• Early onset type 2 diabetes: risk factors, clinical impact and management.

      Wilmot, Emma (2014-11)
      Early onset type 2 diabetes mellitus (T2DM) is increasingly prevalent with a significant impact on the individual, healthcare service delivery and planning. The individuals are likely to be obese, lead a sedentary lifestyle, have a strong family history of T2DM, be of black and minority ethnic (BME) origin and come from a less affluent socioeconomic group. They have a heightened risk of developing microvascular and macrovascular complications, often at an earlier stage and with greater frequency than seen in type 1 diabetes. As such, early and aggressive risk factor management is warranted. Early onset T2DM is complex and impacts on service delivery with a need for multidisciplinary care of complications and comorbidities', in addition to adequate educational and psychological support. This review on the impact of early onset T2DM provides the latest insights into this emerging epidemic.
    • Effect of diabetes on the cutaneous microcirculation of the feet in patients with intermittent claudication.

      Donnelly, Richard; Lingam, Krishna (2015-10)
      AIMS: To evaluate endothelial-dependent and - independent cutaneous vasodilator responses in the feet of patients with peripheral arterial disease (PAD) with or without Type 2 diabetes. METHODS: Cutaneous microvascular responses in the dorsum of both lower limbs were measured in the supine position using Laser Doppler Fluximetry combined with iontophoretic administration of endothelial-dependent (acetylcholine, Ach) and -independent (sodium nitroprusside, SNP) vasodilators in diabetic (n = 19) and non diabetic (n = 17) patients with PAD (presenting as unilateral calf intermittent claudication (IC). RESULTS: In patients with diabetes and IC, endothelial-dependent vasodilation was significantly impaired in the symptomatic limb [74 (57,105) vs 68 (24,81) PU, Z =-2.79, p = 0.005] compared to the asymptomatic limb. Patients without diabetes showed no impairment of vasodilation. Resting ankle-brachial pressure index did not identify the presence of abnormalities in microvascular function. CONCLUSIONS: The combination of diabetes and PAD is associated with a reduction in endothelial-dependent cutaneous vasodilation in the feet without an associated reduction in endothelial independent vasodilation.
    • Effect of time and day of admission on hospital care quality for patients with chronic obstructive pulmonary disease exacerbation in England and Wales: single cohort study.

      Lowrey, Gillian (2017-09)
      OBJECTIVE: To evaluate if observed increased weekend mortality was associated with poorer quality of care for patients admitted to hospital with chronic obstructive pulmonary disease (COPD) exacerbation. DESIGN: Prospective case ascertainment cohort study. SETTING: 199 acute hospitals in England and Wales, UK. PARTICIPANTS: Consecutive COPD admissions, excluding subsequent readmissions, from 1 February to 30 April 2014 of whom 13 414 cases were entered into the study. MAIN OUTCOMES: Process of care mapped to the National Institute for Health and Care Excellence clinical quality standards, access to specialist respiratory teams and facilities, mortality and length of stay, related to time and day of the week of admission. RESULTS: Mortality was higher for weekend admissions (unadjusted OR 1.20, 95% CI 1.00 to 1.43), and for case-mix adjusted weekend mortality when calculated for admissions Friday morning thro ugh to Monday night (adjusted OR 1.19, 95% CI 1.00 to 1.43). Median time to death was 6 days. Some clinical processes were poorer on Mondays and during normal working hours but not weekends or out of hours. Specialist respiratory care was less available and less prompt for Friday and Saturday admissions. Admission to a specialist ward or high dependency unit was less likely on a Saturday or Sunday. CONCLUSIONS: Increased mortality observed in weekend admissions is not easily explained by deficiencies in early clinical guideline care. Further study of out-of-hospital factors, specialty care and deaths later in the admission are required if effective interventions are to be made to reduce variation by day of the week of admission.
    • Effect of weekend admission on mortality associated with severe acute kidney injury in England: A propensity score matched, population-based study

