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Lessons learned from the development and implementation of a patient-reported outcome and experience measure (POEM) in an Australian glaucoma practice.
No full textBACKGROUND
A patient's perception of how their glaucoma is managed will influence both adherence to their medication and outcome measures such as quality of life.
METHODS
Prospective consecutive study using a Glaucoma Patient-reported Outcome and Experience Measure (POEM) modified for an Australian ophthalmic private clinical practice setting. The Australian Glaucoma POEM consists of eight items related to the patient's understanding of the diagnosis and management, acceptability of the treatment, whether they feel their glaucoma is getting worse, interfering with their daily life and concerns regarding loss of vision as well as addressing whether they feel safe under the care of their glaucoma team and how well their care is organised.
RESULTS
Two hundred and two patients (M:F 91:111) participated in the study. Mean ± standard deviation for subject age was 69 ± 13 years. Patient's overall perception of their treatment and outcome was favourable. Younger patients felt their glaucoma interfered more with their daily lives and were more worried about losing vision from glaucoma. The greater the number of medications in use, the more they felt their glaucoma was getting worse and that glaucoma interfered with their daily lives. With all other variables accounted for by the multivariate linear model, female patients more strongly agreed that they understood their glaucoma diagnosis and glaucoma management. The patients with a severe visual defect in their worse eye, reported a greater perceived understanding of their glaucoma diagnosis and management and that they felt that glaucoma had a greater interference on their daily life. They were also more concerned about losing vision from glaucoma than their fellow glaucoma patients with less severe or no visual field deficit in the worse eye.
CONCLUSIONS
The modified POEM demonstrates potential to capture the concerns of a practice's glaucoma cohort with a view to enhancing the quality of glaucoma care delivered
Risk adjusted assessment of individual surgeon's pancreatic fistula outcomes.
No full textBACKGROUND
Post-operative pancreatic fistula (POPF) is a major cause of morbidity following pancreatoduodenectomy. The risk of POPF varies between individuals and thus assessment without risk adjustment is crude. However, despite the availability of numerous scores to determine risk, no study has provided a risk adjusted assessment of POPF outcomes.
METHODS
The observed and risk adjusted occurrence of POPF from consecutive patients operated upon by eight surgeons were recorded. Surgeons varied in experience from newly appointed (n = 5) to established (n = 3). CUSUM (cumulative sum) analysis was used to assess performance.
RESULTS
104 POPF occurred among 519 patients (20.0%). The occurrence of POPF was significantly lower among experienced surgeons (20/186, 10.7% vs 84/333, 25.2%; p < 0.001). Following risk adjustment surgeons observed 16.6 fewer to 6.5 excess POPF per 100 patients than predicted. Analysis of the CUSUM plots demonstrated the experienced surgeons performed steadily with a gradual reduction in observed POPF compared to what was predicted. The new surgeon's performance was less consistent and evidence of a learning curve was observed with steady improvement occurring after 50-70 patients.
CONCLUSIONS
Risk adjusted assessment of POPF demonstrates differences between experienced and less experienced surgeons. This method could be used to audit practice and observe effects of changes to technique
Tenofovir disoproxil fumarate/emtricitabine is associated with a higher risk of hypocalcemia compared to abacavir/lamivudine - results from a German cohort study.
No full textHyperparathyroidism has been described in people living with HIV undergoing tenofovir disoproxil fumarate (TDF)-containing antiretroviral therapy (ART), but differences in calcium levels have never been investigated in detail. We aimed to compare the prevalence of hypocalcemia between patients with and without TDF-containing ART. The patients and methods were a retrospective cohort study in HIV-infected adult patients receiving dolutegravir and either abacavir (ABC)/lamivudine (3TC) or TDF/emtricitabine in a single center in Munich, Germany. Of 172 patients, 126 (73.3%) were male and the median age was 48.5 years (interquartile range 42-54). Average calcium levels were 2.24 (2.21-2.29) mmol/l and 2.21 (2.16-2.26) mmol/l (P < 0.001) with a prevalence of at least one episode of total calcium <2.12 mmol/l of 16.2 and 34.4% in the groups treated with ABC/3TC and TDF/emtricitabine, respectively (P = 0.006). TDF use was independently associated with the occurrence of albumin-corrected calcium levels of <2.12 mmol/l (odds ratio: 6.7 [1.3-35.6]; P = 0.025). Hypocalcemia seems to occur more often in TDF-treated patients. Further research into hypocalcemia with TDF and potential cardiovascular effects may be of benefit based on these findings
Editorial: effect of exercise on physical frailty in patients with chronic liver disease. Authors' reply.
No full textPredicting Postoperative Lung Function Following Lung Cancer Resection: A Systematic Review and Meta-analysis.
No full textBackground
Lung resection remains the gold standard treatment for early stage lung cancer; prediction of postoperative lung function is a key selection criterion for surgery with the aim of determining risk of postoperative dyspnoea. We aimed to identify the different prediction techniques used, and compare their accuracy.
