5366 research outputs found
Sort by
Antecedent infections and vaccinations in chronic inflammatory demyelinating polyneuropathy: a European collaborative study.
No full textINTRODUCTION/AIMS
Chronic inflammatory demyelinating polyneuropathy (CIDP) may be rarely preceded by infection. A causative link remains unproven, in contrast to Guillain-Barré syndrome (GBS), which is commonly post-infectious with well-demonstrated pathophysiologic mechanisms of molecular mimicry following Campylobacter jejuni enteritis. Uncommonly, infections are reported before the onset of CIDP. We aimed to determine the frequency and characteristics of CIDP occurring after antecedent infections or vaccinations in two large European cohorts.
METHODS
We reviewed the records of 268 subjects with "definite" or "probable" CIDP from the Inflammatory Neuropathy clinic, Birmingham, U.K. (129 subjects), and from the Serbian national CIDP database (139 subjects).
RESULTS
Twenty-five of 268 (9.3%) subjects had a respiratory or gastrointestinal infection in the 6 weeks preceding CIDP onset and 3/268 (1.1%) had received an influenza vaccination. CIDP disease onset occurred at a younger age (44.25 years S.D. 17.36 vs. 54.05 years S.D. 15.19; p < 0.005) and acute-onset CIDP was more common (42.9% vs. 12.1%; OR: 5.46; 95% CI: 2.35-12.68; p < 0.001), in subjects with preceding infections or vaccinations. No differences in CIDP subtype, rates of cerebrospinal fluid protein level elevation, disability or likelihood of treatment response, were observed.
DISCUSSION
Antecedent infections or vaccinations may precede about 10% of cases of CIDP and are more common in younger subjects. Acute-onset CIDP is more frequent after antecedent events. These findings may suggest specific pathophysiological mechanisms in such cases. This article is protected by copyright. All rights reserved
Community-based intervention for prevention and management of chronic obstructive pulmonary disease in Nepal (COBIN-P trial): study protocol for a cluster-randomized controlled trial.
No full textBACKGROUND
Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide and the commonest of non-communicable diseases (NCDs) in Nepal. Risk factors like indoor and outdoor air pollution, a high prevalence of smoking, and the lack of awareness of COPD make it a serious public health concern. However, no attempt has been made in Nepal to estimate its burden and address the disease at the community level.
METHOD
This study aims to evaluate the effect of a community-based health educational intervention administered by Female Community Health Volunteers (FCHVs) on the prevention and management of COPD. An open-label, two-group, community-based, cluster-randomized controlled trial will be implemented in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) located in the Kaski district of Nepal. The estimated sample size of the intervention will be 1143. The unit of randomization is the ward (administrative unit) of the study area. The follow-up survey will be conducted immediately after 12 months of FCHVs-led interventions. The difference in the rate of decline of forced expiratory volume in 1 s (FEV) and FEV/FVC (forced vital capacity) ratio are the primary outcomes and the change in the proportion of modifiable risk factors of COPD, health-related quality of life scores, and change in knowledge of COPD will be secondary outcomes.
DISCUSSION
This study will estimate the burden of COPD, the magnitude of risk factors and generate evidence to mobilize community health workers for COPD prevention and management at the community level in Nepal.
TRIAL REGISTRATION
ClinicalTrials.gov NCT03797768 . Registered on January 9, 2019
The removal of educational achievements by the UK Foundation Programme: What does this mean for oral and maxillofacial trainees?
No full textAnticoagulation for patients with mechanical heart valves at the end of life: understanding clinician attitudes and improving decision making.
No full textBACKGROUND
Decisions regarding continuation or cessation of anticoagulation for patients with mechanical heart valves nearing the end of life represent a difficult balance of risks. The risk of suffering and disability that may result from thromboembolism must be weighed against the burden of continued anticoagulation therapy and the excess bleeding risk this confers. Data allowing quantification of the relative risks are scarce, and this translates to a lack of published guidance on the topic. Here we describe how this lack of guidance is impacting upon healthcare professionals and their patients through misconception of risk and under-confidence in decision-making. We also present local guidance we have developed that aims to improve objective risk assessment and promote individualised, patient-centred decision-making.
METHODS
Our survey was developed by specialists in palliative care and cardiology. The survey explored respondents' conception of the risks of stopping anticoagulation for patients with mechanical heart valves at the end of life, as well as their ability to identify patient factors that modify this risk. Respondent decision-making, confidence, and readiness to accept further guidance were also explored. Healthcare professionals at two university teaching hospitals were invited to participate in the survey. The study population included hospital specialists, generalists, and trainees.
RESULTS
Fifty-two healthcare professionals completed the survey, including 16 palliative care specialists. 47 (90%) of respondents felt poorly informed of the risks of stopping or continuing anticoagulation. 6 (12%) correctly identified risk of thromboembolism in patients with mechanical heart valves who are not anticoagulated. The remainder overestimated risk by a factor of two (18, 35%) or five (27, 52%). 49 (94%) would find further guidance on this issue helpful.
