The British Journal of General Practice, May 1, 2004
In December 2000, the Committee for Safety of Medicines (CSM) advised that thioridazine may prolo... more In December 2000, the Committee for Safety of Medicines (CSM) advised that thioridazine may prolong QT intervals risking arrhythmias. We investigated the impact on general practitioner prescribing of thioridazine using a time series analysis. Numbers of items and costs of antipsychotics and benzodiazepines prescribed in Leeds from May 1999 until April 2002 were collated. Post-advice, thioridazine prescriptions dropped by 810 items per month (95% confidence interval = 420 to 1200, P<0.001) but others increased slightly in response. Costs mimicked these changes. Fresh criteria are proposed for appraising the quality of evidence needed to inform future urgent facsimile transmissions.
Family caregivers provide significant care at the end of life. We aimed to describe caregiver cha... more Family caregivers provide significant care at the end of life. We aimed to describe caregiver characteristics, and of those unwilling to repeat this role under the same circumstances. Observational study of adults in private households (Health Survey for England [HSE]). Caregiving questions included: whether someone close to them died within past 5 years; relationship to the deceased; provision, intensity and duration of care; supportive/palliative care services used; willingness to care again; able to carry on with life. Comparison between those willing to care again or not used univariable analyses and an exploratory multiple logistic regression. A descriptive comparison with Health Omnibus Survey (Australia) data was conducted. HSE response was 64%. 2167/8861 (25%) respondents had someone close to them die in the previous 5 years. Some level of personal care was provided by 645/8861 (7.3%). 57/632 (9%) former caregivers would be unwilling to provide care again irrespective of time since the death, duration of care, education and income. Younger age (≤65; odds ratio [OR] 2.79; 95% CI 136, 5.74) and use of palliative care services (odds ratio: 1.95, 95% CI: 1.09, 3.48) showed greater willingness to provide care again. Apart from use of palliative care services, findings were remarkably similar to the Australian data. A significant group of caregivers would be unwilling to provide care again. Older people and those who had not used palliative care services were more likely to be unwilling to care again. Barriers preventing access for disadvantaged groups need to be overcome.
BackgroundA Social Story™ (Carol Gray) is a child-friendly intervention that is used to give chil... more BackgroundA Social Story™ (Carol Gray) is a child-friendly intervention that is used to give children with autism spectrum disorders (ASDs) social information in situations where they have social difficulties. Limited evidence mainly using single-case designs suggests that they can reduce anxiety and challenging behaviour.ObjectivesThe objectives were to conduct a systematic review, use this to develop a manualised intervention and run a feasibility trial to inform a fully powered randomised controlled trial (RCT) on their clinical effectiveness and cost-effectiveness in schools.DesignThis is a three-stage study following the Medical Research Council framework for complex interventions. Specifically, it involved a theoretical phase, a qualitative stage and a feasibility trial stage.SettingQualitative interviews and focus groups took place in Child and Adolescent Mental Health Service and primary care settings. The feasibility study took place in 37 local mainstream schools.Participa...
National Institute for Health and Care Excellence guidelines used to triage patients with head in... more National Institute for Health and Care Excellence guidelines used to triage patients with head injury to CT imaging are based on research conducted in populations presenting within 24 h of injury.We aim to compare guideline use, and outcomes, in patients with head injury that undergo CT imaging presenting within, and after 24 h of injury. ED trauma CT head scan requests over a period of 6 months were matched to ED records. Case note review of adult patients with head injury that had undergone CT imaging was completed. Logistic regression was used to assess whether presentation after 24 h affected the guideline&amp;amp;amp;amp;#39;s ability to predict significant injuries. 650 case records were available for analysis. 8.6% (56/650) showed a traumatic abnormality, 1.5% (10/650) required neurosurgery or died. 15.5% (101/650) of CT scans were for patients presenting after 24 h. 8.4% (46/549) of those presenting within, and 9.9% (10/101) of those presenting after 24 h had traumatic CT abnormalities.The sensitivity of the guidelines for intracranial injuries was 98% (95% CI 87.0% to 99.9%) in those presenting within 24 h and 70% (95% CI 35.4% to 91.9%) in those presenting after 24 h of injury. The presence of a guideline indication statistically predicted significant injury, and this was unaffected by time of presentation. Patients with head injury presenting after 24 h of injury are a clinically significant population. Existing guidelines appear to predict traumatic CT abnormalities irrespective of timing of presentation. However, their sole use in patients presenting after 24 h may result in significant injuries not being identified.
