Commentary: Advocating for patient and public involvement and engagement in health economic evaluation

BACKGROUND

Patient and public involvement in health economic evaluation is still relatively rare, compared to other areas of health and social care research. Developing stronger patient and public involvement in health economic evaluation will be important in the future because such evaluations can impact on the treatments and interventions that patients can access in routine care.

MAIN TEXT

The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) is a reporting guideline for authors publishing health economic evaluations. We established an international group of public contributors who were involved in the update of the CHEERS 2022 reporting guidance, ensuring two items (areas of reporting) specifically about public involvement were included. In this commentary we focus on the development of a guide to support public involvement in reporting, a key suggestion made by the CHEERS 2022 Public Reference Group, who advocated for greater public involvement in health economic evaluation. This need for this guide was identified during the development of CHEERS 2022 when it became apparent that the language of health economic evaluation is complex and not always accessible, creating challenges for meaningful public involvement in key deliberation and discussion. We took the first step to more meaningful dialogue by creating a guide that patient organisations could use to support their members to become more involved in discussions about health economic evaluations.

CONCLUSIONS

CHEERS 2022 provides a new direction for health economic evaluation, encouraging researchers to undertake and report their public involvement to build the evidence base for practice and may provide some reassurance to the public that their voice has played a part in evidence development. The CHEERS 2022 guide for patient representatives and patient organisations aims to support that endeavour by enabling deliberative discussions among patient organisations and their members. We recognise it is only a first step and further discussion is needed about the best ways to involve public contributors in health economic evaluation.

A Roadmap for Increasing the Usefulness and Impact of Patient-Preference Studies in Decision Making in Health: A Good Practices Report of an ISPOR Task Force

Many qualitative and quantitative methods are readily available to study patient preferences in health. These methods are now being used to inform a wide variety of decisions, and there is a growing body of evidence showing studies of patient preferences can be used for decision making in a wide variety of contexts. This ISPOR Task Force report synthesizes current good practices for increasing the usefulness and impact of patient-preference studies in decision making. We provide the ISPOR Roadmap for Patient Preferences in Decision Making that invites patient-preference researchers to work with decision makers, patients and patient groups, and other stakeholders to ensure that studies are useful and impactful. The ISPOR Roadmap consists of 5 key elements: (1) context, (2) purpose, (3) population, (4) method, and (5) impact. In this report, we define these 5 elements and provide good practices on how patient-preference researchers and others can actively contribute to increasing the usefulness and impact of patient-preference studies in decision making. We also present a set of key questions that can support researchers and other stakeholders (eg, funders, reviewers, readers) to assess efforts that promote the ongoing impact (both intended and unintended) of a particular preference study and additional studies in the future.

Epidemiology of cardiomyopathies and incident heart failure in a population-based cohort study

AIMS

The population prevalence of cardiomyopathies and the natural history of symptomatic heart failure (HF) and arrhythmia across cardiomyopathy phenotypes is poorly understood. Study aims were to estimate the population-diagnosed prevalence of cardiomyopathies and describe the temporal relationship between a diagnosis of cardiomyopathy with HF and arrhythmia.

METHODS

People with cardiomyopathy (n=4116) were identified from linked electronic health records (~9 million individuals; 2000-2018) and categorised into hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), restrictive cardiomyopathy (RCM) and cardiac amyloidosis (CA). Cardiomyopathy point prevalence, rates of symptomatic HF and arrhythmia and timing relative to a diagnosis of cardiomyopathy were determined.

RESULTS

In 2018, DCM was the most common cardiomyopathy. DCM and HCM were twice as common among men, with the reverse trend for ARVC. Between 2010 and 2018, prevalence increased for ARVC by 180% and HCM by 9%. At diagnosis, more patients with CA (66%), DCM (56%) and RCM (62%) had pre-existing HF compared with ARVC (29%) and HCM (27%). Among those free of HF at diagnosis of cardiomyopathy, annualised HF incidence was greatest in CA and DCM. Diagnoses of all cardiomyopathies clustered around the time of HF onset.

CONCLUSIONS

The recorded prevalence of all cardiomyopathies increased over the past decade. Recognition of CA is generally preceded by HF, whereas individuals with ARVC or HCM more often developed HF after their cardiomyopathy diagnosis suggesting a more indolent course or better asymptomatic recognition. The clustering of HF and cardiomyopathy diagnoses suggests opportunities for presymptomatic or earlier diagnosis.

