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Prescott RJ. The value of registries for rare and severe adverse events in paediatrics. Lancet Child Adolesc Health 2024:S2352-4642(24)00106-8. [PMID: 38697176 DOI: 10.1016/s2352-4642(24)00106-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/04/2024]
Affiliation(s)
- Robin J Prescott
- Usher Institute, University of Edinburgh, Edinburgh EH8 9AG, UK.
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Makaram NS, Prescott RJ, Alexander P, Robb JE, Gaston MS. Validation of a modified Care and Comfort Score and responsiveness to hip surgery in children with cerebral palsy in Gross Motor Function Classification System levels IV and V. Bone Jt Open 2023; 4:580-583. [PMID: 37558227 PMCID: PMC10412107 DOI: 10.1302/2633-1462.48.bjo-2023-0051.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
AIMS The purpose of this study was to assess the reliability and responsiveness to hip surgery of a four-point modified Care and Comfort Hypertonicity Questionnaire (mCCHQ) scoring tool in children with cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels IV and V. METHODS This was a population-based cohort study in children with CP from a national surveillance programme. Reliability was assessed from 20 caregivers who completed the mCCHQ questionnaire on two occasions three weeks apart. Test-retest reliability of the mCCHQ was calculated, and responsiveness before and after surgery for a displaced hip was evaluated in a cohort of children. RESULTS Test-retest reliability for the overall mCCHQ score was good (intraclass correlation coefficient 0.78), and no dimension demonstrated poor reliability. The surgical intervention cohort comprised ten children who had preoperative and postoperative mCCHQ scores at a minimum of six months postoperatively. The mCCHQ tool demonstrated a significant improvement in overall score from preoperative assessment to six-month postoperative follow-up assessment (p < 0.001). CONCLUSION The mCCHQ demonstrated responsiveness to intervention and good test-retest reliability. The mCCHQ is proposed as an outcome tool for use within a national surveillance programme for children with CP.
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Affiliation(s)
- Navnit S. Makaram
- Department of Orthopaedics and Trauma, Royal Hospital for Children and Young People, Edinburgh, UK
- University of Edinburgh, Edinburgh, UK
| | | | - Phyllida Alexander
- Department of Orthopaedics and Trauma, Royal Hospital for Children and Young People, Edinburgh, UK
| | - James E. Robb
- Department of Orthopaedics and Trauma, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Mark S. Gaston
- Department of Orthopaedics and Trauma, Royal Hospital for Children and Young People, Edinburgh, UK
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Ramirez CM, Prescott RJ, Varon J. "Are out-of-hospital cardiac arrest outcomes really unpredictable?". Resuscitation 2022; 180:137-139. [PMID: 36113735 DOI: 10.1016/j.resuscitation.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/16/2022]
Affiliation(s)
| | - Robin J Prescott
- Emeritus Professor of Health Technology Assessment, University of Edinburgh, UK
| | - Joseph Varon
- The University of Houston School of Medicine, Associate Dean, Caribbean Medical University, Chief of Critical Care, United Memorial Medical Center, Houston, TX, USA.
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McCahill J, Stebbins J, Prescott RJ, Harlaar J, Theologis T. Responsiveness of the Foot Profile Score in children with hemiplegia. Gait Posture 2022; 95:160-163. [PMID: 35500365 DOI: 10.1016/j.gaitpost.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/13/2022] [Accepted: 04/15/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Foot Profile Score (FPS) is a single score that summarises foot posture and dynamic foot motion during the gait cycle based on the kinematic data of the Oxford Foot Model. The FPS enables clinicians and researchers to quantify foot abnormalities during gait, to monitor change in foot/ankle motion over time, and to measure the outcome of intervention. With the creation of a new outcome measure, it is important to test its responsiveness in a clinical population for whom it may be sensitive to change. AIM To evaluate the responsiveness of the FPS in a clinical population following isolated foot and ankle surgery. METHODS Using previous work completed to validate the FPS, we defined the minimal clinically important difference (MCID) for the FPS. Using this MCID, we applied it to a clinical population of 37 children with cerebral palsy, spastic hemiplegia, comparing their FPS before and after foot and ankle surgery. A regression analysis looked at potential relationships between the change in FPS and their pre-operative FPS, age at surgery, and time since surgery. RESULTS An MCID of 2.4 degrees was calculated through regression analysis. The mean change from the pre-operative FPS to the post-operative FPS was 4.6 (SD 3.7 with a range from -0.1 to 13.4). Twenty-eight children (76%) had a change in their FPS greater than the MCID. A regression analyses only showed a clear regression between pre-operative FPS and change in FPS (R2 = 0.58 p < 0.01).
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Affiliation(s)
- Jennifer McCahill
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK; Amsterdam University Medical Centers, Amsterdam Movement Science, Dept Rehabilitation Medicine, The Netherlands.
| | - Julie Stebbins
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
| | | | - Jaap Harlaar
- Delft University of Technology, Dept of Biomechanical Engineering, The Netherlands; Erasmus Medical Center, Dept of Orthopedics & Sports Medicine, Rotterdam, The Netherlands
| | - Tim Theologis
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK
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Edwards TA, Thompson N, Prescott RJ, Stebbins J, Wright JG, Theologis T. A comparison of conventional and minimally invasive multilevel surgery for children with diplegic cerebral palsy. Bone Joint J 2021; 103-B:192-197. [PMID: 33380192 DOI: 10.1302/0301-620x.103b1.bjj-2020-0714.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP). METHODS A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11 months), and 36 children following MI-MLS, with mean age at surgery of ten years seven months (seven years one month to 14 years ten months), was performed. The Gait Profile Score (GPS) and walking speed were collected preoperatively and six, 12 and 24 months postoperatively. Type and frequency of procedures as part of MLS, surgical adverse events, and subsequent surgery were recorded. RESULTS In both groups, GPS improved from the preoperative gait analysis to the six-month assessment with maintenance at 12 and 24 months postoperatively. While reduced at six months in both groups, walking speed returned to preoperative speed by 12 months. The overall pattern of change in GPS and walking speed was similar over time following C-MLS and MI-MLS. There was a median of ten procedures per child as part of both C-MLS (interquartile range (IQR) 8.0 to 11.0) and MI-MLS (IQR 7.8 to 11.0). Surgical adverse events occurred in seven (37%) and 13 (36%) children, with four (21%) and 13 (36%) patients requiring subsequent surgery following C-MLS and MI-MLS, respectively. CONCLUSION This study indicates similar improvements in gait kinematics and walking speed 24 months after C-MLS and MI-MLS for children with diplegic CP. Cite this article: Bone Joint J 2021;103-B(1):192-197.
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Affiliation(s)
- Tomos A Edwards
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - Nicky Thompson
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - Robin J Prescott
- Centre for Population Health Sciences, Usher Institute, Edinburgh, UK
| | - Julie Stebbins
- Oxford Gait Laboratory, Nuffield Orthopaedic Centre, Oxford, UK
| | - James G Wright
- Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Prescott RJ. Response to comments on "Two-tailed significance tests for 2 × 2 contingency tables: What is the alternative?". Stat Med 2020; 39:99-101. [PMID: 31808186 DOI: 10.1002/sim.8433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Robin J Prescott
- Centre for Population Health Sciences, Usher Institute, The University of Edinburgh, Edinburgh, UK
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Prescott RJ. Two-tailed significance tests for 2 × 2 contingency tables: What is the alternative? Stat Med 2019; 38:4264-4269. [PMID: 31264237 DOI: 10.1002/sim.8294] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 05/03/2019] [Accepted: 06/05/2019] [Indexed: 11/11/2022]
Abstract
Two-tailed significance testing for 2 × 2 contingency tables has remained controversial. Within the medical literature, different tests are used in different papers and that choice may decide whether findings are adjudged to be significant or nonsignificant; a state of affairs that is clearly undesirable. In this paper, it is argued that a part of the controversy is due to a failure to recognise that there are two possible alternative hypotheses to the Null. It is further argued that, while one alternative hypothesis can lead to tests with greater power, the other choice is more applicable in medical research. That leads to the recommendation that, within medical research, 2 × 2 tables should be tested using double the one-tailed exact probability from Fisher's exact test or, as an approximation, the chi-squared test with Yates' correction for continuity.
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Affiliation(s)
- Robin J Prescott
- Centre for Population Health Studies, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
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Affiliation(s)
- Ian D Civil
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Robin J Prescott
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, UK.
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Abstract
SummaryThe incidence of deep vein thrombosis (DVT) as diagnosed by the 125I fibrinogen test (125IFT) was determined in a series of 300 newly admitted medical and 201 surgical patients. 6 medical patients died before 125IFT screening could be completed. The incidence of DVT was l4% in medical patients and 18% in surgical patients. Increasing age, a malignant condition and a past history of thromboembolism all increased the risk of DVT. Increasing levels of cigarette smoking were found to be associated with a reduced incidence of DVT. Although statistical significance was achieved at only the 10% level for this finding it is in agreement with the results from studies on patients with myocardial infarction. The protective effect of cigarette smoking was observed at all ages, and in both medical and surgical patients.
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Affiliation(s)
- R J Prescott
- The Medical Computing and Statistics Unit, University of Edinburgh and Departments of Clinical Surgery and Medicine, Western General Hospital, Edinburgh, Great Britain
| | - D R B Jones
- The Medical Computing and Statistics Unit, University of Edinburgh and Departments of Clinical Surgery and Medicine, Western General Hospital, Edinburgh, Great Britain
| | - C Vasilescu
- The Medical Computing and Statistics Unit, University of Edinburgh and Departments of Clinical Surgery and Medicine, Western General Hospital, Edinburgh, Great Britain
| | - J T Henderson
- The Medical Computing and Statistics Unit, University of Edinburgh and Departments of Clinical Surgery and Medicine, Western General Hospital, Edinburgh, Great Britain
| | - C V Ruckley
- The Medical Computing and Statistics Unit, University of Edinburgh and Departments of Clinical Surgery and Medicine, Western General Hospital, Edinburgh, Great Britain
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Forrest AP, Black RB, Humeniuk V, Cant EL, Hawkins RA, Prescott RJ, Roberts MM, Shivas AA, Stewart HJ, Smith AF, Sumerling M, Sumerling M. Preoperative Assessment and Staging of Breast Cancer: Preliminary Communication. J R Soc Med 2018; 73:561-6. [PMID: 7230232 PMCID: PMC1437852 DOI: 10.1177/014107688007300805] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A prospective study has been carried out in 172 women to determine the sensitivity of methods to detect occult metastatic disease in the skeleton and liver. With the exception of bone scintiscans, the results of these tests bore little relationship to recurrence rates. On the other hand, knowledge of the histopathology of the lower axillary (pectoral) lymph nodes is of value in this respect. A follow-up study is also reported which confirms the importance of accurate measurements of the primary tumour clinical node status and oestrogen receptor contact of the tumour in defining prognostic groups. Elastosis (estimated in 165 tumours) did not prove to be a useful prognostic index.
