Staff Publication

Current evidence and future perspectives on the effective practice of patient-centered laboratory medicine (2015)

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Type of publication:
Journal article

Author(s):
*Hallworth M.J., Epner P.L., Ebert C., Fantz C.R., Faye S.A., Higgins T.N., Kilpatrick E.S., Li W., Rana S.V., Vanstapel F.

Citation:
Clinical Chemistry, April 2015, vol./is. 61/4(589-599), 0009-9147;1530-8561 (01 Apr 2015)

Abstract:
BACKGROUND: Systematic evidence of the contribution made by laboratory medicine to patient outcomes and the overall process of healthcare is difficult to find. An understanding of the value of laboratory medicine, how it can be determined, and the various factors that influence it is vital to ensuring that the service is provided and used optimally. CONTENT: This review summarizes existing evidence supporting the impact of laboratory medicine in healthcare and indicates the gaps in our understanding. It also identifies deficiencies in current utilization, suggests potential solutions, and offers a vision of a future in which laboratory medicine is used optimally to support patient care. SUMMARY: To maximize the value of laboratory medicine, work is required in 5 areas: (a) improved utilization of existing and new tests; (b) definition of new roles for laboratory professionals that are focused on optimizing patient outcomes by adding value at all points of the diagnostic brain-to-brain cycle; (c) development of standardized protocols for prospective patient-centered studies of biomarker clinical effectiveness or extraanalytical process effectiveness; (d) benchmarking of existing and new tests in specified situations with commonly accepted measures of effectiveness; (e) agreed definition and validation of effectiveness measures and use of checklists for articles submitted for publication. Progress in these areas is essential if we are to demonstrate and enhance the value of laboratory medicine and prevent valuable information being lost in meaningless data. This requires effective collaboration with clinicians, and a determination to accept patient outcome and patient experience as the primary measure of laboratory effectiveness.

The Achilles tendon resting angle as an indirect measure of Achilles tendon length following rupture, repair, and rehabilitation (2015)

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Type of publication:
Journal article

Author(s):
*Carmont M.R., Gravare Silbernagel K., Brorsson A., Olsson N., Maffulli N., Karlsson J.

Citation:
Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology, April 2015, vol./is. 2/2(49-55), 2214-6873 (01 Apr 2015)

Abstract:
Background Rupture of the Achilles tendon may result in reduced functional activity and reduced plantar flexion strength. These changes may arise from elongation of the Achilles tendon. An observational study was performed to quantify the Achilles tendon resting angle (ATRA) in patients following Achilles tendon rupture, surgical repair, and rehabilitation, respectively. Methods Between May 2012 and January 2013, 26 consecutive patients (17 men), with a mean (standard deviation, SD) age of 42 (8) years were included and evaluated following injury, repair, and at 6 weeks, 3 months, 6 months, 9 months, and 12 months, respectively (rehabilitation period). The outcome was measured using the ATRA, Achilles tendon total rupture score (ATRS), and heel-rise test. Results Following rupture, the mean (SD) absolute ATRA was 55 (8)degree for the injured side compared with 43 (7)degree(p < 0.001) for the noninjured side. Immediately after repair, the angle reduced to 37 (9)degree(p < 0.001). The difference between the injured and noninjured sides, the relative ATRA, was -12.5 (4.3)degree following injury; this was reduced to 7 (7.9)degree following surgery (p < 0.001). During initial rehabilitation, at the 6-week time point, the relative ATRA was 2.6 (6.2)degree(p = 0.04) and at 3 months it was -6.5 (6.5)degree(p < 0.001). After the 3-month time point, there were no significant changes in the resting angle. The ATRS improved significantly (p < 0.001) during each period up to 9 months following surgery, where a score of 85 (10)degreewas reported. The heel-rise limb symmetry index was 66 (22)% at 9 months and 82 (14)% at 12 months. At 3 months and 6 months, the absolute ATRA correlated with the ATRS (r = 0.63, p = 0.001, N = 26 and r = 0.46, p = 0.027, N = 23, respectively). At 12 months, the absolute ATRA correlated with the heel-rise height (r = -0.63, p = 0.002, N = 22). Conclusion The ATRA increases following injury, is reduced by surgery, and then increases again during initial rehabilitation. The angle also correlates with patient-reported symptoms early in the rehabilitation phase and with heel-rise height after 1 year. The ATRA might be considered a simple and effective means to evaluate Achilles tendon function 1 year after the rupture.