Clinical profiles and incident heart failure in cardiomyopathies: a population-based linked electronic health record cohort study

Background

Cardiomyopathies frequently cause heart failure (HF), however their prevalence in the general population and the natural history of incident HF across the spectrum of cardiomyopathy phenotypes is poorly understood. Improved understanding will help guide rational selection of diagnostic tests and accelerate the recognition of underlying causes of HF.

Purpose

To estimate the prevalence of cardiomyopathies using electronic health records; to compare clinical characteristics between patients with cardiomyopathy phenotypes; and to describe the temporal relationship between diagnosis of cardiomyopathy and incident HF.

Methods

A population-based cohort of patients with cardiomyopathy (n=4058) was provided by the UK Clinical Practice Research Datalink (CPRD) from a denominator sample of ∼9 million individuals. Patients were phenotyped into groups according to ESC criteria: hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC) and restrictive cardiomyopathy (RCM). An additional group of transthyretin amyloid cardiomyopathy (ATTR-CM) was reported separately. Point prevalence was estimated for each cardiomyopathy subtype and clinical characteristics defined. An index date at first diagnosis of HF was determined for each patient and the time from/to first diagnosis of cardiomyopathy calculated relative to the index date and presented graphically.

Results

DCM was the most common cardiomyopathy phenotype among women and men with 3.4 and 7.7 cases per 10,000 population, respectively. The 2-fold increase in prevalence among men was consistent across DCM, HCM and RCM; the reverse trend was observed for ARVC which was found in 2.3 per 10,000 women and 1.1 per 10,000 men. At the time of first diagnosis of cardiomyopathy, most patients with ATTR-CM (73.5%), DCM (71.0%) and RCM (71.3%) had pre-existing HF though this proportion fell to 41.0% in ARVC and 31.0% in HCM. In relation to incident HF, a diagnosis of HCM and DCM were recorded earliest at a mean −2.2 years (SE 0.2) and −0.6 years (SE 0.1), respectively. We observed a clustering of diagnoses of RCM (mean −0.2 years, SE 0.4) and ARVC (mean 0.1 years, SE 0.1) around the time of onset of heart failure, whereas a diagnosis of ATTR-CM was first recorded at a mean of 0.9 years (SE 0.2) following the onset of heart failure.

Conclusions

Most diagnoses of ATTR-CM, DCM and RCM were preceded by clinical expression of HF whereas most people with ARVC or HCM developed HF after their cardiomyopathy diagnosis. Our findings in ARVC and HCM suggest a more indolent course with respect to cardiac function or better recognition in an asymptomatic phase. The clustering of a diagnosis of heart failure around the time of diagnosis of cardiomyopathy highlights a need for greater awareness of specific aetiologies of heart failure in routine practice and suggests opportunities for presymptomatic or earlier diagnosis.

Temporality of HF in cardiomyopathies

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Pfizer

Prophylactic levofloxacin to prevent infections in newly diagnosed symptomatic myeloma: the TEAMM RCT

BACKGROUND

Myeloma causes profound immunodeficiency and recurrent serious infections. There are approximately 5500 new UK cases of myeloma per annum, and one-quarter of patients will have a serious infection within 3 months of diagnosis. Newly diagnosed patients may benefit from antibiotic prophylaxis to prevent infection. However, the use of prophylaxis has not been established in myeloma and may be associated with health-care-associated infections (HCAIs), such as Clostridium difficile. There is a need to assess the benefits and cost-effectiveness of the use of antibacterial prophylaxis against any risks in a double-blind, placebo-controlled, randomised clinical trial.

OBJECTIVES

To assess the risks, benefits and cost-effectiveness of prophylactic levofloxacin in newly diagnosed symptomatic myeloma patients.

DESIGN

Multicentre, randomised, double-blind, placebo-controlled trial. A central telephone randomisation service used a minimisation computer algorithm to allocate treatments in a 1 : 1 ratio.

SETTING

A total of 93 NHS hospitals throughout England, Northern Ireland and Wales.

PARTICIPANTS

A total of 977 patients with newly diagnosed symptomatic myeloma.

INTERVENTION

Patients were randomised to receive levofloxacin or placebo tablets for 12 weeks at the start of antimyeloma treatment. Treatment allocation was blinded and balanced by centre, estimated glomerular filtration rate and intention to give high-dose chemotherapy with autologous stem cell transplantation. Follow-up was at 4-week intervals up to 16 weeks, with a further follow-up at 1 year.

MAIN OUTCOME MEASURES

The primary outcome was to assess the number of febrile episodes (or deaths) in the first 12 weeks from randomisation. Secondary outcomes included number of deaths and infection-related deaths, days in hospital, carriage and invasive infections, response to antimyeloma treatment and its relation to infection, quality of life and overall survival within the first 12 weeks and beyond.