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Fielding RG, Macnab M, Swann S, Kunkler IH, Brebner J, Prescott RJ, Maclean JR, Chetty U, Neades G, Walls A, Bowman A, Dixon JM, Gardner T, Smith M, Lee MJ, Lee RJ. Attitudes of breast cancer professionals to conventional and telemedicine-delivered multidisciplinary breast meetings. J Telemed Telecare 2016; 11 Suppl 2:S29-34. [PMID: 16447355 DOI: 10.1258/135763305775124812] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We surveyed the attitudes of breast cancer professionals to standard face-to-face and future telemedicine-delivered breast multidisciplinary team (MDT) meetings. Interviews, which included the Group Behaviour Inventory, were conducted face-to-face (n = 19) or by telephone (n = 26). The mean total score on the Group Behaviour Inventory was 96 (SD 19) for 33 respondents, which indicated satisfaction with standard MDT meetings, irrespective of role and base hospital. Positive attitudes to videoconferencing were more common among participants with previous experience of telemedicine (Spearman's rank correlation 0.26, P = 0.91). Common themes emerging from the interviews about telemedicine-delivered MDTs included group leadership, meeting efficiency, group interaction, group atmosphere and technical quality of communication. Most participants were satisfied with standard breast MDTs. Nurses and allied health professionals were least supportive of telemedicine.
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Mowat C, Arnott I, Cahill A, Smith M, Ahmad T, Subramanian S, Travis S, Morris J, Hamlin J, Dhar A, Nwokolo C, Edwards C, Creed T, Bloom S, Yousif M, Thomas L, Campbell S, Lewis SJ, Sebastian S, Sen S, Lal S, Hawkey C, Murray C, Cummings F, Goh J, Lindsay JO, Arebi N, Potts L, McKinley AJ, Thomson JM, Todd JA, Collie M, Dunlop MG, Mowat A, Gaya DR, Winter J, Naismith GD, Ennis H, Keerie C, Lewis S, Prescott RJ, Kennedy NA, Satsangi J. Mercaptopurine versus placebo to prevent recurrence of Crohn's disease after surgical resection (TOPPIC): a multicentre, double-blind, randomised controlled trial. Lancet Gastroenterol Hepatol 2016; 1:273-282. [PMID: 28404197 PMCID: PMC6358144 DOI: 10.1016/s2468-1253(16)30078-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Up to 60% of patients with Crohn's disease need intestinal resection within the first 10 years of diagnosis, and postoperative recurrence is common. We investigated whether mercaptopurine can prevent or delay postoperative clinical recurrence of Crohn's disease. METHODS We did a randomised, placebo-controlled, double-blind trial at 29 UK secondary and tertiary hospitals of patients (aged >16 years in Scotland or >18 years in England and Wales) who had a confirmed diagnosis of Crohn's disease and had undergone intestinal resection. Patients were randomly assigned (1:1) by a computer-generated web-based randomisation system to oral daily mercaptopurine at a dose of 1 mg/kg bodyweight rounded to the nearest 25 mg or placebo; patients with low thiopurine methyltransferase activity received half the normal dose. Patients and their carers and physicians were masked to the treatment allocation. Patients were followed up for 3 years. The primary endpoint was clinical recurrence of Crohn's disease (Crohn's Disease Activity Index >150 plus 100-point increase in score) and the need for anti-inflammatory rescue treatment or primary surgical intervention. Primary and safety analyses were by intention to treat. Subgroup analyses by smoking status, previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis were also done. This trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN89489788) and the European Clinical Trials Database (EudraCT number 2006-005800-15). FINDINGS Between June 6, 2008, and April 23, 2012, 240 patients with Crohn's disease were randomly assigned: 128 to mercaptopurine and 112 to placebo. All patients received at least one dose of study drug, and no randomly assigned patients were excluded from the analysis. 16 (13%) of patients in the mercaptopurine group versus 26 (23%) patients in the placebo group had a clinical recurrence of Crohn's disease and needed anti-inflammatory rescue treatment or primary surgical intervention (adjusted hazard ratio [HR] 0·54, 95% CI 0·27-1·06; p=0·07; unadjusted HR 0·53, 95% CI 0·28-0·99; p=0·046). In a subgroup analysis, three (10%) of 29 smokers in the mercaptopurine group and 12 (46%) of 26 in the placebo group had a clinical recurrence that needed treatment (HR 0·13, 95% CI 0·04-0·46), compared with 13 (13%) of 99 non-smokers in the mercaptopurine group and 14 (16%) of 86 in the placebo group (0·90, 0·42-1·94; pinteraction=0·018). The effect of mercaptopurine did not significantly differ from placebo for any of the other planned subgroup analyses (previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis). The incidence and types of adverse events were similar in the mercaptopurine and placebo groups. One patient on placebo died of ischaemic heart disease. Adverse events caused discontinuation of treatment in 39 (30%) of 128 patients in the mercaptopurine group versus 41 (37%) of 112 in the placebo group. INTERPRETATION Mercaptopurine is effective in preventing postoperative clinical recurrence of Crohn's disease, but only in patients who are smokers. Thus, in smokers, thiopurine treatment seems to be justified in the postoperative period, although smoking cessation should be strongly encouraged given that smoking increases the risk of recurrence. FUNDING Medical Research Council.
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Affiliation(s)
- Craig Mowat
- Gastrointestinal Unit, Ninewells Hospital, Dundee, UK
| | - Ian Arnott
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK
| | - Aiden Cahill
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Malcolm Smith
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK; IBD Pharmacogenetics Unit, University of Exeter, Exeter, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon Travis
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - John Morris
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - John Hamlin
- Department of Gastroenterology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, Darlington, UK
| | - Chuka Nwokolo
- Department of Gastroenterology, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Cathryn Edwards
- Department of Gastroenterology, Torbay Hospital, South Devon Healthcare NHS Foundation Trust, Torbay, Devon, UK
| | - Tom Creed
- Department of Gastroenterology, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mohamed Yousif
- Department of Gastroenterology, Rotherham NHS Foundation Trust Hospital, Rotherham, UK
| | - Linzi Thomas
- Department of Gastroenterology, Singleton Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Simon Campbell
- Department of Gastroenterology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Stephen J Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Sandip Sen
- Department of Gastroenterology, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Simon Lal
- Department of Gastroenterology, Salford Royal NHS Foundation Trust Hospital, Salford, UK
| | - Chris Hawkey
- Department of Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Charles Murray
- Department of Gastroenterology, Royal Free London NHS Foundation Trust Hospital, London, UK
| | - Fraser Cummings
- Department of Gastroenterology, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jason Goh
- Department of Gastroenterology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James O Lindsay
- Department of Gastroenterology, Barts Health NHS Trust, Barts and the London School of Medicine, London, UK
| | - Naila Arebi
- Inflammatory Bowel Disease Unit, St Mark's Hospital, North West London Hospitals NHS Trust, London, UK
| | - Lindsay Potts
- Gastrointestinal Unit, Raigmore Hospital, Inverness, UK
| | | | - John M Thomson
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - John A Todd
- Gastrointestinal Unit, Ninewells Hospital, Dundee, UK
| | - Mhairi Collie
- Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | | | - Ashley Mowat
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Daniel R Gaya
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Jack Winter
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Holly Ennis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Nicholas A Kennedy
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK; IBD Pharmacogenetics Unit, University of Exeter, Exeter, UK
| | - Jack Satsangi
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK.
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Ruckley CV, Dale JJ, Gibson B, Brown D, Lee AJ, Prescott RJ. Multi-layer compression: comparison of four different four-layer bandage systems applied to the leg. Phlebology 2016. [DOI: 10.1258/026835503322381324] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective: To compare on standardized laboratory models the performance of four commercially available four-layer bandage systems. Methods: Four experienced bandagers applied each of the four systems [Profore® Regular (Smith & Nephew, Hull, UK), Ultra Four (Robinsons, Chesterfield, UK), System 4 (SSL International, Knutsford, UK) and K-Four® (Parema, Loughborough, UK)] to two models: a 12.5 cm diameter padded cylinder and a 9.5-14.5 cm padded cone. Bandages were applied individually in single layers and as a completed system using standard application techniques. Pressures were measured by the Borgnis Medical Stocking Tester at positions corresponding to ankle, gaiter and mid-calf areas as determined by the pressure sensor. Results: A total of 768 observations were made: 384 for each model, 192 for each bandaging system, 192 for each bandager and 128 for each measuring point. The increase in pressure produced by each additional layer was in the range of 50-60% of the pressure achieved by the same bandage when used as a single layer. Each bandage system and each bandager produced a gradient of final mean pressure irrespective of whether the bandage was applied to a cylinder or a cone. However, there were no significant differences in the gradients between the four bandage systems or between the four bandagers. There were significant differences in the final pressures achieved among the bandage systems when applied as completed systems (mean: Profore® = 42 mmHg; System 4 = 45 mmHg; K-Four® = 48 mmHg; and Ultra Four = 51 mmHg; P<0.001). Conclusions: These results challenge a commonly-held assumption concerning the additive effect of pressures generated by successive bandage layers. When applied as part of a multi-layered system each bandage adds just over half the pressure achieved by the same bandage when applied alone. The four completed systems produced pressures within a range appropriate for ulcer therapy, although there were significant differences in mean pressures. This capability of the systems to produce different pressures could be clinically important in the hands of inexperienced bandagers or with patients at risk of pressure damage..
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Olasveengen TM, Prescott RJ, Kramer-Johansen J. Impedance threshold device (ITD) during cardiac arrest – Does it work or not? Resuscitation 2015. [DOI: 10.1016/j.resuscitation.2015.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kunkler IH, Williams LW, Jack W, Canney P, Prescott RJ, Dixon MJ. Abstract S2-01: The PRIME II trial: Wide local excision and adjuvant hormonal therapy ± postoperative whole breast irradiation in women ≥ 65 years with early breast cancer managed by breast conservation. Cancer Res 2013. [DOI: 10.1158/0008-5472.sabcs13-s2-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background. Local Recurrence rates after breast conserving surgery (BCS) are falling because of increasing use of effective systemic therapy. The question of whether whole breast radiotherapy (WBRT) can be omitted in carefully defined groups of older patients receiving appropriate systemic therapy has not been addressed. PRIME II is an International phase III RCT addressing this question.
Methods. Between April 2003 and December 2009, 1326 patients were randomised to receive (n = 658) or nor receive (n = 668) radiotherapy (RT). Eligiblity criteria were ≥65 years, T1-2 (up to 3cm), N0, M0, hormone receptor positive, clear excision margins (≥ 1mm), axillary node negative women in receipt of adjuvant hormone therapy. Patients could have Grade 3 tumours or lympho-vascular invasion but not both. An accrual of 1300 was planned to detect a difference based on estimates of local recurrence of 2% in RT group and 5% in no RT arm at 5 years, with 80% power and 5% significance. The primary endpoint was ipsilateral breast tumour recurrence (IBTR). Secondary endpoints were regional recurrence, contralateral breast cancer, distant metastases and overall survival (OS). Median follow up is 5.0 years.