CONCLUSIONS
The healthcare professionals we surveyed felt poorly informed and ill-equipped to make decisions regarding anticoagulation for patients with mechanical heart valves at the end of life. They were objectively poor at estimating the risks involved. In the absence of robust data to support protocolisation of practice, we believe these decisions must be taken in conversation with the patient, taking account of individual circumstances and priorities. We have developed guidance for local use to support such individualised decision-making
Bioethics in humanitarian disaster relief operations: a military perspective.
No full textThe ethical dilemmas faced every day by military personnel working within the NHS will potentially be very different to ones that will be faced in the wake of a humanitarian disaster. Allied to this the potentially differing objectives from military personnel when compared with other healthcare workers in these scenarios and a conflict of ethics could arise.Within this paper, the fundamentals of this conflict will be explored and how working within the military framework can affect clinical decisions. This is a paper commissioned as a part of the humanitarian and disaster relief operations special issue of BMJ Military Health
Paediatric mitral valve disease - from presentation to management.
No full textMitral valve diseases are relatively rare in the paediatric population; however, they can cause considerable mortality and morbidity worldwide. Acquired causes are a major contributor to cardiovascular disease burden in the paediatric population. Diseases can be detected before birth, at birth, or when the child is older and presents with symptoms of advanced heart failure. Definitive management consists of surgical intervention, with mitral valve replacement being the gold standard.Conclusion: Repair has been gaining popularity; however, its outcomes require further study. Percutaneous mitral balloon valvuloplasty is an emerging technique which holds promise as a bridge to surgical treatment. The effect of these interventions on quality of life must be emphasised and requires further study. What is Known: • The epidemiology of mitral valve disease in the paediatric population - predominant causes include rheumatic disease and congenital defects. • Mitral valve repair and replacement are the standard treatment methods for paediatric mitral valve disease. What is New: • Emergence of percutaneous mitral valve interventions and their potential as bridge-to-surgery or definitive treatment in high-risk surgical candidates. • Recent evidence comparing mitral valve repair and replacement in the paediatric population demonstrates increasing popularity of repair techniques
Clinical negligence claims in oral and maxillofacial surgery over the last 10 years.
No full textAccording to NHS Resolution, the cost of harm from clinical activity in the last year was £8.3 billion. The steady increase in litigation within the National Health Service (NHS) has led to concerns being raised regarding the sustainability of the NHS, the increasing practice of defensive medicine, and the psychological impact on healthcare professionals. To our knowledge, litigation within oral and maxillofacial surgery has not been investigated in the UK since 2010, therefore our aims were to identify the trends within our specialty and the common reasons for negligence claims over the last 10 years. A freedom of information request was made to NHS Resolution for all clinical negligence claims from 2010 to 2020. A total of 1,122 claims were registered and the total for damages paid was £32,631,131. The claims were categorised by the primary injury and further divided into groups of cause codes. Four types of primary injury comprised 65.4% (n = 734) of all negligence claims and were as follows: additional or unnecessary operations (n = 313, 27.9%), unnecessary pain (n = 156, 13.9%), nerve damage (n = 139, 12.4%), and dental damage (n = 126, 11.2%). The damages associated with nerve damage were the costliest, with a total of £8,033,737 being paid. The significant increase in the number and cost of clinical negligence claims is concerning. The lessons from these claims must be shared and implemented to reduce the burden on the NHS, and ensure that we are providing a high quality of care with improved patient outcomes
Is a fasting testosterone level really necessary for the determination of androgen status in men?
No full textBACKGROUND
As circulating testosterone may be suppressed in the post-prandial state, it has been recommended that measurements are carried out with the patient fasted.
OBJECTIVES
In this regard, we assessed the effect of fasting/non-fasting status on total testosterone (T) levels in men.
MATERIALS AND METHODS
Data was collected in a single UK Hospital in men with two serum T requests taken within a 6-month period of each other and sampled at a time of day ≤ 2 h apart. Three groups were established, with T levels compared via signed-rank test in men with both a fasting and non-fasting sample (Group 1; n = 69), and in men with paired non-fasting (Group 2; n = 126) and paired fasting (Group 3; n = 18) samples. The differences in T levels between the paired samples was compared between the three groups using the rank-sum test and also via multiple regression analysis with the groups factorised.
RESULTS
Median (Interquartile Range, IQR) age did not vary significantly between Groups 1, 2 and 3 at 49 (38-56), 51.5 (42-60) and 51.5 (40-59) years, respectively. No significant difference (p = 0.89) was found between the T levels in Group 1 with non-fasting (median (IQR) T = 11.1 (9.3-13.6) nmol/L) versus fasting samples T = 10.8 (8.9-14.1) nmol/L). Paired T levels did not significantly differ in each of the other two groups (2 and 3). There was no significant association between the differences in paired T levels between the three groups, even when the model was adjusted for age and time, with Group 1 (as reference) versus Group 2 (p = 0.79) and versus Group 3 (p = 0.63).
