5366 research outputs found
Sort by
Evaluation of elderly specific pre-hospital trauma triage criteria: a systematic review.
No full textBACKGROUND
Pre-hospital identification of major trauma in elderly patients is key for delivery of optimal care, however triage of this group is challenging. Elderly-specific triage criteria may be valuable. This systematic review aimed to summarise the published pre-hospital elderly-specific trauma triage tools and evaluate their sensitivity and specificity and associated clinical outcomes.
METHODS
MEDLINE and EMBASE databases were searched using predetermined criteria (PROSPERO: CRD42019140879). Two authors independently assessed search results, performed data extraction, risk of bias and quality assessments following the Grading of Recommendations, Assessment, Development and Evaluation system.
RESULTS
801 articles were screened and 11 studies met eligibility criteria, including 1,332,300 patients from exclusively USA populations. There were eight unique elderly-specific triage criteria reported. Most studies retrospectively applied criteria to trauma databases, with few reporting real-world application. The Ohio Geriatric Triage Criteria was reported in three studies. Age cut-off ranged from 55 to 70 years with ≥ 65 most frequently reported. All reported existing adult criteria with modified physiological parameters using higher thresholds for systolic blood pressure and Glasgow coma scale, although the values used varied. Three criteria added co-morbidity or anti-coagulant/anti-platelet use considerations. Modifications to anatomical or mechanism of injury factors were used by only one triage criteria. Criteria sensitivity ranged from 44 to 93%, with a median of 86.3%, whilst specificity was generally poor (median 54%). Scant real-world data showed an increase in patients meeting triage criteria, but minimal changes to patient transport destination and mortality. All studies were at risk of bias and assessed of "very low" or "low" quality.
CONCLUSIONS
There are several published elderly-specific pre-hospital trauma triage tools in clinical practice, all developed and employed in the USA. Consensus exists for higher thresholds for physiological parameters, however there was variability in age-cut offs, triage criteria content, and tool sensitivity and specificity. Although sensitivity was improved over corresponding 'adult' criteria, specificity remained poor. There is a paucity of published real-world data examining the effect on patient care and clinical outcomes of elderly-specific triage criteria. There is uncertainty over the optimal elderly triage tool and further study is required to better inform practice and improve patient outcomes
Using patient-reported outcome measures during the management of patients with end-stage kidney disease requiring treatment with haemodialysis (PROM-HD): a qualitative study.
No full textOBJECTIVES
Patients undergoing haemodialysis report elevated symptoms and reduced health-related quality of life, and often prioritise improvements in psychosocial well-being over long-term survival. Systematic collection and use of patient-reported outcomes (PROs) may help support tailored healthcare and improve outcomes. This study investigates the methodological basis for routine PRO assessment, particularly using electronic formats (ePROs), to maximise the potential of PRO use, through exploration of the experiences, views and perceptions of patients and healthcare professionals (HCPs) on implementation and use of PROs in haemodialysis settings.
STUDY DESIGN
Qualitative study.
SETTING AND PARTICIPANTS
Semistructured interviews with 22 patients undergoing haemodialysis, and 17 HCPs in the UK.
ANALYTICAL APPROACH
Transcripts were analysed deductively using the Consolidated Framework for Implementation Research (CFIR) and inductively using thematic analysis.
RESULTS
For effective implementation, the potential value of PROs needs to be demonstrated empirically to stakeholders. Any intervention must remain flexible enough for individual and aggregate use, measuring outcomes that matter to patients and clinicians, while maintaining operational simplicity. Any implementation must sit within a wider framework of education and support for both patients and clinicians who demonstrate varying previous experience of using PROs and often confuse related concepts. Implementation plans must recognise the multidimensionality of end-stage kidney disease and treatment by haemodialysis, while acknowledging the associated challenges of delivering care in a highly specialised environment. To support implementation, careful consideration needs to be given to barriers and facilitators including effective leadership, the role of champions, effective launch and ongoing evaluation.
CONCLUSIONS
Using the CFIR to explore the experiences, views and perceptions of key stakeholders, this study identified key factors at organisational and individual levels which could assist effective implementation of ePROs in haemodialysis settings. Further research will be required to evaluate subsequent ePRO interventions to demonstrate the impact and benefit to the dialysis community
Surgical management of a giant abdominal wall desmoid tumour.