Results
IBTR at 5 years was 4.1% (95% CI 2.4, 5.7%) without RT, 1.3% (95% CI 0.2, 2.3%) with RT. The hazard ratio for IBTR in those IBTR receiving radiotherapy was 4.34 (1.79, 10.55) (p = 0.001).
Overall actuarial survival at 5 years was 93.8% (95% CI 91.6, 95.9%) without RT and 94.2% (95% CI 92.2, 96.3%) with RT, (p = 0.24). No significant differences in regional recurrence (1.4% no RT vs 0.5% RT), contralateral breast cancer (0.9% no RT vs 1.5% RT), nor distant metastases (1.0% vs 0.3%) were seen. Breast cancer-free survival was 94.6% (95% CI 92.7, 96.5%)for no RT and 97.3% (95% CI 95.9, 98.8%) for those receiving RT (p = 0.003): this difference was due to the greater IBTR in no RT group. The majority of deaths were not linked to breast cancer (35 no RT vs 29 RT from a total of 87 deaths), with no influence of omission of RT (p = 0.27).
Conclusions
The randomised International Trial has shown that
• Omission of RT in women ≥65 year of age with N0, ER positive breast cancer receiving endocrine therapy results in only a 4.1% 5 year IBTR
• Although RT reduces IBTR significantly, the absolute reduction in this study is very small.
• RT does not reduce the rate of regional recurrence, distant metastases or affect overall survival.
• Omission of postoperative WBRT in this population based on the 5 year rate of IBTR appears safe, especially in the presence of comorbidities.
Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S2-01.
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Affiliation(s)
- IH Kunkler
- University of Edinburgh, Edinburgh, Midlothian, United Kingdom; Edinburgh Cancer Centre, Edinburgh, Midlothian, United Kingdom; Beatson Oncology Centre, Glasgow, West of Scotland, United Kingdom
| | - LW Williams
- University of Edinburgh, Edinburgh, Midlothian, United Kingdom; Edinburgh Cancer Centre, Edinburgh, Midlothian, United Kingdom; Beatson Oncology Centre, Glasgow, West of Scotland, United Kingdom
| | - W Jack
- University of Edinburgh, Edinburgh, Midlothian, United Kingdom; Edinburgh Cancer Centre, Edinburgh, Midlothian, United Kingdom; Beatson Oncology Centre, Glasgow, West of Scotland, United Kingdom
| | - P Canney
- University of Edinburgh, Edinburgh, Midlothian, United Kingdom; Edinburgh Cancer Centre, Edinburgh, Midlothian, United Kingdom; Beatson Oncology Centre, Glasgow, West of Scotland, United Kingdom
| | - RJ Prescott
- University of Edinburgh, Edinburgh, Midlothian, United Kingdom; Edinburgh Cancer Centre, Edinburgh, Midlothian, United Kingdom; Beatson Oncology Centre, Glasgow, West of Scotland, United Kingdom
| | - MJ Dixon
- University of Edinburgh, Edinburgh, Midlothian, United Kingdom; Edinburgh Cancer Centre, Edinburgh, Midlothian, United Kingdom; Beatson Oncology Centre, Glasgow, West of Scotland, United Kingdom
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Stanworth SJ, Walsh TS, Prescott RJ, Lee RJ, Watson DM, Wyncoll DL. Thrombocytopenia and platelet transfusion in UK critical care: a multicenter observational study. Transfusion 2012; 53:1050-8. [DOI: 10.1111/j.1537-2995.2012.03866.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Avery AJ, Rodgers S, Cantrill JA, Armstrong S, Cresswell K, Eden M, Elliott RA, Howard R, Kendrick D, Morris CJ, Prescott RJ, Swanwick G, Franklin M, Putman K, Boyd M, Sheikh A. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012; 379:1310-9. [PMID: 22357106 PMCID: PMC3328846 DOI: 10.1016/s0140-6736(11)61817-5] [Citation(s) in RCA: 223] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. METHODS In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to researchers and statisticians involved in processing and analysing the data. The allocation was not masked to general practices, pharmacists, patients, or researchers who visited practices to extract data. [corrected]. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299. FINDINGS 72 general practices with a combined list size of 480,942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38-0·89); a β blocker if they had asthma (0·73, 0·58-0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34-0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months. INTERPRETATION The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. FUNDING Patient Safety Research Portfolio, Department of Health, England.
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Affiliation(s)
- Anthony J Avery
- Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK.
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Billington PD, Prescott RJ, Lapsia S. Diagnosis of a biliary cystadenoma demonstrating communication with the biliary system by MRI using a hepatocyte-specific contrast agent. Br J Radiol 2012; 85:e35-6. [PMID: 22308224 DOI: 10.1259/bjr/52850720] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Biliary cystadenomas are predominately benign tumours that have a low malignant potential. We present a case of a 30-year-old female with a histopathological confirmation of a biliary cystadenoma following resection. The diagnosis was made pre-operatively by MRI using the hepatocyte-specific contrast agent gadobenate dimeglumine (Gd-BOPTA) (MultiHance; Bracco Diagnostics Inc., Princeton, NJ). At the biliary excretory phase, delayed phase images demonstrated communication between the multilocular cystic mass and the biliary tree, which helped to confirm the diagnosis of biliary cystadenoma. This highlights the beneficial use of hepatocyte-specific agents for their dual function as an extracellular agent and a hepatobiliary agent.
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Affiliation(s)
- P D Billington
- Departments of Radiology, East Lancashire Hospitals NHS Trust, Royal Blackburn Hospital, Blackburn, UK.
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Begh RA, Aveyard P, Upton P, Bhopal RS, White M, Amos A, Prescott RJ, Bedi R, Barton P, Fletcher M, Gill P, Zaidi Q, Sheikh A. Promoting smoking cessation in Pakistani and Bangladeshi men in the UK: pilot cluster randomised controlled trial of trained community outreach workers. Trials 2011; 12:197. [PMID: 21854596 PMCID: PMC3177779 DOI: 10.1186/1745-6215-12-197] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 08/19/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Smoking prevalence is high among Pakistani and Bangladeshi men in the UK, but there are few tailored smoking cessation programmes for Pakistani and Bangladeshi communities. The aim of this study was to pilot a cluster randomised controlled trial comparing the effectiveness of Pakistani and Bangladeshi smoking cessation outreach workers with standard care to improve access to and the success of English smoking cessation services. METHODS A pilot cluster randomised controlled trial was conducted in Birmingham, UK. Geographical lower layer super output areas were used to identify natural communities where more than 10% of the population were of Pakistani and Bangladeshi origin. 16 agglomerations of super output areas were randomised to normal care controls vs. outreach intervention. The number of people setting quit dates using NHS services, validated abstinence from smoking at four weeks, and stated abstinence at three and six months were assessed. The impact of the intervention on choice and adherence to treatments, attendance at clinic appointments and patient satisfaction were also assessed. RESULTS We were able to randomise geographical areas and deliver the outreach worker-based services. More Pakistani and Bangladeshi men made quit attempts with NHS services in intervention areas compared with control areas, rate ratio (RR) 1.32 (95%CI: 1.03-1.69). There was a small increase in the number of 4-week abstinent smokers in intervention areas (RR 1.30, 95%CI: 0.82-2.06). The proportion of service users attending weekly appointments was lower in intervention areas than control areas. No difference was found between intervention and control areas in choice and adherence to treatments or patient satisfaction with the service. The total cost of the intervention was £124,000; an estimated cost per quality-adjusted life year (QALY) gained of £8,500. CONCLUSIONS The intervention proved feasible and acceptable. Outreach workers expanded reach of smoking cessation services in diverse locations of relevance to Pakistani and Bangladeshi communities. The outreach worker model has the potential to increase community cessation rates and could prove cost-effective, but needs evaluating definitively in a larger, appropriately powered, randomised controlled trial. These future trials of outreach interventions need to be of sufficient duration to allow embedding of new models of service delivery. TRIAL REGISTRATION Current Controlled Trials ISRCTN82127540.
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Affiliation(s)
- Rachna A Begh
- UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Paul Aveyard
- UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Penney Upton
- Psychological Sciences, Institute of Health and Society, University of Worcester, Worcester, WR2 6AJ, UK
| | - Raj S Bhopal
- Ethnicity and Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Martin White
- Fuse, UKCRC Centre for Translational Research in Public Health, Institute of Health & Society, Newcastle University, NE2 4HH, UK
| | - Amanda Amos
- UK Centre for Tobacco Control Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Robin J Prescott
- Ethnicity and Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Raman Bedi
- International Centre for Child Oral Health, King's College London, London, WC2B 5RL, UK
| | - Pelham Barton
- Health Economics, University of Birmingham, Birmingham, B15 2TT, UK
| | | | - Paramjit Gill
- UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Qaim Zaidi
- British Heart Foundation, London, W1H 6DH, UK
| | - Aziz Sheikh
- Allergy & Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
- CAPHRI, University of Maastricht, The Netherlands
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Begh RA, Aveyard P, Upton P, Bhopal RS, White M, Amos A, Prescott RJ, Bedi R, Barton PM, Fletcher M, Gill P, Zaidi Q, Sheikh A. Experiences of outreach workers in promoting smoking cessation to Bangladeshi and Pakistani men: longitudinal qualitative evaluation. BMC Public Health 2011; 11:452. [PMID: 21658229 PMCID: PMC3146431 DOI: 10.1186/1471-2458-11-452] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 06/09/2011] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite having high smoking rates, there have been few tailored cessation programmes for male Bangladeshi and Pakistani smokers in the UK. We report on a qualitative evaluation of a community-based, outreach worker delivered, intervention that aimed to increase uptake of NHS smoking cessation services and tailor services to meet the needs of Bangladeshi and Pakistani men. METHODS This was a longitudinal, qualitative study, nested within a phase II cluster randomised controlled trial of a complex intervention. We explored the perspectives and experiences of five outreach workers, two stop smoking service managers and a specialist stop smoking advisor. Data were collected through focus group discussions, weekly diaries, observations of management meetings, shadowing of outreach workers, and one-to-one interviews with outreach workers and their managers. Analysis was undertaken using a modified Framework approach. RESULTS Outreach workers promoted cessation services by word of mouth on the streets, in health service premises, in local businesses and at a wide range of community events. They emphasised the reasons for cessation, especially health effects, financial implications, and the impact of smoking on the family. Many smokers agreed to be referred to cessation services, but few attended, this in part being explained by concerns about the relative inflexibility of existing service provision. Although outreach workers successfully expanded service reach, they faced the challenges of perceived lack of awareness of the health risks associated with smoking in older smokers and apathy in younger smokers. These were compounded by perceptions of "lip service" being given to their role by community organisations and tensions both amongst the outreach workers and with the wider management team. CONCLUSIONS Outreach workers expanded reach of the service through taking it to diverse locations of relevance to Pakistani and Bangladeshi communities. The optimum method of outreach to retain and treat Bangladeshi and Pakistani smokers effectively in cessation programmes needs further development.
