Introduction of an electronic physiological early warning system: effects on mortality and length of stay

BACKGROUND

The Worthing physiological scoring system (PSS) was first validated in 2005 as a tool to predict hospital mortality on admission and was subsequently introduced into clinical practice at Worthing Hospital, UK. Five years on, this study was conducted to determine the effects on mortality and length of stay (LOS) after the introduction of electronic alerting software using the PSS. In addition, we investigated whether the Worthing PSS predictive ability could be improved by addition of further variables.

METHODS

Prospective observational study conducted in the acute medical unit, Worthing Hospital, UK. Patient physiological data on admission and discharge/transfer were collected between February and July 2010 from the electronic alerting software VitalPAC™. Patient characteristics, co-morbidity, outcomes, and biochemistry data were taken from the hospital administration and pathology systems.

RESULTS

The observed mortality reduction from 8.3% to 5.2% over 5 yr was not statistically significant after adjustment for admission Worthing PSS score. Median LOS was reduced from 4 to 2 days, but this reflected an increase in short stay admissions. Worthing PSS was not significantly improved with the addition of biochemical variables or patient co-morbidity. A score taken before admission to a medical ward showed an improved predictive ability when compared with the initial admission score, but further analysis found no additional clinical benefit.

CONCLUSIONS

The introduction of an electronic alerting PSS did not lead to a reduction in mortality when adjusted for severity of illness defined by physiological variables. Predictive performance was not enhanced by the addition of biochemical variables and co-morbidities.

Cost-effectiveness of combining systematic identification and treatment of co-morbid major depression for people with chronic diseases: the example of cancer

BACKGROUND

Co-morbid major depression occurs in approximately 10% of people suffering from a chronic medical condition such as cancer. Systematic integrated management that includes both identification and treatment has been advocated. However, we lack information on the cost-effectiveness of this combined approach, as published evaluations have focused solely on the systematic (collaborative care) treatment stage. We therefore aimed to use the best available evidence to estimate the cost-effectiveness of systematic integrated management (both identification and treatment) compared with usual practice, for patients attending specialist cancer clinics.

METHOD

We conducted a cost-effectiveness analysis using a decision analytic model structured to reflect both the identification and treatment processes. Evidence was taken from reviews of relevant clinical trials and from observational studies, together with data from a large depression screening service. Sensitivity and scenario analyses were undertaken to determine the effects of variations in depression incidence rates, time horizons and patient characteristics.

RESULTS

Systematic integrated depression management generated more costs than usual practice, but also more quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) was £11,765 per QALY. This finding was robust to tests of uncertainty and variation in key model parameters.

CONCLUSIONS

Systematic integrated management of co-morbid major depression in cancer patients is likely to be cost-effective at widely accepted threshold values and may be a better way of generating QALYs for cancer patients than some existing medical and surgical treatments. It could usefully be applied to other chronic medical conditions.

A randomised, phase II trial of the DNA-hypomethylating agent 5-aza-2'-deoxycytidine (decitabine) in combination with carboplatin vs carboplatin alone in patients with recurrent, partially platinum-sensitive ovarian cancer

BACKGROUND

Our previous laboratory and clinical data suggested that one mechanism underlying the development of platinum resistance in ovarian cancer is the acquisition of DNA methylation. We therefore tested the hypothesis that the DNA hypomethylating agent 5-aza-2'-deoxycytodine (decitabine) can reverse resistance to carboplatin in women with relapsed ovarian cancer.

METHODS

Patients progressing 6-12 months after previous platinum therapy were randomised to decitabine on day 1 and carboplatin (AUC 6) on day 8, every 28 days or carboplatin alone. The primary objective was response rate in patients with methylated hMLH1 tumour DNA in plasma.

RESULTS

After a pre-defined interim analysis, the study closed due to lack of efficacy and poor treatment deliverability in 15 patients treated with the combination. Responses by GCIG criteria were 9 out of 14 vs 3 out of 15 and by RECIST were 6 out of 13 vs 1 out of 12 for carboplatin and carboplatin/decitabine, respectively. Grade 3/4 neutropenia was more common with the combination (60% vs 15.4%) as was G2/3 carboplatin hypersensitivity (47% vs 21%).

