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To improve the quality of e-discharge summaries for patients potentially in their last 12 months of life using the G.R.E.A.T toolIntroduction Concise e-discharge summaries undoubtedly support seamless transition to enable clear treatment plans and ensure that patient preferences considered wherever possible. 'Ambitions-for-Palliative-and-End-of-Life-Care' national guidelines emphasise the importance of well-coordinated care; a concise summary will enable this ambition to be fulfilled. Now, discharge summaries fall under the purview of the medical team and serve as primary documents for communicating a patient's care plan between settings. While sifting through patient records, doctors need to know which information to include, to ensure excellent follow-up. Setting Margaret Centre (MC) is an 11-bed specialist inpatient palliative care unit. In its 2021/22 annual report, 1 in 3 of all admissions were discharged to the community. The centre's vision is to provide 'specialist services without walls', achievable through healthy partnerships and collaborations at various levels. Method As part of the Gold standard formwork, we examined e-discharge summaries for all discharges from 1st January to 30th September 2022. We used the G.R.E.A.T tool, adapted from Dudley Group NHS. G.R.E.A.T is an acronym for G- GSF Code; R- resuscitation status; E- End-of-life care (EOLC) medications; AAdvance Care Planning (ACP)including the Urgent Care Plan (previously Coordinate-My-Care; and T - treatment escalation plan (TEP). Results Patients aged 60-102years. 20 males. All potentially within their last 12 months. 9 e-discharges were for Medical Outliers. These were excluded. 32 discharges from MC were to: nursing home (44%), home (38%), acute ward (9%), hospice (6%), and interim placement (3%). 4 discharges had no e-discharge summary. Of 28 patients with summaries: Patient GSF-code was recorded 36% summaries; resuscitation status 43%; present/ absent EOLC medications 61%; inpatient ACP discussions 54%; TEP 50%. All five elements of G.R.E.A.T. present in only 25% of e-discharge summaries. Conclusion A quarter of e-discharge summaries on patients within the last 12 months of life, did not include any information regarding G.R.E.A.T. Junior doctors can be supported in this respect.
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The utility of novel accelerometer metrics for characterising clinical features in patients living with rheumatoid arthritis.Research-grade accelerometers are commonly used to measure physical activity (PA) in rheumatology research, demonstrating superior reliability and validity relative to self-report methods. Several accelerometers offer manufacturer software and embedded proprietary algorithms to reduce the complexities of data processing. However, algorithms vary between device brands, and hinder standardisation of data processing and analysis. Best practice in PA research is now therefore considered to be the collection and analysis of raw accelerometer data, to which transparent and replicable data transformation methods can be carried out post-processing. Novel metrics include average acceleration, intensity gradient, and MX metrics, which represent PA volume, intensity and patterns, and have not been examined in rheumatic diseases. To explore the utility of novel accelerometer metrics for characterising clinical features in Rheumatoid Arthritis (RA), i.e. disease activity and severity, cardiovascular disease (CVD) risk. People living with RA (n = 104) provided demographic data, medical history, a fasted blood sample, and completed the health assessment questionnaire (HAQ, disease severity). Disease activity was measured using the Disease Activity Score 28-CRP (DAS28-CRP), and CVD risk determined using the QRISK3. Participants wore a GT3X Actigraph accelerometer on their right hip for 7-days during waking hours. Accelerometer data were analysed using GGIR (v.2.1-1) to determine average acceleration (AA, mg, proxy for daily volume of PA), intensity gradient (IG = distribution of PA across the day) and MX metrics (acceleration above which a person's most active �X� mins are accumulated e.g., M5 = most active 5 mins). A higher AA and more positive IG indicate a favourable activity profile.