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Affiliation(s)
- Rachna A Begh
- UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Paul Aveyard
- UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Penney Upton
- Psychological Sciences, Institute of Health and Society, University of Worcester, Worcester, WR2 6AJ, UK
| | - Raj S Bhopal
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Martin White
- Fuse, UKCRC, Centre for Translational Research in Public Health, Institute of Health & Society, Newcastle University, NE2 4HH, UK
| | - Amanda Amos
- UK Centre for Tobacco Control Studies, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Robin J Prescott
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Raman Bedi
- International Centre for Child Oral Health, King's College London, London, WC2B 5RL, UK
| | - Pelham M Barton
- Health Economics, University of Birmingham, Birmingham, B15 2TT, UK
| | | | - Paramjit Gill
- UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| | - Qaim Zaidi
- British Heart Foundation, London, W1H 6DH, UK
| | - Aziz Sheikh
- Allergy & Respiratory Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH8 9AG, UK
- CAPHRI, University of Maastricht, The Netherlands
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Stanworth SJ, Walsh TS, Prescott RJ, Lee RJ, Watson DM, Wyncoll D. A national study of plasma use in critical care: clinical indications, dose and effect on prothrombin time. Crit Care 2011; 15:R108. [PMID: 21466676 PMCID: PMC3219386 DOI: 10.1186/cc10129] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 03/09/2011] [Accepted: 04/05/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Fresh frozen plasma (FFP) is widely used, but few studies have described patterns of plasma use in critical care. We carried out a multicentre study of coagulopathy in intensive care units (ICUs) and here describe overall FFP utilisation in adult critical care, the indications for transfusions, factors indicating the doses used and the effects of FFP use on coagulation. METHODS We conducted a prospective, multicentre, observational study of all patients sequentially admitted to 29 adult UK general ICUs over 8 weeks. Daily data throughout ICU admission were collected concerning coagulation, relevant clinical outcomes (including bleeding), coagulopathy (defined as international normalised ratio (INR) >1.5, or equivalent prothrombin time (PT)), FFP and cryoprecipitate use and indications for transfusion. RESULTS Of 1,923 admissions, 12.7% received FFP in the ICU during 404 FFP treatment episodes (1,212 FFP units). Overall, 0.63 FFP units/ICU admission were transfused (0.11 units/ICU day). Reasons for FFP transfusion were bleeding (48%), preprocedural prophylaxis (15%) and prophylaxis without planned procedure (36%). Overall, the median FFP dose was 10.8 ml kg⁻¹, but doses varied widely (first to third quartile, 7.2 to 14.4 ml kg⁻¹). Thirty-one percent of FFP treatments were to patients without PT prolongation, and 41% were to patients without recorded bleeding and only mildly deranged INR (<2.5). Higher volumes of FFP were administered when the indication was bleeding (median doses: bleeding 11.1 ml kg⁻¹, preprocedural prophylaxis 9.8 ml kg⁻¹, prophylaxis without procedure 8.9 ml kg⁻¹; P = 0.009 across groups) and when the pretransfusion INR was higher (ranging from median dose 8.9 ml kg⁻¹ at INR ≤ 1.5 to 15.7 ml kg⁻¹ at INR >3; P < 0.001 across ranges). Regression analyses suggested bleeding was the strongest predictor of higher FFP dose. Pretransfusion INR was more frequently normal when the transfusion indication was bleeding. Overall, posttransfusion corrections of INR were consistently small unless the pretransfusion INR was >2.5, but administration during bleeding was associated with greater INR corrections. CONCLUSIONS There is wide variation in FFP use by ICU clinicians, and a high proportion of current FFP transfusions are of unproven clinical benefit. Better evidence from clinical trials could significantly alter patterns of use and modify current treatment costs.
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Affiliation(s)
- Simon J Stanworth
- Department of Haematology/Transfusion Medicine, John Radcliffe Hospital, NHS Blood & Transplant/Oxford Radcliffe Hospitals Trust, and University of Oxford, Osler Road, Headington, Oxford, OX3 9BQ, UK.
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Avery AJ, Rodgers S, Cantrill JA, Armstrong S, Elliott R, Howard R, Kendrick D, Morris CJ, Murray SA, Prescott RJ, Cresswell K, Sheikh A. Erratum to: Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices. Trials 2010. [PMCID: PMC2838883 DOI: 10.1186/1745-6215-11-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Reed MJ, Newby DE, Coull AJ, Prescott RJ, Jacques KG, Gray AJ. The ROSE (risk stratification of syncope in the emergency department) study. J Am Coll Cardiol 2010; 55:713-21. [PMID: 20170806 DOI: 10.1016/j.jacc.2009.09.049] [Citation(s) in RCA: 173] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 09/11/2009] [Accepted: 09/22/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of this study was to develop and validate a clinical decision rule (CDR) to predict 1-month serious outcome and all-cause death in patients presenting with syncope to the emergency department. BACKGROUND Syncope is a common, potentially serious condition accounting for many hospital admissions. METHODS This was a single center, prospective, observational study of adults presenting to the emergency department with syncope. A CDR was devised from 550 patients in a derivation cohort and tested in a validation cohort of a further 550 patients. RESULTS One-month serious outcome or all-cause death occurred in 40 (7.3%) patients in the derivation cohort. Independent predictors were brain natriuretic peptide concentration > or =300 pg/ml (odds ratio [OR]: 7.3), positive fecal occult blood (OR: 13.2), hemoglobin < or =90 g/l (OR: 6.7), oxygen saturation < or =94% (OR: 3.0), and Q-wave on the presenting electrocardiogram (OR: 2.8). One-month serious outcome or all-cause death occurred in 39 (7.1%) patients in the validation cohort. The ROSE (Risk stratification Of Syncope in the Emergency department) rule had a sensitivity and specificity of 87.2% and 65.5%, respectively, and a negative predictive value of 98.5%. An elevated B-type natriuretic peptide (BNP) concentration alone was a major predictor of serious cardiovascular outcomes (8 of 22 events, 36%) and all-cause deaths (8 of 9 deaths, 89%). CONCLUSIONS The ROSE rule has excellent sensitivity and negative predictive value in the identification of high-risk patients with syncope. As a component, BNP seems to be a major predictor of serious cardiovascular outcomes and all-cause death. The ROSE rule and BNP measurement might be valuable risk stratification tools in patients with emergency presentations of syncope and should now be subjected to external validation.
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Affiliation(s)
- Matthew J Reed
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
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Amiwero C, Campbell IA, Prescott RJ. A re-appraisal of warfarin control in the treatment of deep vein thrombosis and / or pulmonary embolism. Afr Health Sci 2009; 9:179-85. [PMID: 20589148 PMCID: PMC2887034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Warfarin is commonly used for management of deep vein thrombosis (DVT) and pulmonary embolism (PE), controlling therapy by means of the International Normalized Ratio (INR). OBJECTIVES To identify differences in INR results between patients with thromboembolic and haemorrhagic complications and controls. METHODS Two nested case-control studies from within a controlled trial of the duration of warfarin therapy (47 thrombotic and 16 haemorrhagic complications). RESULTS Patients whose thromboembolism failed to resolve during treatment or recurred during or after treatment had non-significantly lower INR levels than matched controls (geometric mean 2.2 versus 2.3, p = 0.12). Patients with haemorrhage also had not statistically significant lower INR levels than their matched controls (2.1 versus 2.3, p = 0.22). The variability of INR levels was similar in both case groups and controls. The mean percentage of INR levels in the therapeutic range 2 - 3 was almost identical in thrombotic cases and controls (56.5% versus 56.1%). Compared to the haemorrhagic group, better control was achieved in controls (61.5% versus 43.0%, p=0.01), but controls had slightly more INR values above the therapeutic range (12.1% versus 10.5%, p = 0.74) whilst haemorrhagic cases had more INR values below the therapeutic range (46.6% versus 26.4%, p = 0.03). CONCLUSION In this study, higher INR levels were not associated with haemorrhage suggesting that, for patients being treated for DVT/PE, a modest increase in the target therapeutic range could be considered.
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Affiliation(s)
- C Amiwero
- Federal Medical Centre, Department of Haematology and Blood Transfusion, Bida, Niger state, Nigeria.
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Snedeker KG, Shaw DJ, Locking ME, Prescott RJ. Primary and secondary cases in Escherichia coli O157 outbreaks: a statistical analysis. BMC Infect Dis 2009; 9:144. [PMID: 19715594 PMCID: PMC2741466 DOI: 10.1186/1471-2334-9-144] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 08/28/2009] [Indexed: 11/13/2022] Open
Abstract
Background Within outbreaks of Escherichia coli O157 (E. coli O157), at least 10–15% of cases are thought to have been acquired by secondary transmission. However, there has been little systematic quantification or characterisation of secondary outbreak cases worldwide. The aim of this study was to characterise secondary outbreak cases, estimate the overall proportion of outbreak cases that were the result of secondary transmission and to analyse the relationships between primary and secondary outbreak cases by mode of transmission, country and median age. Methods Published data was obtained from 90 confirmed Escherichia coli O157 outbreaks in Great Britain, Ireland, Scandinavia, Canada, the United States and Japan, and the outbreaks were described in terms of modes of primary and secondary transmission, country, case numbers and median case age. Outbreaks were tested for statistically significant differences in the number of ill, confirmed, primary and secondary cases (analysis of variance and Kruskal-Wallis) and in the rate of secondary cases between these variables (Generalised Linear Models). Results The outbreaks had a median of 13.5 confirmed cases, and mean proportion of 0.195 secondary cases. There were statistically significant differences in the numbers of ill, confirmed, primary and secondary cases between modes of primary transmission (p < 0.021), and in primary and secondary cases between median age categories (p < 0.039) and modes of secondary transmission (p < 0.001). Secondary case rates differed statistically significantly between modes of secondary and primary transmission and median age categories (all p < 0.001), but not between countries (p = 0.23). Statistically significantly higher rates of secondary transmission were found in outbreaks with a median age <6 years and those with secondary transmission via person to person spread in nurseries. No statistically significant interactions were found between country, mode of transmission and age category. Conclusion Our analyses indicated that ~20% of E. coli O157 outbreak cases were the result of secondary spread, and that this spread is significantly influenced by age and modes of primary and secondary transmission, but not country. In particular, the results provide further data emphasising the importance of simple but effective preventive strategies, such as handwashing, that can reduce the risk of secondary spread, particularly amongst young children in nurseries.
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Affiliation(s)
- Kate G Snedeker
- Department of Population Medicine and Centre for Public Health and Zoonoses, Ontario Veterinary College, University of Guelph, Guelph, Ontario, N1G 2W1, Canada.
