Author: Jason Curtis

Peri-operative temperature monitoring (2019)

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Type of publication:
Conference abstract

Author(s):
Clulow C.; *Lewis B.; *Law R.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 71

Abstract:
The maintenance of normothermia during the peri-operative period is important in regulating homeostatic processes during physiological stress. Therefore, temperature monitoring is essential to avoid hypothermia or hyperthermia, which might complicate anaesthesia. Inadvertent peri-operative hypothermia (IPH) can contribute to many complications including coagulopathy, infection, delayed wound healing, increased hospital stay, cardiac events and death [1, 2]. Therefore, reducing the incidence of IPH could minimise the morbidity and mortality associated with this problem. Methods This was a prospective observational audit involving 102 cases. We analysed elective surgical cases coming from the Day Case Unit and the Surgical Admissions Suite from April to June 2018. Data collection was performed by the authors using a proforma based on the National Institute for Health and Care Excellence (NICE) clinical guideline 65 [1], and the Royal College of Anaesthetists audit recipe book [2]. We compared our results to the primary audit conducted in 2016. Results Only 9.8% of patients had a temperature recorded within 1 h of surgery. Less than 5% had a temperature < 36degreeC preoperatively. There was an improvement in prophylactically warming at-risk patients from 39.1% to 70.5%. Warming interventions in operations with duration > 30 min were used in 73% of cases in comparison to 39.2% previously. Temperature was measured every 30 min in only 24.3% of cases and 9.8% of cases left theatre 'cold', but none left recovery with a temperature < 36degreeC. Discussion IPH was reduced from 13.7% to 9.8%. The two factors identified that have the most influence on this is improved prophylactic intra-operative warming of the at-risk population and warming methods being used in operations lasting > 30 min. The suboptimal intraoperative monitoring was disappointing to see, but given few cases left theatre 'cold', it may be assumed that this was due to a deficiency in documentation rather than monitoring.

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A quality improvement project to improve anaesthetic peri-operative documentation through excellence reporting (2019)

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Type of publication:
Conference abstract

Author(s):
*Cunningham D.; *Travis M.; *Leach S.

Citation:
Anaesthesia; Jul 2019; vol. 74 ; p. 27

Abstract:
Incomplete or poor quality peri-operative documentation has both clinical and legal implications. As such, anaesthetic professional bodies issue guidance relating to documentation. It is unclear to what extent this guidance is followed by anaesthetists in our hospital. We aimed to improve the quality of documentation through excellence reporting and to test this methodology as a means of implementing change.
Methods: The completeness of anaesthetic charts (n = 50) are analysed annually over a 1- week period, using a proforma. The proforma highlights details that should be included as part of the peri-operative documentation. Several months prior to collection of the 2018 data, we initiated an excellence reporting project. This involved analysing a sample of charts on alternate weeks over a 12-week period. The five anaesthetists with the most complete charts were issued with a certificate. The anaesthetist with the highest scoring chart won a prize. Results were publicised on posters and presented at monthly governance meetings. If multiple charts scored full marks, judgement was used to determine the winner. Following this intervention period, results from the 2018 annual audit were compared with data from the previous year.
Results: The annual audit requires that the anaesthetic charts be scored on 27 key points outlined in the proforma. In 2018, 13 categories scored greater than 95% completeness with the remaining 14 categories scoring less than 95% completeness. In 2017, 10 categories scored greater than 95% completeness with 17 scoring less than 95%. The 2018 data scored greater than or equal to the 2017 data in 16 categories. In the other 11 categories, the 2017 data scored higher. Legibility is not considered in the annual audit but subjectively appeared to improve over the period of excellence reporting.
Discussion: Through the use of excellence reporting, we have seen some improvement in the completeness and legibility of peri-operative documentation in our hospital. This outcome suggests that excellence reporting is a useful tool for managing positive change. However, both data from 2017 and 2018 did not reveal 100% completeness in all categories, and with the potential legal and clinical ramifications, it is important that we continue to improve anaesthetic documentation.

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Coronary heart disease mortality in severe and non-severe familial hyper-cholesterolaemia : data from the UK Simon Broome FH register (2019)

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Type of publication:
Conference abstract

Author(s):
Humphries S.; Cooper J.; *Capps N.; Durrington P.; Jones B.; McDowell I.; Soran H.; Neil A.

