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Real-world assessment of the clinical impact of symptomatic infection with severe acute respiratory syndrome coronavirus (COVID-19 disease) in patients with Multiple Myeloma receiving systemic anti-cancer therapy.
No full textInfection with the novel coronavirus SARS-CoV-2 virus resulting in an acute respiratory disease (COVID-19 disease) is the cause of the current pneumonia pandemic, with a rapid rise in cases being reported in the European Union and UK (1, 2). The UK index case was identified on the 31 of January, 2020 and given the rapid spread and high mortality rate of COVID-19, it is imperative to define the impact on patients with co-existing medical conditions(3)
Diagnostic uncertainty and urinary tract infection in the emergency department: a cohort study from a UK hospital.
No full textBACKGROUND
Suspected urinary tract infection (UTI) syndromes are a common reason for empirical antibiotics to be prescribed in the Emergency Department (ED), but differentiating UTI from other conditions with a similar presentation is challenging. We investigated how often an ED diagnosis of UTI is confirmed clinically/microbiologically, and described conditions which present as UTI syndromes.
METHODS
Observational study using electronic health records from patients who attended the ED with suspected UTI and had a urine sample submitted for culture. We compared the ED diagnosis to diagnosis at discharge from hospital (ICD-10 codes), and estimated the proportion of cases with clinical/microbiological evidence of UTI.
RESULTS
Two hundred eighty nine patients had an ED diagnosis of UTI syndrome comprising: lower UTI (191), pyelonephritis (56) and urosepsis (42). In patients admitted to hospital with an ED diagnosis of lower UTI, pyelonephritis or urosepsis, clinical/microbiological evidence of UTI was lacking in 61/103, 33/54 and 31/42 cases respectively. The ED diagnosis was concordant with the main reason for admission in less than 40% of patients with UTI syndromes, and antibiotics were stopped within 72 h in 37/161 patients.
CONCLUSIONS
Clinical/microbiological evidence of UTI was lacking in 60-70% of patients, suggesting scope to revise empirical prescribing decisions for UTI syndromes in light of microbial culture and clinical progression
Young adults have worse kidney transplant outcomes than other age groups.
No full textBACKGROUND
The objective of this study was to establish if renal transplant outcomes (graft and patient survival) for young adults in England were worse than for other age groups.
METHODS
Outcomes for all renal transplant recipients in England (n = 26 874) were collected from Hospital Episode Statistics and the Office for National Statistics databases over 12 years. Graft and patient outcomes, follow-up and admissions were studied for all patients, stratified by age bands.
RESULTS
Young adults (14-23 years) had substantially greater likelihood [hazard ratio (HR) = 1.26, 95% confidence interval (CI) 1.10-1.19; P < 0.001] of kidney transplant failure than any other age band. They had a higher non-attendance rate for clinic appointments (1.6 versus 1.2/year; P < 0.001) and more emergency admissions post-transplantation (25% of young adults on average are admitted each year, compared with 15-20% of 34- to 43-year olds). Taking into account deprivation, ethnicity, transplant type and transplant centre, in the 14- to 23-year group, return to dialysis remained significantly worse than all other age bands (HR = 1.41, 95% CI 1.26-1.57). For the whole cohort, increasing deprivation related to poorer outcomes and black ethnicity was associated with poorer outcomes. However, neither ethnicity nor deprivation was over-represented in the young adult cohort.
CONCLUSIONS
Young adults who receive a kidney transplant have a significant increased likelihood of a return to dialysis in the first 10 years post-transplant when compared with those aged 34-43 years in multivariable analysis
The experiences of diploma registered nurses returning to undergraduate study in Qatar: A descriptive qualitative study.
No full textBACKGROUND
Qatar aspires to provide world-class healthcare comparable with Western countries. Compelling evidence demonstrating the positive effects of bachelor of nursing (BN) educated nurses on patient outcomes is creating a global demand for these graduates, particularly in contexts such as Qatar where historically RN-to-BN programs were unavailable.
OBJECTIVE
The aim of this study was to examine the return to education experiences of diploma educated registered nurses (RNs) undertaking a bachelor program.
METHODS
This descriptive qualitative study included 19 diploma educated registered nurses enrolled in a BN program in a Qatar campus of a Canadian university. Focus groups and thematic analysis were used.