No full textDesmoid tumours are clonal fibroblastic proliferations in soft tissues, characterised by infiltrative growth and local recurrence, but not metastasis. Various treatment strategies for desmoid tumours exist, varying from observation, medical and systemic therapy to radiotherapy and surgery. A 25-year-old woman with a background of familial adenomatous polyposis was referred with an enlarging abdominal desmoid tumour measuring 40×40×40 cm despite repeated radiofrequency ablation, surgical debulking and hormone therapy. The patient had a two-stage operation. The first stage involved excision of the desmoid tumour with full-thickness abdominal wall. The abdominal wall was not closed, and a topical negative pressure seal was applied. After 2 days, she underwent the second stage: reconstruction of the abdominal wall defect with a large porcine mesh which was covered with anterolateral thigh flaps. Postoperative complications included ileus and a fall which required further surgery. The patient was discharged 1 month after the first operation. Abdominal MRI scans were performed at 3 and 7 months postdischarge and showed no recurrence of diseaseBackground
Latent Cytomegalovirus Infection and Previous Capsular Polysaccharide Vaccination Predict Poor Vaccine Responses in Older Adults, Independent of Chronic Kidney Disease.
No full textBACKGROUND
Patients with chronic kidney disease (CKD) are more prone to severe infection. Vaccination is a key strategy to reduce this risk. Some studies suggest vaccine efficacy may be reduced in patients with CKD, despite preserved maintenance of long-term responses to some pathogens and vaccines. Here, we investigated immune responses to 2 vaccines in patients with CKD to identify predictors of immunological responsiveness.
METHODS
Individuals >65 years old, with or without nondialysis CKD (n = 36 and 29, respectively), were vaccinated with a nonadjuvanted seasonal influenza vaccine (T-dependent) and Pneumovax23 (23-valent pneumococcal polysaccharide [PPV23], T-independent). Humoral responses were measured at baseline, day 28, and 6 months. Lymphocyte subset and plasma cell/blast analyses were performed using flow cytometry. Cytomegalovirus (CMV) serotyping was assessed by enzyme-linked immunosorbent assay.
RESULTS
Only modest responsiveness was observed to both vaccines, independent of CKD status (25% adequate response in controls vs. 12%-18% in the CKD group). Unexpectedly, previous immunization with PPV23 (median 10-year interval) and CMV seropositivity were associated with poor PPV23 responsiveness in both study groups (P < .001 and .003, respectively; multivariable linear regression model). Patients with CKD displayed expanded circulating populations of T helper 2 and regulatory T cells, which were unrelated to vaccine responses. Despite fewer circulating B cells, patients with CKD were able to mount a similar day 7 plasma cell/blast response to controls.
CONCLUSION
Patients with nondialysis CKD can respond similarly to vaccines as age- and sex-matched healthy individuals. CKD patients display an immune signature that is independent of vaccine responsiveness. Prior PPV23 immunization and CMV infection may influence responsiveness to vaccination. Clinical Trials Registration. NCT02535052
Renin-angiotensin system blockade in patients with chronic kidney disease: benefits, problems in everyday clinical use, and open questions for advanced renal dysfunction.
No full textManagement of hypertension and albuminuria are considered among the primary goals of treatment to slow the progression of chronic kidney disease (CKD). Renin-angiotensin system (RAS) blockers, i.e., angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are the main drugs to achieve these goals. Seminal studies have showed that RAS blockers present significant renoprotective effects in CKD patients with very high albuminuria. In post hoc analyses of such trials, these renoprotective effects appeared more robust in patients with more advanced CKD. However, randomized trials specifically addressing whether RAS blockers should be initiated or maintained in patients with advanced CKD are scarce and do not include subjects with normoalbuminuria, thus, many clinicians are unconvinced for the beneficial effects of RAS blockade in these patients. Further, the fear of hyperkalemia or acute renal decline is another factor due to which RAS blockers are usually underprescribed and are easily discontinued in patients with more advanced CKD; i.e., those in Stages 4 and 5. This review summarizes evidence from the literature regarding the use of RAS blockers in patients with advanced CKD
Is image guidance essential for external ventricular drain insertion?
No full textBACKGROUND
This study aimed to compare the EVD placement accuracy and complication rates, between neuronavigation-guided, ultrasound-guided and free-hand techniques in our single centre cohort, and through an additional meta-analysis of the currently available literature.
METHODS
A retrospective review of patients who underwent EVD insertion from January 2016 to April 2019 was conducted. Information regarding demographics, indication, Evan's index, use of image guidance, accuracy of catheter tip placement and procedural complications were extracted from electronic records and imaging systems. The accuracy of the EVD tip placement was classified according to the Kakarla grading system into optimal, suboptimal or misplaced based on its proximity to the Foramen of Monro and involvement of non-eloquent/eloquent structures.
RESULTS
In total, 221 patients (mean age of 51.6 years) underwent EVD insertion during the study period. 108 catheters were placed free-hand, 70 Neuronavigation-guided and 43 ultrasound-guided; and the mean Evan's ratios were 0.34, 0.30 and 0.32 respectively. EVD placement was significantly more accurate with neuronavigation guidance versus free-hand placement (89.4% versus 79.2% respectively, p=0.0035). Meta-analysis of three studies demonstrates a statistically significant reduction in suboptimal EVD placement when compared to free-hand placement with a pooled OR of 0.50 (95% CI: 0.32 - 0.77, p=0.002). Surgeon seniority and other procedural related factors had no significant impact on EVD placement accuracy or complications.
CONCLUSIONS
Image-guided EVD placement significantly reduced the rate of suboptimally placed EVD's. We conclude in appropriately selected cases, image-guided EVD insertions will improve accuracy of catheter placements and reduce associated complications of the procedure
Robinow syndrome in an extremely preterm infant: Novel homozygous ROR2 variant detected by rapid exome sequencing.
No full textAn extremely preterm infant presented with clinical and radiological features of Robinow syndrome including butterfly vertebrae, posterior rib fusion, brachydactyly, nail hypoplasia, and retromicrognathia resulting in difficult endotracheal intubation in the intensive care setting. Rapid trio exome sequencing detected a novel homozygous likely pathogenic missense variant in the ROR2 gene, NM_004560.3:c.950A>G, p.(Tyr317Cys), for which both parents were heterozygous carriers. In-silico protein modeling predicted a deleterious effect on the function of the protein. We report an extreme premature infant with novel homozygous likely pathogenic variant in the ROR2 gene consistent with autosomal recessive Robinow syndrome. This case expands the phenotypic and genotypic spectrum of this disorder and highlights the benefit of performing rapid exome sequencing early during evaluation to aid in patient management and providing accurate genetic counseling to families
Transmission, adaptation and geographical spread of the Liverpool epidemic strain.
No full textThe Liverpool epidemic strain (LES) is an important transmissible clonal lineage of that chronically infects the lungs of people with cystic fibrosis (CF). Previous studies have focused on the genomics of the LES in a limited number of isolates, mostly from one CF centre in the UK, and from studies highlighting identification of the LES in Canada. Here we significantly extend the current LES genome database by genome sequencing 91 isolates from multiple CF centres across the UK, and we describe the comparative genomics of this large collection of LES isolates from the UK and Canada. Phylogenetic analysis revealed that the 145 LES genomes analysed formed a distinct clonal lineage when compared with the wider population. Notably, the isolates formed two clades: one associated with isolates from Canada, and the other associated with UK isolates. Further analysis of the UK LES isolates revealed clustering by clinic geography. Where isolates clustered closely together, the association was often supported by clinical data linking isolates or patients. When compared with the earliest known isolate, LESB58 (from 1988), many UK LES isolates shared common loss-of-function mutations, such as in genes and . Other loss-of-function mutations identified in previous studies as common adaptations during CF chronic lung infections were also identified in multiple LES isolates. Analysis of the LES accessory genome (including genomic islands and prophages) revealed variations in the carriage of large genomic regions, with some evidence for shared genomic island/prophage complement according to clinic location. Our study reveals divergence and adaptation during the spread of the LES, within the UK and between continents
Concepts and prospects of minimally invasive colorectal cancer surgery.
No full textIt is important that clinical radiologists understand and appreciate the minimally invasive surgery (MIS) options available to surgeons. Operative technologies are constantly evolving, and accurate, informed interpretation of clinical imaging is essential for optimum surgical management. Concurrent advancements in both MIS and radiological staging have certainly improved treatment decisions and outcomes. This article outlines the history, current concepts, evolving techniques, and future prospects of MIS as it pertains to colorectal cancer surgery