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Begh RA, Aveyard P, Upton P, Bhopal RS, White M, Amos A, Prescott RJ, Bedi R, Barton P, Fletcher M, Gill P, Zaidi Q, Sheikh A. Promoting smoking cessation in Bangladeshi and Pakistani male adults: design of a pilot cluster randomised controlled trial of trained community smoking cessation workers. Trials 2009; 10:71. [PMID: 19682374 PMCID: PMC2746807 DOI: 10.1186/1745-6215-10-71] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 08/14/2009] [Indexed: 11/16/2022] Open
Abstract
Background The prevalence of smoking is higher among Pakistani and Bangladeshi males than among the general population. Smokers who receive behavioural support and medication quadruple their chances of stopping smoking, but evidence suggests that these populations do not use National Health Service run stop smoking clinics as frequently as would be expected given their high prevalence of smoking. This study aims to tackle some of the main barriers to use of stop smoking services and adherence to treatment programmes by redesigning service delivery to be more acceptable to these adult male populations. The study compares the effectiveness of trained Pakistani and Bangladeshi smoking cessation workers operating in an outreach capacity ('clinic + outreach') with standard care ('clinic only') to improve access to and success of National Health Service smoking cessation services. Methods/design This is a pilot cluster randomised controlled trial based in Birmingham, UK. Super output areas of Birmingham will be identified in which more than 10% of the population are of Pakistani and/or Bangladeshi origin. From these areas, 'natural geographical communities' will be identified. Sixteen aggregated agglomerations of super output areas will be identified, separating areas from each other using buffer regions in order to reduce potential contamination. These natural communities will be randomised to 'clinic + outreach' (intervention) or 'clinic only' (control) arms. The use of stop smoking services and the numbers of people quitting smoking (defined as prolonged self-reported abstinence at four weeks, three months and six months) will be assessed in each area. In addition, we will assess the impact of the intervention on adherence to smoking cessation treatments and patient satisfaction. Trial registration Current Controlled Trials ISRCTN 82127540.
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Affiliation(s)
- Rachna A Begh
- UK Centre for Tobacco Control Studies, Primary Care Clinical Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
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Taylor PRA, White JM, Prescott RJ, Angus B, Galloway MJ, Jackson GH, Lessells AM, Lucraft HH, Summerfield GP, Proctor SJ. The addition of oral idarubicin to a chlorambucil/dexamethasone combination has a significant impact on time to treatment failure but none on overall survival in patients with low grade non-Hodgkin's lymphoma: Results of the Scotland and Newcastle Lymphoma Group randomized NHL VIII trial. Leuk Lymphoma 2009; 47:2321-30. [PMID: 17107904 DOI: 10.1080/10428190600881256] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Two hundred untreated patients with low grade NHL (KIEL), including 155 follicular NHL, were randomized to six courses of treatment with chlorambucil 20 mg m-2 for 3 days and dexamethasone 4 mg bd for 5 days (CD) vs the same regimen plus oral idarubicin 10 mg m-2 for 3 days (CID). Responding patients could be randomized to no further treatment or maintenance treatment for up to 36 months with alpha interferon. Complete remissions/CRu were more frequent in the CID arm (35% vs 24%) but the overall response rate was similar; 87/91 (96%) vs 86/92 (93%). Overall survival (OS) did not differ between the two arms. Time to treatment failure (TTTF) was prolonged in the CID arm, p = 0.03; median time 28 vs 19 months. TTTF for the B-cell follicular group alone was for CID (77 patients) 33 months vs 18 months for CD (78 patients). Interferon conferred no apparent benefit. The Follicular Lymphoma International Prognostic Index (FLIPI) is confirmed as a good predictor of risk groups including a group of 23% with shorter survival. The addition of the oral anthracycline, idarubicin, led to a significant improvement in TTTF with low toxicity. The use of radiotherapy in this sub-group may have contributed to this result. CID is a potential for combination with antibody therapy particularly in older patient groups.
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Affiliation(s)
- P R A Taylor
- Newcastle Hospitals Trust and Newcastle University, Newcastle upon Tyne, UK
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Avery AJ, Rodgers S, Cantrill JA, Armstrong S, Elliott R, Howard R, Kendrick D, Morris CJ, Murray SA, Prescott RJ, Cresswell K, Sheikh A. Protocol for the PINCER trial: a cluster randomised trial comparing the effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices. Trials 2009; 10:28. [PMID: 19409095 PMCID: PMC2685134 DOI: 10.1186/1745-6215-10-28] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 05/01/2009] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medication errors are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. METHODS RESEARCH SUBJECT GROUP: "At-risk" patients registered with computerised general practices in two geographical regions in England. DESIGN Parallel group pragmatic cluster randomised trial. INTERVENTIONS Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. PRIMARY OUTCOME MEASURES The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs; - with a computer-recorded diagnosis of asthma being prescribed beta-blockers; - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. SECONDARY OUTCOME MEASURES; These relate to a number of other examples of potentially hazardous prescribing and medicines management. ECONOMIC ANALYSIS An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. QUALITATIVE ANALYSIS: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. SAMPLE SIZE 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. DISCUSSION At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.
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Affiliation(s)
- Anthony J Avery
- Division of Primary Care, The Medical School, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Sarah Rodgers
- Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Judith A Cantrill
- Drug Usage & Pharmacy Practice Group, School of Pharmacy & Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Sarah Armstrong
- Trent Research Design Service, Division of Primary Care, Tower Building, University Park, Nottingham, NG7 2RD, UK
| | - Rachel Elliott
- Division for Social Research in Medicines and Health, The School of Pharmacy, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Rachel Howard
- School of Pharmacy, University of Reading, PO Box 226, Whiteknights, Reading, RG6 6AP, UK
| | - Denise Kendrick
- Division of Primary Care, The Medical School, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Caroline J Morris
- Department of Primary Health Care and General Practice, Wellington School of Medicine and Health Sciences, University of Otago, Mein Street, Wellington South, New Zealand
| | - Scott A Murray
- Centre for Population Health Sciences, University of Edinburgh, 20 West Richmond Street, Edinburgh, EH8 9DX, UK
| | - Robin J Prescott
- Centre for Population Health Sciences, University of Edinburgh, 20 West Richmond Street, Edinburgh, EH8 9DX, UK
| | - Kathrin Cresswell
- Centre for Population Health Sciences, University of Edinburgh, 20 West Richmond Street, Edinburgh, EH8 9DX, UK
| | - Aziz Sheikh
- Centre for Population Health Sciences, University of Edinburgh, 20 West Richmond Street, Edinburgh, EH8 9DX, UK
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Campbell IA, Douglas JG, Francis RM, Prescott RJ, Reid DM. Hormone replacement therapy (HRT) or etidronate for osteoporosis in postmenopausal asthmatics on glucocorticoids: a randomised factorial trial. Scott Med J 2009; 54:21-5. [PMID: 19291931 DOI: 10.1258/rsmsmj.54.1.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The study was designed to establish the effects of HRT on osteoporosis and fractures over five years in postmenopausal women with asthma receiving regular glucocorticoids and to compare with etidronate. METHODS Postmenopausal patients receiving inhaled and/or oral glucocorticoids were randomly assigned to HRT, cyclical etidronate, HRT plus cyclical etidronate or no treatment for five years. The trial was multi-centre and aimed to recruit 750 patients. Outcomes were fractures and changes in bone mineral density (BMD). RESULTS For reasons detailed in the discussion section of the text, only 50 patients were entered. Three did not fulfil the eligibility criteria and were excluded from the analysis. Among the remaining 47 patients, three (6%) experienced new, symptomatic fractures, one on etidronate and two in the no treatment group. New or worsening morphometric fractures of the thoracolumbar spine occurred in 50% of the 22 patients with spinal radiographs on entry and at five years (one HRT, three etidronate, two HRT plus etidronate and five on no treatment). BMD improved by approximately 1% per annum in those receiving HRT and/or etidronate; comparisons of HRT vs no HRT tended to favour HRT but were only statistically significant at proximal femur. The same trends emerged in the etidronate vs no etidronate comparison, but none reached the 5% level of statistical significance. DISCUSSION For postmenopausal patients receiving glucocorticoids for asthma, HRT appears as effective as etidronate in preventing loss of BMD over five years and may have a similar effect on fracture prevention.
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Affiliation(s)
- I A Campbell
- Chest Department, Llandough Hospital, Penarth, UK.
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Al-Daraji WI, Prescott RJ, Abdellaoui A, Khan MM, Kulkarni K, Youssef MM, Zelger BG, Zelger B. Cutaneous epithelioid angiomatous nodule: different views or interpretations in the analysis of ten new cases. Dermatol Online J 2009; 15:2. [PMID: 19379646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Classification schemes proposed for vascular lesions are the subjects of significant controversy. Cutaneous epithelioid angiomatous nodule (CEAN) was described in 2004, but there is no agreement as to whether this is a distinct entity or a type of either epithelioid hemangioma or angiolymphoid hyperplasia with eosinophilia. We present a typical case of CEAN and discuss nine other cases from our institution. We then provide two opposing viewpoints concerning its classification.
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Affiliation(s)
- W I Al-Daraji
- Department of Histopathology, Nottingham, United Kingdom.
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Al-Daraji WI, Prescott RJ, Abdellaoui A, Khan MM, Kulkarni K, Youssef MM, Zelger BG, Zelger B. Cutaneous Epithelioid Angiomatous Nodule: Different views or interpretations in the analysis of ten new cases. Dermatol Online J 2009. [DOI: 10.5070/d322q709vb] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Abstract
With increasing numbers of research groups carrying out radiostereometric analysis (RSA), it is important to reach a consensus on how the main aspects of the technique should be carried out and how the results should be presented in an appropriate and consistent way. In this collection of guidelines, we identify a number of methodological and reporting issues including: measurement error and precision, migration and migration direction data, and the use of RSA as a screening technique. Alternatives are proposed, and a statistical analysis is presented, from which a sample size of 50 is recommended for screening of newly introduced prostheses.
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Affiliation(s)
| | - Robin J Prescott
- 2Medical Statistics Unit,Public Health Sciences, University of Edinburgh Medical SchoolEdinburghUK
| | - Martyn L Porter
- 1Centre for Hip Surgery, Wrightington HospitalAppley BridgeUK
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Husain EA, Prescott RJ, Haider SA, Al-Mahmoud RWT, Zelger BG, Zelger B, Al-Daraji WI. Gallbladder sarcoma: a clinicopathological study of seven cases from the UK and Austria with emphasis on morphological subtypes. Dig Dis Sci 2009; 54:395-400. [PMID: 18618258 DOI: 10.1007/s10620-008-0358-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 06/03/2008] [Indexed: 12/09/2022]
Abstract
BACKGROUND Primary sarcoma of the gallbladder (PGBS) is rare, with only 40 cases reported in the literature. Most of these have been diagnosed as leiomyosarcoma. We aimed to evaluate the histological features of a case series of this rare tumor and correlate these with clinical features. DESIGN Cases recorded as "gallbladder sarcoma" from different institutes were reviewed and the clinicopathological features of these cases were recorded. Only primary gallbladder wall mesenchymal tumors were included. Epithelial tumors, mixed tumors (carcinosarcoma or sarcomatoid carcinoma), and tumors extending into the gallbladder from the abdomen or sarcoma with other known primaries were specifically excluded. RESULT PGBS occurred in one male and six females with a median age of 70 (range 64-82) years. Patients presented with acute or chronic cholecystitis, abdominal pain, weight loss, and pruritus. They were generally found to have elevated alkaline phosphatase and bilirubin, and leukocytosis. Tumors ranged from 1.1 to 4 cm with a median size of 3 cm. Most PGBS arose in the body but one arose in the fundus. All tumors were associated with ulcerated mucosa. Based on morphological and immunohistochemical features of the PGBS, there were three myxofibrosarcomas (malignant fibrous histiocytoma, MFH, storiform pleomorphic), one leiomyosarcoma (LMS), one angiosarcoma (AS), and two liposarcomas (LS). All patients received cholecystectomy and three received adjuvant chemotherapy. Follow-up revealed that six patients died of the disease 6 weeks to 2 years after diagnosis and one died of unrelated causes. CONCLUSION PGBS are rare and mainly occur in the gallbladder body in middle-aged females. They generally present with acute cholecystitis and have a very poor prognosis. A variety of sarcoma types are found with MFH being the predominant variant.