CONCLUSIONS

With this schedule, the addition of decitabine appears to reduce rather than increase the efficacy of carboplatin in partially platinum-sensitive ovarian cancer and is difficult to deliver. Patient-selection strategies, different schedules and other demethylating agents should be considered in future combination studies.

Treatment of depression in adults with cancer: a systematic review of randomized controlled trials

BACKGROUND

Depression is a leading cause of disease burden worldwide and is especially problematic in people with chronic diseases, including cancer. Although depression can be effectively treated in the general population using antidepressant medication and psychological treatments, these treatments may have different benefits and harms in cancer patients. Previous reviews have not adequately addressed this topic. We therefore aimed to determine which, if any, treatments are effective for patients with diagnoses of both cancer and depression.

METHOD

We conducted a systematic review of relevant randomized controlled trials identified through searches of Medline, EMBASE, PsycINFO and The Cochrane Central Register of Controlled Trials (CENTRAL).

RESULTS

Seven relatively small trials met the selection criteria. These provided some evidence that antidepressant medication, given alone or in combination with a psychological treatment, may be effective. We found no good evidence for psychological treatments given alone or for any other forms of treatment.

CONCLUSIONS

There is very limited evidence from clinical trials to guide the treatment of cancer patients with a diagnosis of depression, especially for psychological treatments. High quality trials of treatments for depression in patients with cancer are urgently needed.

Psychosocial consequences of cancer cachexia: the development of an item bank

CONTEXT

Cancer cachexia syndrome (CCS) is often accompanied by psychosocial consequences (PSC). To alleviate PSC, a systematic assessment method is required. Currently, few assessment tools are available (e.g., Functional Assessment of Anorexia/Cachexia Therapy). There is no systematic assessment tool that captures the PSC of CCS.

OBJECTIVES

To develop a pilot item bank to assess the PSC of CCS.

METHODS

A total of 132 questions, generated from patient answers in a previous study, were reduced to 121 items by content analysis and evaluation by multidisciplinary experts (doctor, nutritionists, and nurses). In our two-step, cross-sectional study, patients, judged by staff to have PSC of CCS, were included, and the questions were randomly allocated to the patients. Questions were evaluated for understandability and triggering emotions, and patients were asked to provide a response using a four-point Likert scale. Subsequently, problematic questions were revised, reformulated, and retested.

RESULTS

A total of 20 patients with a variety of tumor types participated. Of the 121 questions, 31 had to be reformulated after Step 1 and were retested in Step 2, after which seven were again evaluated as not being perfectly comprehensible. In Step 1, 22 questions were found to trigger emotions, but no item required remodeling. Item performance using the Likert scale revealed no consistent floor or ceiling effects. Our final pilot question bank comprised 117 questions.

CONCLUSION

The final item bank contains questions that are understood and accepted by the patients. This item bank now needs to be developed into a measurement tool that groups items into domains and can be used in future research studies.

Screening medical patients for distress and depression: does measurement in the clinic prior to the consultation overestimate distress measured at home?

BACKGROUND

Medical patients are often screened for distress in the clinic using a questionnaire such as the Hospital Anxiety and Depression Scale (HADS) while awaiting their consultation. However, might the context of the clinic artificially inflate the distress score ? To address this question we aimed to determine whether those who scored high on the HADS in the clinic remained high scorers when reassessed later at home.

METHOD

We analysed data collected by a distress and depression screening service for cancer out-patients. All patients had completed the HADS in the clinic (on computer or on paper) prior to their consultation. For a period, patients with a high score (total of > or = 15) also completed the HADS again at home (over the telephone) 1 week later. We used these data to determine what proportion remained high scorers and the mean change in their scores. We estimated the effect of ‘ regression to the mean’ on the observed change.

RESULTS

Of the 218 high scorers in the clinic, most [158 (72.5 %), 95% confidence interval (CI) 66.6–78.4] scored high at reassessment. The mean fall in the HADS total score was 1.74 (95% CI 1.09–2.39), much of which could be attributed to the estimated change over time (regression to the mean) rather than the context.

