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Burn center function during the COVID-19 pandemic: An international multi-center report of strategy and experience.
No full textThe novel coronavirus, SARS-CO V2 responsible for COVID-19 pandemic is rapidly escalating across the globe. Burn centers gearing for the pandemic must strike a balance between contributing to the pandemic response and preserving ongoing burn care in a safe and ethical fashion. The authors of the present communication represent seven burn centers from China, Singapore, Japan, Italy, Spain, the United Kingdom (UK), and the United States (US). Each center is located at a different point along the pandemic curve and serves different patient populations within their healthcare systems. We review our experience with the virus to date, our strategic approach to burn center function under these circumstances, and lessons learned. The purpose of this communication is to share experiences that will assist with continued preparations to help burn centers advocate for optimum burn care and overcome challenges as this pandemic continues
Effects of Primary Sclerosing Cholangitis on Risks of Cancer and Death in People With Inflammatory Bowel Diseases, Based on Sex, Race, and Age.
No full textBACKGROUND & AIMS
There are insufficient population-level data on effects of primary sclerosing cholangitis (PSC) in patients with inflammatory bowel disease (IBD).
METHODS
We identified incident cases of IBD, with PSC (PSC-IBD) and without, from April 2006 through to April 2016 and collected data on outcomes through April 2019. We linked data from national healthcare registries maintained for all adults in England on hospital attendances, imaging and endoscopic evaluations, surgical procedures, cancer, and deaths. Our primary aim was to quantify the effects of developing PSC in patients with all subtypes of IBD and evaluate its effects on hepatopancreatobiliary disease, IBD-related outcomes, and all-cause mortality, according to sex, race, and age.
RESULTS
Over 10 years, we identified 284,560 incident cases of IBD nationwide; of these 2588 developed PSC. In all, we captured 31,587 colectomies, 5608 colorectal cancers (CRCs), 173 first liver transplants, 6608 cholecystectomies and 41,055 patient deaths. Development of PSC was associated with increased risk of death and CRC (hazard ratios [HRs], 3.20 and 2.43, respectively; P7), in contrast to those who received a diagnosis of IBD older than 60 years (incidence rate ratio <1.5). Among patients with PSC-IBD, liver transplantation and PSC-related events accounted for approximately 75% of clinical events when patients received a diagnosis of PSC at an age younger than 40 years, vs 31% of patients who received a diagnosis older than 60 years (P<.001). Afro-Caribbean heritage associated with increased risks of liver transplantation or PSC-related death compared with Caucasian race (HR, 2.05; P<.001), whereas female sex associated with reduced risk (HR, 0.74; P=.025).
CONCLUSIONS
In a 10-year, nationwide study, we confirmed that patients with PSC-IBD have increased risks of CRC, hepatopancreatobiliary cancers, and death compared to patients with IBD alone. In the PSC-IBD group, diagnosis of IBD at age younger than 40 years was associated with greater risks of CRC and all-cause mortality compared with diagnosis of IBD at older ages. Patients who receive a diagnosis of PSC at an age younger than 40 years, men, and patients of Afro-Caribbean heritage have an increased incidence of PSC-related events
'You have got a foreign body in there': renal transplantation, unexpected mild-to-moderate distress and patients' support needs: a qualitative study.
No full textOBJECTIVE
To explore why transplant patients experience unexpected mild-to-moderate distress and what support they may need.
DESIGN
Qualitative study using individual in-depth interviews.
SETTING
Four National Health Service (NHS) Trusts in the Midlands, UK.
PARTICIPANTS
Fifteen renal transplant patients meeting the criteria for mild-to-moderate distress from their responses to emotion thermometers.
MAIN OUTCOME MEASURES
Identification of the reasons for distress and support options acceptable to renal transplant patients.
RESULTS
Three themes were interpreted from the data: 'I am living with a "foreign body" inside me', 'why am I distressed?' and 'different patients want different support'. Following their transplant, participants felt that they should be happy and content, but this was often not the case. They described a range of feelings about their transplant, such as uncertainty about the lifespan of their new kidney, fear of transplant failure or fear of the donor having health conditions that may transfer to them. A few experienced survivors' guilt when others they had met at the dialysis unit had not received a transplant or because someone had died to enable them to receive the transplant. No longer having regular contact with the renal unit made participants feel isolated. Some participants did not initially attribute the source of their distress to their transplant. Participants' preferred support for their distress and their preferences about who should deliver it varied from peer support to seeing a psychologist.
CONCLUSIONS
Raising the issue of post-transplant mild-to-moderate distress with patients and encouraging them to think about and plan coping strategies pretransplant may prove beneficial for the patient and healthcare provider. Patients should be able to choose from a variety of support options
Regulating the risk-reward trade-off in transplantation.
