Author: Jason Curtis

Prospective validation of the rapid clinical risk prediction score in patients with pleural infection: The pleural infection longitudinal outcome study (PILOT) (2018)

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Type of publication:
Conference abstract

Author(s):
Corcoran J.P.; Dobson M.; Shaw R.; Hedley E.L.; Sabia A.; Robinson B.; Rahman N.M.; Psallidas I.; Hallifax R.J.; Gerry S.; Collins G.S.; Piccolo F.; Read C.; Koegelenberg C.F.; Saba T.; Saba J.; Daneshvar C.; Ward N.; Fairbairn I.; *Heinink R.; West A.; Stanton A.E.; Holme J.; Kastelik J.A.; Steer H.; Downer N.J.; Haris M.; Baker E.H.; Everett C.F.; Pepperell J.; Bewick T.; Yarmus L.B.; Maldonado F.; Khan B.; Hart-Thomas A.; Hands G.; Warwick G.; Munavvar M.; Guhan A.; Shahidi M.; Pogson Z.E.; Dowson L.; Bhatnagar R.; Davies H.E.; Yu L.; Maskell N.A.; Miller R.F.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2018; vol. 197

Abstract:
RATIONALE Pleural infection is increasingly common and associated with significant morbidity and mortality, with no current robust means of predicting which patients will suffer poor clinical outcomes. A validated risk score at baseline would allow high-risk patients to be identified early, and directed towards more invasive management strategies aimed at improving prognosis. METHODS The Pleural Infection Longitudinal Outcome Study (PILOT) was a prospective observational cohort study, recruiting adult patients with pleural infection from 29 centres in four countries, with patients undergoing protocolised management based on widely accepted national guidelines adapted for local practice. The study was powered to validate a previously described clinical risk prediction score (RAPID), derived and retrospectively validated using data from two large multicentre randomised trials in pleural infection (MIST1 and MIST2). The primary outcome was mortality associated with pleural infection at 3 months; secondary outcomes included mortality at 12 months, length of hospital stay, need for thoracic surgical intervention, failure of initial medical management (according to predefined criteria), and lung function impairment at 3 months. Study follow-up was for 12 months. The study was funded by the UK Medical Research Council, and registered with ClinicalTrials.gov (ISRCTN 50236700). RESULTS 551 participants were recruited between October 2013 and October 2016, and data were available in 542 (98.4%) patients. 383/542 (70.7%) were male; mean age was 58 years (SD 20). Overall mortality was 10% at 3 months (54/542) and 19% (101/542) at 12 months. Mortality increased according to RAPID score overall (Figure 1a) and 3 month mortality was closely associated with RAPID category; low-risk (RAPID score 0-2) 4/216 (1.9%, 95% CI 0.5 to 3.6), medium risk (RAPID score 3-4) 22/233 (9.4%, 95% CI 5.7 to 13.2), and high-risk (RAPID score 5- 7) 28/93 (30.1%, 95% CI 20.8 to 39.4) (Figure 1b). C-indexes (AUROC) for the prediction score at 3 months and 12 months were 0.79 (95% CI 0.73 to 0.85) and 0.77 (95% CI 0.72 to 0.82) respectively. CONCLUSIONS RAPID is a robust prediction score for mortality in adult patients with pleural infection, and should now be used to guide clinical care. Further studies are now required to assess if targeting more interventional treatment strategies in higher risk groups can reduce mortality.

Correlating chest CT radiological reporting of tree-in-bud with clinical diagnosis (2018)

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Type of publication:
Conference abstract

Author(s):
*Muthusami R.; *Makan A.; *Ahmad N.; *Srinivasan K.S.; *Moudgil H.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2018; vol. 197

Abstract:
RATIONALE Although initially describing Endobronchial Tuberculosis, the Tree-in-Bud (TIB) pattern is increasingly recognised in a wider number of conditions. Objective here was to establish how frequently this was reported and the spectrum of subsequent diagnosis. METHODS Reports relating to all Chest CT scans undertaken at our District General Hospital during 2015 were identified and those with reference to TIB further explored from electronic medical records. RESULTS 27 patients had the TIB (2.7% of total CTs) pattern reported. Average age was 72 years with 59% female. The right lung was affected (78%) more than the left (52%) along with one of the lower lobes (55%). The most common lobe affected was the RLL (41%) followed by the RML (37%) and then RUL & LLL (both 33%). 21 (78%) were seen by a Respiratory Physician. For the group as a whole, two had died from advanced cancer (1 lung cancer) and one with advanced dementia. An Infectious Aetiology was proposed in 16 (59%) with half confirmed with a positive microbiological result. 2 patients had Non-Tuberculous Mycobacteria, alongside Chronic Cavitatory Pulmonary Aspergillosis (1), ABPA (Allergic BronchoPulmonary Aspergillosis) in 3 (11%), Emphysema (3), Asbestos Disease (2) and one each had Pulmonary Sarcoid and BOOP (Bronchiolitis Obliterans Organizing Pneumonia). CONCLUSION The Tree-in-Bud pattern occurs as a result of a number of processes, although often they co-exist in the same condition and though we identified some mycobacterial disease, cases identified had a wider spectrum including other infectious, allergic, and vasculitic pathways alongside malignancy. The radiological distribution of disease within the lungs further proposes a role for silent aspiration into the airways. (Figure Presented) .