CONCLUSIONS

Pre-consultation distress screening in clinic is widely used. Reassuringly, it only modestly overestimates distress measured later at home and consequently would result in a small proportion of unnecessary further assessments. We conclude it is a reasonable and convenient strategy.

Transforming rural health systems through clinical academic leadership: lessons from South Africa

CONTEXT

Under-resourced and poorly managed rural health systems challenge the achievement of universal health coverage, and require innovative strategies worldwide to attract healthcare staff to rural areas. One such strategy is rural health training programs for health professionals. In addition, clinical leadership (for all categories of health professional) is a recognised prerequisite for substantial improvements in the quality of care in rural settings.

ISSUE

Rural health training programs have been slow to develop in low- and middle-income countries (LMICs); and the impact of clinical leadership is under-researched in such settings. A 2012 conference in South Africa, with expert input from South Africa, Canada and Australia, discussed these issues and produced recommendations for change that will also be relevant in other LMICs. The two underpinning principles were that: rural clinical leadership (both academic and non-academic) is essential to developing and expanding rural training programs and improving care in LMICs; and leadership can be learned and should be taught.

LESSONS LEARNED

The three main sets of recommendations focused on supporting local rural clinical academic leaders; training health professionals for leadership roles in rural settings; and advancing the clinical academic leadership agenda through advocacy and research. By adopting the detailed recommendations, South Africa and other LMICs could energise management strategies, improve quality of care in rural settings and impact positively on rural health outcomes.

[Regional analysis of drug treatment prevalence and medication of diabetes mellitus in Germany]

BACKGROUND AND AIM

Diabetes mellitus is a widespread chronic disease. Diabetes prevalence was already analyzed in multiple complex studies. The goal of this analysis was the determination of the regional drug treatment prevalence and medication of diabetes mellitus in Germany. Simultaneously, we examined and validated the applicability of prescription data of the German statutory health insurance (SHI) as the basis for reliable and comparable prevalence estimations.

PATIENTS AND METHODS

For the analysis, we used anonymized data from a prescription database as well as the member statistics of the German federal Ministry of Health. By using defined prescription profiles with anti-diabetic medication, we determined the diabetic patients and treatment schemes per Association of SHI Physicians. Subsequently, we calculated and described the drug treatment prevalence and medication. A differentiation between type 1 and type 2 diabetes was not possible.

RESULTS

The total prevalence of drug-treated patients in Germany was 7.77%. The regional values ranged from 6.40% in Schleswig-Holstein until 11.37% in Saxony-Anhalt. The highest numbers of drug treatment prevalence were found in the East of Germany. Insulin treatment was frequent in Hamburg, but rare in Bavaria. Insulin combined with oral anti-diabetic medication was mainly dispensed in Saxony-Anhalt and Brandenburg, least in Hamburg. A treatment with one or more oral anti-diabetics was most common in Bavaria and Bremen, lowest in Rhineland-Palatinate and Mecklenburg-West Pomerania.

CONCLUSION

We developed an easy to use evaluation algorithm for prescription data to estimate the drug treatment prevalence of a chronic disease. The estimated prevalence confirms the increasing trend reported from other studies and appears to be plausible in comparison. More research is required to validate and enhance the method.

Treatment and outcome of Wilms' tumour patients: an analysis of all cases registered in the UKW3 trial

BACKGROUND

The randomised findings of the UKW3 trial were that preoperative chemotherapy was associated with a more advantageous stage distribution and reduction in therapy burden versus immediate nephrectomy without compromising outcome in localised Wilms' tumour (WT). We analysed outcome in all WT registered in UKW3.

PATIENTS AND METHODS

Seven hundred and eighteen WT cases (7% anaplastic) were registered in UKW3. We assigned a treatment stage and conducted survival analysis.