RESULTS

In total, 977 patients were randomised (levofloxacin, n = 489; placebo, n = 488). A total of 134 (27%) events (febrile episodes, n = 119; deaths, n = 15) occurred in the placebo arm and 95 (19%) events (febrile episodes, n = 91; deaths, n = 4) occurred in the levofloxacin arm; the hazard ratio for time to first event (febrile episode or death) within the first 12 weeks was 0.66 (95% confidence interval 0.51 to 0.86; p = 0.002). Levofloxacin also reduced other infections (144 infections from 116 patients) compared with placebo (179 infections from 133 patients; p-trend of 0.06). There was no difference in new acquisitions of C. difficile, methicillin-resistant Staphylococcus aureus and extended-spectrum beta-lactamase Gram-negative organisms when assessed up to 16 weeks. Levofloxacin produced slightly higher quality-adjusted life-year gains over 16 weeks, but had associated higher costs for health resource use. With a median follow-up of 52 weeks, there was no significant difference in overall survival (p = 0.94).

LIMITATIONS

Short duration of prophylactic antibiotics and cost-effectiveness.

CONCLUSIONS

During the 12 weeks from new diagnosis, the addition of prophylactic levofloxacin to active myeloma treatment significantly reduced febrile episodes and deaths without increasing HCAIs or carriage. Future work should aim to establish the optimal duration of antibiotic prophylaxis and should involve the laboratory investigation of immunity, inflammation and disease activity on stored samples funded by the TEAMM (Tackling Early Morbidity and Mortality in Myeloma) National Institute for Health Research Efficacy and Mechanism Evaluation grant (reference number 14/24/04).

TRIAL REGISTRATION

Current Controlled Trials ISRCTN51731976.

FUNDING DETAILS

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 62. See the NIHR Journals Library website for further project information.

International benchmarking for health policy evaluation: the French National Health Strategy

Background

International benchmarking is a valued source of inspiration and learning for policy-makers to develop successful public health policies. Through comparison, the external coherence of one policy can be measured and its objectives redesigned. The French national health strategy (SNS) 2018-2022 comprises the French health policy framework focusing on four priority areas. The aim of this study was to conduct international benchmarking of current national health strategies to explore the external coherence of the SNS and evaluation methods.

Methods

A scoping review was conducted through available governmental and public health agencies' websites to survey national/federal health strategies in select high-income countries.

Strategical approaches, governance and policy duration were compared with four health priorities of the French SNS: prevention, social/territorial inequalities, quality of care, innovation. A descriptive analysis of these strategies' evaluation methods, including relevant indicators, was executed.

Results

Out of 18 countries selected, 11 have a current strategy akin to the four priorities of the French SNS, with a timeline stipulated to implement the policy. The strategies of Australia and Switzerland, out of nine countries with strategies covering these areas, bear the closest resemblance to the French SNS. Evaluation methods varied largely across countries.

Conclusions

The majority of countries contain a health strategy with a longer duration compared to the French SNS, irrespective of governance. Similar priorities were found for countries with a national health strategy, with other countries developing at least prevention plans. Most countries provided only partial evaluation methods or overall health target indicators, to be taken into account for the development of the French SNS evaluation plan

Key messages

International benchmarking is essential to identify best practices in health policy design. As a result, future French health strategies may benefit from a longer duration of implementation. If great efforts were put in place in France to build a strategy evaluation plan, other countries focused mostly on implementation reports or monitoring national health targets through indicators.

Diagnostic pathways in multiple myeloma and their relationship to end organ damage: an analysis from the Tackling Early Morbidity and Mortality in Myeloma (TEAMM) trial

Multiple myeloma is associated with significant early morbidity and mortality, with considerable end organ damage often present at diagnosis. The Tackling EArly Morbidity and Mortality in Multiple Myeloma (TEAMM) trial was used to evaluate routes to diagnosis in patients with myeloma and the relationship between diagnostic pathways, time to diagnosis and disease severity. A total of 915 participants were included in the study. Fifty-one per cent were diagnosed by direct referral from primary care to haematology; 29% were diagnosed via acute services and 20% were referred via other secondary care specialties. Patients diagnosed via other secondary care specialties had a longer diagnostic interval (median 120 days vs. 59 days) without an increase in features of severe disease, suggesting they had a relatively indolent disease. Marked intrahospital delay suggests possible scope for improvement. A quarter of those diagnosed through acute services reported >30 days from initial hospital consultation to haematology assessment. Participants diagnosed through acute services had poorer performance status (P < 0·0001) and higher burden of end organ damage (P < 0·0001) with no difference in the overall length of diagnostic pathway compared to those diagnosed by direct referral (median 59 days). This suggests that advanced disease in patients presenting through acute services predominantly reflects disease aggression.

