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Domiciliary subcutaneous furosemide in patients with CKD and HF: a quality improvement project
Get PDFHospital admissions to treat fluid overload are common in patients with both heart failure and chronic kidney disease (CKD-HF). This is a population with high levels of frailty. Recurrent hospital admissions are costly to both patients and healthcare systems. We designed a proof-of-concept, multidisciplinary quality improvement project to deliver at-home subcutaneous furosemide to treat fluid overload in patients with CKD-HF. This project involved collaboration between a hospital, community remote monitoring hub and hospital-at-home team, including general practitioners, secondary care physicians, nurses and pharmacists. Patients were considered suitable for the intervention if they had CKD-HF, fluid overload and were haemodynamically stable. Following review, suitable patients were treated at-home with 80 mg subcutaneous furosemide over 5 hours, for 5 days. This was administered by the hospital-at-home team in liaison with hospital specialists, with continuous patient monitoring provided by the remote monitoring hub. Renal function and weight were assessed daily. Following treatment, patients were reviewed by the secondary-care team to adjust their maintenance medications. Data collected and analysed included daily weights, renal function and observations, as well as the number of hospitalisations and/or death at 30 days following the intervention. 10 patients successfully completed treatment. All potentially required hospitalisation at baseline and all avoided hospitalisation during the 5-day course of subcutaneous furosemide. One patient was admitted to the hospital following their final hospital review, and two patients were hospitalised for 4 and 14 days respectively, after their final dose of subcutaneous furosemide. Renal function and potassium did not significantly change throughout the treatment. No major safety concerns were identified. Patients welcomed the intervention. This quality improvement project demonstrates that it is logistically feasible, with primary care collaboration, to treat fluid overload in patients with CKD-HF at-home using subcutaneous furosemide
How Epilepsy risks might be introduced and discussed in clinical consultations
No full textAdverse impacts of epilepsy (e.g., injury, depression, and Sudden Unexpected Death from Epilepsy (SUDEP) can be mitigated by factors that patients may control, such as medication adherence, improved sleep and diet, reduced alcohol and taking care around pregnancy. New guidelines state that risk should be discussed at the time of diagnosis but some clinicians express concern about not wanting to raise anxiety.
Objective
To explicate practices by which epilepsy expert clinicians broach discussions of risk in specialist epilepsy clinics.
Methods
24 recordings of initial telephone appointments at specialist clinics where epilepsy is diagnosed from two specialist outpatient epilepsy services in England were subjected to Conversation Analysis. Data in British English. A single case study, identified as largely typical of the data set but also highlighting points of interest, is included to illustrate the findings.
We also present reflections from analysis of 12 extracts examined in joint-analysis sessions with clinicians, researchers and patients.
Results
The analysis revealed that broaching risk was sensitive and challenging. Conversations involved confronting confusion about risk and negotiation between clinician and patient. Clinicians employ questions to establish the patient’s knowledge. They were ‘repair implicative’ that is including lots of changes of sentence direction to achieve mutual understanding (intersubjectivity). Further, the Joint-Analysis highlighted the significance of epistemic matters - who knows what and how.
Conclusion
Clinicians invite patients to share what they know about risk as a springboard for discussing behaviour change, enabling them to avoid naming specific risks (such as death). However, this often led to interactional trouble, and patients expressed a preference for more direct conversations.
Practice Implications
Clinicians can carefully calibrate risk information according to what the patient with epilepsy already knows, sensitively broaching risk of death. However, caution is needed to maximise patient engagement in risk management discussions
Multisystemic, Possibly Familial Sarcoidosis Ameliorated by an mTOR Inhibitor
Get PDFBACKGROUND: Sarcoidosis is an inflammatory, multisystemic, potentially life-threatening disease with a precise etiology that remains largely unknown. It is characterized by granuloma formation in various organs that can lead to permanent organ scarring and failure. Currently there is no curative treatment. Traditional drug interventions target reduction of inflammation and symptom control and have not shown definitive proof of a survival benefit. CASE SUMMARY: We present the cases of a mother and son treated for chronic aggressive multiorgan sarcoidosis with sirolimus, a mammalian target of rapamycin (mTOR) inhibitor. Both patients experienced a marked reversal of inflammation in their respective affected organs coupled with profound symptom relief. CONCLUSIONS: Inhibition of mTOR may be an effective, safe treatment option for patients with conventional-drug-resistant forms of systemic sarcoidosis
Interpreting whole-genome sequencing data during neonatal Klebsiella oxytoca complex outbreak management
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K. oxytoca generally has a benign susceptibility profile and low virulence but can cause invasive infections in vulnerable populations, like preterm infants. We aim to describe how whole-genome sequencing (WGS) was used to inform management of a prolonged K. oxytoca outbreak on a neonatal intensive care unit (NICU) and implications for outbreak response involving similar organisms.