�Statistical analyses:�Participants were grouped according to DAS28-CRP (remission = <2.6, low = 2.6 - 3.1, moderate = 3.2 � 5.1, high = >5.1) disease severity (HAQ; low = <1, moderate = 1 � 1.9, high = ?2) and QRISK3 (low = <10%, moderate = 10 - 19%, high = ?20%. Between group differences in AA and IG were analysed using analysis of variance, adjusted for accelerometer wear time. Radar plots were produced in R, to illustrate differences in MX metrics according to clinical features. Valid accelerometer data (?10 hr on ?4 days), were available for n = 102 participants (M �SD, AA = 13.7 �5.2 mg, IG = -2.91�.36). Participants in remission and with low CVD risk, demonstrated a better activity profile (i.e. [M �SE, all�p<.05] significantly higher AA [DAS28-CRP = 17.9 �1.1; QRISK3 = AA = 15.4 �0.6] and more positive IG [DAS28-CRP = -2.62 �0/07, QRISK3 = 2.80 �0.04], compared to patients with moderate or high disease activity and CVD risk (DAS28-CRP [moderate, AA = 12.8 �0.6, IG = -2.99�.04] and [high, AA = 11.2 �1.1, IG = -3.07�.08], QRISK3 [moderate, AA = 12.0 �1.0; IG = -3.0 �0.07] and [high AA = 10.3 �1.1; IG = -3.16 �0.08]). For disease severity IG was significantly more positive in patients with low (-2.78 �0.05) vs. high (-3.10 �0.08) HAQ scores. Radar plots (Figure 1) showed the intensity of the most active accumulated 2-45 mins (M2-M45) was greater (with M10 exceeding 75mg) among participants with better disease profiles (i.e. remission/low DAS28-CRP, HAQ and QRISK3 scores vs. moderate/high). This is the first study to demonstrate the clinical utility of novel accelerometer metrics in RA. Results suggest higher AA, more positive IGs, and accumulating ?10 mins at an intensity indicative of a slow walk (M10 >75mg), is characteristic of more favourable disease profiles. Future studies utilising these raw accelerometer metrics could provide valuable, standardised accelerometer data that can be used to deliver more personalised care (i.e. precision medicine).
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Systematic review of groin wound surgical site infection incidence after arterial intervention.The objectives were to determine the surgical site infection incidence (including superficial/deep) fter arterial intervention through non?infected groin incisions and identify variables associated with incidence. MEDLINE, EMBASE and CENTRAL databases were searched for randomised controlled trials and observational studies of adults undergoing arterial intervention through a groin incision and reported surgical site infection. Infection incidence was examined in subgroups, variables were subjected to meta?regression. One hundred seventeen studies reporting 65 138 groin incisions in 42 347 patients were included. Overall surgical site infection incidence per incision was 8.1% (1730/21 431): 6.3% (804/12 786) were superficial and 1.9% (241/12 863) were deep. Superficial infection incidence was higher in randomised controlled trials (15.8% [278/1762]) compared with observational studies (4.8% [526/11 024]); deep infection incidence was similar (1.7% (30/1762) and 1.9% (211/11 101) respectively). Aneurysmal pathology (? = ?10.229, P <.001) and retrospective observational design (? = ?1.118, P =.002) were associated with lower infection incidence. Surgical site infection being a primary outcome was associated with a higher incidence of surgical site infections (? = 3.429, P =.017). The three?fold higher incidence of superficial surgical site infection reported in randomised controlled trials may be because of a more robust clinical review of patients. These results should be considered when benchmarking practice and could inform future trial design.
