• Barriers and enablers to the implementation of a complex quality improvement intervention for acute kidney injury: A qualitative evaluation of stakeholder perceptions of the Tackling AKI study.

      Fluck, Richard; Selby, Nicholas (2019-09)
      BACKGROUND: Acute kidney injury in hospital patients is common and associated with reduced survival and higher healthcare costs. The Tackling Acute Kidney Injury (TAKI) quality improvement project aimed to reduce mortality rates in patients with acute kidney injury by implementing a multicomponent intervention comprising of an electronic alert, care bundle and education in five UK hospitals across a variety of wards. A parallel developmental evaluation using a case study approach was conducted to provide the implementation teams with insights into factors that might impact intervention implementation and fidelity. The qualitative element of the evaluation will be reported. METHODS: 29 semi-structured interviews with implementation teams across the five hospitals were carried out to identify perceived barriers and enablers to implementation. Interviews were taped and transcribed verbatim and Framework analysis was conducted. RESULTS: Interviews generated four 'barriers and enablers' to implementation themes: i) practical/contextual factors, ii) skills and make-up of the TAKI implementation team, iii) design, development and implementation approach, iv) staff knowledge, attitudes, behaviours and support. Enablers included availability of specialist teams (e.g. educational teams), multi-disciplinary implementation teams with strong leadership, team-based package completion and proactive staff. Barriers were frequently the converse of facilitators. CONCLUSIONS: Despite diversity of sites, a range of common local factors-contextual, intervention-based and individual-were identified as potential barriers and enablers to fidelity, including intervention structure/design and process of/approach to implementation. Future efforts should focus on early identification and management of barriers and tailored optimisation of known enablers such as leadership and multidisciplinary teams to encourage buy-in. Improved measures of real-time intervention and implementation fidelity would further assist local teams to target their support during such quality improvement initiatives.
    • Be on alert for pediatric AKI

      Selby, Nicholas (2017-08)
      Acute kidney injury in children is associated with adverse outcomes, although much of our current understanding originates from studies in intensive care units. Holmes et al. used an automated acute kidney injury detection method to obtain epidemiologic data on pediatric acute kidney injury at a national level in outpatient, inpatient, and intensive care unit settings. We discuss the impact of these important results and the considerations needed with this approach.
    • Bilateral pneumothorax, surgical emphysema and pneumomediastinum in a young male patient following MDMA intake

      Obiechina, Nonyelum (2018-04)
      MDMA (3,4-methylenedioxymethamphetamine) or 'Ecstasy' is an illicit drug frequently used by young people at parties and 'raves'. It is readily available in spite of the fact that it is illegal.1 It is perceived by a lot of young people as being 'harmless', but there have been a few high-profile deaths associated with its use.2 Known side effects of MDMA include hyperthermia, rhabdomyolysis, coagulopathy and cardiac arrhythmias.3 Rarer side effects include surgical emphysema and pneumomediastinum, which have been better described with cocaine abuse.4-6 We present a case of bilateral pneumothorax, surgical emphysema and pneumomediastinum in a young man after taking ecstasy.
    • Biological mesh reconstruction of perineal wounds following enhanced abdominoperineal excision of rectum (APER).

      Peacock, Oliver; Pandya, H; Sharp, T; Hurst, NG; Speake, WJ; Tierney, Gillian; Lund, Jonathan (2012-04)
      INTRODUCTION: An abdominoperineal excision of rectum (APER) may be required for rectal tumours less than 6 cm from the anal verge. Recently, the cylindrical APER has been used to prevent the "surgical waist" and so decrease margin involvement. However, removal of the levators leaves a large defect. Myocutaneous flaps [e.g. vertical rectus abdominis (VRAM)] are often used to fill the cylindrical resection defect, but have disadvantages associated with operative time, expertise and morbidity. We report our early experience of pelvic floor reconstruction with a biological mesh following cylindrical APER. METHODS: Data on consecutive patients having cylindrical APER between January 2008 and November 2010 were collected. Outcomes were compared between a VRAM reconstruction group and a mesh group. RESULTS: In 15 consecutive patients with low rectal cancer, five patients had VRAM pelvic floor reconstruction prior to ten patients having biosynthetic mesh repairs. The median operative time for the VRAM cohort was 405 min, compared with 259 min for the mesh (p = 0.0013). The median length of postoperative stay was 20 days for VRAM and 10 days for the mesh group (p = 0.067). There were four early complications for the VRAM group compared with seven for the mesh cohort (p = 0.37). The median cost per patient for the VRAM cohort was £11,075 compared to a median cost of £6,513 for the Mesh (p = 0.0097). CONCLUSION: The use of a biological mesh for pelvic floor reconstruction following cylindrical APER is feasible with morbidity comparable to VRAM reconstruction. There is significant cost-saving using a biosynthetic mesh, mainly due to reduced length of stay.
    • Biomarkers During Recovery From AKI and Prediction of Long-term Reductions in Estimated GFR.