Methods
We retrospectively reviewed outbreak-associated clinical and environmental isolates from a Swiss NICU. WGS was used to track evolution of resistance and highlighted multiple concurrent outbreaks. WGS was performed using a MiSeq or NextSeq 500 Illumina sequencer. The resulting genome sequences were analysed using Ridom SeqSphere. The current report conforms to ORION reporting guidelines.
Results
Of 152 Klebsiella spp. patient-derived isolates, 83 were genotyped using WGS, along with six environmental isolates. This confirmed two outbreak waves (November 2021-February 2022, ST18 wildtype; July 2022-June 2023, main cluster ST18 KI β-lactamase hyperproducer), with multiple genotypically connected clusters during the second wave. Confirmed sepsis (K. oxytoca ST18 wildtype) occurred in four preterm or low birthweight infants. Twins presented a genotypically identical ST with a different susceptibility phenotype (ST18 wildtype vs. K1 OXY-hyperproducer). WGS combined with epidemiological investigation and environmental sampling identified an environmental source. There was a second outbreak wave after source removal, presumably due to the prolonged presence of colonised infants with typically long NICU stays and insufficient standard infection prevention and control measures to prevent transmission.
Conclusion
WGS use in NICU outbreaks involving low-virulence bacteria can support identification and removal of potentiating environmental sources. These measures, however, will often be insufficient to contain the outbreak, and ongoing WGS surveillance of ubiquitous species may uncover multiple concurrent outbreaks, presumably driven by continuing transfer-transmission between different sources and infants in the NICU. Maximising standard infection prevention and control (IPC) measures is appropriate in this context
Evaluating the Risk of Hypophosphatemia with Ferric Carboxymaltose and the Recommended Approaches for Management: A Consensus Statement
Get PDFBackground/Objectives: The development of hypophosphatemia has been associated with intravenous iron products, with the rate of hypophosphatemia found to be higher with ferric carboxymaltose. This consensus statement provides clinical guidance on the risk of hypophosphatemia development with ferric carboxymaltose and the approaches for management. To develop consensus recommendations regarding the clinical implications of hypophosphatemia after the administration of ferric carboxymaltose, the assessment of patient risk profile, and recommended approaches for risk reduction. Methods: Consensus statements were developed from an in-person meeting of specialists with expertise in iron pathophysiology and iron therapy and further supplemented with literature review. The multidisciplinary expert panel comprised global iron specialists spanning anesthesiology, cardiology, gastroenterology, obstetrics/gynecology, hematology, nephrology, and iron molecular biology. Structured discussions were held in an in-person meeting to gather expert opinion on the evidence base regarding intravenous iron and hypophosphatemia. Consolidated summary opinions underwent further iterations of panel review to form consensus recommendation statements. Results: The expert panel developed the following consensus statements: (1) Routine serum phosphate level measurement is not recommended for low-risk patients before or after treatment with ferric carboxymaltose, as most cases of hypophosphatemia that occur following the administration of ferric carboxymaltose are asymptomatic and transient; (2) patients receiving ferric carboxymaltose should be assessed for the degree of risk for developing symptomatic or severe hypophosphatemia prior to administration; (3) monitoring serum phosphate is recommended for patients at an increased risk for developing low serum phosphate or who require repeated courses of ferric carboxymaltose treatment at higher doses; (4) prophylactic oral phosphorus after ferric carboxymaltose is unlikely to effectively elevate phosphate and is not recommended for routine clinical practice; and (5) hypophosphatemic osteomalacia is rare and the risk of development after the administration of ferric carboxymaltose, in particular single infusion, is low. Conclusions: Hypophosphatemia following ferric carboxymaltose is predominantly asymptomatic and transient. Individuals at higher risk for developing hypophosphatemia with ferric carboxymaltose treatment include those who receive multiple infusions, higher cumulative doses, or long-term iron treatment or who have underlying clinical risk factors. These consensus statements provide structured guidance on the risk of hypophosphatemia with ferric carboxymaltose and the approaches to clinical management
Protocol for a first-in-human feasibility study of T regulatory cells (TR004) for inflammatory bowel disease using (ex vivo) Treg expansion (TRIBUTE).