DISCUSSION
We found no significant differences between fasting and non-fasting T levels. A definitive confirmatory study is required to determine whether fasting status is necessary to diagnose hypogonadism.
CONCLUSION
Non-requirement of fasting status when checking testosterone levels would remove a major hurdle in the diagnosis of hypogonadism
Redefining β-blocker response in heart failure patients with sinus rhythm and atrial fibrillation: a machine learning cluster analysis.
No full textBACKGROUND
Mortality remains unacceptably high in patients with heart failure and reduced left ventricular ejection fraction (LVEF) despite advances in therapeutics. We hypothesised that a novel artificial intelligence approach could better assess multiple and higher-dimension interactions of comorbidities, and define clusters of β-blocker efficacy in patients with sinus rhythm and atrial fibrillation.
METHODS
Neural network-based variational autoencoders and hierarchical clustering were applied to pooled individual patient data from nine double-blind, randomised, placebo-controlled trials of β blockers. All-cause mortality during median 1·3 years of follow-up was assessed by intention to treat, stratified by electrocardiographic heart rhythm. The number of clusters and dimensions was determined objectively, with results validated using a leave-one-trial-out approach. This study was prospectively registered with ClinicalTrials.gov (NCT00832442) and the PROSPERO database of systematic reviews (CRD42014010012).
FINDINGS
15 659 patients with heart failure and LVEF of less than 50% were included, with median age 65 years (IQR 56-72) and LVEF 27% (IQR 21-33). 3708 (24%) patients were women. In sinus rhythm (n=12 822), most clusters demonstrated a consistent overall mortality benefit from β blockers, with odds ratios (ORs) ranging from 0·54 to 0·74. One cluster in sinus rhythm of older patients with less severe symptoms showed no significant efficacy (OR 0·86, 95% CI 0·67-1·10; p=0·22). In atrial fibrillation (n=2837), four of five clusters were consistent with the overall neutral effect of β blockers versus placebo (OR 0·92, 0·77-1·10; p=0·37). One cluster of younger atrial fibrillation patients at lower mortality risk but similar LVEF to average had a statistically significant reduction in mortality with β blockers (OR 0·57, 0·35-0·93; p=0·023). The robustness and consistency of clustering was confirmed for all models (p<0·0001 vs random), and cluster membership was externally validated across the nine independent trials.
INTERPRETATION
An artificial intelligence-based clustering approach was able to distinguish prognostic response from β blockers in patients with heart failure and reduced LVEF. This included patients in sinus rhythm with suboptimal efficacy, as well as a cluster of patients with atrial fibrillation where β blockers did reduce mortality.
FUNDING
Medical Research Council, UK, and EU/EFPIA Innovative Medicines Initiative BigData@Heart
The impact of the COVID-19 pandemic on microbial keratitis presentation patterns.
No full textBACKGROUND
Microbial keratitis (MK) is the most common non-surgical ophthalmic emergency, and can rapidly progress, causing irreversible sight-loss. This study explored whether the COVID-19 (C19) national lockdown impacted upon the clinical presentation and outcomes of MK at a UK tertiary-care centre.
METHODS
Medical records were retrospectively reviewed for all patients with presumed MK requiring corneal scrapes, presenting between 23rd March and 30th June in 2020 (Y2020), and the equivalent time windows in 2017, 2018 and 2019 (pre-C19).
RESULTS
In total, 181 and 49 patients presented during the pre-C19 and Y2020 periods, respectively. In Y2020, concurrent ocular trauma (16.3% vs. 5.5%, p = 0.030) and immunosuppression use (12.2% vs 1.7%, p = 0.004) were more prevalent. Despite proportionately fewer ward admissions during the pandemic (8.2% vs 32.6%, p<0.001), no differences were observed in baseline demographics; presenting visual acuity (VA; median 0.6 vs 0.6 LogMAR, p = 0.785); ulcer area (4.0 vs 3.0mm2, p = 0.520); or final VA (0.30 vs 0.30 LogMAR, p = 0.990). Whilst the overall rates of culture positivity were similar in Y2020 and pre-C19 (49.0% vs. 54.7%, p = 0.520), there were differences in the cultures isolated, with a lower rate of poly-microbial cultures in Y2020 (8.3% vs. 31.3%, p = 0.022).
CONCLUSIONS
Patient characteristics, MK severity and final visual outcomes did not appear to be affected in the first UK lockdown, despite fewer patients being admitted for care. Concurrent trauma and systemic immunosuppression use were greater than in previous years. The difference in spectra of isolated organisms may relate to behavioural changes, such as increased hand hygiene