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SeHCAT study: a useful tool to investigate chronic diarrhoea?Introduction The SeHCAT (tauroselcholic [75 selenium] acid) test is the investigation of choice for patients with suspected bile acid diarrhoea (BAD). NICE guidelines advocate against the routine use of SeHCAT for the diagnosis of BAD in patients with chronic diarrhoea of unknown cause.1 We aimed to evaluate the diagnostic yield of SeHCAT testing in relation to risk factors for BAD and assess the tolerability of cholestyramine as a first-line treatment. Methods Retrospective data was collected from 84 sequential patients who had undergone SeHCAT testing at Russells Hall Hospital between January 2022 and July 2022. Data on patient demographics, comorbidities, referral reason, outcome and treatment were collected from electronic records. BAD was defined as less than 15% retention of SeHCAT after 7 days and classified into three subtypes: type 1 (secondary to ileal disease/resection); type 2 (primary or idiopathic); and type 3 (secondary to other gastrointestinal disorders).2 Results Mean age at the time of SeHCAT scanning was 50.5 years. Male:female ratio was 1:2.5. The most common reason for referral was suspected BAD type 2 which accounted for 50.0% of all scans performed. of the 84 patients, 52.4% were diagnosed with BAD following SeHCAT. The mean bile acid retention score for all patients was 18.0%. of patients referred with suspected BAD type 1 and 3, 76.5% and 75.0% were positive, respectively. In patients referred with suspected BAD type 2, a positive scan was found in 33.0%. Cholestyramine was initiated as the first line treatment in 88.6% of cases with confirmed BAD. 23.1% of those commenced on cholestyramine had subsequently switched to colesevelam. Reasons included lack of availability of cholestyramine (66.7%), poor response (22.2%) and intolerable side effects (11.1%). Conclusions SeHCAT is a useful test to investigate chronic diarrhoea in patients with comorbidities related to the development of BAD types 1 and 3. Although patients without underlying risk factors for BAD represent the majority of referrals, the overall diagnostic yield of SeHCAT testing in this cohort is low. This supports current NICE recommendations against routine SeHCAT use. Furthermore, cholestyramine is generally well tolerated as a first line bile acid sequestrant, with the largest barrier to long term treatment being availability of this medication.
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MYC/BCL6 double hit lymphoma negative for t(3;8) bcl6A small proportion of large B cell non-Hodgkin lymphoma (NHL) has�MYC�and�BCL6�rearrangements, detectable by fluorescence in-situ hybridisation (FISH) break-apart probes. There are conflicting reports on the prognosis of this group. A proportion of them have a single�t(3;8)�BCL6
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Review of MND patients known to the specialist palliative care team to improve service provision.Introduction Dudley Group NHS Trust provides support to patients with a diagnosis of Motor Neurone Disease, working in conjunction with the Regional Specialist Motor Neurone Disease service based at University Hospital's Birmingham and Primary Care Serivces. Care is provided by the Specialist Palliative Care (SPC) department, Dudley Rehabilitation Service, Community Dietitians, Speech and Language services, and District Nursing. Currently all patients are discussed in a bimonthly MDT meeting attended by the MND CNS (from UHB) and health professionals from the SPC team, Dietician and Speech and Language Therapist. A review of MND patients known to the specialist palliative care team to see if any themes was carried out. Method Using a proforma a review of patients known to the Specialist Palliative team on the 5.4.22 and deaths during 2022 was carried out using Somerset where MDT and visits are recorded. Results Eighteen patients known to the specialist palliative care team during this period, 12 male and 6 female. Of the 18 patients 10 died during the review period (Jan - July 2022) with 6 dying at home and 4 in hospital. With regards to the hospital deaths 2 had no DNACPR or ACP in community and this was completed in hospital. Advance care planning discussions were documented for 9 of the patients. There was documentation that some of the patients were GSF blue and therefore, not commenced yet, however, for a number there was documentation that ACP discussions had been challenging. DNACPR in place for 11 of the 18, however for 3 of these were completed in hospital. Discussion This review has provided useful information regarding the challenge of Advance care planning and that 40% of deaths occurred in hospital. Next steps are to agree standards for referral, discharge and min review when on the caseload and who should be involved including nursing, medical and therapy.