RESULTS
Three major themes described RNs' experiences of returning to education: the right time, balancing act and rewards. The convergence of timing, BN program availability and employer sponsorship were significant levers. Returning to education was challenging and required balancing competing demands of work, home, and study. The exposure to enquiry-based learning required rapid development of study skills to enable learning. Previous education was often seen as incongruent with requirements for academic success. A notable omission from accounts was reference to professional identity. Undertaking the program brought returns such as increased self-esteem, enhanced knowledge and potential for career progression. Organizational culture and commitment appeared to impact on students' experience.
CONCLUSIONS
Completing a BN program was reward for the challenges engendered by returning to education. Effective partnerships and structural support between academic and service providers are required to ensure the benefits of BN attainment become embedded and impact on professional identity
Real-world tyrosine kinase inhibitor treatment pathways, monitoring patterns and responses in patients with chronic myeloid leukaemia in the United Kingdom: the UK TARGET CML study.
No full textManagement of chronic myeloid leukaemia (CML) has recently undergone dramatic changes, prompting the European LeukemiaNet (ELN) to issue recommendations in 2013; however, it remains unclear whether real-world CML management is consistent with these goals. We report results of UK TARGET CML, a retrospective observational study of 257 patients with chronic-phase CML who had been prescribed a first-line TKI between 2013 and 2017, most of whom received first-line imatinib (n = 203). Although 44% of patients required ≥1 change of TKI, these real-world data revealed that molecular assessments were frequently missed, 23% of patients with ELN-defined treatment failure did not switch TKI, and kinase domain mutation analysis was performed in only 49% of patients who switched TKI for resistance. Major molecular response (MMR; BCR-ABL1 ≤0·1%) and deep molecular response (DMR; BCR-ABL1 ≤0·01%) were observed in 50% and 29%, respectively, of patients treated with first-line imatinib, and 63% and 54%, respectively, receiving a second-generation TKI first line. MMR and DMR were also observed in 77% and 44% of evaluable patients with ≥13 months follow-up, receiving a second-generation TKI second line. We found little evidence that cardiovascular risk factors were considered during TKI management. These findings highlight key areas for improvement in providing optimal care to patients with CML
Physical Activity Intervention for Loneliness (PAIL) in community-dwelling older adults: a randomised feasibility study.
No full textBackground
Low quality social relationships in older adults are strongly associated with feelings of loneliness. Physical activity interventions could reduce loneliness and improve psychological well-being, among other health benefits. The aim of this study was to examine the feasibility of a Physical Activity Intervention for Loneliness (PAIL) in community-dwelling older adults at risk of loneliness.
Methods
The PAIL feasibility study was a 12-week randomized controlled feasibility trial (RCT) conducted in Birmingham, United Kingdom, from February 2018 to August 2018, and ran in two waves of data collection. Eligible participants were community-dwelling adults aged 60 years and older, sedentary (less than 20 min of moderate-to-vigorous PA (MVPA) a week), and at risk of loneliness. The intervention included once-weekly group walk and health education workshop up to 90 min per session in total, with a wait-listed (WL) control group. The primary feasibility outcomes were to estimate recruitment, retention rates and adherence to the intervention. Secondary outcome measures (not blinded assessment) were body mass index, blood pressure, physical activity and psychosocial variables. Process and outcome evaluations were conducted using focus groups interviews. The recruitment and retention progression criteria for the definitive large-scale RCT was set a-priori.
Results
Forty-eight participants were recruited over 4 months with a recruitment rate of 25% (48/195); 52% (25/48) met the inclusion criteria and 100% (25/25) were randomised into the intervention ( = 12) and WL control groups ( = 13). Participants were 25 older adults (mean (SD) 68.5(8.05) years), 14 (56%) female, and 18 (72%) white. At 12 weeks, 10/12 (83.3%) intervention and 10/13 (76.9%) control participants completed the final assessments. The average attendance rate was 58.3% for the intervention group (range 33.0%-75.0%) and 42.3% (range 23.1%-69.2%) among controls. The a priori recruitment and retention criteria for progression were not met. No serious adverse events occurred. The focus group results identified three themes which showed overall positive experiences of participation in PAIL in terms of (1) study design and intervention; (2) walking sessions; and (3) health education workshops.
Conclusions
The findings suggest that community-dwelling older adults at risk of loneliness found the intervention and measures acceptable and could safely participate. However, a more extensive and robust strategy would be needed to support adequate recruitment of lonely older adults and adherence into a definitive RCT.
Trial registration
Clinicaltrials.gov, NCT03458793
Can a transition clinic bridge the gap between paediatric and adult inflammatory bowel disease care models?
