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The Severe Asthma Questionnaire: sensitivity to change and minimal clinically important difference (MCID).
No full text
A time-sensitive analysis of the prognostic utility of vasopressor dose in septic shock.
No full textIt is unclear whether the association between vasopressor dose and mortality is affected by duration of administration. We examined whether prognostication in septic shock is feasible through the use of daily median vasopressor doses. We undertook a single-centre retrospective cohort study. We included patients with a diagnosis of septic shock admitted to the intensive care unit at Queen Elizabeth Hospital, Birmingham, UK, between April 2016 and July 2019. The primary outcome measure was 90-day mortality. We defined vasopressor dose as the median norepinephrine equivalent dose (equivalent infusion rates of all vasopressors and inotropes) recorded for each day, for the first four days of septic shock. We divided patients into groups by vasopressor dose quintiles and calculated their 90-day mortality rate. We examined area under the receiver operator characteristic curves for prognostic ability. In total, 844 patients were admitted with septic shock and had a 90-day mortality of 43% (n = 358). Over the first four days, median vasopressor dose decreased in 93% of survivors and increased in 56% of non-survivors. The mortality rate associated with a given vasopressor dose quintile increased on sequential days of septic shock. The area under the receiver operator characteristic curves of daily median vasopressor dose against mortality increased from day 1 to day 4 (0.67 vs. 0.86, p 0.05 μg.kg .min had an 80% sensitivity and specificity for mortality. The prognostic utility of vasopressor dose improved considerably with shock duration. Prolonged administration of small vasopressor doses was associated with a high attributable mortality
Current practice and registration patterns among United Kingdom Haemophilia Centre Doctors' Organisation centers for patients with unclassified bleeding disorders.
No full textBACKGROUND
Bleeding of unknown cause (BUC) and unclassified bleeding disorders (UBD) are increasingly recognized. There is no guidance on diagnosis and management.
OBJECTIVES
To examine UK haemophilia centre registration patterns and current practice for UBD patients.
METHODS
In a two-step process, the UK National Haemophilia Database (NHD) was reviewed for registration patterns of UBD patients and a survey of UK haemophilia centers was conducted (January/February 2021) to capture current practice for diagnosis and management of patients with UBD.
RESULTS/DISCUSSION
Overall, registrations with the NHD for UBD patients has sharply risen from 2012 to 2020 and in 2019 accounted for 2.65% of registered patients. For the survey, the response rate was 52/67 (78%). Practice was widely variable; 35/52 (67%) centers register UBD; among these 35 centers, terminology included UBD (28 centers), undiagnosed bleeding disorder (four centers), and BUC (three centers); 34/52 (65%) centers use a formal bleeding assessment tool. For management of dental extraction and high bleeding risk surgery in a fictional UBD patient we found that tranexamic acid was widely used; however, beyond this a variety of hemostatic products were advised including blood products, recombinant factor VIIa/prothrombin complex concentrate, and desmopressin. There was general consensus (≈90%) on avoiding regional anesthesia in pregnancy, but no agreement on the need for fetal precautions to avoid bleeding at delivery (50% would advise these). There was a disparity of opinion on chemical thromboprophylaxis, and management of patients without prior hemostatic challenges and offspring of these patients.
CONCLUSION
This study provides a snapshot of current practice and real-world data in this area. Future studies need to address the gaps in evidence
Inter- and Intra-individual Variation, and Limited Prognostic Utility, of Serum Alkaline Phosphatase in a Trial of Patients With Primary Sclerosing Cholangitis.
No full textBACKGROUND & AIMS
Serum alkaline phosphatase (ALP) and the enhanced liver fibrosis (ELF) score are used as endpoints in trials of patients with primary sclerosing cholangitis (PSC). We aimed to quantify inter- and intra-individual variation in levels of ALP and the ELF score over time, and evaluated their association with fibrosis progression.
