Showing papers by "Aintree University Hospitals NHS Foundation Trust published in 2008"

Fine-needle aspiration cytology in a regional head and neck cancer center: comparison with a systematic review and meta-analysis.

Abstract: Background Fine-needle aspiration cytology (FNAC) is used to diagnose masses presenting in the head and neck region. No systematic review of FNAC in this group has yet been performed. Methods A systematic review of the published literature and meta-analysis of data extracted from the included studies were compared with a 10-year review of head and neck FNAC from our institution. Results Systematic review identified 30 studies; 3459 FNAC aspirates from all head and neck sites were included. Overall results were as follows: sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were 89.6%, 96.5%, 93.1%, 96.2%, and 90.3%, respectively. Two thousand seven hundred two head and neck aspirates were included in our institutional review. Sensitivity, specificity, PPV, NPV, and accuracy were 89.5%, 98.5%, 97.3%, 94.0%, and 95.1%, respectively. Conclusion Meta-analysis and comparative systematic review confirm that FNAC is highly effective in the diagnosis of head and neck masses, with some limitations. © 2008 Wiley Periodicals, Inc. Head Neck, 2008

Unanticipated difficult airway management in anaesthetised patients: a prospective study of the effect of mannequin training on management strategies and skill retention

Abstract: This prospective study on a medium-fidelity simulator (SimMan, Laerdal Medical Corporation, Wappingers Falls, NY, USA) examined the management of unanticipated difficult airway by 21 anaesthetists and the effect of training in this context. There were two scenarios investigated: 'cannot intubate, can ventilate' (CI) and 'cannot intubate, cannot ventilate' (CICV). Following initial evaluation, volunteers underwent training in the 'Difficult Airway Society' (DAS) algorithms and associated technical skills. At 6-8 weeks and 6-8 months, performance was compared with the initial evaluation. There was a more structured approach following training (p < 0.05), which was sustained at 6-8 months, but only for the CICV scenario (p < 0.01). In CI, use of standard and intubating laryngeal mask airway increased following training (p = 0.021). This was sustained over time (p = 0.01). In both scenarios there was a reduced incidence of equipment misuse (p < 0.0005), which was sustained over time (p < 0.0001). We conclude that simulation-based training significantly improves performance for at least 6-8 weeks. Training should be repeated at intervals of 6 months or less.

Rheumatoid factor, smoking, and disease severity: associations with mortality in rheumatoid arthritis.

Abstract: The majority of mortality studies published over the last 15 years have identified excess mortality in rheumatoid arthritis (RA) cohorts compared to that in the general population (Table 11–17), and many have highlighted excess mortality from cardiovascular causes. Methodology and study design seem to affect the magnitude of the mortality rates, with community-based and inception-cohort followup studies being associated with smaller increases in standardized mortality ratios (SMR) than studies of established prevalent RA cohorts. In this issue of The Journal , Gonzalez, et al explore mortality rates in a population-based cohort of RA patients from Rochester, Minnesota, USA, stratified by…

Chickenpox in varicella IgG positive patients: experience of a regional paediatric oncology centre.

Abstract: Aciclovir prophylaxis was previously given to all immunocompromised patients treated by our unit, following contact with varicella zoster. In 2003, we changed practice according to National Guidelines, giving prophylaxis only to patients without serum varicella zoster immunoglobulin G antibody (VZ IgG) at diagnosis of their malignancy. Since then we have seen nine patients with acute lymphoblastic leukaemia (ALL) and VZ IgG positivity at diagnosis of their malignancy develop chickenpox. Our observations question current practice for patients with ALL. Pediatr Blood Cancer 2008;51:540–542. © 2008 Wiley-Liss, Inc.

Blood pressure measurement.

Abstract: Blood pressure measurement is an essential clinical skill for all nurses. However, if the procedure is not followed carefully there is potential for error that can adversely affect patient management. Nurses performing blood pressure measurement should be appropriately trained and updated on the procedure and the correct use of equipment. This article outlines the procedure for measuring blood pressure using a conventional mercury or aneroid sphygmomanometer and an electronic blood pressure monitor. It also identifies potential sources of error.

Tonometer disinfection practice in the United Kingdom: a national survey.