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Review of patients known to community specialist palliative care team that are admitted to Dudley Group of Hospitals NHS FT.Introduction The Specialist Palliative Care team in Dudley is an integrated team and therefore, when patients known to the team are admitted to Russells Hall Hospital an email alert is triggered that the hospital team can process. Approximately 50% of the patients on the hospital caseload are patients known to the community part of the integrated team. Therefore, a review of these admissions was planned to identify any themes to improve patient outcomes. Method Review of March 2022 patients on the hospital caseload using proforma to capture information including diagnosis, reason for admission and if admission was organised by the specialist palliative care team. Results In March 2022 there were 24 admissions to Russells Hall Hospital for 19 patients known to the community team. Two patients had 3 admissions and 1 patient 2 admissions. Most patients had a cancer diagnosis. With regards to the admissions 5 were arranged by the community specialist palliative care team. The admissions were for a range of reasons including possible malignant spinal cord compression, chemotherapy side effects, symptoms including pain, nausea and vomiting and breathlessness that required further investigation. The minimum a patient should be seen in community known to the specialist palliative care team is monthly and of the admissions only 1 patient had not been seen within a month of admission. Discussion With the caseload held by the hospital team having approximately 50% of patients known to the community team this review has provided assurance that admissions were appropriate. Next steps include a review of criteria for prioritisation of patients either known to the integrated team or ward referrals and criteria for minimum number of visits including consideration of phase of illness supporting the need of specialist input.
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Biologic use regulates the impact of inflammation on ischemic cardiovascular risk in rheumatoid arthritis.Chronic inflammation contributes to enhanced cardiovascular risk in patients with rheumatoid arthritis (RA). Biologic disease modifying antirheumatic drugs (bDMARDs) have been shown to effectively control inflammation in many conventional synthetic DMARD non-responders and improve cardiovascular outcomes. We here explored whether baseline bDMARD use may influence the impact of disease activity and systemic inflammation on long-term cardiovascular risk in patients with RA. We studied 4370 patients with RA who were free of cardiovascular disease upon registration to�Annternational�Cardiovascular�Consortium for people with�RA�(ATACC-RA) and followed prospectively. Prespecified outcomes included (a) major adverse cardiovascular events (MACE) defined as non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death and (b) any ischemic cardiovascular events (CVE) comprising MACE, coronary revascularization, stable angina pectoris, transient ischemic attack and peripheral arterial disease with or without revascularization. Missing covariate data were imputed using multiple imputation with 10 repetitions. Multivariable Cox models stratified by center evaluated the impact of disease activity [based on 28 joint counts and C-reactive protein (DAS28-CRP)], systemic inflammation (CRP), bDMARD use and their respective interactions on CVE risk after adjusting for age, gender, hypertension, diabetes, family history of CAD, smoking and total cholesterol to high-density lipoprotein ratio. Two corroborating sensitivity analyses were performed; the first included patients enrolled in the cohort on or after January 1, 2000, when bDMARD use became more prevalent among enrollees. The second used inverse probability of treatment weights (IPTW) to balance differences in bDMARD treated and untreated patients. Throughout 26534 patient years of follow-up, 239 first MACE and 362 total ischemic CVE were recorded. Among bDMARD nonusers, incidence of MACE and any ischemic CVE was [9.3 (95% CI 8.2-10.6) and 14.2 (12.8-15.8) events/1000PY respectively. Corresponding rates for bDMARD users were [5.4 (95% CI 2.9-10.1) and 8.2 (5.0-13.6) events/1000PY respectively. In the entire cohort, DAS-28 CRP and CRP(ln) associated with greater risk of MACE [(adjusted hazards ratio [HR] 1.19 (95%CI 1.06-1.34), p=0.004 and HR 1.15 (1.02-1.28), p=0.017 respectively], while for all ischemic CVE the association was significant for DAS-28 CRP [adjusted HR 1.1 (95%CI 1.07 to 1.30)], but not CRP(ln) [HR 1.06 (0.97 to 1.16)]. In bDMARD nonusers at baseline, higher DAS28-CRP and CRP(ln) associated with greater risk of MACE [adjusted HR 1.21 (95%CI 1.07-1.37), p=0.002 and HR 1.16 (1.04-1.30), p=0.009 respectively]. However, this was not the case in bDMARD users [p-for-interaction= 0.017 and 0.011 correspondingly, Figure 1]. In contrast, no significant interaction between DAS28-CRP or CRP and bDMARD use on any ischemic CVE risk was observed (p-for-interaction= 0.167 and 0.237 respectively). Both sensitivity analyses yielded similar results. Higher disease activity and systemic inflammation at baseline associated with greater risk of MACE in bDMARD nonusers but not in patients receiving bDMARDs. This may suggest the presence of additional bDMARD-specific benefits directly on atherosclerotic plaque �such as plaque stabilization[1]� above and beyond their effects on systemic inflammation.