Levofloxacin prophylaxis in patients with newly diagnosed myeloma (TEAMM): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial

Background

Myeloma causes profound immunodeficiency and recurrent, serious infections. Around 5500 new cases of myeloma are diagnosed per year in the UK, and a quarter of patients will have a serious infection within 3 months of diagnosis. We aimed to assess whether patients newly diagnosed with myeloma benefit from antibiotic prophylaxis to prevent infection, and to investigate the effect on antibiotic-resistant organism carriage and health care-associated infections in patients with newly diagnosed myeloma.

Methods

TEAMM was a prospective, multicentre, double-blind, placebo-controlled randomised trial in patients aged 21 years and older with newly diagnosed myeloma in 93 UK hospitals. All enrolled patients were within 14 days of starting active myeloma treatment. We randomly assigned patients (1:1) to levofloxacin or placebo with a computerised minimisation algorithm. Allocation was stratified by centre, estimated glomerular filtration rate, and intention to proceed to high-dose chemotherapy with autologous stem cell transplantation. All investigators, patients, laboratory, and trial co-ordination staff were masked to the treatment allocation. Patients were given 500 mg of levofloxacin (two 250 mg tablets), orally once daily for 12 weeks, or placebo tablets (two tablets, orally once daily for 12 weeks), with dose reduction according to estimated glomerular filtration rate every 4 weeks. Follow-up visits occurred every 4 weeks up to week 16, and at 1 year. The primary outcome was time to first febrile episode or death from all causes within the first 12 weeks of trial treatment. All randomised patients were included in an intention-to-treat analysis of the primary endpoint. This study is registered with the ISRCTN registry, number ISRCTN51731976, and the EU Clinical Trials Register, number 2011-000366-35.

Findings

Between Aug 15, 2012, and April 29, 2016, we enrolled and randomly assigned 977 patients to receive levofloxacin prophylaxis (489 patients) or placebo (488 patients). Median follow-up was 12 months (IQR 8–13). 95 (19%) first febrile episodes or deaths occurred in 489 patients in the levofloxacin group versus 134 (27%) in 488 patients in the placebo group (hazard ratio 0·66, 95% CI 0·51–0·86; p=0·0018. 597 serious adverse events were reported up to 16 weeks from the start of trial treatment (308 [52%] of which were in the levofloxacin group and 289 [48%] of which were in the placebo group). Serious adverse events were similar between the two groups except for five episodes (1%) of mostly reversible tendonitis in the levofloxacin group.

Interpretation

Addition of prophylactic levofloxacin to active myeloma treatment during the first 12 weeks of therapy significantly reduced febrile episodes and deaths compared with placebo without increasing health care-associated infections. These results suggest that prophylactic levofloxacin could be used for patients with newly diagnosed myeloma undergoing anti-myeloma therapy.

Funding

UK National Institute for Health Research.

Individual Trade-Offs Between Possible Benefits and Risks of Cancer Treatments: Results from a Stated Preference Study with Patients with Multiple Myeloma

The objectives of this study were to ascertain the treatment preferences of patients with multiple myeloma, considering benefits and risks of particular cancer treatments, and to illustrate how such data may be used to estimate patients' acceptance of new treatments.

Background.

The objectives of this study were to elicit the preferences of patients with multiple myeloma regarding the possible benefits and risks of cancer treatments and to illustrate how such data may be used to estimate patients’ acceptance of new treatments.

Patients and Methods.

Patients with multiple myeloma from the cancer charity Myeloma UK were invited to participate in an online survey based on multicriteria decision analysis and swing weighting to elicit individual stated preferences for the following attributes: (a) 1‐year progression‐free survival (PFS, ranging from 50% to 90%), (b) mild or moderate toxicity for 2 months or longer (ranging from 85% to 45%), and (c) severe or life‐threatening toxicity (ranging from 80% to 20%).

Results.

