Staff Publication

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.

Link to full-text [NHS OpenAthens account required]

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.

A stroke-like presentation due to balo concentric sclerosis (2018)

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Type of publication:
Conference abstract

Author(s):
*Albuidair A.

Citation:
European Stroke Journal; May 2018; vol. 3, Supp 1

Abstract:
Background and Aims: A young woman presented with a 'stroke like' episode subsequently found to be due to a rare form of multiple sclerosis, Balo concentric sclerosis (BCS). Method: A literature search was conducted (5/ 1/2018) using the key words: 'Balo concentric sclerosis ' and 'Stroke ' finding only 30 PUbMed and 5 Medline references respectively. Few case reports exist of such a presentation. Results: The Hungarian neuropathologist Josef Balo published a case report in 1928 of a young man with a new hemiparesis who was found at autopsy to have lesions described as encephalitis periaxialis concerntrica. With the advent of MRI, imaging characteristically shows an onion ring or whorled appearance. Recently it has been classified to lie within the spectrum of atypical idiopathic inflammatory demyelinating disorders, and practically is considered as a form of relapsing-remitting MS. It is more common in Chinese and Filipino populations with an estimated 2:1 female predilection with on-going uncertainty as to the relative role of genetic or environmental predespositions. We describe a 33 year old lady presenting acutely with left arm heaviness, incoordination and paraesthesia. She had no vascular risk factors and no relevant past medical or family history. MRI confirmed a classical BCS ringed lesion within the white matter of the right frontal gyrus, Lumbar puncture showed raised lymphocytes and oligoclonal bands. Conclusion: Stroke-like presentations are not uncommonly found to be due to MS but rarely of the atypical BCS type. BCS shows a characteristic onion ring appearance on MRI.

Validating the portal population of the United Kingdom Multiple Sclerosis Register (2018)

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Type of publication:
Journal article

Author(s):
Middleton R.M.; Rodgers W.J.; Akbari A.; Tuite-Dalton K.; Lockhart-Jones H.; Griffiths D.; Noble D.G.; Jones K.H.; Ford D.V.; Chataway J.; Schmierer K.; Rog D.; Galea I.; Al-Din A.; Craner M.; Evangelou N.; Harman P.; Harrower T.; Hobart J.; Husseyin H.; Kasti M.; Kipps C.; McDonnell G.; *Owen C.; Pearson O.; Rashid W.; Wilson H.

Citation:
Multiple Sclerosis and Related Disorders; Aug 2018; vol. 24 ; p. 3-10

Abstract:
 The UK Multiple Sclerosis Register (UKMSR) is a large cohort study designed to capture 'real world' information about living with multiple sclerosis (MS) in the UK from diverse sources. The primary source of data is directly from people with Multiple Sclerosis (pwMS) captured by longitudinal questionnaires via an internet portal. This population's diagnosis of MS is self-reported and therefore unverified. The second data source is clinical data which is captured from MS Specialist Treatment centres across the UK. This includes a clinically confirmed diagnosis of MS (by Macdonald criteria) for consented patients. A proportion of the internet population have also been consented at their hospital making comparisons possible. This dataset is called the 'linked dataset'. The purpose of this paper is to examine the characteristics of the three datasets: the selfreported portal data, clinical data and linked data, in order to assess the validity of the self-reported portal data. The internet (n = 11,021) and clinical (n = 3,003) populations were studied for key shared characteristics. We found them to be closely matched for mean age at diagnosis (clinical = 37.39, portal = 39.28) and gender ratio (female %, portal = 73.1, clinical = 75.2). The Two Sample Kolmogorov-Smirnov test was for the continuous variables to examine is they were drawn from the same distribution. The null hypothesis was rejected only for age at diagnosis (D = 0.078, p < 0.01). The populations therefore, were drawn from different distributions, as there are more patients with relapsing disease in the clinical cohort. In all other analyses performed, the populations were shown to be drawn from the same distribution. Our analysis has shown that the UKMSR portal population is highly analogous to the entirely clinical (validated) population. This supports the validity of the self-reported diagnosis and therefore that the portal population can be utilised as a viable and valid cohort of people with Multiple Sclerosis for study.