METHODS
We analyzed data from 234 patients with large-duct PSC enrolled in a 2-year, phase 2b placebo-controlled trial of simtuzumab. Participants were assessed by laboratory tests every 4 weeks, and liver biopsies collected at time of screening, week 48, and week 96.
RESULTS
Serum levels of ALP and ELF scores did not differ significantly between simtuzumab and placebo groups, so the data were pooled. Median per-patient variations in ALP between clinic visits were approximately 12% over 12 weeks, 20% over 48 weeks, and 20% over 96 weeks. Reductions, unrelated to study intervention, of more than 40% in ALP were observed in 10.9% of patients with baseline activity greater than 2-fold the upper limit of normal (ULN) and 12.5% of patients with more than 3-fold the ULN at 1 year. At 2 years, reductions of more than 40% in ALP were observed in 15.8% of patients with baseline activity greater than 2-fold the ULN and 17.9% of patients with more than 3-fold the ULN. Among the 209 patients with Ishak fibrosis stage 0-4 at baseline, serum ALP activity did not associate with development of cirrhosis or with a 2-point increase in fibrosis stage at 2 years. In contrast, the median per-patient variation in ELF scores between clinic visits was approximately 3% over 12 weeks, 4% over 48 weeks, and 4% over 96 weeks. Elevated ELF scores at baseline and at weeks 12, 24 and 48, each associated with development of cirrhosis at 2 years (odds ratio >2.75; P < .01 for all timepoints). ELF scores at baseline and weeks 12, 24 and 48, also associated with a 2-point increase in fibrosis stage at 2 years (odds ratios all greater than 2; P < .01 for all timepoints).
CONCLUSIONS
In an analysis of data from patients with large-duct PSC enrolled in a prospective trial, we found large interindividual and intraindividual variations in serum ALP activity. Serum ALP activity did not associate with disease progression over a 2-year period. Variations in ELF score were smaller, and scores determined at multiple timepoints associated with fibrosis progression and development of cirrhosis
Why, when and how do secondary-care clinicians have emergency care and treatment planning conversations? Qualitative findings from the ReSPECT Evaluation Study.
No full textBACKGROUND
The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is an emergency care and treatment planning (ECTP) process, developed to offer a patient-centred approach to deciding about and recording treatment recommendations. Conversations between clinicians and patients or their representatives are central to the ReSPECT process. This study aims to understand why, when, and how ReSPECT conversations unfold in practice.
METHODS
ReSPECT conversations were observed in hospitals within six acute National Health Service (NHS) trusts in England; the clinicians who conducted these conversations were interviewed. Following observation-based thematic analysis, five ReSPECT conversation types were identified: resuscitation and escalation; confirmation of decision; bad news; palliative care; and clinical decision. Interview-based thematic analysis examined the reasons and prompts for each conversation type, and the level of detail and patient engagement in these different conversations.
RESULTS
Whereas resuscitation and escalation conversations concerned possible futures, palliative care and bad news conversations responded to present-tense changes. Conversations were timed to respond to organisational, clinical, and patient/relative prompts. While bad news and palliative care conversations included detailed discussions of treatment options beyond CPR, this varied in other conversation types. ReSPECT conversations varied in doctors' engagement with patient/relative preferences, with only palliative care conversations consistently including an open-ended approach.
CONCLUSIONS
While ReSPECT supports holistic, person-centred, anticipatory decision-making in some situations, a gap remains between the ReSPECT's aims and their implementation in practice. Promoting an understanding and valuing of the aims of ReSPECT among clinicians, supported by appropriate training and structural support, will enhance ReSPECT conversations
The Dual Vascular Pedicle: A Novel Method to Approach Challenging Cases in Single-Stage Mastopexy/Augmentation.
No full textBACKGROUND
Age, pregnancy and weight change can affect the shape of the female breast. Various mastopexy/augmentation techniques have been described to address these changes which work well in primary and uncomplicated cases. However, there is a distinctive category of high-risk patients which includes post-bariatric, active smokers, those with poor skin quality, wanting larger implants or undergoing secondary surgery. The complications reported in this group of patients are as high as 32%.