Health technology assessment (Winchester, England), 2015
Home oxygen therapy (HOT) is commonly used for patients with severe chronic heart failure (CHF) w... more Home oxygen therapy (HOT) is commonly used for patients with severe chronic heart failure (CHF) who have intractable breathlessness. There is no trial evidence to support its use. To detect whether or not there was a quality-of-life benefit from HOT given as long-term oxygen therapy (LTOT) for at least 15 hours per day in the home, including overnight hours, compared with best medical therapy (BMT) in patients with severely symptomatic CHF. A pragmatic, two-arm, randomised controlled trial recruiting patients with severe CHF. It included a linked qualitative substudy to assess the views of patients using home oxygen, and a free-standing substudy to assess the haemodynamic effects of acute oxygen administration. Heart failure outpatient clinics in hospital or the community, in a range of urban and rural settings. Patients had to have heart failure from any aetiology, New York Heart Association (NYHA) class III/IV symptoms, at least moderate left ventricular systolic dysfunction, and ...
The UK South Asian population has poorer health outcomes. Little is known about their process of ... more The UK South Asian population has poorer health outcomes. Little is known about their process of care in general practice, or in particular the process of communication with GPs. To compare the ways in which white and South Asian patients communicate with white GPs. Observational study of video-recorded consultations using the Roter Interactional Analysis System (RIAS). West Yorkshire, UK. One hundred and eighty-three consultations with 11 GPs in West Yorkshire, UK were video-recorded and analysed. Main outcome measures were consultation length, verbal domination, 16 individual abridged RIAS categories, and three composite RIAS categories; with comparisons between white patients, South Asian patients fluent in English and South Asian patients nonfluent in English. South Asians fluent in English had the shortest consultations and South Asians non-fluent in English the longest consultations (one-way ANOVA F = 7.173, P = 0.001). There were no significant differences in verbal dominatio...
ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term ... more ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term mortality following invasive pneumococcal disease (IPD). There is a lack of evidence regarding the underlying causes, but work in pneumonia suggests an increase in cardiovascular deaths. We conducted a retrospective cohort study to examine the causes of death in the two years following IPD. Methods: All adult cases of IPD presenting to Hull and East Yorkshire Hospitals (1400 bed teaching hospital), 2007 to 2009 were identified via the Dept. of Microbiology&#39;s electronic-database. Medical records were reviewed and death certificates obtained for patients who died within 2 years of an episode of IPD. Causes of death within 30 days (early) were compared to those between 30 days and 2 years (late). Late deaths were compared to causes of death in our local population (N = 5819) in 2010. Results: 207 patients (50.7% male, mean age 64.9) were included. Most patients (80%) had pneumonia. Mortality at 30 days following IPD was 20.8% (n=43) and 38.6% (n=80) by 2 years. Within 30 days, infection was the primary cause of death in 60.5% and contributed to 83.72%. Infection remained an important cause of late death, being the primary cause in 24.3% and contributory in 45.9%. Of late deaths due to infection, 89% were due to respiratory infection. Malignancy was the primary cause of most late deaths (48.6%). A higher proportion of deaths between 30 days and 2 years were caused by respiratory disease (including respiratory infection) and malignancy compared to overall deaths locally (27.0% vs. 15.7% and 48.6% vs. 29.0%, respectively), but less were due to cardiovascular disease (10.8% vs. 32.6%). Conclusion: The majority of early deaths following IPD are due to infection, which remained an important primary and contributory cause of death during follow-up. Respiratory diseases (including pneumonia) were responsible for a greater proportion of late deaths compared to the general population. This work does not support the hypothesis that IPD increases late cardiovascular deaths with the majority of non-infective deaths being due to malignancy. Whether late deaths can be prevented by intervention (e.g. conjugate vaccine) after the IPD episode is unclear, but should be explored.
Cancer patients in lower socioeconomic groups are significantly less likely to die at home and ex... more Cancer patients in lower socioeconomic groups are significantly less likely to die at home and experience more barriers to access to palliative care. It is unclear whether receiving palliative care may mediate the effect of socioeconomic status on place of death. This review examines whether and how use of specialist palliative care may modify the effect of socioeconomic status on place of death. A systematic review was conducted. Eligible papers were selected and the quality appraised by two independent reviewers. Data were synthesised using a narrative approach. MEDLINE, Embase, CINAHL, PsycINFO and Web of Knowledge were searched (1997-2013). Bibliographies were scanned and experts contacted. Papers were included if they reported the effect of both socioeconomic status and use of specialist palliative care on place of death for adult cancer patients. Nine studies were included. All study subjects had received specialist palliative care. With regard to place of death, socioeconomic...