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Affiliation(s)
- E A Husain
- Department of Histopathology, Aberdeen Royal Infirmary, Aberdeen, UK
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Harkness M, Freer Y, Prescott RJ, Warner P. Implementation of NICE recommendation for a policy of routine antenatal anti-D prophylaxis: a survey of UK maternity units. Transfus Med 2008; 18:292-5. [PMID: 18937736 DOI: 10.1111/j.1365-3148.2008.00882.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to determine how many UK maternity units have implemented National Institute for Clinical Excellence (NICE) guidance for routine antenatal anti-D prophylaxis (RAADP). In May 2002, the NICE recommended a policy of RAADP for RhD-negative pregnant women. The policy has the potential to reduce maternal sensitization and prevent deaths from haemolytic disease of the foetus and newborn, but implementation entails considerable clinical, financial and organizational challenges. A postal survey of all 324 UK maternity units was completed in 2005.Responses were received from 91% of units (294 of 324). RAADP was offered by 220 of 294 (75%) and in England and Wales 19% of those offered a single-dose regime. At 12% of maternity units, routine paternal blood group testing was offered. For 84% of maternity units, staff education was offered at the time of implementation. Written patient information was provided at 97% of maternity units and 147 of 217 (69%) returned a copy. We received 60 different leaflets. Three years after NICE guidance was issued, one in four maternity units did not offer RAADP. Among those that do offer RAADP, practice with regard to anti-D administration, paternal testing, provision of written information and staff education varied. Unit and clinician level research is required to understand why.
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Affiliation(s)
- M Harkness
- Better Blood Transfusion Programme, Scottish National Blood Transfusion Service, Edinburgh, UK.
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Aldhous MC, Prescott RJ, Roberts S, Samuel K, Waterfall M, Satsangi J. Does nicotine influence cytokine profile and subsequent cell cycling/apoptotic responses in inflammatory bowel disease? Inflamm Bowel Dis 2008; 14:1469-82. [PMID: 18618634 DOI: 10.1002/ibd.20523] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Smoking differentially influences susceptibility to the inflammatory bowel diseases (IBDs) Crohn's disease (CD) and ulcerative colitis (UC). We investigated the effects of nicotine on cytokine, cell cycle, and apoptotic responses in peripheral blood mononuclear cells (PBMCs) from IBD patients and healthy controls (HCs). METHODS PBMCs from IBD patients and HC were stimulated with lipopolysaccharide (LPS; 1 microg/mL) or phytohemagglutinin (PHA, 5 or 0.5 microg/mL), +/- nicotine (1, 10, 100 microg/mL). Cytokines (IL1beta, IL2, IL10, IL12/IL23p40, TGFbeta, TNFalpha) were measured in supernatants at 24 hours. After 72 hours cells were analyzed by flow cytometry for cell cycle and apoptosis. Statistical modeling was used to identify interactions between cytokines and cell cycle / apoptosis and minimize confounding effects. RESULTS Stimulation by LPS and PHA (5 microg/mL) increased IL12/IL23p40 production from CD and UC versus HC (P < 0.05); PHA (0.5 microg/mL) increased IL1beta in UC and decreased TGFbeta from CD and UC (P < 0.01). In all groups, nicotine reduced LPS- and PHA (0.5 microg/mL)-stimulated production of IL1beta, IL10, TGFbeta, and TNFalpha (P < 0.001). Cell cycle analysis showed that PHA, but not LPS, induced proliferation and decreased G(0)/G(1) resting cells in CD and UC versus HC (P < 0.001). Nicotine decreased PHA-stimulated S-phase proliferation and increased G(0)/G(1) resting cells (P < 0.01). Modeling showed independent associations between IL12/IL23p40 and apoptosis (P = 0.01), IL1beta and resting cells (P = 0.006), TNFalpha and proliferating cells (P < 0.001). Disease activity and smoking habit had no effect. CONCLUSIONS Dysregulated cytokine profiles in UC and CD are associated with specific alterations in cell cycle responses; these effects may be modified by nicotine, and potentially by anticytokine therapies.
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Affiliation(s)
- Marian C Aldhous
- Gastrointestinal Unit, School of Clinical and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, Scotland, UK.
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Abstract
In a survey of 142 type 1 diabetic males, 40—59 years of age, 76 (54%) had erectile dysfunction (ED). Using a multi-variate analysis, the six most significant associations with ED were age (p = 0.009), duration of diabetes (p = 0.001), glycaemic control as assessed by HbA1c (p = 0.003), weight (p = 0.003), hypertension (p = 0.06) and microalbuminuria (p = 0.04). ED was associated with a higher cardiovascular risk score. In an assessment of categorical variables, retinopathy and laser therapy were also significant, reflecting the severity of underlying microangiopathy. It is concluded that despite advances in the management of micro- and macrovascular complications over the past 30 years, ED is still a common problem in diabetic males requiring careful assessment and appropriate treatment.
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Affiliation(s)
- Fiona Jamieson
- Diabetic Department, Victoria Hospital, Kirkcaldy, Fife KY2 5AH, Scotland, UK
| | - John Chalmers
- Diabetic Department, Victoria Hospital, Kirkcaldy, Fife KY2 5AH, Scotland, UK
| | - Catriona Duncan
- Diabetic Department, Victoria Hospital, Kirkcaldy, Fife KY2 5AH, Scotland, UK
| | - Robin J Prescott
- Diabetic Department, Victoria Hospital, Kirkcaldy, Fife KY2 5AH, Scotland, UK
| | - Ian W Campbell
- Diabetic Department, Victoria Hospital, Kirkcaldy, Fife KY2 5AH, Scotland, UK,
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Jenkins PA, Campbell IA, Banks J, Gelder CM, Prescott RJ, Smith AP. Clarithromycin vs ciprofloxacin as adjuncts to rifampicin and ethambutol in treating opportunist mycobacterial lung diseases and an assessment of Mycobacterium vaccae immunotherapy. Thorax 2008; 63:627-34. [DOI: 10.1136/thx.2007.087999] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cunningham S, Logan C, Lockerbie L, Dunn MJG, McMurray A, Prescott RJ. Effect of an integrated care pathway on acute asthma/wheeze in children attending hospital: cluster randomized trial. J Pediatr 2008; 152:315-20. [PMID: 18280833 DOI: 10.1016/j.jpeds.2007.09.033] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2007] [Revised: 08/13/2007] [Accepted: 09/17/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To determine whether an integrated care pathway (ICP) could improve care delivered to patients coming to an emergency department only or to patients who were subsequently admitted. STUDY DESIGN Children (age, 2-16 years; n = 298) coming to the ED with acute asthma/wheeze, were randomized by using a cluster design to either standard care or care delivered by an ICP. RESULTS Children discharged from the ED who received care with an ICP (n = 118) received more prednisolone (81%; standard, 63%; P = .03) and increased advice to obtain primary care review (72%; standard, 33%; P < .0001). A total of 180 children were admitted (94 ICP, 86 standard). The rate of recovery was unchanged by ICP. The mean ICP length of stay (37.6 hours; range, 33.5-42.4 hours), was 93% of the mean standard length of care (40.7 hours; range, 35.9-46; P = .36). When a discharge checklist was completed (60 of 94 cases), the mean ICP length of stay was 34.2 hours (range, 30.5-38.4 hours; P = .07 versus standard). An ICP resulted in a 30% reduction in prescribing errors (mean, 10.4; standard, 14.8; P = .002). Eighty-four of 94 children with an ICP received a 48-hour discharge plan (89%) versus 35 of 86 children with standard care (41%). More clinical contacts were observed in children receiving care by an ICP (mean, 22, versus standard, 19.2: P = .0004). CONCLUSION An acute asthma/wheeze ICP improved education and prescribing errors, modestly reduced the length of stay when discharge criteria were adhered to, but did not influence recovery time. Further consideration of the effect on staff workload is required.
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Affiliation(s)
- Steve Cunningham
- Department of Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, United Kingdom
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Prescott RJ, Kunkler IH, Williams LJ, King CC, Jack W, van der Pol M, Goh TT, Lindley R, Cairns J. A randomised controlled trial of postoperative radiotherapy following breast-conserving surgery in a minimum-risk older population. The PRIME trial. Health Technol Assess 2007; 11:1-149, iii-iv. [PMID: 17669280 DOI: 10.3310/hta11310] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To assess whether omission of postoperative radiotherapy in women with 'low-risk' axillary node negative breast cancer (T0-2) treated by breast-conserving surgery and endocrine therapy improves quality of life and is more cost-effective. DESIGN A randomised controlled clinical trial, using a method of minimisation balanced by centre, grade of cancer, age, lymphatic/vascular invasion and preoperative endocrine therapy, was performed. A non-randomised cohort was also recruited, in order to complete a comprehensive cohort study. SETTING The setting was breast cancer clinics in cancer centres in the UK. PARTICIPANTS Patients aged 65 years or more were eligible provided that their cancers were considered to be at low risk of local recurrence, were suitable for breast-conservation surgery, were receiving endocrine therapy and were able and willing to give informed consent. INTERVENTIONS The standard treatment of postoperative breast irradiation or the omission of radiotherapy. MAIN OUTCOME MEASURES Quality of life was the primary outcome measure, together with anxiety and depression and cost-effectiveness. Secondary outcome measures were recurrence rates, functional status, treatment-related morbidity and cosmesis. The principal method of data collection was by questionnaire, completed at home with a research nurse at four times over 15 months. RESULTS The hypothesised improvement in overall quality of life with the omission of radiotherapy was not seen in the EuroQol assessment or in the functionality and symptoms summary domains of the European Organisation for Research in the Treatment of Cancer (EORTC) scales. Some differences were apparent within subscales of the EORTC questionnaires, and insights into the impact of treatment were also provided by the qualitative data obtained by open-ended questions. Differences were most apparent shortly after the time of completion of radiotherapy. Radiotherapy was then associated with increased breast symptoms and with greater fatigue but with less insomnia and endocrine side-effects. Patients had significant concerns about the delivery of radiotherapy services, such as transport, accommodation and travel costs associated with receiving radiotherapy. By the end of follow-up, patients receiving radiotherapy were expressing less anxiety about recurrence than those who had not received radiotherapy. Functionality was not greatly affected by treatment. Within the randomised controlled trial, the Barthel Index demonstrated a small but significant fall in functionality with radiotherapy compared with the no radiotherapy arm of the trial. Results from the non-randomised patients did not confirm this effect, however. Cosmetic results were better in those not receiving radiotherapy but this did not appear to be an important issue to the patients. The use of home-based assessments by a research nurse proved to be an effective way of obtaining high-quality data. Costs to the NHS associated with postoperative radiotherapy were calculated to be of the order of 2000 pounds per patient. In the follow-up in this study, there were no recurrences, and the quality of life utilities from EuroQol were almost identical. CONCLUSIONS Although there are no differences in overall quality of life scores between the patients treated with and without radiotherapy, there are several dimensions that exhibit significant advantage to the omission of irradiation. Over the first 15 months, radiotherapy for this population is not a cost-effective treatment. However, the early postoperative outcome does not give a complete answer and the eventual cost-effectiveness will only become clear after long-term follow-up. Extrapolations from these data suggest that radiotherapy may not be a cost-effective treatment unless it results in a recurrence rate that is at least 5% lower in absolute terms than those treated without radiotherapy. Further research is needed into a number of areas including the long-term aspects of quality of life, clinical outcomes, costs and consequences of omitting radiotherapy.