A total of 560 participants completed the survey. The average weight given to PFS was 0.54, followed by 0.32 for severe or life‐threatening toxicity and 0.14 for mild or moderate chronic toxicity. Participants who ranked severe or life‐threatening toxicity above mild or moderate chronic toxicity (56%) were more frequently younger, working, and looking after dependent family members and had more frequently experienced severe or life‐threatening side effects. The amount of weight given to PFS did not depend on any of the collected covariates. The feasibility of using the collected preference data to estimate the patients’ acceptance of specific multiple myeloma treatments was demonstrated in a subsequent decision analysis example.

Conclusion.

Stated preference studies provide a systematic approach to gain knowledge about the distribution of preferences in the population and about what this implies for patients’ acceptance of specific treatments.

Implications for Practice.

This study demonstrated how quantitative preference statements from a large group of participants can be collected through an online survey and how such information may be used to explore the acceptability of specific treatments based on the attributes studied. Results from such studies have the potential to become an important new tool for gathering patient views and studying heterogeneity in preferences in a systematic way, along with other methods, such as focus groups and expert opinions.

Guidelines for screening and management of late and long-term consequences of myeloma and its treatment

A growing population of long-term survivors of myeloma is now accumulating the 'late effects' not only of myeloma itself, but also of several lines of treatment given throughout the course of the disease. It is thus important to recognise the cumulative burden of the disease and treatment-related toxicity in both the stable and active phases of myeloma, some of which is unlikely to be detected by routine monitoring. We summarise here the evidence for the key late effects in long-term survivors of myeloma, including physical and psychosocial consequences (in Parts 1 and 2 respectively), and recommend the use of late-effects screening protocols in detection and intervention. The early recognition of late effects and effective management strategies should lead to an improvement in the management of myeloma patients, although evidence in this area is currently limited and further research is warranted.

Accelerating target discovery using pre-competitive open science-patients need faster innovation more than anyone else

We are experiencing a new era enabled by unencumbered access to high quality data through the emergence of open science initiatives in the historically challenging area of early stage drug discovery. At the same time, many patient-centric organisations are taking matters into their own hands by participating in, enabling and funding research. Here we present the rationale behind the innovative partnership between the Structural Genomics Consortium (SGC)-an open, pre-competitive pre-clinical research consortium and the research-focused patient organisation Myeloma UK to create a new, comprehensive platform to accelerate the discovery and development of new treatments for multiple myeloma.

The MUK five protocol: a phase II randomised, controlled, parallel group, multi-centre trial of carfilzomib, cyclophosphamide and dexamethasone (CCD) vs. cyclophosphamide, bortezomib (Velcade) and dexamethasone (CVD) for first relapse and primary refractory multiple myeloma

Background

Multiple myeloma is a plasma cell tumour with an annual incidence in the UK of approximately 40–50 per million i.e. about 4500 new cases per annum. The triple combination cyclophosphamide, bortezomib (Velcade®) and dexamethasone (CVD) is an effective regimen at relapse and has emerged in recent years as the standard therapy at first relapse in the UK. Carfilzomib has good activity as a single agent in the relapsed setting, and it is expected that efficacy will be improved when used in combination with dexamethasone and cyclophosphamide.

Methods

MUK Five is a phase II open label, randomised, controlled, parallel group, multi-centre trial that will compare the activity of carfilzomib, cyclophosphamide and dexamethasone (CCD) with that of CVD, given over an equivalent treatment period (24 weeks), in participants with multiple myeloma at first relapse, or refractory to no more than 1 line of treatment. In addition, the study also aims to assess the utility of a maintenance schedule of carfilzomib in these participants. The primary objective of the trial is to assess whether CCD provides non-inferior activity in terms of ≥ VGPR rates at 24 weeks, and whether the addition of maintenance treatment with carfilzomib to CCD provides superior activity in terms of progression-free survival, as compared to CCD with no maintenance. Secondary objectives include comparing toxicity profiles, further summarizing and comparing the activity of the different treatment arms and analysis of the effect of each treatment arm on minimal residual disease status.

Discussion

The development of carfilzomib offers the opportunity to further explore the anti-tumour efficacy of proteasome inhibition and, based on the available evidence, it is important and timely to obtain data on the activity, toxicity and tolerability of this drug. In contrast to ongoing phase III trials, this phase II trial has a unique subset of participants diagnosed with multiple myeloma at first relapse or refractory to no more than 1 line of treatment and will also evaluate the utility of maintenance with carfilzomib for up to 18 months and investigate minimal residual disease status to provide information on depth of response and the prognostic impact thereof.

Trial registration

The trial is registered under ISRCTN17354232, December 2012.

In-depth performance analysis of an EEG based neonatal seizure detection algorithm

•

A novel method for in-depth analysis of neonatal seizure detection algorithms is proposed.

