Heart of England: HEFT Repository
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Carvedilol versus endoscopic band ligation for secondary prophylaxis of variceal bleeding-long-term follow-up of a randomised control trial.
No full textBACKGROUND AND AIMS
Carvedilol reduces rates of variceal bleeding and rebleeding by lowering portal pressure. However, an associated pleiotropic survival benefit has been proposed. We aimed to assess long-term survival in a cohort of patients previously randomised to receive either carvedilol or endoscopic band ligation (EBL) following oesophageal variceal bleeding (OVB).
METHODS
The index study randomised 64 cirrhotic patients with OVB between 2006 and 2011 to receive either carvedilol or EBL. Follow-up was undertaken to April 2020 by review of electronic patient records. The primary outcome was survival. Other outcomes including variceal rebleeding and liver decompensation events were compared.
RESULTS
26 out of 33 participants received carvedilol in the follow-up period and 28 out of 31 attended regular EBL sessions. The median number of follow-up days for all patients recruited was 1459 (SE = 281.74). On the intention to treat analysis, there was a trend towards improved survival in the carvedilol group (p = 0.09). On per-protocol analysis, carvedilol use was associated with improved long-term survival (p = 0.005, HR 3.083, 95% CI 1.397-6.809), fewer liver-related deaths (0% vs 22.57%, p = 0.013, OR ∞, 95%CI 1.565-∞) and fewer admissions with decompensated liver disease (12% vs 64.29%, p = 0.0002, OR 13.2, 95% CI 3.026-47.23) compared to the EBL group. There was no statistically significant difference in variceal rebleeding rates.
CONCLUSION
Following OVB in cirrhotic patients, carvedilol use is associated with survival benefit, fewer liver-related deaths and fewer hospital admissions with decompensated liver disease. Further studies are needed to validate this finding
The move towards integrated care: Lessons learnt from managing patients with multiple morbidities in the UK.
No full textINTRODUCTION
The multi-disciplinary care offered to patients with multi-morbidities offers a powerful example of the practical challenges faced by the National Health Service's planned move to more closely integrated models of care.
PURPOSE, OBJECTIVE, AND CONTRIBUTIONS
The intention of this work was to identify the opportunities and obstacles presented by the current provision of integrated care and explore their implications for existing and future policy initiatives.
MATERIALS AND METHODS
We conducted a qualitative exploration of the experiences of senior managers, commissioners and clinicians, using a post-hoc content analysis to populate and present the results within the multi-componential Sustainable integrated chronic care model for multi-morbidity: delivery, financing, and performance (SELFIE) framework designed to understand integrated care.
RESULTS
A total of 13 senior medical directors, commissioners, and managers, and 15 clinicians from a range of care settings were interviewed. Relative factors within the six framework components were identified namely; issues around communication between settings (Service delivery), the importance of collaborative leadership (Leadership & governance); the need for high-level collaboration (Workforce), better directed financial incentives (Financing), the lack of software interoperability (Technologies and medical products) and constraints on sharing and utilising patient data (Information & Research).
CONCLUSIONS
The SELFIE framework has provided valuable insight into the challenges presented by inter-organisational and inter-professional working that will help guide the design and implementation of policies promoting integrated care. These may be mitigated by sharing the varied experiences and priorities that exist across primary and care settings, alongside improving communication and supporting collaborative leadership. There also appears a clear role for refocussing financial incentives to reward shared responsibility at all levels of service delivery
Resuscitation highlights in 2021.
No full textBACKGROUND
This review is the latest in a series of regular annual reviews undertaken by the editors and aims to highlight some of the key papers published in Resuscitation during 2021.
METHODS
Hand-searching by the editors of all papers published in Resuscitation during 2021. Papers were selected based on then general interest and novelty and were categorised into themes.
RESULTS
98 papers were selected for brief mention.
CONCLUSIONS
Resuscitation science continues to evolve and incorporates all links in the chain of survival
Global Current Practice Patterns for the Management of Central Retinal Artery Occlusion.
No full textGlobal practice paradigms for central retinal artery occlusion (CRAO) were summarized. Responses were collected from specialists via survey. Management patterns for CRAO rely on physician and center-level preferences given the lack of evidence-based international guidelines
The impact of the COVID-19 pandemic on application of European Society of Cardiology (ESC) guidelines for exercise in adults with CHD: a data-based questionnaire.
No full textINTRODUCTION
Regular physical activity is safe and effective therapy for adults with CHD and is recommended by European Society of Cardiology guidelines. The COVID-19 pandemic poses enormous challenges to healthcare teams and patients when ensuring guideline compliance. We explored the implications of COVID-19 on physical activity levels in adult CHD patients.
MATERIALS AND METHODS
A data-based questionnaire was distributed to adult CHD patients at a regional tertiary centre from October to November 2020.