Abstract: To assess current tonometer disinfection practice in the UK, and compare with published recommendations. Every ophthalmology unit with training recognition in the UK was contacted (n=155). A senior nurse at each institution completed a telephone questionnaire regarding local tonometer disinfection practice. The response rate was 100%. Thirty-five units (23%) reported exclusive use of disposable tonometer heads and were excluded from further analysis. One hundred and twenty units (77%) used either reusable or a combination of reusable and disposable tonometer heads. Where reusable heads were used, 80 units (67%) immersed them in a chlorine-based solution such as sodium hypochlorite or sodium dichloroisocyanurate. Others used isopropyl alcohol (18 units), hydrogen peroxide (12 units), chloramine (5 units), chlorhexidine (4 units) and peracetic acid (1 unit). Where a chlorine-based agent was used, the concentration of available chlorine ranged from 125 to 30 000 p.p.m., with 50 units (63%) using a concentration of less than 5 000 p.p.m. (i.e., inadequate based on published recommendations). Where the tonometer head was immersed in disinfectant between patients (n=101), 29 units (29%) provided just one tonometer head per practitioner, making adequate soak time between patients unlikely. Every unit replenished the disinfectant at least daily, deemed sufficient for most agents. However, hydrogen peroxide solutions should be replenished twice daily, which did not take place in nine units. This survey reveals disparity between current tonometer disinfection practice and published international recommendations, with some institutions using practices that may render patients susceptible to transmissible infection.

Extensive necrosis of visceral melanoma metastases after immunotherapy.

Abstract: The prognosis for metastatic melanoma remains poor even with traditional decarbazine or interferon therapy. 5-year survival is markedly higher amongst patients undergoing metastatectomy. Unfortunately not all are suitable for metastatectomy. Alternative agents for systemic therapy have, to date, offered no greater rates of survival beyond traditional therapy. A toll-like receptor 9 agonist, PF-3512676 (formerly known as CPG 7909) is currently being evaluated for its potential. We present the case of a 54-year-old Caucasian male with completely resected metastatic cutaneous melanoma after immunotherapy. The patient initially progressed during adjuvant high-dose interferon, with metastases to the liver, spleen, and pelvic lymph nodes. During an 18-month treatment period with PF-3512676 (formerly known as CPG 7909), a synthetic cytosine-phosphorothioate-guanine rich oligodeoxynucleotide, slow radiologic disease progression was demonstrated at the original disease sites. Subsequent excision of splenic and pelvic nodal metastases was performed, followed by resection of the liver metastases. Histologic examination of both hepatic and splenic melanoma metastases showed extensive necrosis. Subsequent disease-free status was demonstrated by serial positron emission tomography (PET). Existing evidence from phase I/II trials suggests systemic treatment with PF-3512676 is capable of provoking a strong tumor-specific immune response and may account for the prolonged tumor control in this instance.

The North West Diabetic Pregnancy Audit: a practical system for multi-centre diabetic pregnancy audit.

Abstract: Aims Improving care for women with pre-gestational diabetic pregnancy is a core objective of the St Vincent Declaration and the Diabetes National Service Framework. The aim was to develop a practicable collaborative audit methodology for pre-gestational diabetic pregnancy. Methods In 1999, care professionals in the north-west of England agreed standards and a simple monthly data collection system. Annual reports are compiled to summarize compliance with the standards. Each hospital receives an individualized report comprising tables and funnel plots that allow between-hospital comparisons. Results Data on pre-gestational diabetic pregnancies are collated from 30 maternity units. Funnel plots and tables presented in the annual reports highlight any large differences between hospitals in booking and outcome measures for diabetic pregnancies. Conclusions The annual audit reports allow the assessment of current management and outcomes for diabetic pregnancies at a regional and local level. These reports help to identify areas where diabetic pregnancy care requires further attention.

Changes in cardiovascular risk factors in a type 1 diabetes population: a 3.5‐year study