MATERIALS AND METHODS
We describe a new technique of one-stage mastopexy/augmentation, using a wide dermo-glandular pedicle, and our early results with 51 consecutive patients.
RESULTS
Fifty-one patients were operated between January 2016 and September 2018, with a mean age of 40.0 years. Ten patients were smokers, eight were post-massive weight loss, six had previous mastopexy. At a mean follow-up of 22 months, only two patients had a unilateral bottoming out. There were no incidents of hematoma, seroma, capsular contracture or major tissue-related complications.
CONCLUSION
Plastic surgery has been described as a struggle between beauty and blood supply. We have performed a one-stage mastopexy/augmentation using a wide and thick dermo-glandular glandular pedicle to maximize the blood supply in a range of challenging patients with promising results.
LEVEL OF EVIDENCE IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266
Age is just a number: Is frailty being ignored in vascular access planning for dialysis?
No full textCurrent international guidelines advocate fistula creation as first choice for vascular access in haemodialysis patients, however, there have been suggestions that in certain groups of patients, in particular the elderly, a more tailored approach is needed. The prevalence of more senior individuals receiving renal replacement therapy has increased in recent years and therefore including patient age in decision making regarding choice of vascular access for dialysis has gained more relevance. However, it seems that age is being used as a surrogate for overall clinical condition and it can be proposed that frailty may be a better basis to considering when advising and counselling patients with regard to vascular access for dialysis. Frailty is a clinical condition in which the person is in a vulnerable state with reduced functional capacity and has a higher risk of adverse health outcomes when exposed to stress inducing events. Prevalence of frailty increases with age and has been associated with an increased risk of mortality, hospitalisation, disability and falls. Chronic kidney disease is associated with premature ageing and therefore patients with kidney disease are prone to be frailer irrespective of age and the risk increases further with declining kidney function. Limited data exists on the relationship between frailty and vascular access, but it appears that frailty may have an association with poorer outcomes from vascular access. However, further research is warranted. Due to complexity in decision making in dialysis access, frailty assessment could be a key element in providing patient-centred approach in planning and maintaining vascular access for dialysis
Factors associated with frequent exacerbations in the UK Severe Asthma Registry.
No full textBACKGROUND
Frequent exacerbations are an important cause of morbidity in patients with severe asthma.
OBJECTIVE
Our aim was to identify factors associated with frequent exacerbations in a large well-characterized severe asthma population and determine whether factors differed in patients treated with and without maintenance oral corticosteroids (OCS).
METHODS
Adults with severe asthma from specialized asthma centers across the UK were recruited to the UK Severe Asthma Registry (UKSAR). Demography, co-morbidities and physiological measurements were collected. We conducted univariable and multivariable logistic regression analyses to identify factors associated with frequent exacerbations, defined as ≥3 exacerbations treated with high-dose systemic corticosteroids in the past year.
RESULTS
Of 1592 patients with severe asthma from the UKSAR, 1137 (71%) were frequent exacerbators (FE) and 833 (52%) were on maintenance OCS. FE were more likely to be ex-smokers, have gastroesophageal reflux disease (GERD), higher Asthma Control Questionnaire-6 (ACQ-6) score and blood eosinophilia. Multivariable regression analyses showed ACQ-6 score >1.5 (OR 4.25, p50ppb (OR 1.54, p=0.044) were independently associated with frequent exacerbations. Past smoking history correlated with frequent exacerbations only in patients on maintenance OCS (OR 2.25, p=0.004), whereas ACQ-6 score >1.5 was independently associated with frequent exacerbations in those treated with and without maintenance OCS (OR 2.74, p=0.017 and OR 6.42, p<0.001, respectively).
CONCLUSION
Several factors were associated with frequent exacerbations in a large UK severe asthma registry population. High ACQ-6 score had the strongest association with frequent exacerbations irrespective of maintenance OCS status