      Packington, Rebecca; Shaw, Susan; Akani, A; Selby, Nicholas (2021)
      RATIONALE & OBJECTIVE: The effects of acute kidney injury (AKI) on long-term kidney function, cardiovascular disease, and mortality are well documented. We aimed to identify biomarkers for estimating the risk of new or worsening chronic kidney disease (CKD) following AKI. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: Adults from a single clinical center who developed AKI between May 2013 and May 2016, and survived until 3 years after the hospitalization during which AKI occurred. Participants included those with and without pre-existing CKD. PREDICTORS: Panel of 11 plasma biomarkers measured 3-months after hospitalisation. OUTCOME: Kidney disease progression, defined as a ≥25% decline in eGFR combined with a decline in CKD stage, assessed three years after the occurrence of AKI. ANALYTICAL APPROACH: Associations between biomarkers and kidney disease progression were evaluated in multivariable logistic regression models. Importance of predictor variables was assessed by constructing multiple decision trees, with penalised Lasso logistic regression for variable selection used to produce multivariable models. RESULTS: A total of 500 patients were studied. Soluble tumour necrosis factor receptor 1 (sTNFR1), sTNFR2, cystatin C, neutrophil gelatinase-associated lipocalin (NGAL), three-month eGFR and urine albumin:creatinine ratio (ACR) were independently associated with kidney disease progression and were more important than AKI severity or duration. A multivariable model containing sTNFR1, sTNFR2, cystatin C and eGFR discriminated between those with and without kidney disease progression (AUC 0.79, 95% CI 0.7-0.83). Optimising the cut-point to maximise utility as a 'rule-out' test to identify those at low risk increased the sensitivity of the model to 95% and its negative predictive value to 92%. LIMITATIONS: Lack of external validation cohort. Analyses limited to patients surviving for 3 years after AKI. Mixed population of patients with and without baseline CKD. CONCLUSIONS: A panel of plasma biomarkers measured 3-months after discharge from a hospitalization complicated by AKI provides potential opportunity to identify patients who are at very low risk of incident or worsening CKD. Further study is required to determine its clinical utility through independent prospective validation.
    • Brain white matter microstructure in end-stage kidney disease, cognitive impairment, and circulatory stress.

      Eldehni, Mohamed (http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1542-4758, 2019-07)
      INTRODUCTION: Structural and functional brain white matter abnormalities are poorly characterized in patients with end-stage kidney disease. METHODS: We examined the prevalence of the brain white matter microstructure disruption using diffusion tensor magnetic resonance imaging and its association with hemodynamic performance and cognitive defects in 49 incident hemodialysis (HD) patients and compared these to 25 age-matched normal controls. We analysed fractional anisotropy (FA) and mean diffusivity (MD) maps of the images, a voxelwise statistical analysis was done using tract-based spatial statistics. Hemodynamic assessment was done using extrema points analysis model of continuous blood pressure monitoring. FINDINGS: We found significant white matter damage in HD patients compared with normal controls (peak FA 0.471 ± 0.031 vs 0.486 ± 0.022 P = 0.023, peak MD 0.00194 ± 0.000363 10-3 mm2 .s-1 vs 0.00167 ± 0.0003 10-3 mm2 .s-1 P = 0.002). There was diffuse pattern of white matter damage in HD patients, which was independent of age, gender, and the presence of ischaemic heart disease and diabetes with significantly lower FA values in HD patients than normal controls (0.467 ± 0.037 vs 0.507 ± 0.026, P < 0.05 corrected for family wise error. HD patients had worse cognitive scores that correlated with white matter damage (for peak FA, Montreal cognitive assessment r = 0.478 P = 0.001, Trail A r = -0.486 P = 0.001, Trail B r = -0.464 P = 0.001; for peak MD, Montreal cognitive assessment r = -0.533 P < 0.001, Trail A r = 0.641 P < 0.001, Trail B r = 0.514 P < 0.001). In a multivariable linear regression analysis that included age, smoking, the presence of ischaemic heart disease, and diabetes mellitus, higher frequency of mean arterial blood pressure extrema points during HD was independently associated with white matter damage (β = -0.296, P = 0.036, Adjusted R2 for the whole model = 0.400). DISCUSSION: End-stage kidney disease patients on HD have more brain white matter damage and cognitive impairment than age-matched controls that are linked to hemodynamic functional measures.
    • Breathlessness in advanced disease. 1: Definitions, epidemiology and pathophysiology.

