We describe a case of severe symptomatic hypoglycaemia in a non-diabetic patient presenting to A&... more We describe a case of severe symptomatic hypoglycaemia in a non-diabetic patient presenting to A&E. The associated discussion outlines the management of hypoglycaemia and explores the differential diagnosis, investigation and localisation of a potential insulinoma. Case presentation A 51-year-old lady presented to A&E following an absence episode. Her husband left her in the morning and on his return, 8 hours later, found her still sitting in the same chair confused and disorientated. There was no history of alcohol use. During routine triage assessment a blood capillary glucose level was 2.1mmol/L, which was promptly treated. The patient was admitted and on further direct questioning described a 3-month history of poor concentration, difficulty completing tasks, intermittent sweating episodes and tiredness, which had been attributed to the menopause. The symptoms were unrelated to food. Past-medical history consisted of endometrial ablation for menorrhagia. There was no significant...
A case of severe rhabdomyolysis caused by an interaction between fusidic acid and simvastatin is ... more A case of severe rhabdomyolysis caused by an interaction between fusidic acid and simvastatin is described. Fusidic acid significantly reduces the excretion of simvastatin resulting in increased plasma levels thereby increasing the side effect profile. Simvastatin treatment should be temporarily withheld during treatment with fusidic acid.
A case is described in which a patient inadvertently applied undiluted Robinul to a sweat rash in... more A case is described in which a patient inadvertently applied undiluted Robinul to a sweat rash in the groin and experienced two episodes of atropine-like poisoning. We highlight important diagnostic issues and identify concerns with prescribing unfamiliar medications.
One of the main features of ward rounds is the professional conversation that occurs between doct... more One of the main features of ward rounds is the professional conversation that occurs between doctors and nurses. Such conversation needs to be perfected to avoid iatrogenic harm and increase efficiency. This article looks at data collected from 146 consultant-led medical ward rounds at a hospital trust using the Caldwell considerative checklist process (Herring et al 2011) to identify the frequency and quality of such conversations. A total of 1,921 patients' reviews were undertaken. A nurse was present during preparatory discussions on 604 occasions (31 per cent) and during bedside review on 1,134 occasions (59 per cent). These data demonstrate an urgent need to change ward cultures to improve the professional conversations between doctors, nurses and patients. By increasing nurse presence as a result of this research patient care and safety has improved at ward level, increasing satisfaction for everyone involved.
Previous studies have shown insulin detemir to be partially hepato-preferential at euglycemia and... more Previous studies have shown insulin detemir to be partially hepato-preferential at euglycemia and hypoglycemia. Using a novel non-steady state protocol, the differential effects of subcutaneous detemir and NPH insulin on glucose flux and lipid metabolism following insulin withdrawal were investigated. Following a period of insulin withdrawal resulting in whole blood glucose of 7 mmol/l, eleven participants (5 males, age 41.0 years, BMI 25 kg/m2) with type 1 diabetes (HbA1c 57 mmol/mol, diabetes duration 14 years) received in random order 0.5 Units/kg BW subcutaneous insulin detemir or NPH insulin. Stable isotopes of glucose and glycerol were infused intravenously throughout the study protocol. Glucose concentration decreased following insulin treatment due to suppression of endogenous glucose production (Ra), which was similar with detemir and NPH insulin. Glucose rate of disappearance (Rd) was not increased significantly with either insulin. When the effect of detemir and NPH insul...
As the main tool through which doctors treat the medically unwell, prescribing is a practice that... more As the main tool through which doctors treat the medically unwell, prescribing is a practice that is undervalued and under-taught within modern medicine. Paradoxically prescribing not only has the potential to cure, it also has the potential to cause great harm if carried out incorrectly and unsafely. Prescribing errors have remained an issue in patient safety for many years, yet education in safe prescribing at both undergraduate and postgraduate level appears to be lacking. 'Check and Correct' is an innovation developed at Worthing Hospital in West Sussex to educate both medical students and junior doctors on the importance of safe prescribing. As a final-year medical student I used 'Check and Correct' on busy post-take ward rounds for 2 weeks. The aim was to research the main areas where prescribing standards set by the hospital had not been met, whilst improving awareness in safe prescribing for both myself and the post-take team. The process involved checking the drug chart of every patient seen on the post-take round and addressing errors on the chart with the team for correction at the bedside. 'Check and Correct' reaffirms the assertion that further education is required in safe prescribing. The success of the process is highly dependent on the consultant leading the ward round ensuring that errors are vocalised and addressed. If conducted correctly, this exercise can educate doctors and medical students by addressing errors and emphasising the importance of prescribing, whilst ensuring the safety and care of patients.