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Clinical trajectories of multifactorial hand function deterioration in systemic sclerosis.Hand function deterioration is a major multifactorial driver of disability in Systemic Sclerosis (SSc) whose rate has been poorly described. The aim of this study is to describe incidence and risk factors of hand functional worsening in a longitudinal, multicenter, observational SSc cohort. Hand involvement and disability were evaluated in consecutively enrolled patients for 24 months. Patient-reported hand impairment was captured with Cochin Hand Disability Score (CHFS) and the corresponding minimal clinical important differences (MCID) and patient acceptable symptom state (PASS). Clinical association with CHFS change over time and clinically meaningful worsening (MCID-Worsening) were investigated. Three-hundred-ninety-six patients from 10 centres were evaluated and 201 SSc (age 55.7�12.2 years, male 13.4%) were included in the final analysis. Median (IQR) disease duration was 5 (2-11) years while the proportion of patients with diffuse cutaneous variant was the 29.9%. Fifty-six (27.8%) patients had a CHFS ?PASS at baseline. CHFS increased over time 35.8% of patients reaching CHFS?PASS (p<0.001), and 52.2% of patients reporting MCID-Worsening at 24 months. A LASSO model simultaneously exploring the effects of multiple baseline clinical variables showed that MCID-Worsening was associated with male gender, LeRoy diffuse variant, late capillaroscopy pattern, shorter disease duration, absence of digital ulcers, presence of tenosynovitis, pain, Raynaud�s phenomenon, and global and hand disability severity, together with treatment with immunosuppressants, vasoactive medications, and second-line analgesics. Hand function tends to deteriorate over time in one SSc patient in two despite available therapies and clinical assessment support risk stratification. These results pave the way to inform design of intervention studies aimed at improving the outcome of this major driver of disability in SSc.
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Gold standards framework implementation to improve individual plan of care for patients in the last year of life.Introduction A third of hospital patients are in their last year of life and almost 50% of people die in hospital. At Dudley Group NHS Foundation Trust (DGFT) we have implemented the Gold Standards Framework (GSF) to support identification of patients in the last year of life and development of individual plan of care. Method A GSF document is completed on the hospital electronic patient record following identification and there is one document per admission which is used to record if advance care planning has been offered, commencement of priorities for care and preferred place of care documented. Results From previous audits completed in the Trust we have confirmed approximately 30% of patients at anyone time are in the last year of life and this can also be reported by ward to support individual wards. The percentage of patients identified as GSF is increasing and as of June 2022 this was 14% and the percentage of GSF red patients with Priorities for care communication document has improved to 49% and the target is 70%. Discussion A number of initiatives are being used to improve identification of patients in the last year of life including introduction of level 2 priority training and also working with Deteriorating patient group on a bespoke 12 week course to support wards with the timely identification and appropriate management of deteriorating patients.