Get PDFINTRODUCTION: Crohn's disease (CD) is a chronic, immune-mediated inflammatory bowel disease (IBD), presenting with symptoms of abdominal pain and bleeding from the gastrointestinal tract. There is no known cure. In vitro-expanded 'thymus-derived' regulatory T cells (tTreg) have shown promise in preclinical models of IBD, leading to interest in their use as a potential therapy in CD. We present a study protocol for a first-in-human study of Tregs for IBD using ex vivo Treg expansion. This study will explore the preliminary safety and tolerability of a single dose of Treg immunotherapy and will inform the design of a subsequent larger trial. METHODS AND ANALYSIS: Four patients will be recruited from gastroenterology clinics at Guy's and St Thomas' NHS Foundation Trust. Eligible participants are those who are at least 18 years old, have a diagnosis of active moderate to severe CD and have failed to respond to or tolerate at least two prior lines of standard medication. Participants receive a single dose of autologous ex vivo-expanded Tregs and will be followed up to week 21 to collect safety and exploratory efficacy data. Additional safety monitoring will occur at 1 and 2 years post-dose. The primary endpoint is defined as the occurrence of dose-limiting toxicity occurring within 5 weeks post-infusion. ETHICS AND DISSEMINATION: The study protocol and related documents have been approved by a NHS Research Ethics Committee, the Health Research Authority and the Medicines and Healthcare products Regulatory Agency for Clinical Trial Authorisation. It is intended that the results of the trial will be presented at international conferences and will be submitted for publication in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER: NCT03185000
Supporting someone after their stroke: family members' views and experiences of self-management
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Self-management has increased in recognition in stroke research and rehabilitation along with growing trends of shorter hospital stays and more patient-centred care. Family members are key persons in the self-management process, but their views and experiences of self-management have not been studied in detail. This study aimed to explore family members’ understanding of self-management, the strategies they use and the challenges they face when providing support.
Methods
For this descriptive study, semi-structured interviews with family members (n = 27) were conducted. Data were analysed using inductive content analysis.
Results
The analysis resulted in three main categories and eight subcategories. Most family members saw self-management as performing practical tasks, such as daily living activities and rehabilitation training. However, family members described a broad range of actions to support self-management, including emotional and motivational support. They found it challenging to give the right amount of support and expressed a need of more information after discharge.
Conclusions
Family members’ conceptualisations of self-management differ from the strategies they use to provide support. A clearer understanding of self-management as a collective process can benefit the development and delivery of efficient self-management support
Mental Health Trajectories of Men and Women Who Start Providing Personal Care: European Findings From SHARE Using Propensity Score Matching
Get PDFObjectives
We examine the mental health trajectories of people who start providing personal care and compare their trajectories with matched controls who remain non-carers. We also investigate whether trajectories vary by gender, financial resources, and supportive long-term care policies.
Methods
Using 9 waves of the Survey of Health, Ageing, and Retirement in Europe, collected in 28 European countries from 2004 to 2022, we analyze longitudinal data from 68,075 men and women aged 50 or older. We identify transitions into regular personal care within the household and use depressive symptoms from up to 4 waves before and after transitioning into care to measure mental health trajectories. Financial resources are measured by household wealth, whereas 3 macro indicators assess (1) support for caregivers, (2) support for care recipients, and (3) public care service availability. Propensity score matching, applied separately for men and women, identifies matched noncaregivers from the same country, and we use piecewise growth curve models to examine changes before, during, and after becoming a carer.