      Barnes, D (2010-11)
      This first in a two part unit on breathlessness in advanced disease defines the condition and discusses the epidemiology. It gives an overview of the complex pathophysiology that contributes to breathlessness.
    • Breathlessness in advanced disease. 2: Patient assessment and management.

      Barnes, D (2010-11)
      This second of a two part unit on breathlessness addresses patient assessment and management, including common treatments. Interventions that can be taught to, and used independently by, patients and carers are explored.
    • British Thoracic Society Clinical Statement on Pulmonary Arteriovenous Malformations.

      Donaldson, James (2017-12)
      Pulmonary arteriovenous malformations (PAVMs) are structurally abnormal vascular communications that provide a continuous right-to-left shunt between pulmonary arteries and veins. Their importance stems from the risks they pose (>1 in 4 patients will have a paradoxical embolic stroke, abscess or myocardial infarction while life-threatening haemorrhage affects 1 in 100 women in pregnancy), opportunities for risk prevention, surprisingly high prevalence and under-appreciation, thus representing a challenging condition for practising healthcare professionals. The driver for the current Clinical Statement was the plethora of new data since previous hereditary haemorrhagic telangiectasia (HHT) guidelines generated in 2006 and a systematic Cochrane Review for PAVM embolisation in 2011. The British Thoracic Society (BTS) identified key areas in which there is now evidence to drive a change in practice. Due to the paucity of data in children, this Statement focused on adults over 16 years. The Statement spans the management of PAVMs already known to be present (interventional and medical), screening and diagnosis (for PAVMs and HHT) and follow-up of patients following a first diagnosis, intervention or negative screen for PAVMs. The Good Practice Points (in bold) were generated for a target audience of general respiratory, medical and specialist clinicians and were approved by the BTS Standards of Care Committee, before formal peer review and public consultation. The Statement spans embolisation treatment, accessory medical management and issues related to the likelihood of underlying HHT.
    • British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism.

      Donaldson, James (2018-06)
      The following is a summary of the recommendations and good practice points for the BTS Guideline for the initial outpatient management of pulmonary embolism. Please refer to the full guideline for full information about each section.
    • Burnout in diabetes and endocrinology specialist registrars across England, Scotland and Wales in the pre-COVID era.

      Agha, A
      BACKGROUND: Presence of either emotional exhaustion, depersonalization or lack of personal accomplishment define Burnout Syndrome which may lead to decreased workforce productivity, increased absenteeism, depression and medical errors as well as decreased patient satisfaction. OBJECTIVE: The aim of this study was to assess the frequency of burnout syndrome among Diabetes Specialist Registrars across England, Scotland and Wales and to identify any self-reported factors which may be contributory to burnout. METHODS: Over 430 Diabetes Specialist Registrars were invited to anonymously participate in an electronic survey which used Maslach Burnout Inventory and selfreporting questionnaire to identify burnout and contributory factors. RESULTS: In this pre-pandemic times study, Burnout was identified in 61 (57.5%; n = 106) respondents using Maslach burnout cut-off scores. 45.2% (48/106) participants had scored high in Emotional Exhaustion, while lack of personal accomplishment and depersonalization was seen in 24.5% (26/106) and 21.6% (23/106) of the respondents respectively. The commonest self-reported stressors by participants were "General Internal Medicine workload" 60.4% (64/106) followed by "Lack of specialty training" 36.8% (39/106) and "Lack of audit/research/Continuing Professional Development time" 10.8% (11/106) CONCLUSION: Burnout syndrome is frequent among the participating Diabetes Specialist Registrars and urgent steps may be required address this problem nationally to ensure that these physicians remain physically and mentally healthy, especially after the pandemic.
    • Carbohydrate counting and insulin dose adjustment: group education for people with type 2 diabetes.