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Is faecal calprotectin a predictive measure to refer to GI specialist?.Introduction Calprotectin is a calcium binding protein which also classified as a damage associated molecular pattern protein. 1,2 Faecal calprotectin(FC) is patient friendly test measured easily from ELISA technique.3 FC >250micg/g indicates GI inflammation and may require evaluation.4 We noticed high FC was the reason for many referrals to our paediatric GI unit. Objectives 1. To evaluate relationship of common GI symptoms with high FC triggered referral. 2. To evaluate relationship of FC and other investigation to diagnosis Methodology This is a retrospective case notes study at Russells Hall Hospital, District General Hospital in West Midlands between Jan-Dec 2021. We collected data of all the children referred to the Paediatric GI clinic with a FC value during the study period. Data collected and analysed using SPSS. Results 50 set of notes was analysed. (M:F = 48:52, mean age 8.8 years and mean duration of symptoms 7.8 months) There were 16 (32%) of subjects with FC >250micg/g. We analysed relationship of FC in 3 age group: a) <5 years b) 6-10 years and c)>11 years. The commonest symptoms and association with FC and age group described in table 1. IBD was diagnosed on only one occasion (2%) of all referrals and it was associated with FC above 1000mic/g. The commonest diagnosis among the less than 249 & above 250 groups was Functional Constipation with 58% and 28% respectively. (table 2) Raised WBC count, raised ESR had a PPV of 100% for a FC >250. Low albumin level and low Haemoglobin had PPV of 67% and 50% respectively. 38 (76%) of the children referred been discharged within first 2 visits. of 38 children discharged 25 (66%) had FC less than 249 micg/g. Abdominal pain had a PPV for FC >250 of 27%. In children with abdominal pain absence of diarrhoea or bloody stools had a NPV of 74% and 72% for FC <249 respectively. Conclusion In our cohort, FC <250 did not yield a pathological diagnosis and most of them were discharged after first review. None of the children in 1-5 or 6 -10 age groups had a significant condition which can be detected from FC measurements. In children with abdominal pain, absence of diarrhoea or bloody stools will increase the likelihood to have an insignificant FC values. In the children referred high WBC count, high ESR and low albumin increased the likelihood of getting a significant FC level.
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Management of adults with systemic lupus erythematosus (sle) in 2021: a multi-centre audit within wales as part of an ongoing quality improvement exercise.Background/Aims Significant changes to working practices within rheumatology have occurred since the beginning of the COVID-19 pandemic: virtual consultations have now become commonplace. This audit was undertaken as part of ongoing quality improvement work to assess the standards of care provided to patients with SLE attending rheumatology departments across Wales. Care was audited against the standards outlined in the 2018 British Society of Rheumatology guideline for the management of adults with SLE. Results were compared with the previous multi-centre audits of SLE care in Wales and the UK. We were interested to see whether changes to working practices had significantly affected the care of patients with SLE across Wales. Methods Rheumatology services in Wales were invited via email to participate. Data collection occurred between June and August 2021. Data was collected via online questionnaire, held securely by the Dudley Group NHSFT. Unit questionnaires were submitted by a lead clinician in each centre. Five centres across Wales submitted data from 62 clinical encounters with patients with SLE. Result(s): Conclusion Results of this multi-centre audit do not demonstrate any widespread significant changes in care for patients with SLE in Wales between 2019 and 2021, despite 48% of consultations audited being undertaken virtually. Blood pressure and urinalysis were not consistently measured in 2021, likely secondary to the increased prevalence of virtual consultations. Group education has been undertaken as to the importance of facilitating observations in the virtual environment and centres have shared their experiences of how they tackle this challenge locally. (Table Presented).
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A new kid on the block: erector spinae plane block (espb) 'tea-trolley' teaching.Background and Aims ESPB's provide postoperative analgesia for patients undergoing breast, thoracic and abdominal surgery (1-3) and improve respiratory function in rib fracture patients (4,5). Lack of awareness, competence or belief in practicality are intrinsic barriers for regional anaesthesia implementation (6). 'Tea-trolley' teaching is a novel and fun modality of condensed practical skill teaching within working clinical environments (7,8). We delivered ESPB 'tea-trolley' teaching at Russells Hall Hospital (RHH) to overcome these barriers and increase ESPB provision. Methods The 'tea-trolley' teaching team attended RHH ICU and each operating theatre (day case, main and obstetric). A three minute ESPB presentation (9) was delivered (along with hot beverages/biscuits) followed by each candidate undergoing live-volunteer scanning practice and then immediate ESP mannequin needling practice. Each candidate completed pre-/postteaching surveys. Results There were 17 survey respondents; 9 consultants, 8 trainees. Pre-teaching, 76% respondents had not seen/performed an ESPB (including 8 consultants) and 65% of respondents were unaware of relevant anatomical landmarks for safe performance; post-teaching 100% respondents were aware. Pre-teaching, 82% of respondents felt either quite/ very under-confident performing an ESPB (12% felt neither confident/under-confident); post-session 88% of respondents felt either quite/very confident performing an ESPB. Of those respondents involved in management of rib fractures or breast surgery 100% responded the training would change their practice (50% 'yes definitely'/50% 'yes maybe'). Conclusions 'Tea-trolley' is a low-tech, inclusive and effective teaching modality for ESPB. Our data suggests 'tea-tolley' training is an effective modality to overcome intrinsic barriers of regional anaesthesia implementation and therefore a useful modality for teaching other regional anaesthetic techniques.