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Affiliation(s)
- R J Prescott
- Medical Statistics Unit, University of Edinburgh, UK
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Reed MJ, Newby DE, Coull AJ, Jacques KG, Prescott RJ, Gray AJ. Role of brain natriuretic peptide (BNP) in risk stratification of adult syncope. Emerg Med J 2007; 24:769-73. [PMID: 17954830 DOI: 10.1136/emj.2007.048413] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To assess the value of a near-patient brain natriuretic peptide (BNP) test to predict medium term (3 month) serious outcome for adult syncope patients presenting to a UK emergency department (ED). METHODS This was a prospective cohort pilot study. Consecutive patients aged > or = 16 years presenting with syncope over a 3 month period were eligible for prospective enrolment. All patients who were medium or high risk according to our ED's existing syncope guidelines underwent near-patient BNP testing using the Triage point of care machine. RESULTS 99 patients were recruited. 72 of 82 high and medium risk patients underwent BNP measurement. 11 patients had a serious outcome, 9 of whom had BNP measured. In 25 (35%) patients, BNP was > or = 100 pg/ml, and in 3 of these it was > 1000 pg/ml. 6 of the 25 patients (24%) with a BNP > 100 pg/ml, and all 3 patients with a BNP > 1000 pg/ml, were in the serious outcome group. BNP was raised over 100 pg/ml in 6 of the 9 serious outcome patients having a BNP measured (66%), and over 1000 pg/ml in 3 (33%). CONCLUSIONS This early work suggests that BNP may have a role in the risk assessment of syncope patients in the ED. Further work is required to see how BNP interacts with other clinical variables. Near-patient BNP testing may be shown to be an independent predictor of adverse outcome either alone or incorporated into existing syncope clinical decision rules and scores in order to improve their sensitivity and specificity. Further studies are required to evaluate this.
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Affiliation(s)
- Matthew J Reed
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
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Reed MJ, Newby DE, Coull AJ, Jacques KG, Prescott RJ, Gray AJ. The Risk stratification Of Syncope in the Emergency department (ROSE) pilot study: a comparison of existing syncope guidelines. Emerg Med J 2007; 24:270-5. [PMID: 17384381 PMCID: PMC2658233 DOI: 10.1136/emj.2006.042739] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS This study was conducted as a feasibility pilot for the Risk stratification Of Syncope in the Emergency department (ROSE) study. The secondary aim was to compare the performance of our existing emergency department (ED) guidelines with existing clinical decision rules (Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) Score and San Francisco Syncope Rule; SFSR) at predicting short-term (1 week and 1 month) and medium-term (3 months) serious outcomes for patients with syncope presenting to the ED. METHODS This was a prospective cohort study. All patients presenting with syncope aged > or = 16 years between 7 November 2005 and 7 February 2006 were prospectively enrolled. RESULTS 99 patients were recruited over a 3-month period. 44 patients were admitted and 55 discharged from the ED. 11 patients had a serious outcome: 8 by 7 days and a further 3 by 3 months. Five patients died by 3 months and six others had an alternative serious outcome. All 11 patients had been admitted from the ED, 7 were at high risk, 4 were at medium risk and none were at low risk according to our existing ED guidelines. Percentages of serious outcomes were 0%, 2.9%, 8.0%, 22.7% and 37.5% for OESIL scores of 0, 1, 2, 3 and 4 respectively. 40 patients had none of the 5 SFSR high-risk factors (0 serious outcomes = 0%) and 59 patients had an SFSR high-risk factor (11 serious outcomes = 18.6%). The risk of serious outcome at 7 days, 1 month and 3 months was 8.1%, 8.1% and 11.1%, respectively. CONCLUSIONS A study to derive and validate a UK ED syncope clinical decision rule is feasible. This pilot study has evaluated the OESIL score, the SFSR and our existing ED guidelines, and has shown that each is able to identify an increased probability of medium-term serious outcome in patients with syncope. The SFSR shows good sensitivity at the expense of an increase in admissions to hospital; however, our existing ED syncope guidelines and the OESIL Score, although being able to successfully risk stratify patients, are not sufficiently sensitive to be able to reduce admissions without missing patients at risk of a serious outcome. Undoubtedly there is a need for a simple UK-derived clinical decision rule for patients presenting with syncope to enable safe, effective clinical care and to aid less experienced decision makers.
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Affiliation(s)
- Matthew J Reed
- Emergency Department, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
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Campbell IA, Bentley DP, Prescott RJ, Routledge PA, Shetty HGM, Williamson IJ. Anticoagulation for three versus six months in patients with deep vein thrombosis or pulmonary embolism, or both: randomised trial. BMJ 2007; 334:674. [PMID: 17289685 PMCID: PMC1839169 DOI: 10.1136/bmj.39098.583356.55] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine the optimum duration of oral anticoagulant therapy after an episode of deep vein thrombosis or pulmonary embolism, or both. DESIGN Multicentre, prospective, randomised study with follow-up for one year. SETTING 46 hospitals in United Kingdom. PARTICIPANTS Patients aged > or =18 with deep vein thrombosis or pulmonary embolism, or both. INTERVENTIONS Three (n=369) or six months (n=380) of anticoagulation with heparin for five days accompanied and followed by warfarin, with a target international normalised ratio of 2.0-3.5. MAIN OUTCOME MEASURES Death from deep vein thrombosis or pulmonary embolism; failure to resolve, extension, recurrence of during treatment; recurrence after treatment; and major haemorrhage during treatment. RESULTS In the patients allocated to three months' treatment two died from deep vein thrombosis or pulmonary embolism during or after treatment, compared with three in the six month group. During treatment deep vein thrombosis or pulmonary embolism failed to resolve, extended, or recurred in six patients in the three month group without fatal consequences, compared with 10 in the six month group. After treatment there were 23 non-fatal recurrences in the three month group and 16 in the six month group. Fatal and non-fatal deep vein thrombosis or pulmonary embolism during treatment, and after treatment thus occurred in 31(8%) of those who had received three months' anticoagulation compared with 29 (8%) of those who had received six months' (P=0.80, 95% confidence interval for difference -3.1% to 4.7%). There were no fatal haemorrhages during treatment but there were eight major haemorrhages in those treated for six months and none in those treated for three months (P=0.008, -3.5% to -0.7%). Thus 31 (8%) of the patients receiving three months' anticoagulation experienced adverse outcomes as a result of deep vein thrombosis or pulmonary embolism or its treatment compared with 35 (9%) of those receiving six months' (P=0.79, -4.9% to 3.2%). CONCLUSION For patients in the UK with deep vein thrombosis or pulmonary embolism and no known risk factors for recurrence, there seems to be little, if any, advantage in increasing the duration of anticoagulation from three to six months. Any possible advantage would be small and would need to be judged against the increased risk of haemorrhage associated with the longer duration of treatment with warfarin. TRIAL REGISTRATION Clinical Trials NCT00365950 [ClinicalTrials.gov].
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Affiliation(s)
- I A Campbell
- Llandough Hospital, Llandough, Cardiff CF64 2XX.
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Nelson EA, Prescott RJ, Harper DR, Gibson B, Brown D, Ruckley CV. A factorial, randomized trial of pentoxifylline or placebo, four-layer or single-layer compression, and knitted viscose or hydrocolloid dressings for venous ulcers. J Vasc Surg 2007; 45:134-41. [PMID: 17210398 DOI: 10.1016/j.jvs.2006.09.043] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Accepted: 09/14/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We evaluated the effectiveness of pentoxifylline, knitted viscose or hydrocolloid dressings, and single-layer or four-layer bandaging for venous ulceration. METHOD A factorial randomized controlled trial with 24-week follow-up was conducted in leg ulcer clinics in Scotland with blinded allocation to pentoxifylline (1200 mg) or placebo, knitted viscose or hydrocolloid dressings, and single-layer or four-layer bandages. The study enrolled 245 adults with venous ulcers. The main outcome measure was time to complete healing. Secondary outcomes included proportions healed, withdrawals, and adverse events. Analysis was by intention to treat. RESULTS There was no evidence of interaction between the drug, bandages, and dressings. Pentoxifylline was associated with nonsignificant increased ulcer healing (62% vs 53%; P = .21). Four-layer bandages were associated with significantly higher healing rates (67% vs 49%; P = .009). There was no difference in healing between knitted viscose and hydrocolloid dressings (58% and 57%; P = .88). Cox regression models increased the significance of the pentoxifylline effect (relative risk of healing, 1.4; 95% confidence interval, 1.0 to 2.0). CONCLUSIONS Pentoxifylline increased the proportion healing compared with placebo to the same extent as shown in recent systematic reviews, although this finding was only statistically significant when a secondary adjusted analysis was conducted. Four-layer bandaging produced higher healing rates than single-layer bandaging. There was no difference in time to healing between knitted viscose and hydrocolloid dressings.
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Rudd RM, Prescott RJ, Chalmers JC, Johnston IDA. British Thoracic Society Study on cryptogenic fibrosing alveolitis: Response to treatment and survival. Thorax 2007; 62:62-6. [PMID: 16769717 PMCID: PMC2111279 DOI: 10.1136/thx.2005.045591] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Accepted: 05/17/2006] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE The initial results of a survey of 588 patients with a clinical presentation of cryptogenic fibrosing alveolitis (CFA) also known as idiopathic pulmonary fibrosis, have been published. This article reports further results pertaining to response to treatment and survival. METHODS Data on the treatment given and lung function response were collected over 4-6 years. Survival data were collected over 10 years. RESULTS Treatment was given to 445 (76%) patients, 55% were given prednisolone alone and the remainder another immunosuppressive agent, usually with prednisolone. Treated patients had worse lung function initially. At 3 months after study entry, treated patients were more likely to have improved forced vital capacity (FVC) than the untreated patients. Patients whose FVC improved were younger (p = 0.001 analysis of variance (ANOVA)) and had lower initial FVC (p<0.001, ANOVA). Patients who responded to treatment at 3 months or at 1 year survived longer than those who remained stable, who in turn survived longer than those who deteriorated (p = 0.002). These differences were largely accounted for by patients with better lung function surviving longer. Younger age at entry, female sex and higher percentage predicted FVC and carbon monoxide transfer factor [corrected] at study entry were associated with greater chances of survival at 4 years. Overall median survival from entry was 2.43 years (95% confidence interval (CI) 2.17 to 3.18). CONCLUSIONS About a third of patients with CFA showed improved lung function after initiation of corticosteroid or immunosuppressive treatment, and those who improved survived longer. Poorer lung function, male sex and age are adverse prognostic features. Overall survival was poor.