RESULTS
Prior to the COVID-19 pandemic, 96 (79.3%) of 125 respondents reported participating in regular physical activity, with 66 (52.8%) meeting target levels (moderate physical activity for at least 150 minutes per week). Commonest motivations for physical activity were general fitness (53.6%), weight loss (36.0%), and mental health benefits (30.4%). During the pandemic, the proportion that met target levels significantly decreased from 52.8% to 40.8% (p = 0.03). The commonest reason was fear of COVID-19 (28.0%), followed by loss of motivation (23.2%) and gym/fitness centre closure (15.2%).
DISCUSSION
The COVID-19 pandemic has negatively impacted exercise levels of adult CHD patients. Most do not meet recommended physical activity levels, mainly attributable to fear of COVID-19. Even before the pandemic, only half of respondents met physical activity guidelines. Availability of online classes can positively impact exercise levels so could enhance guideline compliance. This insight into health perceptions and behaviours of adult CHD patients may help develop quality improvement initiatives to improve physical activity levels in this population
Reverse-Transcriptase Loop-Mediated Isothermal Amplification Has High Accuracy for Detecting Severe Acute Respiratory Syndrome Coronavirus 2 in Saliva and Nasopharyngeal/Oropharyngeal Swabs from Asymptomatic and Symptomatic Individuals.
No full textPrevious studies have described reverse-transcriptase loop-mediated isothermal amplification (RT-LAMP) method for the rapid detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in nasopharyngeal and oropharyngeal swab and saliva samples. This study describes the validation of an improved sample preparation method for extraction-free RT-LAMP and defines the clinical performance of four different RT-LAMP assay formats for detection of SARS-CoV-2 within a multisite clinical evaluation. Direct RT-LAMP was performed on 559 swabs and 86,760 saliva samples and RNA RT-LAMP on extracted RNA from 12,619 swabs and 12,521 saliva samples from asymptomatic and symptomatic individuals across health care and community settings. For direct RT-LAMP, overall diagnostic sensitivity (DSe) of 70.35% (95% CI, 63.48%-76.60%) on swabs and 84.62% (95% CI, 79.50%-88.88%) on saliva was observed, with diagnostic specificity of 100% (95% CI, 98.98%-100.00%) on swabs and 100% (95% CI, 99.72%-100.00%) on saliva when compared with RT-qPCR; analyzing samples with RT-qPCR ORF1ab C values of ≤25 and ≤33, DSe values of 100% (95% CI, 96.34%-100%) and 77.78% (95% CI, 70.99%-83.62%) for swabs were observed, and 99.01% (95% CI, 94.61%-99.97%) and 87.61% (95% CI, 82.69%-91.54%) for saliva, respectively. For RNA RT-LAMP, overall DSe and diagnostic specificity were 96.06% (95% CI, 92.88%-98.12%) and 99.99% (95% CI, 99.95%-100%) for swabs, and 80.65% (95% CI, 73.54%-86.54%) and 99.99% (95% CI, 99.95%-100%) for saliva, respectively. These findings demonstrate that RT-LAMP is applicable to a variety of use cases, including frequent, interval-based testing of saliva with direct RT-LAMP from asymptomatic individuals who may otherwise be missed using symptomatic testing alone
Metformin and risk of age-related macular degeneration in individuals with type 2 diabetes: a retrospective cohort study.
No full textBACKGROUND
Age-related macular degeneration (AMD) in its late stages is a leading cause of sight loss in developed countries. Some previous studies have suggested that metformin may be associated with a reduced risk of developing AMD, but the evidence is inconclusive.
AIMS
To explore the relationship between metformin use and development of AMD among patients with type 2 diabetes in the UK.
METHODS
A large, population-based retrospective open cohort study with a time-dependent exposure design was carried out using IQVIA Medical Research Data, 1995-2019. Patients aged ≥40 with diagnosed type 2 diabetes were included.The exposed group was those prescribed metformin (with or without any other antidiabetic medications); the comparator (unexposed) group was those prescribed other antidiabetic medications only. The exposure status was treated as time varying, collected at 3-monthly time intervals.Extended Cox proportional hazards regression was used to calculate the adjusted HRs for development of the outcome, newly diagnosed AMD.
RESULTS
A total of 173 689 patients, 57% men, mean (SD) age 62.8 (11.6) years, with incident type 2 diabetes and a record of one or more antidiabetic medications were included in the study. Median follow-up was 4.8 (IQR 2.3-8.3, range 0.5-23.8) years. 3111 (1.8%) patients developed AMD. The adjusted HR for diagnosis of AMD was 1.02 (95% CI 0.92 to 1.12) in patients prescribed metformin (with or without other antidiabetic medications) compared with those prescribed any other antidiabetic medication only.
CONCLUSION
We found no evidence that metformin was associated with risk of AMD in primary care patients requiring treatment for type 2 diabetes
PICaSSO Histologic Remission Index (PHRI) in ulcerative colitis: development of a novel simplified histological score for monitoring mucosal healing and predicting clinical outcomes and its applicability in an artificial intelligence system.
No full textHistological remission is evolving as an important treatment target in UC. We aimed to develop a simple histological index, aligned to endoscopy, correlated with clinical outcomes, and suited to apply to an artificial intelligence (AI) system to evaluate inflammatory activity.