Results
Both men and women have a clear increase in depressive symptoms when becoming a regular carer, and this increase even begins before the transition. The increase during the transition is slightly more pronounced for women and those with lower wealth, but we find no systematic differences by policy indicators.
Discussion
Our study highlights the need for improved support for carers. Although national policies may influence the likelihood of becoming a carer, their effectiveness in mitigating the mental health impact of caring remains unclear
The KNEE study: A prospective multicentre observational study of 459 fractures around the knee in older patients
No full textBackground
The KNEE Study is a prospective multicentre service evaluation examining the current UK management of fragility fractures around the knee. It aims to describe operative decision making, causes of treatment delays, weight-bearing strategies, and post-operative management.
Methods
Data were prospectively collected across a 4-month period via a collaborative approach. All patients aged >60 with a fracture of the proximal tibia or distal femur were included. Data collected include injury classification, operative vs non-operative management, time to theatre, post-operative weight bearing, and post-operative optimisation as per BOAST guidelines for frail older patients.
Results
Data were available for 459 patients across 39 centres. This included 252 distal femoral fractures, and 207 proximal tibial fractures. Distal femoral fractures were significantly older (81.5 vs 73.3), had poorer mobility (42 % mobile ≤1 stick vs 79 %), and were more comorbid (median charlson co-morbidity index 5 vs 3) than proximal tibial fractures. Operative management was undertaken in 292/459 cases (198/252 femur, 94/207 tibia). When operative management was undertaken, there was a delay >36 hours to theatre in 62.8 % of cases. The main reasons for this were theatre capacity (42.6 %) and availability of a specialist surgeon (25.1 %). Only 11.5 % of cases were delayed pending medical optimisation or anticoagulant reversal. Patients managed operatively were significantly more likely to weight-bear on the first day post treatment (69.5 % vs 55.8 %). Operatively managed patients were significantly more likely to receive post-operative standards of care including Geriatric review, physio assessment, and bone health assessment.
Conclusion
Early return to weight bearing and ongoing secondary prevention are core tenants in the management of fragility fractures. Management of fragility fractures around the knee continues to lag behind that of hip fractures, with lower rates of weight bearing, slower access to theatre, and poorer post-operative care
Does the extent of neck surgery based on preoperative calcitonin level influence survival in medullary thyroid carcinoma: a retrospective tertiary centre experience
Get PDFIntroduction
Medullary thyroid carcinoma (MTC) is a rare thyroid cancer arising from the calcitonin-secreting parafollicular cells. Previous studies suggested a preoperative calcitonin level >200ng/l is an indication for prophylactic lateral neck dissection (LND) to remove micrometastases and improve survival outcomes.
Methods
This retrospective single-centre study assessed the efficacy of preoperative calcitonin levels as a marker for determining need for prophylactic LND in MTC. Data were obtained on demographics, preoperative calcitonin levels, size and laterality of index tumour, type of neck dissection (central neck dissection (CND), LND), nodes removed, levels with involved nodes, number of nodes histologically involved, mortality, adjuvant therapy and locoregional recurrence.
Results
A total of 33 patients were identified from St George's University Hospitals NHS Foundation Trust between 1 January 2001 and 19 August 2021; 8 were excluded for data quality issues. Of the 18 classified with a high preoperative calcitonin level (>200ng/l), 10 (56%) had a LND and 8 (44%) had a CND. In the low-calcitonin group, three (43%) patients had a CND only and four (57%) had a LND. There was no difference in absolute or disease-free survival between the low and high groups (p=0.960, p=0.817), or between those who had a CND and LND in the high-calcitonin group (p=0.607, hazard ratio (HR) 0.55; p=0.129, HR 8.78).
Conclusion
There was no statistically significant difference in outcomes between high and low calcitonin groups. A selective approach to performing LND in MTC patients based on clinical and imaging findings suggesting disease presence in the lateral neck should be explored further
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