No full textTransition care in inflammatory bowel disease is increasingly recognized as challenging given the inherent differences between paediatric and adult health care models, disease characteristics and treatment strategies. Transition is a dynamic process involving adolescents and young adults that are moving from a paediatric to an adult health care setting, and it should be flexible, continually updated and tailored to each patient. The implementation of a transition clinic is essential given the increasing incidence of the paediatric population with inflammatory bowel disease and the lifelong impact of this disease. The key question is when and how to structure transition according to the adolescent's clinical, psycho-social, educational needs and expectations to ensure continuity of care. In the attempt to improve the management of transition in inflammatory bowel disease and address the wide gap between adult and child care, we provide an update of the transition clinic and we propose a "treat to target" approach in transition to facilitate an effective and successful transition programme. In the changing landscape of the treatment of inflammatory bowel disease, further studies are necessary to determine the role of the transition clinic in determining the choice and strategy of therapy and its monitoring and the adoption of newer strategies such as biomarkers guided treating to target
Investigating discharge communication for chronic disease patients in three hospitals in India.
No full textOBJECTIVES
Poor discharge communication is associated with negative health outcomes in high-income countries. However, quality of discharge communication has received little attention in India and many other low and middle-income countries.
PRIMARY OBJECTIVE
To investigate verbal and documented discharge communication for chronic non-communicable disease (NCD) patients.
SECONDARY OBJECTIVE
To explore the relationship between quality of discharge communication and health outcomes.
METHODS
DESIGN
Prospective study.
SETTING
Three public hospitals in Himachal Pradesh and Kerala states, India.
PARTICIPANTS
546 chronic NCD (chronic respiratory disease, cardiovascular disease or diabetes) patients. Piloted questionnaires were completed at admission, discharge and five and eighteen-week follow-up covering health status, discharge communication practices and health-seeking behaviour. Logistic regression was used to explore the relationship between quality of discharge communication and health outcomes.
OUTCOME MEASURES
PRIMARY
Patient recall and experiences of verbal and documented discharge communication.
SECONDARY
Death, hospital readmission and self-reported deterioration of NCD/s.
RESULTS
All patients received discharge notes, predominantly on sheets of paper with basic pre-printed headings (71%) or no structure (19%); 31% of notes contained all the following information required for facilitating continuity of care: diagnosis, medication information, lifestyle advice, and follow-up instructions. Patient reports indicated notable variations in verbal information provided during discharge consultations; 50% received ongoing treatment/management information and 23% received lifestyle advice. Within 18 weeks of follow-up, 25 (5%) patients had died, 69 (13%) had been readmitted and 62 (11%) reported that their chronic NCD/s had deteriorated. Significant associations were found between low-quality documented discharge communication and death (AOR = 3.00; 95% CI 1.27,7.06) and low-quality verbal discharge communication and self-reported deterioration of chronic NCD/s (AOR = 0.46; 95% CI 0.25,0.83) within 18-weeks of follow-up.
CONCLUSIONS
Sub-optimal discharge practices may be compromising continuity and safety of chronic NCD patient care. Structured protocols, documents and training are required to improve discharge communication, healthcare integration and NCD management
Results from the first English stool bank using faecal microbiota transplant as a medicinal product for the treatment of infection.
No full textBackground
Faecal Microbiota Transplant (FMT) has improved outcomes for the treatment of infection (CDI) compared to antibiotic therapy. FMT is classified as a medicinal product in the United Kingdom, similar to the USA and Canada, limiting supply via stool banks without appropriate licencing. In the largest UK cohort to date, we describe the clinical outcomes for 124 patients receiving FMT for recurrent or refractory CDI and present a framework to produce FMT as a licenced medicinal product.
Methods
Anonymous unrelated healthy donors, screened via health assessment and microbiological testing donated stool. In aerobic conditions FMT aliquots were prepared for immediate use or frozen storage, following a production framework developed to comply with Good Manufacturing Practice. Outcome measures were clinical response to FMT defined as resolution of diarrhoea within seven days and clinical cure defined as response without diarrhoea recurrence at 90 days.
Findings
Clinical response was 83·9% (95% CI 76·0%-90·0%) after one treatment. Clinical cure was 78·2% (95% CI 67·4%-89·0%) across the cohort. Refractory cases appeared to have a lower initial clinical response rate compared to recurrent cases, however at day 90 there were no differences observed between these groups.
Interpretation
The methodology developed here enabled successful licencing of FMT by The Medicines and Healthcare products Regulatory Agency as a medicinal product. This has widened the availability of FMT in the National Health Service via a stool bank and can be applied in other centres across the world to improve access to safe and quality assured treatments