healthcare professionals, and future priority setting partnerships should consider reporting these separately, as well as in total.

Link to full-text [Open Access - no password required]

Altmetrics:

Identification of a thra mutation in a 2yr old child with clinical features of hypothyroidism and multisystem involvement (2019)

Posted on by

Type of publication:
Conference abstract

Author(s):
*Sakremath R.; Moran C.; Lyons G.; Chatterjee K.; Rajanayagam O.; Boelaert K.; Mohamed Z.

Citation:
Hormone Research in Paediatrics; Sep 2019; vol. 91 ; p. 272

Abstract:
Background: Thyroid hormones act via receptors (TRalpha; TRbeta) encoded by separate genes (THRA, THRB). Mutations in THRA are a recently-recognised cause of Resistance to Thyroid Hormone alpha (RTHalpha), a disorder with tissue-specific hypothyroidism but near-normal thyroid function tests. Aim(s): We describe the youngest recorded case of RTHalpha, in a 2yr old boy with disproportionate short stature, global developmental delay, constipation and a heterozygous missense mutation (p.G291S) in THRA. Case Report: A 16-month old male was referred to endocrine clinic with short stature. He had disproportionate stature with reduced subischial leg length (Table 1). He is in care, with a maternal antenatal history of substance abuse (exposure to methadone, heroine and alcohol in utero). He has global developmental delay and is mildly dysmorphic with constipation, all attributed to chromosome 16p13.11 microduplication. Examination revealed coarse facial appearance, depressed nasal bridge, long philtrum and central hypotonia. He had delayed visual maturation, hypermetropia, small kidneys and gastroesophageal reflux. His motor milestones (unable to sit without support) and speech are delayed. Laboratory analysis revealed normocytic anaemia, elevated creatine kinase levels, low-normal T4 and elevated T3 levels leading to altered T4:T3 ratio, with normal TSH levels. THRA sequencing identified a heterozygous missense (p.G291S) mutation, which is homologous to a known pathogenic mutation in THRB (G345S), causing RTHbeta. Correlation of genotype with phenotype and assessment of response to thyroxine therapy (25mcg/day) is being undertaken. Conclusion(s): We suggest that THRA sequencing should be considered in patients with clinical features of hypothyroidism, raised CK, anaemia and near-normal thyroid function tests but altered T4:T3 ratio. This case broadens the phenotypic spectrum of RTHalpha. (Table Presented).

Link to full-text [no password required]

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

Posted on by

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.

Link to full-text [NHS OpenAthens account required]

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

Posted on by

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.

Link to full-text [NHS OpenAthens account required]

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

Posted on by

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.

Link to full-text [NHS OpenAthens account required]

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)

Posted on by

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.

Link to full-text [open access, no password required]

Altmetrics:

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

Posted on by

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.

Link to full-text [Open access, no password required]

Altmetrics:

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

Posted on by

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.

Full-text available [Open access - no password required]

Altmetrics: