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Improving abdominal aortic aneurysm (AAA) screening uptake through patient engagement-analysis and outcomes of strategies to improve uptake at a regional programme level.
No full textOBJECTIVES
To identify areas of health inequality that adversely affect patient engagement at a regional level within the National Abdominal Aortic Aneurysm Screening Programme (NAAASP). Patient-reported improvements to services were implemented and analysis of subsequent uptake undertaken.
METHODS
Prospective study of 390 men who failed to attend their AAA screening invitation. Non-attendees were contacted by post and telephone. Patients were analysed according to ethnicity, working status and Index of Multiple Deprivation quintile. Patient suggested improvements to the service were recorded, analysed and implemented. Uptake data was then collected for the subsequent two years.
RESULTS
The SMaRT system used by NAAASP is 97% accurate in holding patient contact details and non-attenders are four times more likely to respond to telephone contact. Reasons for failing to attend screening invitations include factors that can be addressed at a regional level such as: inconvenient timings/locations of screening clinics and a lack of awareness or understanding of what AAA screening means as well as language/literacy barriers. The incidence of AAA in the non-attendee group was almost 3 times that of our general (attending) population. Afro-Caribbean men were disproportionately less likely to attend for screening. After implementing patient-suggested improvements to the service, screening uptake increased from 75.2% (2015-16 screening year) to 81.3% (2017-18).
CONCLUSIONS
To date, no other studies have gone on to assess the effectiveness of interventions targeted at reducing inequalities in NAAASP attendance but we show an increase in local screening uptake of 6% in a 2-year period after implementing improvement strategies. This paper adds to existing literature by confirming external factors such as social deprivation adversely influence screening uptake and that AAA are more prevalent in socially deprived groups. It reinforces the importance of regional attempts to contact and engage non-attenders as they may be most at risk of developing AAA
Macrophage infiltrates in coronary plaque erosion and cardiovascular outcome in patients with acute coronary syndrome.
No full textBACKGROUND AND AIMS
Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS), and inflammation plays a key role in plaque instability. We assessed the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value.
METHODS
ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target-vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03-2.58) years].
RESULTS
We included 153 patients [median age (IQR) 64 (53-75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p = 0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression, PE with MØI was an independent predictor of MACEs [HR = 2.95, 95% CI (1.09-8.02), p = 0.034].
CONCLUSIONS
Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up
Development of risk prediction models to predict urine culture growth for adults with suspected urinary tract infection in the emergency department: protocol for an electronic health record study from a single UK university hospital.
No full textBackground
Urinary tract infection (UTI) is a leading cause of hospital admissions and is diagnosed based on urinary symptoms and microbiological cultures. Due to lags in the availability of culture results of up to 72 h, and the limitations of routine diagnostics, many patients with suspected UTI are started on antibiotic treatment unnecessarily. Predictive models based on routinely collected clinical information may help clinicians to rule out a diagnosis of bacterial UTI in low-risk patients shortly after hospital admission, providing additional evidence to guide antibiotic treatment decisions.
Methods
Using electronic hospital records from Queen Elizabeth Hospital Birmingham (QEHB) collected between 2011 and 2017, we aim to develop a series of models that estimate the probability of bacterial UTI at presentation in the emergency department (ED) among individuals with suspected UTI syndromes. Predictions will be made during ED attendance and at different time points after hospital admission to assess whether predictive performance may be improved over time as more information becomes available about patient status. All models will be externally validated for expected future performance using QEHB data from 2018/2019.
Discussion
Risk prediction models using electronic health records offer a new approach to improve antibiotic prescribing decisions, integrating clinical and demographic data with test results to stratify patients according to their probability of bacterial infection. Used in conjunction with expert opinion, they may help clinicians to identify patients that benefit the most from early antibiotic cessation
Endovascular versus medical treatment of venous compression syndrome of the iliac vein - a systematic review.
No full textThe treatment of non-thrombotic iliac vein lesions (NIVL) remains debatable with many advocating conservative treatments, whilst others offering venous stenting. The objective of this review was to systematically assess the treatment options for symptomatic iliac vein compression syndrome (IVCS) in patients without evidence of thrombotic disease at the time of diagnosis. An online search of published literature looking for randomised controlled trials and observational studies that evaluated the treatment for symptomatic NIVL was performed. Nine studies were included with a total 953 patients of which 782 patients had NIVL. Patency rates ranged between 94.8%-100% in the first month, 88.2%-94.1% in six months and 73.4%-98% in 12 months, in patients with NIVL post stenting. Longer follow-up of up to 5 years shows promising patency rates of 94% in patients with IVCS. Patients with IVCS are likely to benefit from a combination of endovenous treatment at the time of diagnosis including stent placement to maintain lumen patency and prevent recurrent deep venpus thrombosis and/or postthrombotic syndrome
Necrotizing Fasciitis: Expect the unexpected.
No full textINTRODUCTION
Necrotizing fasciitis is a rapidly progressive and potentially fatal soft tissue infection. A wide spectrum of aerobic and nonaerobic organisms has been implicated as the causative pathogen. Necrotizing Fasciitis due to Salmonella serovars have previously been implicated both with and without a prodromal diarrheal illness, but mono-microbial Salmonella NF is very rare.
CASE PRESENTATION
We have discussed the case of a 67-year-old man who presented with necrotizing fasciitis of the perianal region in the emergency department of our hospital. He underwent serial debridement and a defunctioning colostomy, tissue and blood cultures revealed Salmonella Newport as the culprit microorganism. He received antibiotic therapy tailored to the organism and was discharged on recovery. He currently awaits a reversal of his colostomy.
DISCUSSION
Necrotizing fasciitis infections are rapidly progressive and potentially lethal, a high index of suspicion and aggressive surgical debridement supplemented with culture sensitive antibiotics is essential. Salmonella Newport has recently been implicated in diarrheal illness, associated with consumption of minced beef in the US. To the best of our knowledge, no previous reports of NF have been published related to Salmonella newport. The unexpected growth of this organism from tissue cultures and the excellent response to treatment prompted us to highlight this case as the first report of its type in the medical literature.
CONCLUSION
Necrotizing soft tissue infections are associated with considerable morbidity and mortality, and delayed recognition and treatment can have severe implications. Necrotizing fasciitis due to Salmonella serovars has been reported with Group B and C however no previous reports of NF have been reported with this serovar
Cardiovascular and renal morbidity in Takayasu arteritis: a population-based retrospective cohort study from UK.
No full textCardiovascular disease (CVD) is a major complication and cause of mortality in Takayasu arteritis (TA). The frequency of cardiovascular, cerebrovascular and renal morbidity or risk of death in TA is unknown in the UK. Population-based controlled studies are lacking in this area.
METHODS
Yearly cohort and cross-sectional studies were performed from 2000 to 2017 to estimate annual incidence rates and prevalence of TA respectively. An open retrospective matched cohort study was conducted to estimate risk of hypertension, diabetes, cardiovascular morbidity, chronic kidney disease (CKD) and all-cause mortality in TA, using a UK primary care database (IQVIA Medical Research Data). Risk (adjusted hazard ratio, aHR) of studied co-morbidities in TA compared to age and sex-matched controls was estimated. Changes in medication prescription were examined over time in both groups.
RESULTS
Overall, 142 patients with TA (median (IQR) age 53.4 (33.8-70.7) years) and 1371 matched controls were included. The annual incidence and prevalence of TA was 0.8/million and 7.5/million respectively. All-cause mortality was increased in TA (aHR 1.88, 95% CI 1.29-2.76). Patients with TA had higher risk of developing ischaemic heart disease, stroke/TIA, combined CVD and peripheral vascular disease than controls, but not hypertension, CKD, heart failure or diabetes during follow up. Only 50% of patients with TA requiring secondary CVD prevention were prescribed statins or anti-platelets within one year after study entry.
CONCLUSION
Cardiovascular morbidity was increased in patients with TA attending primary care services in the UK. Treatment with statins and anti-platelets in these patients was suboptimal
Respiratory trajectories in type 2 and non-ambulant 3 Spinal muscular atrophy in the iSMAC cohort study.
