Royal Devon and Exeter Hospital

About: Royal Devon and Exeter Hospital is a healthcare organization based out in Exeter, United Kingdom. It is known for research contribution in the topics: Population & Randomized controlled trial. The organization has 2282 authors who have published 2526 publications receiving 78866 citations. The organization is also known as: RD&E.

Mydriasis due to Datura inoxia.

Abstract: Unilateral, dilated unresponsive pupil may be secondary to a wide range of ocular and neurological disorders. "Gardener's pupil" is a pharmacological mydriasis caused by exposure to plants containing alkaloids. We report a case of mydriasis related to Datura inoxia, and detail a number of plants that have toxic effects. This report emphasises the importance of accurate history taking when evaluating fixed dilated pupil. We recommend that labelling of such poisonous plants should detail the local and systemic effects of accidental exposure, rather than merely the fact that they are poisonous.

The effectiveness and cost-effectiveness of erythropoiesis-stimulating agents (epoetin and darbepoetin) for treating cancer treatment-induced anaemia (including review of technology appraisal no. 142): a systematic review and economic model.

Abstract: Background Anaemia is a common side effect of cancer treatments and can lead to a reduction in quality of life. Erythropoiesis-stimulating agents (ESAs) are licensed for use in conjunction with red blood cell transfusions to improve cancer treatment-induced anaemia (CIA). Objective To investigate the effectiveness and cost-effectiveness of ESAs in anaemia associated with cancer treatment (specifically chemotherapy). Data sources The following databases were searched from 2004 to 2013: The Cochrane Library, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Web of Science, Cumulative Index to Nursing and Allied Health Literature, British Nursing Index, Health Management Information Consortium, Current Controlled Trials and ClinicalTrials.gov. The US Food and Drug Administration and European Medicines Agency websites were also searched. Bibliographies of included papers were scrutinised for further potentially includable studies. Review methods The clinical effectiveness review followed principles published by the NHS Centre for Reviews and Dissemination. Randomised controlled trials (RCTs), or systematic reviews of RCTs, of ESAs (epoetin or darbepoetin) for treating people with CIA were eligible for inclusion in the review. Comparators were best supportive care, placebo or other ESAs. Anaemia- and malignancy-related outcomes, health-related quality of life (HRQoL) and adverse events (AEs) were evaluated. When appropriate, data were pooled using meta-analysis. An empirical health economic model was developed comparing ESA treatment with no ESA treatment. The model comprised two components: one evaluating short-term costs and quality-adjusted life-years (QALYs) (while patients are anaemic) and one evaluating long-term QALYs. Costs and benefits were discounted at 3.5% per annum. Probabilistic and univariate deterministic sensitivity analyses were performed. Results Of 1457 titles and abstracts screened, 23 studies assessing ESAs within their licensed indication (based on start dose administered) were included in the review. None of the RCTs were completely aligned with current European Union licenses. The results suggest a clinical benefit from ESAs for anaemia-related outcomes and an improvement in HRQoL scores. The impact of ESAs on AEs and survival remains highly uncertain, although point estimates are lower, confidence intervals are wide and not statistically significant. Base-case incremental cost-effectiveness ratios (ICERs) for ESA treatment compared with no ESA treatment ranged from £ 19,429 to £ 35,018 per QALY gained, but sensitivity and scenario analyses demonstrate considerable uncertainty in these ICERs, including the possibility of overall health disbenefit. All ICERs were sensitive to survival and cost. Limitations The relative effectiveness of ESAs was not addressed; all ESAs were assumed to have equivalent efficacy. No studies were completely aligned with their European labelling beyond the starting dose evaluated. There is questionable generalisability given that the included trials were published >20 years ago and there have been many changes to chemotherapy as well as to the quality of supportive treatment. Trial quality was moderate or poor and there was considerable unexplained heterogeneity for a number of outcomes, particularly survival, and evidence of publication bias. Adjustments were not made to account for multiple testing. Conclusions ESAs could be cost-effective when used closer to licence, but there is considerable uncertainty, mainly because of unknown impacts on overall survival. Study registration This study is registered as PROSPERO CRD42013005812. Funding The National Institute for Health Research Health Technology Assessment programme.

Vitamin D levels and risk of delirium: A mendelian randomization study in the UK Biobank

Abstract: Objective To estimate effects of vitamin D levels on incident delirium hospital admissions using inherited genetic variants in mendelian randomization models, which minimize confounding and exclude reverse causation. Methods Longitudinal analysis using the UK Biobank, community-based, volunteer cohort (2006–2010) with incident hospital-diagnosed delirium (ICD-10 F05) ascertained during ≤9.9 years of follow-up of hospitalization records (to early 2016). We included volunteers of European descent aged 60-plus years by end of follow-up. We used single-nucleotide polymorphisms previously shown to increase circulating vitamin D levels, and APOE variants. Cox competing models accounting for mortality were used. Results Of 313,121 participants included, 544 were hospitalized with delirium during follow-up. Vitamin D variants were protective for incident delirium: hazard ratio = 0.74 per 10 nmol/L (95% confidence interval 0.62–0.87, p = 0.0004) increase in genetically instrumented vitamin D, with no evidence for pleiotropy (mendelian randomization–Egger p > 0.05). Participants with ≥1 APOE e4 allele were more likely to develop delirium (e.g., e4e4 hazard ratio = 3.73, 95% confidence interval 2.68–5.21, p = 8.0 × 10 −15 compared to e3e3), but there was no interaction with vitamin D variants. Conclusions and relevance In a large community-based cohort, there is genetic evidence supporting a causal role for vitamin D levels in incident delirium. Trials of correction of low vitamin D levels in the prevention of delirium are needed.

What do trainees think about advanced trauma life support (ATLS)

Abstract: Advanced trauma life support (ATLS) has become a desirable or even essential part of training for many surgeons and anaesthetists, but aspects of the ATLS course have attracted criticism. In the absence of published data on the views of trainees, this study sought their opinions in a structured questionnaire, which was completed by trainees in accident and emergency (A & E) (26), anaesthetic (82), general surgical (26), orthopaedic (42) and other (5) posts in different hospitals (response rate 66%). Of the trainees, 78% had done an ATLS course and, of these, 83% considered ATLS a 'major advantage' or 'essential' for practising their proposed specialty--100% for A & E, 94% for orthopaedics, 92% for general surgery, and 75% for anaesthetics. ATLS was considered a major curriculum vitae (CV) advantage by 94%, 85%, 50%, and 45%, respectively. Over 90% had positive attitudes towards ATLS, and 74% selected 'genuine improvement of management of trauma patients' as the most important reason for doing the course: 93% thought ATLS saved lives. Of the respondents, 83% thought that all existing consultants dealing with trauma patients should have done the course, and 41% thought it offered major advantages to doctors not involved in trauma. Funding problems for ATLS courses had been experienced by 14% trainees. This survey has shown that most trainees view ATLS positively. They believe that it provides genuine practical benefit for patients, and very few regard ATLS primarily as a career advantage or mandate.