Citation:
Atherosclerosis; Aug 2019; vol. 287

Abstract:
Background and Aims: Background: In 2016 the International Atherosclerosis Society (IAS) proposed that patients with "severe" FH (SFH) should be identified since they might warrant early and more aggressive cholesterol-lowering treatment such as with PCSK9 inhibitors. SFH is diagnosed if LDL-cholesterol (LDLC) >10 mmol/L, or LDLC >8.0 mmol/L plus one high-risk feature, or LDLC >5 mmol/L plus two high-risk features. Here we compare CHD mortality in SFH and non-SFH patients in the UK Simon Broome Register since 1991, when
statin use became routine.
Method(s): 2929 Definite or Possible patients (51% women) aged 20-79 years recruited from 21 UK lipid clinics were followed between 1992-2016. The excess CHD standardised mortality ratio (SMR) compared to the population in England and Wales was calculated (95% Confidence intervals).
Result(s): (67.7%) patients met the SFH definition. Post 1991, the SMR for CHD mortality was significantly (p=0.007) higher for SFH (220(184-261) (34,134 person years, 129 deaths observed, vs 59 expected) compared to non-SFH of 144(98-203) (15,432 person years, 32 observed vs 22 expected). After adjustment for traditional risk factors, the Hazard Ratio for CHD mortality in SFH vs non-SFH was 122 (80-187) p=0.36. Applying UK guidelines for the use of PCSK9i agents, overall ~24% of those in the register are likely to be eligible, but if this were restricted to those with SFH, overall ~16% would qualify.
Conclusion(s): CHD mortality remains elevated in treated FH, especially for SFH, emphasising the importance of optimal lipid-lowering, including the use of novel agents, and management of other risk factors

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Practice pattern variability in the management of acute severe colitis: A UK provider survey (2019)

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Type of publication:
Journal article

Author(s):
Sebastian S.; Lisle J.; Subramanian S.; Dhar A.; Shenoy A.; Limdi J.; *Butterworth J.; Allen P.B.; Samuel S.; Moran G.; Shenderey R.; Parkes G.; Raine T.; Lobo A.J.; Kennedy N.A.

Citation:
Frontline Gastroenterology; Jul 2020; vol. 11 (no. 4); p. 272-279

Abstract:
Introduction: Lack of comparative trial data on dosing regimens of infliximab in patients with acute severe ulcerative colitis (ASUC) failing intravenous corticosteroids has resulted in variability of rescue regimes in ASUC with potential impact on clinical outcomes. We aimed to evaluate practice variability and physician perspectives in decision-making with rescue therapy. Methodology: An internet-based survey of members of the inflammatory bowel disease (IBD) section of the British Society of Gastroenterology was conducted. The survey evaluated provider characteristics and general practice in the setting of ASUC, followed by a vignette with linked questions.
Result(s): The response rate of the survey was 31% (209/682 IBD section members). 134 (78%) reported they would use standard infliximab dose (5 mg/kg) while 37 (22%) favoured a higher front-loading dose of 10 mg/kg citing low albumin, high C-reactive protein as their reason for their preference. IBD specialists chose the higher front-loading dose more often compared with other gastroenterologists (p=0.01) In the specific case vignette, accelerated induction (AI) was favoured by 51% of the respondents while 25% used the standard induction regime and 19% favoured colectomy. IBD specialists more often favoured AI compared with other gastroenterologists (p=0.03) with the main reason being presence of predictors of low infliximab levels (74%). The reasons cited for favouring standard induction (n=57) included lack of evidence for AI (18), their usual practice (11), unlicensed regime (7), and safety concerns (4).
Conclusion(s): There are significant variations in practice in the use of infliximab rescue therapies with an urgent need for development of care pathways to standardise practice.

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Infliximab induction regimes in steroid refractory acute severe colitis: A multi-centre retrospective cohort study with propensity score analysis (2019)

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Type of publication:
Conference abstract

Author(s):
Sebastian S.; Myers S.; Syed N.; Argyriou K.; Samuel S.; Moran G.; Martin G.; Allen P.B.; *Los L.; *Butterworth J.; Fiske J.; Limdy J.; Ranjan R.; Dhar A.; Cooper B.; Shenoy A.H.; Patel N.; Subramanian S.; Goodoory V.; Shaikh F.; Shenderey R.; Ching H.L.; Lobo A.; Jayasooriya N.; Parkes G.; Brooks J.; Raine T.