      Shorrock, I (2011)
      A group education programme at the Royal Derby Hospital for type 2 diabetes patients. The impact of the programme, which provided information on carbohydrate and insulin, on patients' weight, HbA1c levels, and insulin dosage is described.
    • Cardiac Output assessed via Esophageal Doppler Monitoring Fails to Predict Changes in Renal Microvascular Perfusion

      Read, David; Doleman, Brett; Williams, John P (2019-10)
      Background: Vasoactive drugs are routinely used clinically to alter mean arterial blood pressure (MAP) and cardiac output (CO) and to maintain organ perfusion. However, the effect of such drugs on microvascular visceral blood flow (MiBF) is not fully understood. We aimed to track changes in renal MiBF, using the well-validated technique of Contrast Enhanced Ultrasound (CEUS), across a range of MAP and CO generated via the vasoactive drugs, phenylephrine and ephedrine. Methods: Baseline cardiovascular measurements were recorded, with renal MiBF determined via CEUS as renal microvascular transit time (RTT). Phenylephrine was then administered, via a standardized protocol, to increase MAP and CO, with repeat CEUS. Following return to baseline, the above was repeated using ephedrine. CEUS time-intensity curves were constructed and renal MiBF calculated. Results: In 11 male volunteers (median age 32), phenylephrine increased MAP (98.7 vs 110.8 mmHg, p<0.001), but not CO (4211 vs. 4089 ml.min-1, p=0.42), while ephedrine increased CO (4110 vs 6097, p<0.001) and MAP (95.6 vs 100.9, p=0.02). Phenylephrine reduced time to organ perfusion (TTOP) (22.3 vs 18.4 secs, p=0.009), but not RTT (14 vs 13.2 secs, p=0.46). Ephedrine decreased TTOP (21.1 vs 14.7 secs, p=0.003), and RTT (3.5 vs 9.6 secs, p=0.007). Change in CO predicted change in TTOP (r2=0.26, p=0.02), but not RTT (r2=0.04, p=0.43). Change in MAP did not predict change in TTOP (r2=0.02, p=0.58), or RTT (r2<0.001, p=0.89). Conclusion: Changes in MAP and CO fail to predict renal MiBF. Key points Question: Do macrovascular changes predict renal microvascular perfusion. Findings: Changes in cardiac output and mean arterial blood pressure fail to predict renal microvascular perfusion. Meaning: Clinical measurement of macrovascular indices may not correlate with microvascular indices.
    • Cardiovascular Determinants of Aerobic Exercise Capacity in Adults With Type 2 Diabetes.

      Wilmot, Emma (2020-07)
      OBJECTIVE: To assess the relationship between subclinical cardiac dysfunction and aerobic exercise capacity (peak VO2) in adults with type 2 diabetes (T2D), a group at high risk of developing heart failure. RESEARCH DESIGN AND METHODS: Cross-sectional study. We prospectively enrolled a multiethnic cohort of asymptomatic adults with T2D and no history, signs, or symptoms of cardiovascular disease. Age-, sex-, and ethnicity-matched control subjects were recruited for comparison. Participants underwent bioanthropometric profiling, cardiopulmonary exercise testing, and cardiovascular magnetic resonance with adenosine stress perfusion imaging. Multivariable linear regression analysis was undertaken to identify independent associations between measures of cardiovascular structure and function and peak VO2. RESULTS: A total of 247 adults with T2D (aged 51.8 ± 11.9 years, 55% males, 37% black or south Asian ethnicity, HbA1c 7.4 ± 1.1% [57 ± 12 mmol/mol], and duration of diabetes 61 [32-120] months) and 78 control subjects were included. Subjects with T2D had increased concentric left ventricular remodelling, reduced myocardial perfusion reserve (MPR), and markedly lower aerobic exercise capacity (peak VO2 18.0 ± 6.6 vs. 27.8 ± 9.0 mL/kg/min; P < 0.001) compared with control subjects. In a multivariable linear regression model containing age, sex, ethnicity, smoking status, and systolic blood pressure, only MPR (β = 0.822; P = 0.006) and left ventricular diastolic filling pressure (E/e') (β = -0.388; P = 0.001) were independently associated with peak VO2 in subjects with T2D. CONCLUSIONS: In a multiethnic cohort of asymptomatic people with T2D, MPR and diastolic function are key determinants of aerobic exercise capacity, independent of age, sex, ethnicity, smoking status, or blood pressure.
    • Care Bundles for Acute Kidney Injury: Do They Work?

      Selby, Nicholas; Kolhe, Nitin (2016-07)
      Acute kidney injury (AKI) is common and is associated with poor patient outcomes, which in some cases appear associated with deficiencies in the provision of care. Care bundles (CBs) are a structured set of practices designed to improve the processes of care delivery and ultimately patient outcomes, and there have been some demonstrations of their utility in areas such as ventilator-associated pneumonia and in sepsis management. While there is a strong rationale for their use, the evidence base around AKI CBs is small but growing. Here, we review the existing data on the effectiveness of AKI CB and discuss optimal approaches to their future study.