•

The analysis estimated how seizure features are exploited by automated detectors.

•

This method led to significant improvement of the ANSeR algorithm.

Objective

To describe a novel neurophysiology based performance analysis of automated seizure detection algorithms for neonatal EEG to characterize features of detected and non-detected seizures and causes of false detections to identify areas for algorithmic improvement.

Methods

EEGs of 20 term neonates were recorded (10 seizure, 10 non-seizure). Seizures were annotated by an expert and characterized using a novel set of 10 criteria.

ANSeR seizure detection algorithm (SDA) seizure annotations were compared to the expert to derive detected and non-detected seizures at three SDA sensitivity thresholds. Differences in seizure characteristics between groups were compared using univariate and multivariate analysis. False detections were characterized.

Results

The expert detected 421 seizures. The SDA at thresholds 0.4, 0.5, 0.6 detected 60%, 54% and 45% of seizures. At all thresholds, multivariate analyses demonstrated that the odds of detecting seizure increased with 4 criteria: seizure amplitude, duration, rhythmicity and number of EEG channels involved at seizure peak. Major causes of false detections included respiration and sweat artefacts or a highly rhythmic background, often during intermediate sleep.

Conclusion

This rigorous analysis allows estimation of how key seizure features are exploited by SDAs.

Significance

This study resulted in a beta version of ANSeR with significantly improved performance.

The Surgical Clerkship and Medical Student Performance in a Standardized Patient Case of Acute Cholecystitis

BACKGROUND

Although an Observed Structured Clinical Examination (OSCE) has been used to evaluate patient interaction and general knowledge competencies of third-year students during their required surgical clerkships, whether surgical clerkship experience predicts satisfactory performance with a surgical patient in an OSCE environment has not been investigated.

OBJECTIVE

We hypothesized that completion of the third-year surgery clerkship would improve student ability to diagnose acute cholecystitis and recognize the further need for hospital admission and treatment.

DESIGN

An observational study design was used to determine student skills in evaluating a simulated surgical patient with abdominal pain from acute cholecystitis. The skills included key data gathering, physical examination, and information-sharing tasks.

SETTING

Tertiary care academic medical center.

PARTICIPANTS

Performance was compared between a cohort of 101 medical students who had completed the third-year surgical clerkship and 72 who had not. A secondary analysis compared performance for 91 students who had completed their third-year clerkship in sites near the University of California, San Francisco School of Medicine, and 10 who did so at a regional campus geographically distant from the medical school.

RESULTS

Of the 173 students who participated in the OSCE, only 42% correctly identified the diagnosis of acute cholecystitis, though 71% did suggest the possibility of a biliary process to the standardized patient. Most of the students who identified the condition as acute cholecystitis or gallbladder-related process had completed their third-year surgical clerkship (odds ratio [OR] = 3.26). Students who completed their surgical clerkship were also better able to recommend appropriate treatment for the patient (OR = 2.35), and recommend admission to the hospital or emergency department (OR = 2.00). Approximately one-third (35.3%) of all students documented a positive Murphy's sign, but only 6.4% identified the triad of leukocytosis, fever, and a Murphy's sign as diagnostic of acute cholecystitis and the need for surgical intervention. Student performance on the clinical examination did not differ depending on whether the students completed their clerkship at a Bay Area or regional hospital.

CONCLUSIONS

Student recognition of the key physical examination and laboratory findings diagnostic of acute cholecystitis was low, but students were better able to recommend further treatment for a patient with acute cholecystitis after completing the third-year surgical clerkship. Our study reveals areas where surgical educators can improve medical student ability to accurately diagnose acute cholecystitis and evaluate acute abdominal processes.

Time to redefine Myeloma

In November 2014 the International Myeloma Working Group (IMWG) revised the definition of multiple myeloma, such that asymptomatic patients with newly diagnosed multiple myeloma without any of the traditional 'CRAB' (hypercalcaemia, renal impairment, anaemia, bone disease) end organ damage criteria but with one of three new criteria would be recommended to start treatment. Previously, the standard of care for such patients was expectant management. These three new criteria are: greater than 60% clonal plasma cells on bone marrow biopsy, a serum free light chain (sFLC) ratio of >100 (the involved sFLC must be >100 mg/l) and greater than one unequivocal focal lesion on advanced imaging (low dose whole body computerized tomography, magnetic resonance imaging, (18) F fluorodeoxyglucose positron emission tomography). Although this would appear to affect a small number of patients, the impact of these changes are broad, leading to an increased use of advanced imaging, a debate around the management of patients previously diagnosed with smouldering myeloma, changed terminology and clinical trial design and an extension of the use of biomarkers. For the first time the philosophy of treatment in myeloma will change from treatment initiation only being triggered by overt end organ damage to an era where sub clinical risk factors will also be taken into account.