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Acute otitis media.Otitis media is defined as a group of inflammatory conditions that affect the middle ear cleft; it consists of acute otitis media (AOM), otitis media with effusion, and chronic otitis media. These terms are often used interchangeably, but should be differentiated from one another by their clinical signs and symptoms, as well as the duration of disease, to ensure the correct diagnosis is reached. Correct diagnosis enables appropriate management of patients within the community, including urgent referral for ear, nose and throat review. This article focuses on the diagnosis and management of AOM for GPs.
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To explore clinical pharmacists' opinions, and their perceived barriers and facilitators, to support clinical research delivery in secondary care.The National Health Service (NHS) is confronted with significant challenges in facilitating clinical research delivery.1�Clinical pharmacists were instrumental in ensuring patient safety while conducting urgent public health studies, such as the RECOVERY trial, during the COVID-19 pandemic.2�Numerous studies have reported the positive impact of pharmacy workforce in supporting clinical research delivery3. However, it remains unclear whether pharmacists are willing to take on this extra responsibility.
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A Literature Review of Methods of Perioperative Pain Management in Thoracic Outlet DecompressionPostoperative pain control in thoracic outlet decompression (TOD) is difficult due to the complex innervation of the anatomical region. Poor postoperative pain control has been associated with worse patient experiences and prolonged inpatient stays. This study aims to identify evidence-based perioperative analgesic strategies for TOD. MEDLINE and Embase searches were performed to identify literature assessing perioperative pain control methods in patients undergoing TOD. Studies were limited to the English language and within 10 years of publication. Abstracts were screened for relevance by 2 reviewers, and identified review articles on TOD were also included for critical appraisal. The primary literature search yielded 124 studies whose abstracts were screened resulting in a total of 16 studies being included for full review and critical appraisal. This included 1 randomized control trial, 7 retrospective cohort studies, 1 case series study, 2 case report study, and 5 review articles. Studies utilized a baseline of multimodal oral analgesics with their main investigative focus centered on the use of different methods of peripheral nerve blockade. There is only 1 published randomized controlled trial study investigating postoperative analgesic modalities in TOD. This deficit of evidence was reflected in the high variation of pain management strategies employed in the published literature.