No full textOBJECTIVE
To describe the respiratory trajectories and their correlation with motor function in an international paediatric cohort of patients with type 2 and non-ambulant type 3 spinal muscular atrophy (SMA).
METHODS
Eight-year retrospective observational study of patients in the iSMAc natural history study. We retrieved anthropometrics, forced vital capacity (FVC) absolute, FVC% predicted (FVC%P.), Non-Invasive ventilation (NIV) requirement. Hammersmith functional motor scale (HFMS) and Revised performance of upper limb (RULM) were correlated with respiratory function. We excluded patients in interventional clinical trials and on Nusinersen commercial therapy.
RESULTS
There were 437 patients with SMA: 348 type 2, 89 non-ambulant type 3. Mean age at first visit was 6.9(±4.4) and 11.1(±4) years. In SMA type 2 FVC%P declined by 4.2%/year from 5 to 13 years, followed by a slower decline (1.0%/year). In type 3 FVC%P declined by 6.3%/year between 8 and 13 years, followed by a slower decline (0.9%/year). 39% SMA type 2 and 9% type 3 required NIV at median age 5.0(1.8-16.6) and 15.1(13.8-16.3) years. 84% SMA type 2 and 80% type 3 had scoliosis, 54% and 46% required surgery, which did not significantly affect respiratory decline. FVC%P positively correlated with HFMS and RULM in both subtypes.
CONCLUSIONS
In SMA type 2 and non-ambulant type 3 lung function declines differently, with a common levelling after age 13 years. Lung and motor function correlated in both subtypes. Our data further defines the milder SMA phenotypes and provides novel information to benchmark the long-term efficacy of new treatments for SMA
Development of a core outcome set for use in community-based bipolar trials-A qualitative study and modified Delphi.
No full textBACKGROUND
A core outcome set (COS) is a standardised collection of outcomes to be collected and reported in all trials within a research area. A COS can reduce reporting bias and facilitate evidence synthesis. This is currently unavailable for use in community-based bipolar trials. This research aimed to develop such a COS, with input from a full range of stakeholders.
METHODS
A co-production approach was used throughout. A longlist of outcomes was derived from focus groups with people with a bipolar diagnosis and carers, interviews with healthcare professionals and a rapid review of outcomes listed in bipolar trials on the Cochrane database. An expert panel with personal and/or professional experience of bipolar participated in a modified Delphi process and the COS was finalised at a consensus meeting.
RESULTS
Fifty participants rated the importance of each outcome. Sixty-six outcomes were included in Round 1 of the questionnaire; 13 outcomes were added by Round 1 participants and were rated in Round 2. Seventy-six percent of participants (n = 38) returned to Round 2 and 60 outcomes, including 4 outcomes added by participants in Round 1, received a rating of 7-9 by >70% and 1-3 by <25% of the sample. Fourteen participants finalised a COS containing 11 outcomes at the consensus meeting: personal recovery; connectedness; clinical recovery of bipolar symptoms; mental health and wellbeing; physical health; self-monitoring and management; medication effects; quality of life; service outcomes; experience of care; and use of coercion.
CONCLUSIONS
This COS is recommended for use in community-based bipolar trials to ensure stakeholder-relevant outcomes, facilitate data synthesis, and transparent reporting. The COS includes guidance notes for each outcome to allow the identification of suitable measurement instruments. Further validation is recommended for use with a wide range of communities and to achieve standardised measurement
Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT.
No full textBACKGROUND
Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased.
OBJECTIVE
To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite.
DESIGN
Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study.
SETTING
Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017.
PARTICIPANTS
Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs.
INTERVENTIONS
Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6-10 weeks and urgent fixation of confirmed non-union.
MAIN OUTCOME MEASURES
The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work.
RESULTS
The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, = 203 of 219; cast, = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of -2.1 in favour of surgery (95% confidence interval -5.8 to 1.6; = 0.27). The non-union rate was low (surgery group, = 1; cast group, = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients' desire to have a 'sense of recovering', which surgeons should address at the outset.
LIMITATION
There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery.
CONCLUSIONS
Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life.
TRIAL REGISTRATION
Current Controlled Trials ISRCTN67901257.
FUNDING
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 24, No. 52. See the NIHR Journals Library website for further project information