RESULTS

Five-year event-free survival (EFS) and overall survival (OS) were 77.2% [95% confidence interval (CI) 73.9-80.2] and 87.5% (95% CI 84.8-89.7) after median follow-up of 9.5 years and 10.0 years, respectively. Five-year OS in localised non-anaplastic cases was 92.9% (95% CI 90.2-94.9). Anaplasia was associated with adverse outcome compared with non-anaplastic cases: 5-year EFS of 42.0% (95% CI 28.3-55.1) versus 79.8% (95% CI 76.5-82.7) and 5-year OS of 60% (95% CI 45.1-72.0) versus 89.6% (95% CI 87.0-91.7), respectively. Outcomes were similar for non-anaplastic stage I or II but significantly poorer in stage III cases than stage I. Five-year OS after relapse was 54.1% (95% CI 44.5-62.8). Forty-seven percent of non-anaplastic WT received anthracycline; 27% were treated with radiotherapy first line.

CONCLUSION

These outcomes provide a baseline for future comparisons of WT treatment approach, burden and patient outcome.

Verteporfin photodynamic therapy for neovascular age-related macular degeneration: cohort study for the UK

OBJECTIVES

The verteporfin photodynamic therapy (VPDT) cohort study aimed to answer five questions: (a) is VPDT in the NHS provided as in randomised trials?; (b) is 'outcome' the same in the nhs as in randomised trials?; (c) is 'outcome' the same for patients ineligible for randomised trials?; (d) is VPDT safe when provided in the NHS?; and (e) how effective and cost-effective is VPDT?

DESIGN

Treatment register.

SETTING

All hospitals providing VPDT in the NHS.

PARTICIPANTS

All patients attending VPDT clinics.

INTERVENTIONS

Infusion of verteporfin followed by infrared laser exposure is called VPDT, and is used to treat neovascular age-related macular degeneration (nAMD). The VPDT cohort study advised clinicians to follow patients every 3 months during treatment or active observation, retreating based on criteria used in the previous commercial 'TAP' (Treatment of Age-related macular degeneration with Photodynamic therapy) trials of VPDT.

MAIN OUTCOME MEASURES

The primary outcome was logarithm of the minimum angle of resolution monocular best-corrected distance visual acuity (BCVA). Secondary outcomes were adverse reactions and events; morphological changes in treated nAMD (wet) lesions; and for a subset of patients, 6-monthly contrast sensitivity, generic and visual health-related quality of life (HRQoL) and resource use. Treated eyes were classified as eligible for the TAP trials (EFT), ineligible (IFT) or unclassifiable (UNC).

RESULTS

Forty-seven hospitals submitted data for 8323 treated eyes in 7748 patients; 4919 eyes in 4566 patients were treated more than 1 year before the last data submission or had completed treatment. Of 4043 eyes with nAMD in 4043 patients, 1227 were classified as EFT, 1187 as IFT and 1629 as UNC. HRQoL and resource use data were available for about 2000 patients. The mean number of treatments in years 1 and 2 was 2.3 and 0.4 respectively. About 50% of eyes completed treatment within 1 year. BCVA deterioration in year 1 did not differ between eligibility groups. EFT eyes lost 11.6 letters (95% confidence interval 10.1 to 13.0 letters) compared with 9.9 letters in VPDT-treated eyes in the TAP trials. EFT eyes had poorer BCVA at baseline than IFT and UNC eyes. Adverse reactions and events were reported for 1.4% of first visits - less frequently than those reported in the TAP trials. Associations between BCVA in the best-seeing eye with HRQoL and community health and social care resource use showed that the 11-letter difference in BCVA between VPDT and sham treatment in the TAP trials corresponded to differences in utility of 0.012 and health and social service costs of £60 and £92 in years 1 and 2, respectively. VPDT provided an incremental cost per quality-adjusted life-year (QALY) of £170,000 over 2 years.