Cancer survivors' and employers' perceptions of working following cancer treatment

BACKGROUND

Earlier diagnosis and improvements in treatment survival rates have led to an increase in the number of cancer survivors for whom returning to work is a realistic outcome. However, cancer survivors face a number of challenges when returning to the workplace. Little is known about how patients' illness and treatment beliefs affect return to work or of employers' beliefs about the impact of cancer on work.

AIMS

To determine patient and employers' beliefs about the impact of cancer on returning to work and to identify differences in the beliefs held by patients and employers.

METHODS

Patients absent from work due to breast, urological, gynaecological or head and neck cancers completed a questionnaire within 4 weeks of completing treatment. Unlinked employer respondents from medium to large organizations completed the same questionnaire. The questionnaire focused on the perceived impact of cancer and its treatment on work and an adapted version of the Brief Illness Perceptions Questionnaire.

RESULTS

One hundred and ninety four patients (response rate of 82%) and 252 employers (response rate 31%) completed the questionnaire. Organizational respondents consistently reported more negative beliefs about the impact of cancer and treatment on work and in general held more negative illness perceptions about cancer in relation to work.

CONCLUSIONS

A discrepancy between beliefs of organizational respondents and cancer survivors could impact on an employees' management of their work and on employers' responsiveness to the needs of survivors. Therefore, it is important that return to work plans include the elicitation of employee beliefs.

Complementary and alternative medicine use in Irish paediatric patients

BACKGROUND

Although very little scientific data exists on the efficacy and side effects of complementary and alternative medicines, their profile and availability is increasing. Use among Irish children is unknown.

AIMS

To determine the nature and prevalence of complementary and alternative medicines (CAM) use in our paediatric population.

METHODS

Parental questionnaires were distributed in 13 paediatric settings over a 4-month period.

RESULTS

There were 57% of parents reported using CAM for their child. Use was significantly higher in the 2-4 years age group (34/105, 32%, P = 0.005). The commonest medicinal CAMs used were vitamins (88%), fish oils (27%) and Echinacea (26%). The commonest non-medicinal CAMs used were homeopathy (16%) and craniosacral therapy (14%). Use varied between paediatric specialties, with the highest in neurological patients (23/25, 92%, P = 0.005). Only 13% of parents had informed their Paediatrician of their child's CAM use.

CONCLUSIONS

More than half of the children surveyed had used some form of CAM, usually without their Paediatrician's knowledge.

Sedation with oral chloral hydrate in children undergoing MRI scanning

In the absence of a general anaesthetic facility for MRI scanning in children, we introduced a sedation protocol using chloral hydrate. Our aim was to evaluate the success and safety of our protocol. This was a retrospective study enrolling 36 children over a 7 month period. The overall success rate was 86% with no child experiencing respiratory complications. In those less than one year, the success rate was 100%, aged 1-5 years 91%, with 50% successful at 80 mg/kg and 50% at 100 mg/kg dose. For children greater than 5 years of age the success rate was 70%. 92% of developmentally normal children and 83% of developmentally delayed children were successfully sedated. Success rates were poorer in children older than 5 years and in those with developmental delay. Our findings suggest that this protocol could be safely used in units where general anaesthetic facilities are unavailable for MRI and for other radiological investigations.

Access to expensive drugs in the NHS: myths and realities for cancer patients

SETTING

Patient support organisation (Myeloma UK) and Hospital Myeloma Clinic.

TYPE OF STUDY

Case review of two patients, one whose treatment is funded by a private insurance company in the UK, and the other who is funded by the National Health Service (NHS) and questionnaire survey of 51 haematologists from Myeloma UK database.

RESULTS

The treatment options available for private patients with myeloma in the UK are broader and more in line with national and international practice than are options available to UK NHS patients. 22/41 (54%) of respondents had received refusals to fund bortezomib by NHS funding agencies; all the rejections had been from Primary Care Trusts in England, which are governed by guidance issued from a different regulator than the other UK countries and subject to divergent local funding arrangements; 19/46 (41%) felt that it was currently (May 2007) more difficult to obtain funding approval for one treatment, bortezomib, than in September 2006, when it received a negative recommendation from the National Institute for health and Clinical Excellence and 15/17 doctors who prescribe on the NHS and privately felt it was easier to obtain bortezomib for a private patient than an NHS patient in the UK.