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Affiliation(s)
- Robin M Rudd
- London Chest Hospital, Bonner Road, London E2 9JX, UK.
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Nelson EA, Harper DR, Prescott RJ, Gibson B, Brown D, Ruckley CV. Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. J Vasc Surg 2006; 44:803-8. [PMID: 17012004 DOI: 10.1016/j.jvs.2006.05.051] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2006] [Accepted: 05/20/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare venous ulcer recurrence and compliance with two strengths of compression hosiery. METHODS This study was a randomized controlled trial with a 5-year follow-up. The setting was the leg ulcer clinics of a teaching and a district general hospital in Scotland, United Kingdom. Patients were 300 outpatients with recently healed venous ulcers, with no significant arterial disease, rheumatoid disease, or diabetes mellitus. Interventions were fitting and supply of class 2 or class 3 compression hosiery. Four-monthly refitting by trained orthotists and surveillance by specialist nurses were performed. The main outcome measures were recurrence of leg ulceration and compliance with treatment. RESULTS Thirty-six percent (107/300) of patients had recurrent leg ulceration by 5 years. Recurrence occurred in 59 (39%) of 151 class 2 elastic compression cases and in 48 (32%) of class 3 compression cases. One hundred six patients did not comply with their randomized compression class, 63 (42%) in class 3 and 43 (28%) in class 2. The difference in recurrence is not statistically significant, but our estimate of the effectiveness of class 3 hosiery is diluted by the lower compliance rate in this group. Restricted ankle movement and four or more previous ulcers were associated with a higher risk of recurrence. CONCLUSIONS There was no evidence of a difference in recurrence rates at the classic level of significance (5%), but the lowest recurrence rates were seen in people who wore the highest degree of compression. Therefore, patients should wear the highest level of compression that is comfortable.
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Nfor TK, Walsh TS, Prescott RJ. The impact of organ failures and their relationship with outcome in intensive care: analysis of a prospective multicentre database of adult admissions. Anaesthesia 2006; 61:731-8. [PMID: 16867083 DOI: 10.1111/j.1365-2044.2006.04707.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The database of a multicentre cohort study was analysed to determine the impact of intensive care unit (ICU) organ failures and their association with ICU mortality using sequential organ failure assessment (SOFA). A consecutive sample of 873 adult patients with a non-neurological diagnosis was identified. SOFA scores were measured every 24 h of ICU stay. The odds of ICU death within 7 days doubled (95% CI 1.3-2.9) for a 5-unit increase in total SOFA score at admission, p < 0.001. However ICU death after 7 days was not associated with total SOFA score at admission, p = 0.36. Compared to patients with a day 6 total SOFA score = 5, there was a 1-unit (95% CI 0.8-3.1) increase in the odds ratio of ICU death after 7 days with every 5-unit increase in SOFA score on day 6, p = 0.009. Continuous assessments of organ failures during an ICU admission are more useful than scores measured at admission to determine outcome and to compare ICUs.
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Affiliation(s)
- T K Nfor
- Public Health Research, University of Edinburgh Medical School, Scotland EH8 9AG, UK.
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Denvir MA, Lee AJ, Rysdale J, Prescott RJ, Eteiba H, Starkey IR, Pell JP, Walker A. Effects of changing clinical practice on costs and outcomes of percutaneous coronary intervention between 1998 and 2002. Heart 2006; 93:195-9. [PMID: 16849373 PMCID: PMC1861374 DOI: 10.1136/hrt.2006.090134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
AIM To assess the effect of changing clinical practice on the costs and outcomes of percutaneous coronary intervention (PCI) between 1998 and 2002. SETTING Two tertiary interventional centres. PATIENTS Consecutive patients undergoing PCI over a 12-month period between 1998 and 2002. DESIGN Comparative observational study of costs and 12-month clinical outcomes of consecutive PCI procedures in 1998 (n = 1047) and 2002 (n = 1346). Clinical data were recorded in the Scottish PCI register. Repeat PCI, coronary artery bypass graft and mortality were obtained by record linkage. Costs of equipment were calculated using a computerised bar-code system and standard National Health Service reference costs. RESULTS Between 1998 and 2002, the use of bare metal stents increased from 44% to 81%, and the use of glycoprotein IIB/IIIA inhibitors increased from 0% to 14% of cases. During this time, a significant reduction was observed in repeat target-vessel PCI (from 8.4% to 5.1%, p = 0.001), any repeat PCI (from 11.7% to 9.2%, p = 0.05) and any repeat revascularisation (from 15.1% to 11.3%, p = 0.009) within 12 months. Significantly higher cost per case in 2002 compared with 1998 (mean (standard deviation) 2311 pounds (1158) v 1785 pounds (907), p<0.001) was mainly due to increased contribution from bed-day costs in 2002 (45.0% (16.3%) v 26.2% (12.6%), p = 0.01) associated with non-elective cases spending significantly longer in hospital (6.22 (4.3) v 4.6 (4.3) days, p = 0.01). CONCLUSIONS Greater use of stents and glycoprotein IIb/IIIa inhibitors between 1998 and 2002 has been accompanied by a marked reduction in the need for repeat revascularisation. Longer duration of hospital stay for non-elective cases is mainly responsible for increasing costs. Strategies to reduce the length of stay could considerably reduce the costs of PCI.
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Affiliation(s)
- M A Denvir
- Centre for Cardiovascular Research, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK.
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Abstract
BACKGROUND People with useful speech after regression constitute a distinct group of those with mutation-positive Rett disorder, 6% (20/331) reported among mutation-positive people in the British Survey. We aimed to determine the physical, mental and genetic characteristics of this group and to gain insight into their experience of Rett syndrome. METHODS Clinical and molecular data for people with Rett, aged 10 or more years at follow-up (the study group, n = 13), with the ability to converse and a MECP2 mutation are presented. They were compared with an age-matched control group (n = 110), who could not converse and had a pathogenic MECP2 mutation. RESULTS The study group differed significantly from the control group with regard to their disease severity (P < 0.001); feeding difficulty scores (P < 0.001); health scores (P < 0.001); epilepsy (P < 0.001); head circumference (P < 0.004); age at onset of the regression period (P < 0.001) (six in the study group did not regress) and mutation frequency (C-terminal deletions P = 0.014, R133C P < 0.006). The results indicate that favourable skewing of X-inactivation is only present in a small proportion of mild cases. Speech was fragmented with a soft, breathless quality, and all but two had obviously irregular breathing. One person with an R168X mutation preferred signing to speech. All enjoyed interpersonal contact, showing affection and preferring people to objects, clearly distinguishing the condition from autism. Most were habitually anxious. Music was a source of pleasure and relaxation also providing a valuable educational asset. Even in these most able cases, understanding was severely restricted in most and little initiative was shown. CONCLUSIONS While the Rett profile is present in these people they are commonly not classic, and the presence of speech, good head growth and lack of regression may lead to missed diagnoses. A strong association was demonstrated between this milder form of the disease and R133C and C-terminal deletions.
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Affiliation(s)
- A M Kerr
- Department of Psychological Medicine, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
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Lee AJ, Dale JJ, Ruckley CV, Gibson B, Prescott RJ, Brown D. Compression Therapy: Effects of Posture and Application Techniques on Initial Pressures Delivered by Bandages of Different Physical Properties. Eur J Vasc Endovasc Surg 2006; 31:542-52. [PMID: 16387515 DOI: 10.1016/j.ejvs.2005.10.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Accepted: 10/23/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To define the pressures and gradients achieved by different bandages when applied by alternative bandaging techniques. METHODS An experienced bandager applied six bandages to the same leg of a volunteer using three application techniques. Pressure measurements were taken at the ankle, gaiter, calf and upper calf in three postures. RESULTS All bandages gave consistent pressures with all standard deviations falling below 7 mmHg. The percentage increase in pressure from resting leg to standing was inversely related to bandage elasticity. Pressures were similar at the upper calf among the bandages for each application technique in each posture (differences <10 mmHg). Small differences in pressure among the bandages (4-15 mmHg) occurred at the ankle for the resting leg with a reduction in pressure between 6 and 63% at the upper calf compared to the ankle. These differences in ankle pressure were more marked on sitting (differences 15-18 mmHg) and standing (differences 15-27 mmHg), which resulted in substantial differences in gradients. CONCLUSIONS Striking variations in pressures and gradients were observed between bandages of different physical properties applied using alternative application techniques. In order to achieve clinical benefits without tissue damage, it is essential that the therapist appreciates how a bandage will react with a specific application technique.
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Affiliation(s)
- A J Lee
- Medical Statistics Unit, University of Edinburgh, Edinburgh, Scotland, UK.
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Church NI, Dallal HJ, Masson J, Mowat NAG, Johnston DA, Radin E, Turner M, Fullarton G, Prescott RJ, Palmer KR. Validity of the Rockall scoring system after endoscopic therapy for bleeding peptic ulcer: a prospective cohort study. Gastrointest Endosc 2006; 63:606-12. [PMID: 16564860 DOI: 10.1016/j.gie.2005.06.042] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2005] [Accepted: 06/08/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND The Rockall scoring system was developed in unselected patients, the majority of whom did not receive endoscopic therapy. The aim of this study was to assess the validity of the Rockall system in high-risk patients who undergo endoscopic therapy for peptic ulcer hemorrhage. METHODS Rockall scores were calculated in 247 patients with major peptic ulcer bleeding entered into a randomized trial of endoscopic therapy. The observed rates of recurrent bleeding and mortality after endoscopic therapy were compared with predicted rates derived from Rockall's study group. The validity of the Rockall system was assessed in terms of calibration and discrimination. RESULTS Rates of recurrent bleeding and mortality after endoscopic therapy increased with an increasing Rockall score. Observed rates of recurrent bleeding and mortality were below predicted rates, and calibration of the Rockall system was poor (Mantel-Haenszel chi square = 25.8, p < 0.0001 for recurrent bleeding; Mantel-Haenszel chi square = 15.1, p < 0.0001 for death). For the prediction of recurrent bleeding, the area under the receiver operating characteristic curve was low (63.4%), but the system was satisfactory when predicting mortality (area under the resulting curve, 84.3%). CONCLUSIONS After endoscopic therapy for a bleeding peptic ulcer, the Rockall scoring system can identify patients at high risk of death, but it is inadequate for the prediction of recurrent bleeding.
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Affiliation(s)
- Nicholas I Church
- Department of Gastroenterology, Middlesex Hospital, Mortimer Street, London W1T 3AA, UK
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