There is little published data reporting outcomes for those found to have a chronic total coronar... more There is little published data reporting outcomes for those found to have a chronic total coronary occlusion (CTO) that is electively treated medically versus those treated by percutaneous coronary intervention (PCI). We sought to compare long-term clinical outcomes between patients treated by PCI and elective medical therapy in a consecutive cohort of patients with an identified CTO. Patients found to have a CTO on angiography between January 2002 and December 2007 in a single tertiary centre were identified using a dedicated database. Those undergoing CTO PCI and elective medical therapy to the CTO were propensity matched to adjust for baseline clinical and angiographic differences. In total, 1957 patients were identified, a CTO was treated by PCI in 405 (20.7%) and medical therapy in 667 (34.1%), 885 (45.2%) patients underwent coronary artery bypass graft surgery. Of those treated by PCI or medical therapy, propensity score matching identified 294 pairs of patients, PCI was successful in 177 patients (60.2%). All-cause mortality at 5 years was 11.6% for CTO PCI and 16.7% for medical therapy HR 0.63 (0.40 to 1.00, p=0.052). The composite of 5-year death or myocardial infarction occurred in 13.9% of the CTO PCI group and 19.6% in the medical therapy group, HR 0.64 (0.42 to 0.99, p=0.043). Among the CTO PCI group, if the CTO was revascularised by any means during the study period, 5-year mortality was 10.6% compared with 18.3% in those not revascularised in the medical therapy group, HR 0.50 (0.28-0.88, p=0.016). Revascularisation, but not necessarily PCI of a CTO, is associated with improved long-term survival relative to medical therapy alone.
BACKGROUNDCerebral palsy is the commonest cause of severe physical disability in childhood. For m... more BACKGROUNDCerebral palsy is the commonest cause of severe physical disability in childhood. For many years treatment has centred on the use of physiotherapy and orthotics to overcome the problems of leg spasticity, which interferes with walking and can lead to limb deformity. Intramuscular botulinum toxin (BT-A) offers a targeted form of therapy to reduce spasticity in specific muscle groups.AIMSTo determine
With an aging population and limited resources, the incidence and prevalence of chronic kidney di... more With an aging population and limited resources, the incidence and prevalence of chronic kidney disease is increasing. We aimed at assessing the impact of the low clearance clinic (LCC) on not only the natural history of patients with deteriorating renal function but also the timing of renal replacement therapy (RRT) and mortality. A retrospective cohort study involving 271 patients who entered the LCC at Hull from July 2007 to December 2010 was conducted. Descriptive analysis based on baseline characteristics was performed and slope-estimated glomerular function rates (eGFR) before and after entry to the LCC were calculated. This aided survival analysis using quartiles and Kaplan-Meier. The change in slope eGFR was the study primary end point, but secondary end points, including mortality and time to RRT, were also measured. The average length of time within the LCC was 14 months and of those receiving RRT, 61% received this intervention within one year compared with 38% after 1 yea...
A clear understanding of the relationship between venous reflux, clinical venous disease and the ... more A clear understanding of the relationship between venous reflux, clinical venous disease and the effects on quality of life (QoL) remains elusive. This study aimed to explore the impact of venous disease, and assess any incremental direct effect of progressive disease on health-related QoL, with the ultimate aim to model venous morbidity. Consecutive patients with venous disease were assessed for inclusion in the study. Patients with isolated, unilateral, single superficial axial incompetence diagnosed on duplex imaging were included. Clinical grading was performed with the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification and Venous Clinical Severity Score (VCSS). Patients completed generic (Short Form 36, SF-36(®); EuroQol 5D, EQ-5D(™)) and disease-specific (Aberdeen Varicose Vein Questionnaire, AVVQ) QoL instruments. Multivariable regression modelling was performed, taking account of demographic and anatomical factors, to explore the effect of clinical severity o...
Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial f... more Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial fractures. The risk is as high as 77% without prophylaxis and around 10% with prophylaxis. Within the current literature there are no figures reported specifically for those individuals treated with circular frames. Our aim was to evaluate the VTE incidence within a single surgeon series and to evaluate potential risk factors. We retrospectively reviewed our consecutive single surgeon series of 177 patients admitted to a major trauma unit with tibial fractures. All patients received standardised care, including chemical thromboprophylaxis within 24h of injury until independent mobility was achieved. We comprehensively reviewed our prospective database and medical records looking at demographics and potential risk factors. Seven patients (4.0%±2.87%) developed symptomatic VTE during the course of frame treatment; three deep vein thrombosis (DVTs) and four pulmonary embolisms (PEs). Those with a VTE event had significantly increased body mass index (BMI) (p=0.01) when compared to those without symptomatic VTE. No differences (p&gt;0.05) were observed between the groups in age, gender, smoking status, fracture type (anatomical allocation or open/closed), delay to frame treatment, weight bearing status post-frame, inpatient stay or total duration of frame treatment. This study suggests that increased BMI is a statistically significant risk factor for VTE, as reported in current literature. In addition, we calculated the true risk of VTE following circular frame treatment for tibial fracture in our series is from 1.13% to 6.87%, which is at least comparable to other forms of treatment.
Journal of Bone and Joint Surgery - British Volume, 2010
We prospectively randomised 78 patients into two groups, &amp;amp;#39;drains&amp;amp;#39;... more We prospectively randomised 78 patients into two groups, &amp;amp;#39;drains&amp;amp;#39; or &amp;amp;#39;no drains&amp;amp;#39; to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.
Many drug users present to primary care requesting detoxification from illicit opiates. There are... more Many drug users present to primary care requesting detoxification from illicit opiates. There are a number of detoxification agents but no recommended drug of choice. The purpose of this study is to compare buprenorphine with dihydrocodeine for detoxification from illicit opiates in primary care. Open label randomised controlled trial in NHS Primary Care (General Practices), Leeds, UK. Sixty consenting adults using illicit opiates received either daily sublingual buprenorphine or daily oral dihydrocodeine. Reducing regimens for both interventions were at the discretion of prescribing doctor within a standard regimen of not more than 15 days. Primary outcome was abstinence from illicit opiates at final prescription as indicated by a urine sample. Secondary outcomes during detoxification period and at three and six months post detoxification were recorded. Only 23% completed the prescribed course of detoxification medication and gave a urine sample on collection of their final prescri...
ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term ... more ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term mortality following invasive pneumococcal disease (IPD). There is a lack of evidence regarding the underlying causes, but work in pneumonia suggests an increase in cardiovascular deaths. We conducted a retrospective cohort study to examine the causes of death in the two years following IPD. Methods: All adult cases of IPD presenting to Hull and East Yorkshire Hospitals (1400 bed teaching hospital), 2007 to 2009 were identified via the Dept. of Microbiology&#39;s electronic-database. Medical records were reviewed and death certificates obtained for patients who died within 2 years of an episode of IPD. Causes of death within 30 days (early) were compared to those between 30 days and 2 years (late). Late deaths were compared to causes of death in our local population (N = 5819) in 2010. Results: 207 patients (50.7% male, mean age 64.9) were included. Most patients (80%) had pneumonia. Mortality at 30 days following IPD was 20.8% (n=43) and 38.6% (n=80) by 2 years. Within 30 days, infection was the primary cause of death in 60.5% and contributed to 83.72%. Infection remained an important cause of late death, being the primary cause in 24.3% and contributory in 45.9%. Of late deaths due to infection, 89% were due to respiratory infection. Malignancy was the primary cause of most late deaths (48.6%). A higher proportion of deaths between 30 days and 2 years were caused by respiratory disease (including respiratory infection) and malignancy compared to overall deaths locally (27.0% vs. 15.7% and 48.6% vs. 29.0%, respectively), but less were due to cardiovascular disease (10.8% vs. 32.6%). Conclusion: The majority of early deaths following IPD are due to infection, which remained an important primary and contributory cause of death during follow-up. Respiratory diseases (including pneumonia) were responsible for a greater proportion of late deaths compared to the general population. This work does not support the hypothesis that IPD increases late cardiovascular deaths with the majority of non-infective deaths being due to malignancy. Whether late deaths can be prevented by intervention (e.g. conjugate vaccine) after the IPD episode is unclear, but should be explored.