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Ibrutinib and rituximab versus fludarabine, cyclophosphamide, and rituximab for patients with previously untreated chronic lymphocytic leukaemia (FLAIR): interim analysis of a multicentre, open-label, randomised, phase 3 trial.The approval of Bruton tyrosine kinase (BTK) inhibitors in patients with previously untreated chronic lymphocytic leukaemia (CLL) was based on trials which compared ibrutinib with alkylating agents in patients considered unfit for fludarabine, cyclophosphamide, and rituximab, the most effective chemoimmunotherapy in CLL. We aimed to assess whether ibrutinib and rituximab is superior to fludarabine, cyclophosphamide, and rituximab in terms of progression-free survival. This study is an interim analysis of FLAIR, which is an open-label, randomised, controlled, phase 3 trial in patients with previously untreated CLL done at 101 UK National Health Service hospitals. Eligible patients were between 18 and 75 years of age with a WHO performance status of 2 or less and disease status requiring treatment according to International Workshop on CLL criteria. Patients with greater than 20% of their CLL cells having the chromosome 17p deletion were excluded. Patients were randomly assigned (1:1) by means of minimisation (Binet stage, age, sex, and centre) with a random element in a web-based system to ibrutinib and rituximab (ibrutinib administered orally at 420 mg/day for up to 6 years; rituximab administered intravenously at 375 mg/m2 on day 1 of cycle 1 and at 500 mg/m2 on day 1 of cycles 2-6 of a 28-day cycle) or fludarabine, cyclophosphamide, and rituximab (fludarabine 24 mg/m2 per day orally on day 1-5, cyclophosphamide 150 mg/m2 per day orally on days 1-5; rituximab as above for up to 6 cycles). The primary endpoint was progression-free survival, analysed by intention to treat. Safety analysis was per protocol. This study is registered with ISRCTN, ISRCTN01844152, and EudraCT, 2013-001944-76, and recruiting is complete. Between Sept 19, 2014, and July 19, 2018, of 1924 patients assessed for eligibility, 771 were randomly assigned with median age 62 years (IQR 56-67), 565 (73%) were male, 206 (27%) were female and 507 (66%) had a WHO performance status of 0. 385 patients were assigned to fludarabine, cyclophosphamide, and rituximab and 386 patients to ibrutinib and rituximab. After a median follow-up of 53 months (IQR 41-61) and at prespecified interim analysis, median progression-free survival was not reached (NR) with ibrutinib and rituximab and was 67 months (95% CI 63-NR) with fludarabine, cyclophosphamide, and rituximab (hazard ratio 0 44 [95% CI 0 32-0 60]; p<0 0001). The most common grade 3 or 4 adverse event was leukopenia (203 [54%] patients in the fludarabine, cyclophosphamide, and rituximab group and 55 [14%] patients in the ibrutinib and rituximab group. Serious adverse events were reported in 205 (53%) of 384 patients receiving ibrutinib and rituximab compared with 203 (54%) of 378 patients receiving fludarabine, cyclophosphamide, and rituximab. Two deaths in the fludarabine, cyclophosphamide, and rituximab group and three deaths in the ibrutinib and rituximab group were deemed to be probably related to treatment. There were eight sudden unexplained or cardiac deaths in the ibrutinib and rituximab group and two in the fludarabine, cyclophosphamide, and rituximab group. Front line treatment with ibrutinib and rituximab significantly improved progression-free survival compared with fludarabine, cyclophosphamide, and rituximab but did not improve overall survival. A small number of sudden unexplained or cardiac deaths in the ibrutinib and rituximab group were observed largely among patients with existing hypertension or history of cardiac disorder.
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The impact of community teaching sessions on onward referral to specialist diabetic foot services.Introduction: Prompt referral of patients with diabetic foot ulceration (DFU) to specialist services can lead to more timely assessment of these patients and subsequent improved rates of limb salvage and patient outcomes. In this study we wanted to determine the impact of education in the primary care setting on onward referrals to our specialist Diabetic Foot multi-disciplinary team (MDT) clinic. Methods: As part of a Diabetic Foot Roadshow, four teaching sessions were delivered in primary care settings across Shropshire by our specialist team from 17th March to the 25th May 2022. Attendees included podiatrists, tissue viability nurses, district nurses and wound care practitioners. Hospital records were used to identify all onward referrals to our Diabetic Foot MDT clinic in the weeks before and after delivery of the roadshow education sessions. Results: 184 referrals were made to the diabetic foot clinic from January to July 2022. There were 0.3 referrals per day in the months prior to the commencement of the education sessions, compared to 1.5 referrals per day following the commencement of the teaching sessions. This increase in referrals was statistically significant (p < 0.0001). Conclusion: Teaching sessions delivered to community specialist healthcare professionals significantly increase onward referral of patients to specialist services, facilitating more timely assessment and management of patients with DFUs. Competing Interests: Declaration of Competing Interest All authors declare that they have no conflicts of interest. Copyright 2023 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.