Citation:
Journal of Crohn's and Colitis; Mar 2019; vol. 13

Abstract:
Background: While infliximab is used as rescue therapy for steroid refractory acute severe colitis (ASUC),
between 30 and 40% of patients do not respond and undergo colectomy. Accelerated induction regimes of
infliximab have been proposed to improve response rates. We aimed to evaluate colectomy rates in steroid
refractory ASUC patients receiving standard induction (SI) vs. accelerated induction (AI) of infliximab.
Method(s): Data collected on hospitalised patients receiving rescue therapy for steroid refractory ASUC. The choice of rescue therapy was at the discretion of the treating clinician. Accelerated induction (AI) was defined as receiving second dose of infliximab within 8 days of first rescue therapy or receiving front loading dose of 10 mg/kg. Our primary outcome was the short-term (in-patient, 30 days and 90 days) colectomy rate. Secondary outcomes were 12-month colectomy rates, length of hospital stay (LOS), and complication rates. We used a propensity score analysis with optimal calliper matching using a priori defined high-risk covariates at the start of rescue therapy (albumin, CRP, CRP-albumin ratio, haemoglobin nadir and pancolitis) to reduce potential provider selection bias.
Result(s): A total of 131 patients receiving infliximab rescue therapy were included, of whom 102 patients
received SI and 29 received AI. There was no difference in age, duration of diagnosis, age at rescue therapy,
Montreal class or use of steroids, 5ASAs or thiopurines prior to index admission. In the unmatched overall
cohort, there was no difference in colectomy during index admission (13% vs. 20%, p = 0.26), 30-day colectomy (18% vs. 20%, p = 0.45), 90-day colectomy (20% vs. 24%, p = 0.38) or 6 month colectomy (25% vs. 27%, p = 0.49). The LOS was shorter in the SI group (14.87 +/- 8.1 days vs. 19.31 +/- 5.8 days, p = 0.007). In patients who underwent colectomy, there were no differences in complications or serious infection rates. In the propensity score-matched cohort of 52 patients, there was no difference in overall colectomy rates between SI and AI groups (57% vs. 31%, p = 0.09), but the index admission colectomy (53% vs. 23%, p = 0.045) and 30-day colectomy (57% vs. 27%, p = 0.048) rates were higher in those receiving SI. There was no significant difference in LOS between SI and AI groups (23.6 +/- 4.3 vs. 18.2 +/- 7.1 days, p = 0.09) or in overall complication and infection rates but there was a mortality in AI group.
Conclusion(s): In this retrospective cohort study, there was no difference in overall colectomy rates in ASUC patients receiving different induction dosing regimens of infliximab. However, using propensity score matching, the short-term colectomy rates appear to be better in those receiving accelerated induction regime. A prospective study to confirm findings is planned.

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MON-112 Home Haemodialysis (HHD) with low dialysate volume (LDV) - The green benefit (2019)

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Type of publication:
Conference abstract

Author(s):
*Nair, S.; Gautier J.