Abstract: This study aimed to assess the prevalence of cardiovascular risk factors in a cohort of patients with type 1 diabetes attending a routine diabetic clinic, and to compare the data with those from a previous study (2003–2004). The clinic records of 218 patients with type 1 diabetes from the previous study were examined. The following were recorded: age, sex, duration of diabetes, insulin regimen, weight, body mass index, blood pressure, glycated haemoglobin (HbA1c), lipid profile, urine albumin–creatinine ratio, and the presence of micro- and macrovascular complications. Data were available from 184 (84.4%) of the original 218 patients— mean age 37.3 years (range 20–76 years), and duration of diabetes 18.4 years (4–42 years). Mean HbA1c, total cholesterol and low-density lipoprotein improved significantly between the two study periods (respectively: 9.6±1.9% vs 9.1±1.7%, p<0.01; 5.0±1.0mmol/L vs 4.4±1.1mmol/L, p<0.01; 2.8±0.8mmol/L vs 2.3±0.8mmol/L, p<0.01). However, systolic (113±19mmHg vs 122±17mmHg, p<0.01) and diastolic blood pressure (65±10mmHg vs 67±9mmHg, p<0.01) increased despite greater use of antihypertensives. It was concluded that attention to cardiovascular risk factors can result in improvements in HbA1c and lipid profile in a routine clinic. However, blood pressure levels increase and compliance with medication must be emphasised. A large proportion of patients with type 1 diabetes continue to have cardiovascular risk factors above current targets and additional strategies are required. Copyright © 2008 John Wiley & Sons.

Integrated care of the patient dying of nonmalignant respiratory disease

Abstract: Educational aims To understand the current limitations to providing the best care to patients dying of nonmalignant respiratory disease. To understand how careful communication and support from the multidisciplinary team can improve this. To discuss the role of an integrated care pathway for use with dying patients. To understand the limitations of current knowledge and the importance of further research in this area. Summary The development of palliative care as a speciality in its own right has led to great improvements in the care of dying patients, but both funding and service arrangements have meant that the majority of these improvements have been seen in patients dying with malignant diseases. Here we will consider how, by making the best use of current resources, we can improve the care and support given to patients dying of nonmalignant respiratory disease, as well as providing support to their families and carers.

Blood pressure control and ACE inhibitor/angiotensin receptor blocker usage

Abstract: The aim of this audit was to determine the changes over a four-year period in the numbers of type 2 patients with microalbuminuria (MA) and diabetic nephropathy (DN) treated with angiotensin converting enzyme inhibitor (ACE-I) and/or angiotensin receptor blocker (ARB) therapy and who had achieved target blood pressure (BP) control. We undertook a retrospective electronic case note audit of 200 type 2 patients attending hospital diabetes clinics. Patients were divided into three groups: MA, DN and normoalbuminuric. Results were compared with a similar audit carried out four years previously. The three groups were well matched for numbers, age, sex and HbA1c. The numbers achieving target BP had not improved in all three groups. There was no improvement in systolic BP but diastolic BP improved significantly in all groups— MA 74±12 to 69±11 (p = 0.03); DN 78±12 to 70±13 (p = 0.02); and normoalbuminuric 73±12 to 69±11 (p = 0.006). Only the normoalbuminuric group showed a significant increase in the numbers prescribed ≥ three antihypertensive drugs (14% to 28%, p = 0.008). Treatment with ACE-I and/or ARB had improved overall in the MA group (53% to 92%, p<0.0001), and in the normoalbuminuric group (41% to 57%, p = 0.01). Usage of ARB therapy increased significantly in all groups— MA 3% to 23% (p = 0.01); DN 13% to 47% (p = 0.003); and normoalbuminuric 2% to 15% (p = 0.0003). We conclude that hypertension remains under-treated, especially in the MA and DN groups despite an improvement in the usage of ACE-I and ARB therapy. Widespread use of protocol-driven, nurse-led clinics may help to intensify management. Copyright © 2008 John Wiley & Sons.

Attempts to prevent holiday‐related diabetic foot ulceration

Abstract: The risk of diabetic foot ulceration is increased on holidays (‘ Diabetic Holiday Foot Syndrome’), often related to barefoot walking and poorly fitting sandals or beach shoes. We introduced an intensive educational programme in our clinic population in order to increase awareness of the problem and advise on preventive approaches. Case notes were audited for the year before (Year 1) and year after (Year 2) introduction of the programme to assess the impact on holiday-related foot ulceration, and its characteristics. In Year 1 there were three new holiday foot ulcers, out of a total of 52 new ulcers in the year (5.8%). In Year 2 the figure was four out of 55 (7.3%). The difference was not significant. There was evidence from individual case histories that educational messages were being received but ignored in a holiday situation. New preventive strategies, other than direct patient education, will be needed if the prevalence of holiday-related diabetic foot ulceration is to be reduced. Copyright © 2008 John Wiley & Sons.