CONCLUSIONS

VPDT was administered less frequently than in the TAP trials, with less than half of those treated followed up for > 1 year in routine clinical practice. Deterioration in BCVA over time in EFT eyes was similar to that in the TAP trials. The similar falls in BCVA after VPDT across the pre-defined TAP eligibility groups do not mean that the treatment is equally effective in these groups because deterioration in BCVA can be influenced by the parameters that determined group membership. Safety was no worse than in the TAP trials. The estimated cost per QALY was similar to the highest previous estimate. Although VPDT is no longer in use as monotherapy for neovascular AMD, its role as adjunctive treatment has not been fully explored. VPDT also has potential as monotherapy in the management of vascular malformations of the retina and choroid and with trials underway in neovascularisation due to myopia and polypoidal choroidopathy.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Immunocastration of Bos indicus x Brown Swiss bulls in feedlot with gonadotropin-releasing hormone vaccine Bopriva provides improved performance and meat quality

The objective of this study was to determine the effects of a GnRH vaccine on feedlot performance and meat quality in Bos indicus Zebu × Brown Swiss bulls. The study was a 2 × 2 factorial arrangement of treatments with 1,600 bulls allocated by BW into 4 groups of ≈ 400 animals. The GnRH vaccine (Bopriva) was injected on d 0 and 42, and anabolic implants given on d 0 (Component E-S) and d 84 (Synovex Choice). Group designations were: Con = placebo control; Imp = implants alone; Vac = GnRH vaccine alone; and Vac+Imp = GnRH vaccine together with implants. The second GnRH vaccination at d 42 resulted in elevated titers of IgG antibody and suppressed concentrations of testosterone in vaccinated groups (Vac and Vac+Imp) at d 56 (P < 0.001), with titers and suppressed testosterone persisting to d 147 (P < 0.001). Groups Vac and Vac+Imp had reduced testes weights at slaughter on d 147 (P < 0.001). Bulls in group Vac were not different in final BW, HCW, or ADG (d 42 to 147) relative to bulls in group Con. Bulls in group Vac+Imp had greater final BW than bulls in group Imp (P = 0.008) and greater BW than bulls in group Vac and group Con (P < 0.001). The HCW of Vac+Imp bulls was greater than the Vac or Con bulls (P < 0.001) but was not different to the Imp bulls (P = 0.294). Improved ADG was obtained by vaccination with the GnRH vaccine, in the presence of implants (group Vac+Imp compared with group Imp, P < 0.001) or absence of implants (group Vac compared with group Con, P = 0.028). Meat quality of bulls receiving the GnRH vaccine was improved irrespective of implant status, with a 1.6- to 2.6-fold increase in the proportion of bulls in groups Vac and Vac+Imp, respectively, grading as USDA Choice (P < 0.002) and with greater fat depth at the 12th rib (P < 0.001). Meat tenderness was improved in the vaccine groups (Vac and Vac+Imp) compared with groups Con and Imp (P < 0.004). Use of the GnRH vaccine Bopriva in Bos indicus × Brown Swiss bulls finishing in a feedlot under Mexican husbandry conditions can provide improved performance in combination with implants (increased BW and ADG) and improved meat quality, with or without implants, and in particular, better USDA carcass grading and loin fat cover.

Vaccination against gonadotropin-releasing factor (GnRF) with Bopriva significantly decreases testicular development, serum testosterone levels and physical activity in pubertal bulls

The aim of this study was to evaluate the effects of vaccination against gonadotropin-releasing factor (GnRF) on testicular development, testosterone secretion, and physical activity in pubertal bulls. The experiment was performed using 44 bulls aged between 6 and 7 mo. Twenty-three animals were vaccinated twice 4 wk apart with 1 mL of Bopriva (Pfizer, Animal Health, Parkville, Australia) and 21 bulls served as matched controls. Serum GnRF antibody titer and testosterone concentration as well as body weight and scrotal circumference were determined in all bulls for 24 wk from the first vaccination. In addition, physical activity was analyzed in 11 vaccinated and in 10 control animals using the ALPRO DeLaval activity meter system (DeLaval AG, Sursee, Switzerland). The results show that vaccination significantly (P < 0.05) influenced all parameters evaluated except body weight. Antibody titers to GnRF began to rise 2 wk after the first vaccination and reached peak values 2 wk after the second injection. Significant group differences in anti-GnRF titer were present for 22 wk following the first vaccination. Testosterone concentrations were significantly lower between weeks 6 to 24 after first vaccination in bulls with Bopriva compared with control animals. In vaccinated bulls testicular development was impaired after the second injection and scrotal circumference was significantly smaller between weeks 8 to 24 after first vaccination. Physical activity of vaccinated bulls was reduced after the booster injection with significant group differences for a continuous period of 106 days. In conclusion, vaccination against GnRF with Bopriva in pubertal bulls decreased testosterone levels in peripheral blood, testicular development, and physical activity but did not affect weight gain.