Assessment of chronic obstructive airways disease in heart failure : An analysis of current practice (2018)

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Type of publication:
Conference abstract

Author(s):
*Muthusami R.; *Mahmoud M.; *Crawford E.; *Makan A.; *Ahmad N.; *Srinivasan K.S.; *Moudgil H.; *Candassamy N.

Citation:
American Journal of Respiratory and Critical Care Medicine; May 2018; vol. 197

Abstract:
RATIONALE Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) are global epidemics incurring significant morbidity and mortality with overlapping symptoms & risk factors. Whereas with other coexisting co-morbidities such as with Diabetes Mellitus and Ischaemic Heart Disease, much work has been done to concurrently improve outcomes from both pathologies, whether anything is uniformly undertaken in practice to firstly recognize and secondly improve outcomes from HF and COPD is less understood. The objective here was to establish our current pattern of assessment to identify potential areas of improvement that would enable us to better manage the modern multi-morbid patient. METHODS Electronic medical records of all patients admitted to our District General Hospital (serving fairly static population 250,000) over a 6 month period to end December 2016 and referred internally to our Heart Failure Specialist Team were assessed. Data for all admitted cases were cross-referenced to Electrocardiography (ECHO) and Pulmonary Function Lab Databases. RESULTS 116 patients (63% male) with mean (SD, range) age 74.9 (11.7, 32-100) years had been admitted and of these 37% had died over the subsequent 12 months follow up period. Of the total, 113 (97%) had prior transthoracic cardiac ECHO (updated within a two year window); Mean estimated Left Ventricular Ejection Fraction (LVEF) was 41%. Comparatively, only 31 (27%) patients had undergone Spirometry testing at our centre over the preceding 10 year period and of these approximately half (51%) had shown obstructive spirometry. Collectively, 44 (38%) were known to have any Obstructive Airways Disease with 32 (28%) being COPD but a slightly higher figure at 50 (43%) were on inhaler treatment. . Sub-analysing, the 59 (51%) specifically with Ischaemic Heart Disease as opposed to other causes for Heart Failure (Valvular Heart Disease, Cardiomyopathy etc.) had a higher 12 month mortality rate (49%) as well as higher prevalence of known COPD (32%), higher proportion of patients with obstructive spirometry (65%) and patients on inhaler therapy (45%). Only 2 of the 7 patients on Amiodarone had Spirometry. CONCLUSION The basic provision of spirometry to Heart Failure patients, and in particular those with Ischaemic Heart Disease, needs to be improved with our findings probably consistent with others providing the same models of diagnosis driven care. Our findings are in a population with established Heart Failure and potentially in their final years of life but there may be improved quality of life and care planning, if assessing those presenting earlier.

Iron deficiency in heart failure: A retrospective review of current practice and patient outcomes in a district general hospital (2018)

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Type of publication:
Conference abstract

Author(s):
*Chatrath N.; *Kundu S.; *Makan J.

Citation:
Heart; Jun 2018; vol. 104, Supp 6

Abstract:
Iron deficiency (ID) affects up to 50% of patients with heart failure (HF) with higher rates in decompensated, hospitalised patients.1 ID is associated with poor functional capacity and recurrent hospital admissions. The 2016 European Society of Cardiology (ESC) guidelines for management of HF advocate measurement of ferritin and Transferrin Saturations (TSAT) in all HF patients. ID is defined by serum ferritin <100 mg/L or 100-299 mg/ L and TSAT <20%0.2 Intravenous Iron therapy is recommended for any patient meeting these parameters. This retrospective study looked at the diagnosis and management of ID in HF patients in a district general hospital. All 111 (n=111) inpatients with a diagnosis of HF with reduced ejection fraction (HFrEF), admitted between April-October 2016 were included. The mean age of the population was 75 (30100), 37% female and 63% male. 64% (n=71) were anaemic (Male n=46, Female n=25) as defined by our laboratory haemoglobin reference ranges for gender. Only 51% (n=57) of all patients had Ferritin checked during admission or within 3 months of discharge with an average Ferritin of 161 mg/L (11-1432). 30.6% (n=34) of all patients had absolute iron deficiency (Ferritin <100 mg/L) and 14.4% (n=11) had ferritin in the range 100300 mg/L, in which further TSAT testing to confirm functional iron deficiency is recommended but is not performed locally unless specifically requested by the clinician. Only 4.5% (n=5) of all patients had further investigations looking into causes of ID, including gastro-intestinal work-up. 47.8% (n=53) died in the 1 year follow-up period with 9% (n=10) not surviving past the initial admission. Of the 101 patients surviving the initial admission, there was a total of 135 hospital admissions within the follow-up period, 58% (n=78) of which were directly related to HF. 11.7% of all patients (n=13) were prescribed oral iron therapy on discharge and only 2 out of all patients had intravenous iron therapy during admission or within 6 months of discharge. This study highlights the high readmission and mortality rates of hospitalised HF patients and that ID is an underdiagnosed comorbidity in this population. A new protocol has been proposed which involves mandatory testing of ferritin, and TSAT if required, at the time of diagnosis and during regular follow-up. Local research is underway to further evaluate the benefits of iron replacement in HF and the effects of the proposed protocol on this population.