Citation:
Kidney International Reports; Jul 2019; vol. 4 (no. 7), S350

Abstract:
Introduction: Man-made greenhouse gas emissions have impacted climate changes significantly. This has
adversely affected human health presently and has serious implications for future generations. Healthcare
industry itself contributes towards these carbon footprints. In England, 3.2% of the total CO2 emissions are accounted for by the healthcare industry alone producing 18 million tons CO2eq emissions. National Health Services (NHS) England CO2 emissions exceeds the total emissions from all aircraft departing from Heathrow, the largest European airport. Dialysis patient care accounts for 62.5% of the carbon footprint of a renal service. In UK, the prevalence rate of dialysis patients is 440 patients per million population, that is 25,261 haemodialysis (HD) patients in 2016. 1256 patients received dialysis at home. In-centre HD undertaking dialysis 4 hours 3 times/week, consumes more than 55,000 Litres of water/patient/year and contributes 3,818 kgCO2eq to the carbon footprint. A LDV system may have less emissions compared to traditional machines.
Method(s): This footprint is influenced more by frequency of treatments rather than duration. On average in Europe, patients using NxStage System One (NSO) dialyse 5.7 times for 2.6 hours/week with 24.3 Litres of dialysate/session to deliver a 2.61 stdKt/V. Based on manufacturers data, we calculated fluids volume, weight and energy required with NSO and we compared with requirements to deliver 3 times/week HD or the same clearance with traditional machines (3.5 times/week to deliver a 2.6 stdKt/V in the same patient).
Result(s): Reduced water usage NSO with PureFlow allows to prepare dialysate in-situ. It includes deionization technology and converts 1 Litre source water to 1 Litre of ultrapure dialysate as against traditional osmosis water systems which have a conversion rate of around 50%. Frequent therapy as above utilizes 7377 Litres of source water/year, only 13% of the 56,160 Litres of water used in centre HD and 12% of the 59,717 Litres of water required to deliver the same clearance with a traditional system. Low shipping volume of dialysate concentrates Fluids is the main contributor to shipping volumes in dialysis supplies. PureFlow system allows a minimal shipping volume of 422 Litres of concentrate including buffer per patient-year vs. 702-780 Litres of acid concentrate (dilution 1/43 or 1/35) in conventional HD or 819-910 Liters to deliver the same clearance as with NSO. PureFlow concentrate equals 1.5ton and 0.8m3 per patient-year. Conventional therapy equals 0.9-1.1 ton and 1.4-1.7 m3 (dilution 1/43 or 1/35) of acid concentrate. Delivering the same clearance with a traditional system equals 1.0-1.2 ton and 1.6-2.0 m3. Less energy consumption NSO with PureFlow utilizes 8.2-10.7 kwh to deliver 6 sessions/week. This is 28% less than 29.6-52.9 kwh to deliver 3 sessions/week with a traditional system. If one includes the energy used for water treatment which amounts to 32.5-63.2 kwh/week without heat disinfection, PureFlow usage is less than 20% of this.
Conclusion(s): Despite increased frequency, HHD with LDV is a much greener option for dialysis patients and significantly reduces the carbon footprint. Such systems are the order of the day where one is constantly looking for effective greener options in delivering treatments for our patients.

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A randomised, multi-centre, double-blind, placebo-controlled study of a targeted release oral cyclosporine formulation in the treatment of mild-to-moderate ulcerative colitis: Efficacy results (2019)

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Type of publication:
Conference abstract

Author(s):
Bloom S.; Iqbal T.; Nwokolo C.; *Smith M.; O'Donoghue D.; Hall J.; Dzyngel B.

Citation:
Journal of Crohn's and Colitis; Mar 2019; vol. 13

Abstract:
Background: Cyclosporine (CsA) is an effective treatment for patients with acute severe ulcerative colitis (UC), and studies have shown that it has an impact on disease activity comparable to the anti-TNF agent,
infliximab.1,2 Concerns regarding systemic toxicities have limited its role to short-term induction therapy and as a bridge to other therapies. ST-0529 is a novel low dose, controlled release formulation of CsA. A Phase 1 dose-ranging study demonstrated that tissue concentrations improved when it is given twice daily (BID).3
Methods: A total of 118 subjects with mild (baseline DAI < 6) or moderate (baseline DAI >= 6) UC were
randomised 1:1 to receive 75 mg ST-0529 once daily or placebo (53 and 65 patients, respectively) for 4 weeks in a multi-centre, randomised, double-blind, placebo-controlled, Phase IIa study. Patients using UC medications (eg low-dose steroids, 5-aminosalicylates, and immunomodulatory agents) on screening could continue them if agreed to maintain a stable dosing regimen during the study. The primary objective was to evaluate the efficacy of ST-0529 in inducing clinical remission (DAI score <=2, with no individual score >1 and rectal bleeding subscore of 0 or 1). The secondary objectives included clinical response, mucosal and histological healing, safety, and tolerability.
Result(s): A numerical although not statistically significant advantage of ST-0529 over placebo was found for rates of clinical remission (ST-0529: 13.2%; placebo: 6.3%, p = 0.2211) and clinical response (ST-0529: 30.2%; placebo: 18.8%, p = 0.1923). There were no differences between the treatment groups for mucosal and histological healing. ST-0529 was safe and well-tolerated. A post hoc subgroup analysis was performed to evaluate effects by disease severity. Clinical remission and clinical response rates in subjects with moderate (baseline DAI >=6) and mild (baseline DAI <6) disease (ITT, N = 118)
Conclusion(s): In this pilot study, ST-0529 given once daily, was safe, well tolerated, and showed a numerically higher, but not statistically significant difference in remission rate in patients with mild-to-moderate UC compared with placebo after 4 weeks of treatment. In the post hoc analysis, differences in the clinical response between treatment subgroups achieved statistical significance in some subgroups, the largest clinical response rate in moderate UC patients taking 5-aminosalicylates and/or steroids. These preliminary data, added to the data from a Phase 1 study, support further development of ST-0529 as a treatment for the induction and maintenance of remission in UC patients with moderate to severe disease. (Table Presented).