The British Journal of General Practice, May 1, 2004
In December 2000, the Committee for Safety of Medicines (CSM) advised that thioridazine may prolo... more In December 2000, the Committee for Safety of Medicines (CSM) advised that thioridazine may prolong QT intervals risking arrhythmias. We investigated the impact on general practitioner prescribing of thioridazine using a time series analysis. Numbers of items and costs of antipsychotics and benzodiazepines prescribed in Leeds from May 1999 until April 2002 were collated. Post-advice, thioridazine prescriptions dropped by 810 items per month (95% confidence interval = 420 to 1200, P<0.001) but others increased slightly in response. Costs mimicked these changes. Fresh criteria are proposed for appraising the quality of evidence needed to inform future urgent facsimile transmissions.
Family caregivers provide significant care at the end of life. We aimed to describe caregiver cha... more Family caregivers provide significant care at the end of life. We aimed to describe caregiver characteristics, and of those unwilling to repeat this role under the same circumstances. Observational study of adults in private households (Health Survey for England [HSE]). Caregiving questions included: whether someone close to them died within past 5 years; relationship to the deceased; provision, intensity and duration of care; supportive/palliative care services used; willingness to care again; able to carry on with life. Comparison between those willing to care again or not used univariable analyses and an exploratory multiple logistic regression. A descriptive comparison with Health Omnibus Survey (Australia) data was conducted. HSE response was 64%. 2167/8861 (25%) respondents had someone close to them die in the previous 5 years. Some level of personal care was provided by 645/8861 (7.3%). 57/632 (9%) former caregivers would be unwilling to provide care again irrespective of time since the death, duration of care, education and income. Younger age (≤65; odds ratio [OR] 2.79; 95% CI 136, 5.74) and use of palliative care services (odds ratio: 1.95, 95% CI: 1.09, 3.48) showed greater willingness to provide care again. Apart from use of palliative care services, findings were remarkably similar to the Australian data. A significant group of caregivers would be unwilling to provide care again. Older people and those who had not used palliative care services were more likely to be unwilling to care again. Barriers preventing access for disadvantaged groups need to be overcome.
BackgroundA Social Story™ (Carol Gray) is a child-friendly intervention that is used to give chil... more BackgroundA Social Story™ (Carol Gray) is a child-friendly intervention that is used to give children with autism spectrum disorders (ASDs) social information in situations where they have social difficulties. Limited evidence mainly using single-case designs suggests that they can reduce anxiety and challenging behaviour.ObjectivesThe objectives were to conduct a systematic review, use this to develop a manualised intervention and run a feasibility trial to inform a fully powered randomised controlled trial (RCT) on their clinical effectiveness and cost-effectiveness in schools.DesignThis is a three-stage study following the Medical Research Council framework for complex interventions. Specifically, it involved a theoretical phase, a qualitative stage and a feasibility trial stage.SettingQualitative interviews and focus groups took place in Child and Adolescent Mental Health Service and primary care settings. The feasibility study took place in 37 local mainstream schools.Participa...
National Institute for Health and Care Excellence guidelines used to triage patients with head in... more National Institute for Health and Care Excellence guidelines used to triage patients with head injury to CT imaging are based on research conducted in populations presenting within 24 h of injury.We aim to compare guideline use, and outcomes, in patients with head injury that undergo CT imaging presenting within, and after 24 h of injury. ED trauma CT head scan requests over a period of 6 months were matched to ED records. Case note review of adult patients with head injury that had undergone CT imaging was completed. Logistic regression was used to assess whether presentation after 24 h affected the guideline&amp;amp;amp;amp;#39;s ability to predict significant injuries. 650 case records were available for analysis. 8.6% (56/650) showed a traumatic abnormality, 1.5% (10/650) required neurosurgery or died. 15.5% (101/650) of CT scans were for patients presenting after 24 h. 8.4% (46/549) of those presenting within, and 9.9% (10/101) of those presenting after 24 h had traumatic CT abnormalities.The sensitivity of the guidelines for intracranial injuries was 98% (95% CI 87.0% to 99.9%) in those presenting within 24 h and 70% (95% CI 35.4% to 91.9%) in those presenting after 24 h of injury. The presence of a guideline indication statistically predicted significant injury, and this was unaffected by time of presentation. Patients with head injury presenting after 24 h of injury are a clinically significant population. Existing guidelines appear to predict traumatic CT abnormalities irrespective of timing of presentation. However, their sole use in patients presenting after 24 h may result in significant injuries not being identified.