Methods
A systematic review and meta-analysis sought to synthesise studies conducted that assess prediction of postoperative lung function up to 18/02/2018 (n = 135). PROBAST was used to assess risk of bias in studies, 17 studies were judged to be at low risk of bias.
Findings
Meta-analysis revealed CT volume and density measurement to be the most accurate (mean difference 71 ml) and precise (standard deviation 207 ml) of the reported techniques used for predicting FEV1; evidence for predicting gas transfer was lacking.
Interpretation
The evidence suggests using CT volume and density is the preferred technique in the prediction of postoperative FEV1. Further studies are required to ensure that the methods and thresholds we propose are linked to patient reported outcomes.
Funding
Salary support for NKO, RM, PN, BN, and AMT was provided by University Hospitals Birmingham NHS Foundation Trust
Durable left ventricular assist device support as a bridge to heart transplant candidacy†.
No full textOBJECTIVES
Left ventricular assist devices are funded in the UK exclusively as a bridge to transplant (BTT). However, patients who potentially could receive a transplant may develop reversible contraindications to transplant. Bridge to candidacy (BTC) has sometimes been controversial, given the uncertain clinical efficacy of BTC and the risk that reimbursement could be denied. We analysed the UK ventricular assist device database to understand how common BTC was and to assess patient survival rates and incidences of transplants.
METHODS
We identified BTC implants in patients with pulmonary hypertension, chronic kidney disease and obesity using the UK guidelines for heart transplants.
RESULTS
A total of 306 of 540 patients had complete data and 157 were identified as BTC (51%). Overall, there was no difference in survival rates between patients designated as BTC and those designated at BTT (71.9 vs 72.9% at 1 year, respectively; P = 0.82). However, the survival rate was lower at all time points in those with an estimated glomerular filtration rate (eGFR) 32 up to 1-year postimplant. There were no significant differences in the incidence of transplant between patients who were BTC and BTT or for any subgroup up to 5 years. However, we noted a diverging trend towards a lower cumulative incidence of transplant for patients with a BMI >32.
CONCLUSIONS
BTC is common in the UK and appears clinically effective, given that the survival rates and the incidence of transplants were comparable with those for BTT. Patients with a high BMI have a worse survival rate through to 1 year and a trend for a lower incidence of a transplant. Patients with a low eGFR also have a worse survival rate, but a similar proportion received transplants
The pharmacist's role in improving the treatment of erectile dysfunction and its underlying causes.
No full textErectile dysfunction (ED), which worldwide is likely to affect in excess of 300 million men by 2025, is often either untreated or insufficiently treated. It can be a prelude to other serious illnesses and may be a cause or consequence of depression in affected individuals. Among men younger than 60 years of age, ED can be a robust early-stage indicator of vascular disease and type 2 diabetes. Untreated or inadequately treated ED can also be a sign of poor communication between health professionals and service users of all ages. Improved treatment of ED could cost-effectively prevent premature deaths and avoidable morbidity. The extension of community pharmacy‒based health care would enable more men living with ED to safely access effective medications, along with appropriate diagnostic services and support for beneficial lifestyle changes such as smoking cessation in conveniently accessible settings. The task of introducing improved methods of affordably addressing problems linked to ED exemplifies the strategic challenges now facing health care systems globally. Promoting professionally supported self-care in pharmacies has the potential to meet the needs of aging populations in progressively more effective ways
Patterns and predictors of relapse following radical chemoradiotherapy delivered using intensity modulated radiotherapy with a simultaneous integrated boost in anal squamous cell carcinoma.
No full textPURPOSE
To describe the patterns and predictors of treatment failure in patients receiving definitive chemoradiotherapy (CRT) for anal squamous cell carcinoma (ASCC), delivered using intensity modulated radiotherapy (IMRT).
MATERIALS AND METHODS
A retrospective cohort analysis of consecutive patients treated with curative intent for ASCC using CRT delivered with a standardised IMRT technique in five UK cancer centres. Patients were included from the start of UK IMRT guidance in February 2013 to 31st October 2017. Collected data included baseline demographics, treatment details, tumour control, sites of relapse and overall survival. Statistical analysis to calculate outcomes and predictive factors for outcome measures were performed using SPSS and R.
RESULTS
The medical records of 385 consecutive patients were analysed. Median follow-up was 24.0 months. 86.7% of patients achieved a complete response (CR) within 6 months of completing chemoradiotherapy. 3yr disease free survival (DFS) and overall survival (OS) were 75.6% and 85.6% respectively. Of all relapses, 83.4% occurred at the site of primary disease. There were two isolated relapses in regional nodes not involved at outset. Predictive factors for cancer recurrence included male sex, high N-stage and failure to complete radiotherapy as planned.