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Reflective doctors and cool babies (2019)

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Type of publication:
Conference abstract

Author(s):
*Charlesworth D.; Cunningham S.; Dudley L.; Bentley F.; Oguntimehin J.; Fairclough S.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology; Jun 2019; vol. 126 ; p. 45

Abstract:
Introduction In 2014, the RCOG launched the 'Each Baby Counts' initiative which included the aim of reducing the number of neonates who are left severely disabled by preventable incidents in labour. The initial report concluded that a different outcome may have been achieved in 76% of cases if different care had been received. Around the same time, reflective practice among doctors faced a significant challenge secondary to negative perceptions of its use in litigation, and resilience continued to be tested as work pressures, insufficient staff numbers, and public perceptions continued to increase. With the interplay between all these factors being crucial in achieving the state of experiential learning necessary to achieve the EBC goals, we look at a different method for reflective practice and quality improvement. Methods In 2015, we launched a series of measures inspired by EBC to reduce our rates of neonates requiring therapeutic hypothermia. One key component of our programme was a change in how our RCAs were undertaken. We changed RCA leads to include staff at all levels from across the multidisciplinary team, promoted a reflective journey and thematic analysis, changed our meetings to include staff recommended by the EBC report to achieve a more multidisciplinary and inclusive representation, promoted team learning, and fed back via casebased, reflective teaching. We then undertook a 48-month retrospective audit from 01/2015 to 12/2018 to see if we had improved care. Results In 2015, our therapeutic hypothermia annual incidence was 12, 11 in 2016, 7 in 2017, and 2 by 12/2018. Thematic analysis of our cases revealed a change in precipitating factors from preventable to unpredictable, and we subsequently increased the proportion of cases in which we concluded we could not improve the end outcome (though learning was identified in all). Staff empowerment increased, hierarchies flattened, and our ability to identify key targeted improvements increased to facilitate change and drive improvement. Conclusion We discovered that, if conducted well, with reflection as a key component, and the aim to promote a culture of learning and becoming, RCA can be used as a powerful teaching tool in training, and to promote improved patient care. As more staff engaged in our new RCA process, feedback indicated an increase in resilience and a more open culture of learning, unhindered by more traditional elements of reflective learning.

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A national survey on the uterotonic use for the prevention of postpartum haemorrhage (2019)

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Type of publication:
Conference abstract

Author(s):
*Stephanou M.; Gallos I.; Coomarasamy A.

Citation:
BJOG: An International Journal of Obstetrics and Gynaecology; Jun 2019; vol. 126 ; p. 148-149

Abstract:
Objective: To map the current national practice of the first line uterotonic drug given for the prevention of
postpartum haemorrhage (PPH) at both vaginal and caesarean section deliveries. Design A prospective national survey was carried out by contacting maternity units by means of telephone contact. Survey questions were set out to evaluate the uterotonic drug of choice in accordance with local hospital policy which was then compared with national guidance.
Methods: Maternity units across England were identified using the NHS Maternity Statistics 2016-2017 data available from NHS Digital. 136 NHS trusts were identified and 143 maternity units were contacted. Responses were collected by means of telephone communication with each of the maternity units. Maternity governance leads were the first point of contact followed by labour ward coordinators and senior labour ward doctors. The Health Research Authority Ethics toolkit was applied and determined that Research and Ethics council approval was not required.
Results: All 143 maternity units identified were contacted to answer the survey. 118 (82.5%) responses were obtained for the uterotonic of choice used for the prevention of postpartum haemorrhage at vaginal birth, of which 75 (63.5%) maternity units administered oxytocin with ergometrine combination as the first-line uterotonic. 116 (81%) responses were collected for the uterotonic of choice at caesarean section, where 95 (81.9%) administered intravenous oxytocin as first line.
Conclusion: The National Institute of Clinical Excellence (NICE) and World Health Organization (WHO)
guidelines recommend oxytocin as the first-line uterotonic of choice for the prevention of postpartum
haemorrhage. This survey has shown that current UK practice conflicts with both international and national guidance, favouring oxytocin with ergometrine over oxytocin alone at vaginal birth. Postpartum haemorrhage is a significant cause of morbidity and mortality; it is recommended that further attention be paid towards the first line uterotonic agent used for the prevention of a PPH in line with the most current up to date evidence.

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