METHODS
Using a set of 614 biopsies from 307 patients with UC enrolled into a prospective multicentre study, we developed the Paddington International virtual ChromoendoScopy ScOre (PICaSSO) Histologic Remission Index (PHRI). Agreement with multiple other histological indices and validation for inter-reader reproducibility were assessed. Finally, to implement PHRI into a computer-aided diagnosis system, we trained and tested a novel deep learning strategy based on a CNN architecture to detect neutrophils, calculate PHRI and identify active from quiescent UC using a subset of 138 biopsies.
RESULTS
PHRI is strongly correlated with endoscopic scores (Mayo Endoscopic Score and UC Endoscopic Index of Severity and PICaSSO) and with clinical outcomes (hospitalisation, colectomy and initiation or changes in medical therapy due to UC flare-up). A PHRI score of 1 could accurately stratify patients' risk of adverse outcomes (hospitalisation, colectomy and treatment optimisation due to flare-up) within 12 months. Our inter-reader agreement was high (intraclass correlation 0.84). Our preliminary AI algorithm differentiated active from quiescent UC with 78% sensitivity, 91.7% specificity and 86% accuracy.
CONCLUSIONS
PHRI is a simple histological index in UC, and it exhibits the highest correlation with endoscopic activity and clinical outcomes. A PHRI-based AI system was accurate in predicting histological remission
Diagnostic test accuracy network meta-analysis methods: A scoping review and empirical assessment.
No full textOBJECTIVE
To a) identify methodological and application papers reporting a model developed specifically for diagnostic test accuracy network meta-analysis (DTA-NMA) or a hierarchical meta-regression method for comparing at least three index tests; b) review and summarize the characteristics of the methods and the application papers; and c) compare DTA-NMA and hierarchical meta-regression methods empirically.
STUDY DESIGN AND SETTINGS
We performed a scoping review and searched major databases until 3 March 2021. We assessed the characteristics of the identified methods, conducted a descriptive analysis of characteristics of the application articles, and applied the DTA-NMA and meta-regression methods to the available data.
RESULTS
We included 49 articles, of which 9 were methodological (describing 11 DTA-NMA methods) and 40 were application papers (data available for 32 DTA-NMAs). Our results showed a steep increase in recent years in DTA-NMA publications. DTA-NMA models may lead to different results. Although sensitivity estimates were comparable between meta-regression and DTA-NMA models, specificity estimates were higher in meta-regression.
CONCLUSIONS
The choice of a DTA-NMA model will depend on the available data, including the use of different thresholds for test positivity, different study designs, and software familiarity. Selection between the methods may impact on the NMA results, especially for specificity
SARS-CoV-2 antigen lateral flow tests for detecting infectious people: linked data analysis.
No full textOBJECTIVES
To investigate the proportion of lateral flow tests (LFTs) that produce negative results in those with a high risk of infectiousness from SARS-CoV-2, to investigate the impact of the stage and severity of disease, and to compare predictions made by influential mathematical models with findings of empirical studies.
DESIGN
Linked data analysis combining empirical evidence of the accuracy of the Innova LFT, the probability of positive viral culture or transmission to secondary cases, and the distribution of viral loads of SARS-CoV-2 in individuals in different settings.
SETTING
Testing of individuals with symptoms attending NHS Test-and-Trace centres across the UK, residents without symptoms attending municipal mass testing centres in Liverpool, and students without symptoms screened at the University of Birmingham.
PARTICIPANTS
Evidence for the sensitivity of the Innova LFT, based on 70 individuals with SARS-CoV-2 and LFT results. Infectiousness was based on viral culture rates on 246 samples (176 people with SARS-CoV-2) and secondary cases among 2 474 066 contacts; distributions of cycle threshold (Ct) values from 231 497 index individuals attending NHS Test-and-Trace centres; 70 people with SARS-CoV-2 detected in Liverpool and 62 people with SARS-CoV-2 in Birmingham (54 imputed).
MAIN OUTCOME MEASURES
The predicted proportions who were missed by LFT and viral culture positive and missed by LFT and sources of secondary cases, in each of the three settings. Predictions were compared with those made by mathematical models.
RESULTS
The analysis predicted that of those with a viral culture positive result, Innova would miss 20% attending an NHS Test-and-Trace centre, 29% without symptoms attending municipal mass testing, and 81% attending university screen testing without symptoms, along with 38%, 47%, and 90% of sources of secondary cases. In comparison, two mathematical models underestimated the numbers of missed infectious individuals (8%, 10%, and 32% in the three settings for one model, whereas the assumptions from the second model made it impossible to miss an infectious individual). Owing to the paucity of usable data, the inputs to the analyses are from limited sources.
CONCLUSIONS
The proportion of infectious people with SARS-CoV-2 missed by LFTs is substantial enough to be of clinical importance. The proportion missed varied between settings because of different viral load distributions and is likely to be highest in those without symptoms. Key models have substantially overestimated the sensitivity of LFTs compared with empirical data. An urgent need exists for additional robust well designed and reported empirical studies from intended use settings to inform evidence based policy