CONCLUSIONS
The treatment results compare favourably to published outcomes from similar cohorts using 3D conformal CRT. The observed patterns of failure support the current UK IMRT voluming guidelines and dose levels, highlighting our prophylactic nodal dose is sufficient to prevent isolated regional relapse in uninvolved nodes. Further investigation into strategies to optimise CR should remain a priority in ASCC, as the site of primary disease remains the overwhelming site of relapse
Successful embolisation of pelvic fistulating vessels to the prostate arising after TURP - a rare cause of postoperative bleeding.
No full textTransurethral resection of the prostate (TURP) is considered the gold-standard operation to treat lower urinary tract symptoms due to benign prostatic enlargement in men. Postoperative bleeding is a recognised complication and managing it is a core skill required by attending urologists. We report a rare case of postoperative bleeding caused by fistulating vessels to the prostate which developed after TURP. These fistulas arose from the right internal iliac vessels and communicated with pre-existing pelvic varices affecting the right paraprostaticand seminal vesicle tissues. The fistulating vessels were successfully embolised with liquid embolic agent. Surgeons should be aware that persisting haemorrhage can occur post-TURP from the rare presence of fistulating vessels communicating with pelvic varices. Early computed tomography angiographic assessment is warranted in cases where bleeding is prolonged and refractory to standard management in view of timely referral for percutaneous embolisation
Prophylactic levofloxacin to prevent infections in newly diagnosed symptomatic myeloma: the TEAMM RCT.
No full textBACKGROUND
Myeloma causes profound immunodeficiency and recurrent serious infections. There are approximately 5500 new UK cases of myeloma per annum, and one-quarter of patients will have a serious infection within 3 months of diagnosis. Newly diagnosed patients may benefit from antibiotic prophylaxis to prevent infection. However, the use of prophylaxis has not been established in myeloma and may be associated with health-care-associated infections (HCAIs), such as . There is a need to assess the benefits and cost-effectiveness of the use of antibacterial prophylaxis against any risks in a double-blind, placebo-controlled, randomised clinical trial.
OBJECTIVES
To assess the risks, benefits and cost-effectiveness of prophylactic levofloxacin in newly diagnosed symptomatic myeloma patients.
DESIGN
Multicentre, randomised, double-blind, placebo-controlled trial. A central telephone randomisation service used a minimisation computer algorithm to allocate treatments in a 1 : 1 ratio.
SETTING
A total of 93 NHS hospitals throughout England, Northern Ireland and Wales.
PARTICIPANTS
A total of 977 patients with newly diagnosed symptomatic myeloma.
INTERVENTION
Patients were randomised to receive levofloxacin or placebo tablets for 12 weeks at the start of antimyeloma treatment. Treatment allocation was blinded and balanced by centre, estimated glomerular filtration rate and intention to give high-dose chemotherapy with autologous stem cell transplantation. Follow-up was at 4-week intervals up to 16 weeks, with a further follow-up at 1 year.
MAIN OUTCOME MEASURES
The primary outcome was to assess the number of febrile episodes (or deaths) in the first 12 weeks from randomisation. Secondary outcomes included number of deaths and infection-related deaths, days in hospital, carriage and invasive infections, response to antimyeloma treatment and its relation to infection, quality of life and overall survival within the first 12 weeks and beyond.
RESULTS
In total, 977 patients were randomised (levofloxacin, = 489; placebo, = 488). A total of 134 (27%) events (febrile episodes, = 119; deaths, = 15) occurred in the placebo arm and 95 (19%) events (febrile episodes, = 91; deaths, = 4) occurred in the levofloxacin arm; the hazard ratio for time to first event (febrile episode or death) within the first 12 weeks was 0.66 (95% confidence interval 0.51 to 0.86; = 0.002). Levofloxacin also reduced other infections (144 infections from 116 patients) compared with placebo (179 infections from 133 patients; -trend of 0.06). There was no difference in new acquisitions of , methicillin-resistant and extended-spectrum beta-lactamase Gram-negative organisms when assessed up to 16 weeks. Levofloxacin produced slightly higher quality-adjusted life-year gains over 16 weeks, but had associated higher costs for health resource use. With a median follow-up of 52 weeks, there was no significant difference in overall survival ( = 0.94).
LIMITATIONS
Short duration of prophylactic antibiotics and cost-effectiveness.
CONCLUSIONS
During the 12 weeks from new diagnosis, the addition of prophylactic levofloxacin to active myeloma treatment significantly reduced febrile episodes and deaths without increasing HCAIs or carriage. Future work should aim to establish the optimal duration of antibiotic prophylaxis and should involve the laboratory investigation of immunity, inflammation and disease activity on stored samples funded by the TEAMM (Tackling Early Morbidity and Mortality in Myeloma) National Institute for Health Research Efficacy and Mechanism Evaluation grant (reference number 14/24/04).
TRIAL REGISTRATION
Current Controlled Trials ISRCTN51731976.
FUNDING DETAILS
This project was funded by the NIHR Health Technology Assessment programme and will be published in full in ; Vol. 23, No. 62. See the NIHR Journals Library website for further project information