Health technology assessment (Winchester, England), 2015
Home oxygen therapy (HOT) is commonly used for patients with severe chronic heart failure (CHF) w... more Home oxygen therapy (HOT) is commonly used for patients with severe chronic heart failure (CHF) who have intractable breathlessness. There is no trial evidence to support its use. To detect whether or not there was a quality-of-life benefit from HOT given as long-term oxygen therapy (LTOT) for at least 15 hours per day in the home, including overnight hours, compared with best medical therapy (BMT) in patients with severely symptomatic CHF. A pragmatic, two-arm, randomised controlled trial recruiting patients with severe CHF. It included a linked qualitative substudy to assess the views of patients using home oxygen, and a free-standing substudy to assess the haemodynamic effects of acute oxygen administration. Heart failure outpatient clinics in hospital or the community, in a range of urban and rural settings. Patients had to have heart failure from any aetiology, New York Heart Association (NYHA) class III/IV symptoms, at least moderate left ventricular systolic dysfunction, and ...
The UK South Asian population has poorer health outcomes. Little is known about their process of ... more The UK South Asian population has poorer health outcomes. Little is known about their process of care in general practice, or in particular the process of communication with GPs. To compare the ways in which white and South Asian patients communicate with white GPs. Observational study of video-recorded consultations using the Roter Interactional Analysis System (RIAS). West Yorkshire, UK. One hundred and eighty-three consultations with 11 GPs in West Yorkshire, UK were video-recorded and analysed. Main outcome measures were consultation length, verbal domination, 16 individual abridged RIAS categories, and three composite RIAS categories; with comparisons between white patients, South Asian patients fluent in English and South Asian patients nonfluent in English. South Asians fluent in English had the shortest consultations and South Asians non-fluent in English the longest consultations (one-way ANOVA F = 7.173, P = 0.001). There were no significant differences in verbal dominatio...
ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term ... more ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term mortality following invasive pneumococcal disease (IPD). There is a lack of evidence regarding the underlying causes, but work in pneumonia suggests an increase in cardiovascular deaths. We conducted a retrospective cohort study to examine the causes of death in the two years following IPD. Methods: All adult cases of IPD presenting to Hull and East Yorkshire Hospitals (1400 bed teaching hospital), 2007 to 2009 were identified via the Dept. of Microbiology&#39;s electronic-database. Medical records were reviewed and death certificates obtained for patients who died within 2 years of an episode of IPD. Causes of death within 30 days (early) were compared to those between 30 days and 2 years (late). Late deaths were compared to causes of death in our local population (N = 5819) in 2010. Results: 207 patients (50.7% male, mean age 64.9) were included. Most patients (80%) had pneumonia. Mortality at 30 days following IPD was 20.8% (n=43) and 38.6% (n=80) by 2 years. Within 30 days, infection was the primary cause of death in 60.5% and contributed to 83.72%. Infection remained an important cause of late death, being the primary cause in 24.3% and contributory in 45.9%. Of late deaths due to infection, 89% were due to respiratory infection. Malignancy was the primary cause of most late deaths (48.6%). A higher proportion of deaths between 30 days and 2 years were caused by respiratory disease (including respiratory infection) and malignancy compared to overall deaths locally (27.0% vs. 15.7% and 48.6% vs. 29.0%, respectively), but less were due to cardiovascular disease (10.8% vs. 32.6%). Conclusion: The majority of early deaths following IPD are due to infection, which remained an important primary and contributory cause of death during follow-up. Respiratory diseases (including pneumonia) were responsible for a greater proportion of late deaths compared to the general population. This work does not support the hypothesis that IPD increases late cardiovascular deaths with the majority of non-infective deaths being due to malignancy. Whether late deaths can be prevented by intervention (e.g. conjugate vaccine) after the IPD episode is unclear, but should be explored.
Cancer patients in lower socioeconomic groups are significantly less likely to die at home and ex... more Cancer patients in lower socioeconomic groups are significantly less likely to die at home and experience more barriers to access to palliative care. It is unclear whether receiving palliative care may mediate the effect of socioeconomic status on place of death. This review examines whether and how use of specialist palliative care may modify the effect of socioeconomic status on place of death. A systematic review was conducted. Eligible papers were selected and the quality appraised by two independent reviewers. Data were synthesised using a narrative approach. MEDLINE, Embase, CINAHL, PsycINFO and Web of Knowledge were searched (1997-2013). Bibliographies were scanned and experts contacted. Papers were included if they reported the effect of both socioeconomic status and use of specialist palliative care on place of death for adult cancer patients. Nine studies were included. All study subjects had received specialist palliative care. With regard to place of death, socioeconomic...