No full textTransplantation benefits from appropriate regulation by ensuring adherence to quality and safety standards. However, Dr. Andreoni highlights in his Personal Viewpoint the unintended consequences of heightened regulatory control . While the article has a US perspective, its message is global. For example, in the UK any center with statistical deviation in actual-versus-expected 30-day survival outcomes can be investigated. US data show that discard rates have risen and the number of patients waiting for transplants has flattened in the era of enhanced regulation; suggesting we are providing fewer transplant opportunities for patients who could potentially benefit
The impact of resuscitation system factors on in-hospital cardiac arrest outcomes across UK hospitals: an observational study.
No full textPURPOSE OF THE STUDY
To explore whether variation in in-hospital cardiac arrest (IHCA) survival can be explained by differences in resuscitation service provision across UK acute hospitals.
METHODS
We linked information on key clinical practices with patient data of adults who had a cardiac arrest on a general hospital ward or emergency admissions unit in 2016/17. We used multi-level Bayesian models to explore associations between system quality indicators (number of resuscitation officers, audits time to first shock, review unexpected non-survivors, arrest team meets at handover, hot debrief, cold debrief, real-time audio-visual feedback, frequency of mock arrest provision) and adjusted hospital survival.
RESULTS
We received survey responses from 110 out of 180 eligible hospitals (response rate 61%) relating to 12285 cardiac arrest cases. Variation across trusts was observed in the number of resuscitation officers (median 0.7 (interquartile range 0.5, 0.9) per 750 clinical staff employed. Key system quality indicators were undertaken infrequently: audit of time to first shock (44.7%), arrest team meeting at handover (28.9%), mock arrests>monthly (22.4%), and use of CPR feedback devices (18.4%). The probability that the system quality indicators had a positive effect on hospital survival ranged from 10% to 89%. However, there was uncertainty in the estimated odds ratios and we cannot exclude the possibility of a clinical benefit. Findings were consistent across secondary outcomes.
CONCLUSION
In this study, we identified variation in implementation of system quality indicators. Amongst hospitals that responded to our survey, the probability that individual factors increase the odds of hospital survival ranges from 10 to 89%.
Denosumab, raloxifene, romosozumab and teriparatide to prevent osteoporotic fragility fractures: a systematic review and economic evaluation.
No full textBACKGROUND
Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture.
OBJECTIVES
The objectives were to evaluate the clinical effectiveness, safety and cost-effectiveness of non-bisphosphonates {denosumab [Prolia; Amgen Inc., Thousand Oaks, CA, USA], raloxifene [Evista; Daiichi Sankyo Company, Ltd, Tokyo, Japan], romosozumab [Evenity; Union Chimique Belge (UCB) S.A. (Brussels, Belgium) and Amgen Inc.] and teriparatide [Forsteo; Eli Lilly and Company, Indianapolis, IN, USA]}, compared with each other, bisphosphonates or no treatment, for the prevention of fragility fracture.
DATA SOURCES
For the clinical effectiveness review, nine electronic databases (including MEDLINE, EMBASE and the World Health Organization International Clinical Trials Registry Platform) were searched up to July 2018.
REVIEW METHODS
A systematic review and network meta-analysis of fracture and femoral neck bone mineral density were conducted. A review of published economic analyses was undertaken and a model previously used to evaluate bisphosphonates was adapted. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years for a simulated cohort of patients with heterogeneous characteristics. This was done for each non-bisphosphonate treatment, a strategy of no treatment, and the five bisphosphonate treatments previously evaluated. The model was populated with effectiveness evidence from the systematic review and network meta-analysis. All other parameters were estimated from published sources. An NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net monetary benefit was estimated using non-parametric regression. A probabilistic sensitivity analysis and scenario analyses were used to assess uncertainty.
RESULTS
Fifty-two randomised controlled trials of non-bisphosphonates were included in the clinical effectiveness systematic review and an additional 51 randomised controlled trials of bisphosphonates were included in the network meta-analysis. All treatments had beneficial effects compared with placebo for vertebral, non-vertebral and hip fractures, with hazard ratios varying from 0.23 to 0.94, depending on treatment and fracture type. The effects on vertebral fractures and the percentage change in bone mineral density were statistically significant for all treatments. The rate of serious adverse events varied across trials (0-33%), with most between-group differences not being statistically significant for comparisons with placebo/no active treatment, non-bisphosphonates or bisphosphonates. The incremental cost-effectiveness ratios were > £20,000 per quality-adjusted life-year for all non-bisphosphonate interventions compared with no treatment across the range of QFracture and FRAX scores expected in the population eligible for fracture risk assessment. The incremental cost-effectiveness ratio for denosumab may fall below £30,000 per quality-adjusted life-year at very high levels of risk or for high-risk patients with specific characteristics. Raloxifene was dominated by no treatment (resulted in fewer quality-adjusted life-years) in most risk categories.