Physiological sex steroid replacement in premature ovarian failure: randomized crossover trial of effect on uterine volume, endometrial thickness and blood flow, compared with a standard regimen

BACKGROUND

Premature ovarian failure (POF) is currently managed by non-physiological sex steroid regimens which are inadequate at optimizing uterine characteristics. Previous short-term studies have demonstrated some benefits of a sex steroid replacement (SSR) regimen devised to replicate the physiological cycle. This study aimed to directly compare the effects of longer-term administration of physiological SSR (pSSR) and standard SSR (sSSR) regimens on the uterine volume, blood flow and endometrial thickness (ET) in women with POF.

METHODS

In a controlled crossover trial, 34 women with POF were randomized to receive 12 months of 4-week cycles of transdermal estradiol and vaginal progesterone (pSSR) followed by 12 months of 4-week cycles of oral ethinylestradiol and norethisterone (sSSR), or vice versa. Each treatment period was preceded by a 2-month washout period. At 0, 3, 6 and 12 months of each treatment period, transvaginal ultrasound examined the uterine volume and ET, as primary end-points, and uterine artery resistance (UARI) and pulsatility indices (UAPI), as secondary end-points. Serum estradiol, progesterone and gonadotrophins were also measured.

RESULTS

Of the 29 women eligible for the uterine analysis, 17 completed the entire study protocol, but 25 women contributed data to statistical analysis of treatment effect. There was a greater estimated mean ET with the use of pSSR (4.8 mm) compared to that with standard therapy (3.0 mm), with an estimated difference of 1.8 mm [95% confidence interval (CI), 0.7 to 2.8, P=0.002]. The estimated mean uterine volume was also greater during physiological treatment (24.8 cm(3)) than during standard treatment (20.6 cm(3)), but the estimated difference of 4.2 cm(3) (95% CI -0.4 to 8.7) was not statitsically significant, P=0.070. The small differences between the two treatments in the mean UARI and mean UAPI were not statistically significant. The estimated treatment differences were fairly constant across the treatment periods, suggesting that prolonged treatment does not increase response.

CONCLUSIONS

pSSR has a greater beneficial effect upon ET in women with POF in comparison with standard therapy. A similar trend was seen for uterine volume. Further studies are required to optimize treatment and to assess pregnancy rate and outcome. Trial Registration www.ClinicalTrials.gov, NCR00732693.

Assessing options for the development of surface water flood warning in England and Wales

This paper explores the technical options for warning of surface water flooding in England and Wales and presents the results of an Environment Agency funded project. Following the extensive surface water flooding experienced in summer 2007 a rainfall threshold-based Extreme Rainfall Alert (ERA) was piloted by the Met Office and Environment Agency providing initial steps towards the establishment of a warning for some types of surface water flooding. The findings of this paper are based primarily on feedback on technical options from a range of professionals involved in flood forecasting and warning and flood risk management, about the current alerts and about the potential options for developing a more targeted surface water flood warning service. Providing surface water flooding warnings presents a set of technical, forecasting and warning challenges related to the rapid onset of flooding, the localised nature of the flooding, and the linking of rainfall and flood forecasts to flood likelihood and impact on the ground. Some examples of rainfall alerting and surface water flood warning services from other countries are evaluated, as well as a small number of recently implemented local services in England and Wales. Various potential options for implementation of a service are then explored and assessed. The paper concludes that development of a surface water flood warning service for England and Wales is feasible and is likely to be useful to emergency responders and operational agencies, although developing such a service for the pluvial components of this type of flooding is likely to be feasible sooner than for other components of surface water flooding such as that caused by sewers. A targeted surface water flood warning service could be developed for professional emergency responders in the first instance rather than for the public for whom such a service without further operational testing and piloting would be premature.