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Individual and monitoring centre influences upon anticoagulation control of AF patients on warfarin: a longitudinal multicentre UK-based study (2018)

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Type of publication:
Journal article

Author(s):
Abohelaika, Salah; Wynne, Hilary; Avery, Peter; Robinson, Brian; Jones, Lisa; Tait, Campbell; Dickinson, Bradley; Salisbury, Julie; Nightingale, Joanna; *Green, Louise; Kamali, Farhad

Citation:
European Journal of Haematology 2018 October, 101:486–495.

Abstract:
OBJECTIVES Time within therapeutic INR range (TTR) predicts benefits/risk of warfarin therapy. Identification of individual- and centre-related factors that influence TTR, and addressing them to improve anticoagulation control, are important. This study examined the impact of individual and centre-related factors uponlong-term anticoagulation control in atrial fibrillation patients in seven UK-based monitoring services. METHODS Data between 2000 and 2014 on 25,270 patients (equating to 203,220 patient years) [18,120 (71.7%) in general practice, 2,348 (9.3%) in hospital-based clinics and 4,802 (19.0%) in domiciliary service] were analysed. RESULTS TTR increased with increasing age, peaking around 77% at 70-75 years, and then declined, was lower in females than males, and in dependent home-monitored patients than those attending clinic (P<0.0001). TTR, number of dose changes and INR monitoring events, and the probability of TTR≤ 65%, differed across the centres (P<0.0001). CONCLUSIONS Although all the participating centres ostensively followed a standard dosing algorithm, our results indicate that variations in practice do occur between different monitoring sites. We suggest feedback on TTR for individual monitoring sites gauged against the average values reported by others would empower the individual centres to improve quality outcomes of anticoagulation therapy by identifying and adjusting contributory factors within their management system.

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Increasing rates for certification of visual impairment at Royal Cornwall Hospital Trust: An audit series (2018)

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Type of publication:
Journal article

Author(s):
*Savage, Nicholas St John ; Claridge, Kate; Green, Jessica

Citation:
British Journal of Visual Impairment; May 2018; vol. 36 (no. 2); p. 143-151

Abstract:
The audit series investigated how rates of Certification of Visual Impairment (CVI) at Royal Cornwall Hospital Trust (RCHT) performed when compared against Public Health England (PHE) indices. Our aim was to assess whether CVI rates could be improved by promoting clinician awareness.We collected CVI data for Sight Impairment (SI) and Severe Sight Impairment (SSI) from a prospective MS Excel database maintained at RCHT for all certifications between 1 August 2014 and 31 July 2016. Annual local certification rates were compared to regional and national rates using data from Public Health Outcomes Framework (PHOF) for glaucoma, agerelated macular degeneration (ARMD), and diabetic eye disease.We found that overall rates of certification were above both those of the South West region and England; however, certifications for ARMD and glaucoma fell below the regional and national rates. Reasons for this may include variations in ethnicity, introduction of anti-vascular endothelial growth factor (anti-VEGF) agents, and/or the potential delay in CVI completion while under treatment for ARMD. We concluded that raising awareness among clinicians did not prove a satisfactory intervention to improve certification rates. In response to these findings, RCHT and a local charity, iSight Cornwall, have jointly funded an Eye Clinic Liaison Officer (ECLO) to enhance the certification process. This is expected to deliver immediate service improvement. Considerable overlap in dual diagnoses presents a problem in interpretation of CVI data, which could be targeted by the implementation of electronic certification.

Is a nurse consultant impact toolkit relevant and transferrable to the radiography profession? An evaluation project (2018)

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Type of publication:
Journal article

Author(s):
B.Snaith, *S.Williams, K.Taylor, Y.Tsang, J.Kelly, N.Woznitzagh

Citation:
Radiography, Volume 24, Issue 3, August 2018, Pages 257-261

Abstract:
Introduction: Consultant posts were developed to strengthen strategic leadership whilst maintaining front line service responsibilities and clinical expertise. The nursing profession has attempted to develop tools to enable individuals to evaluate their own practice and consider relevant measurable outcomes. This study evaluated the feasibility of transferring such a nursing ‘toolkit’ to another health profession. Method: This evaluation was structured around a one-day workshop where a nurse consultant impact toolkit was appraised and tested within the context of consultant radiographic practice. The adapted toolkit was subsequently validated using a larger sample at a national meeting of consultant radiographers.
Results: There was broad agreement that the tools could be adopted for use by radiographers although several themes emerged in relation to perceived gaps within the nursing template, confirming the initial exercise. This resulted in amendments to the original scope and a proposed new evaluation tool.
Conclusion: The impact toolkit could help assess individual and collaborative role impact at a local and national level. The framework provides consultant radiographers with an opportunity to understand and highlight the contribution their roles have on patients, staff, their organisation and the wider profession.