Extrication time prediction tool (2015)

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Type of publication:
Journal article

Author(s):
Nutbeam, Tim, *Fenwick, Rob , Hobson, Charles, Holland, Vikki, Palmer, Michael

Citation:
Emergency medicine journal : EMJ, May 2015, vol. 32, no. 5, p. 401-403 (May 2015)

Abstract:
Many patients will require extrication following a motor vehicle collision (MVC). Little information exists on the time taken for extrication or the factors which affect this time. To derive a tool to predict the time taken to extricate patients from MVCs. A prospective, observational derivation study was carried out in the West Midland Fire Service's metropolitan area. An expert group identified factors that may predict extrication time-the presence and absence of these factors was prospectively recorded at eligible extrications for the study period. A step-down multiple regression method was used to identify important contributing factors. Factors that increased extrication times by a statistically significant extent were: a physical obstruction (10 min), patients medically trapped (10 min per patient) and any patient physically trapped (7 min). Factors that shortened extrication time were rapid access (-7 min) and the car being on its roof (-12 min). All these times were calculated from an arbitrary time (which assumes zero patients) of 8 min. This paper describes the development of a tool to predict extrication time for a trapped patient. A number of factors were identified which significantly contributed to the overall extrication time.

Link to full-text: http://emj.bmj.com/content/32/5/401.abstract

The interconnectedness of ethical, phenomenological and hermeneutical dimensions influencing trustworthiness in the qualitative research interview (2015)

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Type of publication:
Journal article

Author(s):
Ellingsen, Sidsel, Drageset, Sigrunn, *McSherry, Wilfred

Citation:
Nordic Nursing Research / Nordisk Sygeplejeforskning, 01 March 2015, vol./is. 5/1(70-76)

Abstract:
Creating trustworthy research knowledge within the qualitative research interview requires a high level of interpersonal sensitivity and reflexivity. This paper describes how ethical, phenomenological and hermeneutical dimensions are present during the qualitative research interview (QRI) and further discuss their interconnectedness and significance on the overall trustworthiness of the data created. The quality of any qualitative research interview is related to and dependent upon an open approach and the expertise of the researcher to meet ethical, phenomenological and hermeneutical challenges that arise.

 

A model to support staff in raising their concerns (2015)

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Type of publication:
Journal article

Author(s):
McSherry, Robert, *McSherry, Wilfred

Citation:
Nursing Times, 18 February 2015, vol./is. 111/8(15-17)

Abstract:
Sir Robert Francis QC's Freedom to Speak Up review reported that there is still a "serious issue" around the treatment of whistleblowers. This article explores why raising and escalating concerns are integral to healthcare governance systems and processes, and presents Escal8 – a new model that outlines the steps in doing this. It also examines the importance of learning and sharing from escalation, and the impact on quality and safety.

Link to full-text: http://search.proquest.com/docview/1660768724?accountid=49082

 

Autoregulation versus defaecation: An unusual side effect of CPAP (2014)

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Type of publication:
Conference abstract

Author(s):
*Stone H., *Fazal F., *Moudgil H., *Ahmad N., *Naicker T., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 (Suppl 58)

Abstract:
Introduction Continuous Positive Airway Pressure is the first line treatment for symptomatic moderate to severe obstructive sleep apnoea. Side effects of CPAP are well known; however faecal incontinence secondary to CPAP is not documented. We present the case of a patient with OSA who developed this on commencing CPAP. Case A 50 year old female with ulcerative colitis had a total colectomy in 1992 and a subsequent ileo-anal pouch reconstruction. She was referred to the sleep clinic as she was experiencing daytime somnolence (Epworth score of 15/24). Her sleep study demonstrated severe obstructive sleep apnoea with an apnoea-hypopnoea index of 35.2, and for 12.5% of the study, her Sa02 were below 90%. She was commenced on CPAP using auto titration. Initially, she experienced problems with faecal leakage – defecating up to 4 times per night. During this time her mean CPAP pressure had been 17cm water. She was subsequently converted CPAP at 10cms fixed maximum pressure and now tolerates CPAP very well; having a degree of faecal leakage only 2 or 3 times a week, rather than every night as previously. Her Epworth score has now fallen to 9/24, her AHI is 2.5 and her OSA symptoms have improved, leading to better treatment compliance. Conclusion It was hypothesised that the patient's problems were related to increased intra-thoracic pressure from the CPAP, resulting in raised intra-abdominal pressure, putting a strain on the ileo-anal pouch reconstruction giving rise to the faecal incontinence. This resolved with lower CPAP pressures, resolving the faecal frequency whilst still adequately treating the OSA. Limiting pressures should be considered in the future in patients with colorectal disease to avoid faecal incontinence.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P2292.short?rss=1

 

Recurrence patterns for venous thromboembolism-who is most at risk? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E., *Moudgil H., *Naicker T., *Ahmad N., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 Supp 58