CONCLUSION

The current funding arrangements for new drugs to treat myeloma in the UK are inequitable and do not lend themselves to achieve the best possible outcome for patients.

Disaster relief and initial response to the earthquake and tsunami in Meulaboh, Indonesia

The Singapore Humanitarian Assistance Support Group deployed a team of 32 medical relief workers to Meulaboh, Indonesia to provide medical assistance for victims of the 26 December earthquake and tsunami disaster. The team was deployed at a primary healthcare clinic at an internally displaced persons' (IDP) camp and at the sole hospital's emergency and surgical departments. The team saw a total of 1841 patients, 1371 at the clinic and 446 at the hospital's emergency department, and performed surgery on 24 patients. Tsunami-related trauma cases accounted for 31.8% (142) of cases at the emergency department, 1.6% (22) of cases at the clinic, and 91.7% (22) of surgeries. This paper details the difficulties and lessons learnt by the team, including the lack of important resources for healthcare delivery. Water, sanitation, hygiene, and vector control were some of the problems faced, with the goal to provide the most effective public health for the greatest number of people given the limited resources available.

A self-controlled trial to evaluate the use of active hearing defenders in the engine rooms of operational naval vessels

INTRODUCTION

Active Hearing Defenders are established hearing protectors with in-built electro-acoustics that shut-off ambient noise while allowing effective communication between users.

METHODS

A blinded, self-controlled trial was conducted among naval servicemen to compare the effectiveness of two types of active hearing defenders (Howard-Leight Thunder TM and COM-55) in relation to passive hearing defenders in an operational environment.

RESULTS

Subjects felt that the active hearing defenders were more comfortable, durable, and that the active hearing defenders helped them work better. When subjects were tested with a speech discrimination battery (Central Institute of the Deaf, Spondee Word lists), there was a significant difference (p value of 0.04, using the Kruskall-Wallis ANOVA test) between the two active and the passive defenders. However, no significant difference was found between the two types of active hearing defenders.

CONCLUSION

Active hearing defenders are an acceptable and efficacious means of hearing protection in noisy environments.

Management of haemorrhagic stroke with hyperbaric oxygen therapy--a case report

Hyperbaric oxygen therapy (HBOT) has been used in the treatment of cerebral ischaemia with positive effects on tissue oxygenation. We present a case of haemorrhagic stroke treated successfully with HBOT and review the literature on its role in cerebrovascular disease.

Unusual conformational effect in alpha-aminoorganostannanes

[formula: see text] Dynamic NMR analysis of conformationally mobile and rigid 2-tributylstannyl-N-methylpiperidines revealed an unexpected conformational effect that is manifested in a small energy difference between conformers in which the tin is equatorial and axial. The major reason appears to be a distortion of the conformer in which the C-2-Sn bond is synclinal to the nitrogen lone pair.

Effects of sleep deprivation on performance of Naval seamen: I. Total sleep deprivation on performance

Sleep deprivation leads to impairment in performance, loss of efficiency and deterioration in mood states such as tension, depression, aggression, fatigue, confusion and vigour. These can be detrimental to combat readiness and could contribute to "battle stress". In the present study, a homogeneous group of 20 seamen under total sleep deprivation was rated 6 hourly with the Stanford Sleepiness Scale (SSS), Profile of Mood States (POMS) and a battery of performance tests including the trail making, grooved peg board, digit span, digit symbol, sea-shore rhythm, flicker fusion, dynamometer and naval tasks. With the exception of the trail making test and naval tasks, the test performance was observed to correlate significantly (P < 0.05) with the SSS. A higher sleepiness score was associated with a poorer performance in test scores. On the time trends of sleep deprivation on the performance tests measured, a dip in performance was observed in all the tests at 42 hours of sleep deprivation and continuous deterioration of performance was observed after 72 hours of sleep deprivation. The cognitive, vigilance, mood and sleepiness tests were substantially affected by sleep deprivation. Greater effect was observed in tests that involved cognition, speed and precision and smaller effect was observed in routine tasks that involved gross manual movement. The decrease in performance observed at 42 hours of sleep deprivation was 5.9 standard deviation from initial values for SSS; 3.9 for sea-shore rhythm, 3.0 for grooved peg board; 2.6 for dynamometer; 2.4 for mood; 1.8 for digit span; 1.6 for trail making and digit symbol; 1.0 for naval tasks and addition; and 0.9 for flicker fusion.(ABSTRACT TRUNCATED AT 250 WORDS)