There is little published data reporting outcomes for those found to have a chronic total coronar... more There is little published data reporting outcomes for those found to have a chronic total coronary occlusion (CTO) that is electively treated medically versus those treated by percutaneous coronary intervention (PCI). We sought to compare long-term clinical outcomes between patients treated by PCI and elective medical therapy in a consecutive cohort of patients with an identified CTO. Patients found to have a CTO on angiography between January 2002 and December 2007 in a single tertiary centre were identified using a dedicated database. Those undergoing CTO PCI and elective medical therapy to the CTO were propensity matched to adjust for baseline clinical and angiographic differences. In total, 1957 patients were identified, a CTO was treated by PCI in 405 (20.7%) and medical therapy in 667 (34.1%), 885 (45.2%) patients underwent coronary artery bypass graft surgery. Of those treated by PCI or medical therapy, propensity score matching identified 294 pairs of patients, PCI was successful in 177 patients (60.2%). All-cause mortality at 5 years was 11.6% for CTO PCI and 16.7% for medical therapy HR 0.63 (0.40 to 1.00, p=0.052). The composite of 5-year death or myocardial infarction occurred in 13.9% of the CTO PCI group and 19.6% in the medical therapy group, HR 0.64 (0.42 to 0.99, p=0.043). Among the CTO PCI group, if the CTO was revascularised by any means during the study period, 5-year mortality was 10.6% compared with 18.3% in those not revascularised in the medical therapy group, HR 0.50 (0.28-0.88, p=0.016). Revascularisation, but not necessarily PCI of a CTO, is associated with improved long-term survival relative to medical therapy alone.
BACKGROUNDCerebral palsy is the commonest cause of severe physical disability in childhood. For m... more BACKGROUNDCerebral palsy is the commonest cause of severe physical disability in childhood. For many years treatment has centred on the use of physiotherapy and orthotics to overcome the problems of leg spasticity, which interferes with walking and can lead to limb deformity. Intramuscular botulinum toxin (BT-A) offers a targeted form of therapy to reduce spasticity in specific muscle groups.AIMSTo determine
With an aging population and limited resources, the incidence and prevalence of chronic kidney di... more With an aging population and limited resources, the incidence and prevalence of chronic kidney disease is increasing. We aimed at assessing the impact of the low clearance clinic (LCC) on not only the natural history of patients with deteriorating renal function but also the timing of renal replacement therapy (RRT) and mortality. A retrospective cohort study involving 271 patients who entered the LCC at Hull from July 2007 to December 2010 was conducted. Descriptive analysis based on baseline characteristics was performed and slope-estimated glomerular function rates (eGFR) before and after entry to the LCC were calculated. This aided survival analysis using quartiles and Kaplan-Meier. The change in slope eGFR was the study primary end point, but secondary end points, including mortality and time to RRT, were also measured. The average length of time within the LCC was 14 months and of those receiving RRT, 61% received this intervention within one year compared with 38% after 1 yea...
A clear understanding of the relationship between venous reflux, clinical venous disease and the ... more A clear understanding of the relationship between venous reflux, clinical venous disease and the effects on quality of life (QoL) remains elusive. This study aimed to explore the impact of venous disease, and assess any incremental direct effect of progressive disease on health-related QoL, with the ultimate aim to model venous morbidity. Consecutive patients with venous disease were assessed for inclusion in the study. Patients with isolated, unilateral, single superficial axial incompetence diagnosed on duplex imaging were included. Clinical grading was performed with the Clinical Etiologic Anatomic Pathophysiologic (CEAP) classification and Venous Clinical Severity Score (VCSS). Patients completed generic (Short Form 36, SF-36(®); EuroQol 5D, EQ-5D(™)) and disease-specific (Aberdeen Varicose Vein Questionnaire, AVVQ) QoL instruments. Multivariable regression modelling was performed, taking account of demographic and anatomical factors, to explore the effect of clinical severity o...
Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial f... more Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial fractures. The risk is as high as 77% without prophylaxis and around 10% with prophylaxis. Within the current literature there are no figures reported specifically for those individuals treated with circular frames. Our aim was to evaluate the VTE incidence within a single surgeon series and to evaluate potential risk factors. We retrospectively reviewed our consecutive single surgeon series of 177 patients admitted to a major trauma unit with tibial fractures. All patients received standardised care, including chemical thromboprophylaxis within 24h of injury until independent mobility was achieved. We comprehensively reviewed our prospective database and medical records looking at demographics and potential risk factors. Seven patients (4.0%±2.87%) developed symptomatic VTE during the course of frame treatment; three deep vein thrombosis (DVTs) and four pulmonary embolisms (PEs). Those with a VTE event had significantly increased body mass index (BMI) (p=0.01) when compared to those without symptomatic VTE. No differences (p&gt;0.05) were observed between the groups in age, gender, smoking status, fracture type (anatomical allocation or open/closed), delay to frame treatment, weight bearing status post-frame, inpatient stay or total duration of frame treatment. This study suggests that increased BMI is a statistically significant risk factor for VTE, as reported in current literature. In addition, we calculated the true risk of VTE following circular frame treatment for tibial fracture in our series is from 1.13% to 6.87%, which is at least comparable to other forms of treatment.
Journal of Bone and Joint Surgery - British Volume, 2010
We prospectively randomised 78 patients into two groups, &amp;amp;#39;drains&amp;amp;#39;... more We prospectively randomised 78 patients into two groups, &amp;amp;#39;drains&amp;amp;#39; or &amp;amp;#39;no drains&amp;amp;#39; to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.
Many drug users present to primary care requesting detoxification from illicit opiates. There are... more Many drug users present to primary care requesting detoxification from illicit opiates. There are a number of detoxification agents but no recommended drug of choice. The purpose of this study is to compare buprenorphine with dihydrocodeine for detoxification from illicit opiates in primary care. Open label randomised controlled trial in NHS Primary Care (General Practices), Leeds, UK. Sixty consenting adults using illicit opiates received either daily sublingual buprenorphine or daily oral dihydrocodeine. Reducing regimens for both interventions were at the discretion of prescribing doctor within a standard regimen of not more than 15 days. Primary outcome was abstinence from illicit opiates at final prescription as indicated by a urine sample. Secondary outcomes during detoxification period and at three and six months post detoxification were recorded. Only 23% completed the prescribed course of detoxification medication and gave a urine sample on collection of their final prescri...
ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term ... more ABSTRACT Background: Although considered an acute illness, evidence suggests increased long term mortality following invasive pneumococcal disease (IPD). There is a lack of evidence regarding the underlying causes, but work in pneumonia suggests an increase in cardiovascular deaths. We conducted a retrospective cohort study to examine the causes of death in the two years following IPD. Methods: All adult cases of IPD presenting to Hull and East Yorkshire Hospitals (1400 bed teaching hospital), 2007 to 2009 were identified via the Dept. of Microbiology&#39;s electronic-database. Medical records were reviewed and death certificates obtained for patients who died within 2 years of an episode of IPD. Causes of death within 30 days (early) were compared to those between 30 days and 2 years (late). Late deaths were compared to causes of death in our local population (N = 5819) in 2010. Results: 207 patients (50.7% male, mean age 64.9) were included. Most patients (80%) had pneumonia. Mortality at 30 days following IPD was 20.8% (n=43) and 38.6% (n=80) by 2 years. Within 30 days, infection was the primary cause of death in 60.5% and contributed to 83.72%. Infection remained an important cause of late death, being the primary cause in 24.3% and contributory in 45.9%. Of late deaths due to infection, 89% were due to respiratory infection. Malignancy was the primary cause of most late deaths (48.6%). A higher proportion of deaths between 30 days and 2 years were caused by respiratory disease (including respiratory infection) and malignancy compared to overall deaths locally (27.0% vs. 15.7% and 48.6% vs. 29.0%, respectively), but less were due to cardiovascular disease (10.8% vs. 32.6%). Conclusion: The majority of early deaths following IPD are due to infection, which remained an important primary and contributory cause of death during follow-up. Respiratory diseases (including pneumonia) were responsible for a greater proportion of late deaths compared to the general population. This work does not support the hypothesis that IPD increases late cardiovascular deaths with the majority of non-infective deaths being due to malignancy. Whether late deaths can be prevented by intervention (e.g. conjugate vaccine) after the IPD episode is unclear, but should be explored.
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Papers by Victoria Allgar