Abstract:
National guidance regarding the treatment of venous thromboembolism (VTE) advocates anticoagulating newly diagnosed patients for three months, followed by consideration of indefinite anticoagulation to reduce the risk of recurrent VTE in certain clinical situations. (NICE Clinical Guideline CG144, issued June 2012.) There is recent evidence that although deep vein thromboses (DVT) and pulmonary emboli (PE) are manifestations of the same disease, their patterns of recurrence and hence future morbidity and mortality risk are different. (Baglin, T. et al. Journal of Thrombosis and Haemostasis 2010; 8(11):2436-2442.) We undertook a retrospective case-note review of 416 patients diagnosed with a VTE event within our institution between January 2010 and January 2011 to assess risk and pattern of VTE recurrence. 35 patients (8.4%) had a recurrent VTE event in the 3 years following diagnosis. Median time to recurrence was 12 months (mean 16.5, SD 10.5). None of the patients were anticoagulated at the time of recurrence and no patients died as a result of their thromboembolic event. Patterns of VTE recurrence The majority of patients with recurrent VTE in our study presented as a further DVT and as such, could be considered at lower risk of associated morbidity and mortality compared to those presenting with PE. Clinicians should consider the likely presentation of any further VTE recurrence as part of their assessment before advocating indefinite anticoagulation in these patients, particularly as the introduction of new oral anticoagulant drugs is likely to make the logistics of prescribing lifelong anticoagulation less complex.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P4114.short?rss=1

 

The diagnosis of malignancy following a venous thromboembolic event-how high is the risk? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E., *Moudgil H., *Naicker T., *Ahmad N., *Srinivasan K.

Citation:
European Respiratory Journal, September 2014, vol./is. 44 Supp 58

Abstract:
UK guidance on the treatment of venous thromboembolism (VTE) recommends that patients with a first, unprovoked VTE should be screened for malignancy. This is based on two historical population-based studies which suggest that between 7.5 and 11% of patients diagnosed with an unprovoked VTE will develop cancer in the following two years. (Murchison, J. T. et al. Br J Cancer 2004;91(1):92-95. Baron, J.A. et al. Lancet 1998; 351(9109):1077-1080.) We wanted to compare local figures with this historical data in order to aid local guideline development. A retrospective case note review identified 417 patients within our institution diagnosed with VTE between January 2010 and January 2011. Ten of these patients (2%) developed cancer in the two years following diagnosis. Results In 2 out of 10 of these patients, tests performed as part of the routine work-up for VTE identified abnormalities that ultimately led to a diagnosis of cancer. None of the patients had extensive malignancy screening as advocated by current UK guidance. Within our local population, the risk of developing cancer in the two years following an unprovoked VTE appears to be significantly less than figures quoted in the literature. UK guidelines may not reflect current medical practice, which could be identifying cancer earlier, nor does it take into account the possibility of regional and national variations of disease. A cautious approach should be taken when counselling patients regarding future cancer risk and when considering further investigations for malignancy.

Link to more details or full-text: http://erj.ersjournals.com/content/44/Suppl_58/P4115

 

New-onset diabetes after renal transplant (NODAT) presenting as diabetic ketoacidosis (DKA) in a patient with sickle cell disease (2015)

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Type of publication:
Conference abstract

Author(s):
*Kaldindi S.R., *Moulik P., *Macleod A.

Citation:
Diabetic Medicine, March 2015, vol./is. 32/(117-118)

Abstract:
A 42-year-old Afro-Caribbean female presented with 1 week history of polyuria, polydypsia and vomiting. She had a background of transfusion associated iron overload and renal failure secondary to sickle cell disease. She underwent a live donor renal transplant 8 months prior to admission. Immunosuppressive therapy included tacrolimus, mycophenolate, prednisolone 5mg once a day. There was no family history of diabetes. She had a normal body mass index. Results revealed a pH of 7.08, bicarbonate of 6.6mmol/l, capillary blood glucose tests recorded as greater than 28.7mmol/l, ketones 7.0mmol/l, Hb 84 g/l. Her creatinine was 101mumol/l (baseline 90), eGFR 52 and tacrolimus levels were within therapeutic range. No obvious precipitant for diabetic ketoacidosis (DKA) was found. She responded well to intravenous fluids and insulin. Her glutamic acid decarboxylase (GAD) and islet antigen 2 (IA2) antibodies were negative. Possible causes for her diabetes include iron overload, steroid therapy, tacrolimus. In her case, she presented with a short timeline of symptoms along with severe DKA. This is typical of Type 1 diabetes, even though her antibodies were negative. NODAT usually behaves like Type 2 diabetes but, rarely, such patients can also present with an insulin deficient state similar to Type 1 diabetes. The Renal Association suggests lower levels of tacrolimus to decrease NODAT risk and screening for diabetes post-transplant. A steroid sparing immunosuppressive regimen may help in reducing the incidence of NODAT.

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