To conduct a pilot study evaluation of an interprofessional education tool that could improve hea... more To conduct a pilot study evaluation of an interprofessional education tool that could improve healthcare professional confidence, knowledge and quality of inpatient diabetes care. Diabetes specialists designed an education tool for use in the hospital environment to educate qualified pharmacists, nurses, healthcare assistants and junior doctors. The interprofessional learning enabled professionals to learn from and about each other. The education tool was piloted at four hospitals. Diabetes specialists delivered the education programme to 31 healthcare professionals over 8 h either as three individual teaching blocks or a whole day. Healthcare professionals completed a multiple choice questionnaire before and after the education intervention to evaluate acquisition of knowledge. The maximum score was 20. Confidence was evaluated using categorical questions. Diabetes specialists used a clinical audit form before and after the education programme, to evaluate the quality of diabetes care. Healthcare professional's confidence improved from 58 to 94% (P < 0.05) and knowledge improved from 12.4 ± 0.6 to 15.0 ± 0.6 (mean ± sem, P < 0.05). There was a reduction in management errors from 74 to 44% (P < 0.05) and improvement in appropriate blood glucose monitoring from 67 to 92% (P < 0.05). The number of patients with documented foot assessment improved from15 to 33% (P < 0.05). Improvement in the number of appropriate diabetes referrals and reduction in prescribing errors did not reach statistical significance. The education tool improved healthcare professional confidence, knowledge and may improve the quality of inpatient diabetes care.
Current Opinion in Endocrinology, Diabetes and Obesity, 2010
In the last decade there has been an increased use of growth hormone replacement in patients with... more In the last decade there has been an increased use of growth hormone replacement in patients with pituitary insufficiency. It has been shown to improve patient's quality of life, bone mass and cardiovascular risk factors but there are concerns about its mitogenic potential. The most common aetiology of pituitary insufficiency in adults is hypothalamo-pituitary tumours or as a consequence of hypophysectomy or radiotherapy to treat pituitary tumours. Long-term growth hormone replacement is well established in clinical practice. We explore the available evidence concerning growth hormone replacement and its effects on pituitary tumour growth or recurrence and we examine evidence from natural experiments. Despite the limitation of study size, patient case selectivity and treatment modalities, present studies of growth hormone replacement do not appear to demonstrate an increase in pituitary tumour recurrence. Conclusive evidence will only be generated by long-term randomized prospective clinical trials.
We describe a case of severe symptomatic hypoglycaemia in a non-diabetic patient presenting to A&... more We describe a case of severe symptomatic hypoglycaemia in a non-diabetic patient presenting to A&E. The associated discussion outlines the management of hypoglycaemia and explores the differential diagnosis, investigation and localisation of a potential insulinoma. Case presentation A 51-year-old lady presented to A&E following an absence episode. Her husband left her in the morning and on his return, 8 hours later, found her still sitting in the same chair confused and disorientated. There was no history of alcohol use. During routine triage assessment a blood capillary glucose level was 2.1mmol/L, which was promptly treated. The patient was admitted and on further direct questioning described a 3-month history of poor concentration, difficulty completing tasks, intermittent sweating episodes and tiredness, which had been attributed to the menopause. The symptoms were unrelated to food. Past-medical history consisted of endometrial ablation for menorrhagia. There was no significant...
A case of severe rhabdomyolysis caused by an interaction between fusidic acid and simvastatin is ... more A case of severe rhabdomyolysis caused by an interaction between fusidic acid and simvastatin is described. Fusidic acid significantly reduces the excretion of simvastatin resulting in increased plasma levels thereby increasing the side effect profile. Simvastatin treatment should be temporarily withheld during treatment with fusidic acid.
A case is described in which a patient inadvertently applied undiluted Robinul to a sweat rash in... more A case is described in which a patient inadvertently applied undiluted Robinul to a sweat rash in the groin and experienced two episodes of atropine-like poisoning. We highlight important diagnostic issues and identify concerns with prescribing unfamiliar medications.
One of the main features of ward rounds is the professional conversation that occurs between doct... more One of the main features of ward rounds is the professional conversation that occurs between doctors and nurses. Such conversation needs to be perfected to avoid iatrogenic harm and increase efficiency. This article looks at data collected from 146 consultant-led medical ward rounds at a hospital trust using the Caldwell considerative checklist process (Herring et al 2011) to identify the frequency and quality of such conversations. A total of 1,921 patients' reviews were undertaken. A nurse was present during preparatory discussions on 604 occasions (31 per cent) and during bedside review on 1,134 occasions (59 per cent). These data demonstrate an urgent need to change ward cultures to improve the professional conversations between doctors, nurses and patients. By increasing nurse presence as a result of this research patient care and safety has improved at ward level, increasing satisfaction for everyone involved.