LIMITATIONS
The incremental cost-effectiveness ratios are uncertain for very high-risk patients.
CONCLUSIONS
Non-bisphosphonates are effective in preventing fragility fractures, but the incremental cost-effectiveness ratios are generally greater than the commonly applied threshold of £20,000-30,000 per quality-adjusted life-year.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42018107651.
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. 29. See the NIHR Journals Library website for further project information
ENDOCRINOLOGY IN THE TIME OF COVID-19: Management of adrenal insufficiency.
No full textWe provide guidance on prevention of adrenal crisis during the global COVID-19 crisis, a time with frequently restricted access to the usual level of healthcare. Patients with adrenal insufficiency are at an increased risk of infection, which may be complicated by developing an adrenal crisis; however, there is currently no evidence that adrenal insufficiency patients are more likely to develop a severe course of disease. We highlight the need for education (sick day rules, stringent social distancing rules), equipment (sufficient glucocorticoid supplies, steroid emergency self-injection kit) and empowerment (steroid emergency card, COVID-19 guidelines) to prevent adrenal crises. In patients with adrenal insufficiency developing an acute COVID-19 infection, which frequently presents with continuous high fever, we suggest oral stress dose cover with 20 mg hydrocortisone every 6 h. We also comment on suggested dosing for patients who usually take modified release hydrocortisone or prednisolone. In patients with adrenal insufficiency showing clinical deterioration during an acute COVID-19 infection, we advise immediate (self-)injection of 100 mg hydrocortisone intramuscularly, followed by continuous i.v. infusion of 200 mg hydrocortisone per 24 h, or until this can be established, and administration of 50 mg hydrocortisone every 6 h. We also advise on doses for infants and children
Co-administration of 5α-reductase inhibitors worsens the adverse metabolic effects of prescribed glucocorticoids.
No full textCONTEXT
Glucocorticoids (GC) are commonly prescribed, but their use is associated with adverse metabolic effects. 5a-reductase inhibitors (5aRI) are also frequently prescribed, mainly to inhibit testosterone conversion to dihydrotestosterone. However, they also prevent the inactivation of GCs.
OBJECTIVE
We hypothesised that 5aRIs may worsen the adverse effects of GCs.
DESIGN
Prospective, randomised study.
PATIENTS
19 healthy male volunteers (age; 45±2 years, BMI; 27.1±0.7kg/m2).
INTERVENTIONS
Participants underwent metabolic assessments; 2-step hyperinsulinemic, euglycemic clamp incorporating stable-isotopes, adipose tissue microdialysis and biopsy. Participants were then randomised to either prednisolone (10mg daily) or prednisolone (10mg daily) plus a 5aRI (finasteride 5mg daily or dutasteride 0.5mg daily) for 7 days; metabolic assessments were then repeated.
MAIN OUTCOME MEASURES
Ra glucose, glucose utilization (M-value), glucose oxidation, non-esterified fatty acids (NEFA) levels.
RESULTS
Co-administration of prednisolone with a 5aRI increased circulating prednisolone levels (482±96 vs. 761±57nmol/L, p=0.029). Prednisolone alone did not alter Ra glucose (2.55±0.34 vs 2.62±0.19mg/kg/min, p=0.86), M-value (3.2±0.5 vs 2.7±0.7mg/kg/min, p=0.37), or glucose oxidation (0.042±0.007 vs 0.040±0.004mmol/hr/kg/min, p=0.79). However, co-administration with a 5aRI increased Ra glucose (2.67±0.16 vs. 3.05±0.18mg/kg/min, p<0.05) and decreased M-value (4.0±0.5 vs. 2.6±0.4mg/kg/min, p<0.05), and oxidation (0.043±0.003 vs. 0.036±0.002mmol/hr/kg, p<0.01). Similarly, prednisolone did not impair insulin-mediated suppression of circulating NEFA (43.1±28.9 vs. 36.8±14.3μmol/L, p=0.81), unless co-administered with a 5aRI (49.8±8.6 vs. 88.5±13.5μmol/L, p<0.01).
CONCLUSIONS
We have demonstrated that 5aRIs exacerbate the adverse effects of prednisolone. This study has significant translational implications, including the need to consider GC dose adjustments, but also the necessity for increased vigilance for the development of adverse effects