Previous studies have shown insulin detemir to be partially hepato-preferential at euglycemia and... more Previous studies have shown insulin detemir to be partially hepato-preferential at euglycemia and hypoglycemia. Using a novel non-steady state protocol, the differential effects of subcutaneous detemir and NPH insulin on glucose flux and lipid metabolism following insulin withdrawal were investigated. Following a period of insulin withdrawal resulting in whole blood glucose of 7 mmol/l, eleven participants (5 males, age 41.0 years, BMI 25 kg/m2) with type 1 diabetes (HbA1c 57 mmol/mol, diabetes duration 14 years) received in random order 0.5 Units/kg BW subcutaneous insulin detemir or NPH insulin. Stable isotopes of glucose and glycerol were infused intravenously throughout the study protocol. Glucose concentration decreased following insulin treatment due to suppression of endogenous glucose production (Ra), which was similar with detemir and NPH insulin. Glucose rate of disappearance (Rd) was not increased significantly with either insulin. When the effect of detemir and NPH insul...
As the main tool through which doctors treat the medically unwell, prescribing is a practice that... more As the main tool through which doctors treat the medically unwell, prescribing is a practice that is undervalued and under-taught within modern medicine. Paradoxically prescribing not only has the potential to cure, it also has the potential to cause great harm if carried out incorrectly and unsafely. Prescribing errors have remained an issue in patient safety for many years, yet education in safe prescribing at both undergraduate and postgraduate level appears to be lacking. 'Check and Correct' is an innovation developed at Worthing Hospital in West Sussex to educate both medical students and junior doctors on the importance of safe prescribing. As a final-year medical student I used 'Check and Correct' on busy post-take ward rounds for 2 weeks. The aim was to research the main areas where prescribing standards set by the hospital had not been met, whilst improving awareness in safe prescribing for both myself and the post-take team. The process involved checking the drug chart of every patient seen on the post-take round and addressing errors on the chart with the team for correction at the bedside. 'Check and Correct' reaffirms the assertion that further education is required in safe prescribing. The success of the process is highly dependent on the consultant leading the ward round ensuring that errors are vocalised and addressed. If conducted correctly, this exercise can educate doctors and medical students by addressing errors and emphasising the importance of prescribing, whilst ensuring the safety and care of patients.
To conduct a pilot study evaluation of an interprofessional education tool that could improve hea... more To conduct a pilot study evaluation of an interprofessional education tool that could improve healthcare professional confidence, knowledge and quality of inpatient diabetes care. Diabetes specialists designed an education tool for use in the hospital environment to educate qualified pharmacists, nurses, healthcare assistants and junior doctors. The interprofessional learning enabled professionals to learn from and about each other. The education tool was piloted at four hospitals. Diabetes specialists delivered the education programme to 31 healthcare professionals over 8 h either as three individual teaching blocks or a whole day. Healthcare professionals completed a multiple choice questionnaire before and after the education intervention to evaluate acquisition of knowledge. The maximum score was 20. Confidence was evaluated using categorical questions. Diabetes specialists used a clinical audit form before and after the education programme, to evaluate the quality of diabetes care. Healthcare professional's confidence improved from 58 to 94% (P < 0.05) and knowledge improved from 12.4 ± 0.6 to 15.0 ± 0.6 (mean ± sem, P < 0.05). There was a reduction in management errors from 74 to 44% (P < 0.05) and improvement in appropriate blood glucose monitoring from 67 to 92% (P < 0.05). The number of patients with documented foot assessment improved from15 to 33% (P < 0.05). Improvement in the number of appropriate diabetes referrals and reduction in prescribing errors did not reach statistical significance. The education tool improved healthcare professional confidence, knowledge and may improve the quality of inpatient diabetes care.
Current Opinion in Endocrinology, Diabetes and Obesity, 2010
In the last decade there has been an increased use of growth hormone replacement in patients with... more In the last decade there has been an increased use of growth hormone replacement in patients with pituitary insufficiency. It has been shown to improve patient's quality of life, bone mass and cardiovascular risk factors but there are concerns about its mitogenic potential. The most common aetiology of pituitary insufficiency in adults is hypothalamo-pituitary tumours or as a consequence of hypophysectomy or radiotherapy to treat pituitary tumours. Long-term growth hormone replacement is well established in clinical practice. We explore the available evidence concerning growth hormone replacement and its effects on pituitary tumour growth or recurrence and we examine evidence from natural experiments. Despite the limitation of study size, patient case selectivity and treatment modalities, present studies of growth hormone replacement do not appear to demonstrate an increase in pituitary tumour recurrence. Conclusive evidence will only be generated by long-term randomized prospective clinical trials.
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Papers by Roselle Herring