      Kolhe, Nitin; Fluck, Richard; Taal, Maarten (2017-10)
      Background Increased in-hospital mortality associated with weekend admission has been reported for many acute conditions, but no study has investigated “weekend effect” for acute kidney injury requiring dialysis (AKI-D). Methods In this large, propensity score matched cohort of AKI-D, we examined the impact of weekend admission and in-centre nephrology services in 53,170 AKI-D admissions between 1st April 2003 and 31st March 2015 using a hospital episode statistic dataset. Propensity score matching (PSM) was performed to match 4284 weekend admissions with AKI-D with 14,788 admissions on weekdays. Results Of the 53,170 admissions with AKI-D in the whole dataset, 12,357 (23%) were at weekends. The unadjusted mortality for weekend admissions was significantly higher compared to admissions on weekdays (40·6% versus 39·6%, p 0·046). However, in multivariable analysis of the PSM cohort, the odds of death for weekend admissions with AKI-D was 1·01 (95%CI 0·93,1·09). Mortality was higher for weekend admissions in West Midlands (odds ratio (OR) 1·32, 95% confidence interval (CI) 1·05, 1·66) and lower in East of England (OR 0·77, 95%CI 0·59, 1·00) but was not different to weekday admissions in all other regions. In 2003–04, weekend admissions had lower odds of death (OR 0·45, 95%CI 0·21, 0·96) and in 2010–11 higher odds of death (OR 1·28, 95%CI 1·00, 1·63) but in the other ten years observed, there was no significant difference in mortality between weekday and weekend admissions. Provision of in-centre nephrology services was associated with lower odds of death at 0·57 (95%CI 0·54, 0·62). Conclusions Weekend admissions in patients with AKI-D had no effect on mortality. Further research is warranted to elucidate the reasons for the lower mortality in hospitals with in-centre nephrology services.
    • Effects of arteriovenous fistula formation on arterial stiffness and cardiovascular performance and function.

      Korsheed, Shvan; Eldehni, S; John, Stephen; Fluck, Richard; McIntyre, Christopher (2011-10)
      s.korsheed@googlemail.com BACKGROUND: Native arteriovenous fistula (AVF) is the vascular access of choice and its use cf. catheters is associated with sustained reduction in mortality. This may be due to factors beyond dialysis catheter-associated sepsis. This study aimed to investigate the impact of AVF formation on the spectrum of cardiovascular factors that might be important in the pathophysiology of cardiovascular diseases in chronic kidney disease (CKD) patients. METHODS: We recruited 43 pre-dialysis patients who underwent AVF formation. Patients were studied 2 weeks prior to AVF operation and 2 weeks and 3 months post-operatively. Haemodynamic variables were measured using pulse wave analysis, carotid femoral pulse wave velocity (CF-PWV) by applanation tonometry and AVF blood flow by Doppler ultrasound. Bioimpedence analysis was performed and patients underwent serial transthoracic echocardiography. RESULTS: AVF formation was successful in 30/43 patients. Two weeks post-operatively, total peripheral resistance decreased (-17 ± 18%, P = 0.001), stroke volume tended to rise (12 ± 30 mL, P = 0.053) and both heart rate (4 ± 8 bpm, P = 0.01) and cardiac output (1.1 ± 1.5 L/min, P = 0.001) increased. Systolic and diastolic blood pressures (BPs) reduced (-9 ± 18 mmHg; -9 ± 10 mmHg; ≤ P = 0.006) and CF-PWV reduced (-1.1 ± 1.5 m/s, P = 0.004). Left ventricular ejection fraction (LVEF) increased (6 ± 8%, P < 0.001). All the observed changes were largely maintained after 3 months. No change in hydration status/body composition was observed. CONCLUSIONS: AVF formation resulted in a sustained reduction in arterial stiffness and BP as well as an increase in LVEF. Overall, post-AVF adaptations might be characterized as potentially beneficial in these patients and supports the widespread use of native vascular access, including older or cardiovascular compromised individuals.
    • Effects of continuous subcutaneous insulin infusion (CSII) therapy on quality of life and patients' self-management: Clinical survey of routine clinical practice at Derby Teaching Hospital, UK

      Olaoye, H; Anyanwagu, Uche; Idris, Iskandar; Wilmot, Emma; Jennings, P; Ashton-Cleary, S; Sugunendran, Suma; Hughes, D (2016-03)
      Continuous subcutaneous insulin infusion (CSII) therapy for Type 1 diabetes can provide long-term, sustained improvements in glycaemic control and a reduction in hypoglycaemia. We aimed to assess the impact of CSII on quality of life and confidence in diabetes management. Methods: Patient-level data were obtained from the hospital electronic records for 220 CSII users from the Royal Derby Hospital. Patient confidence and satisfaction questionnaires were sent by post. A Likert scale was used to assess confidence in aspects of self-management. STATA v.13 was used for data analysis. Results: 54% (n = 119) responded; mean age 47.8 +/- 14.1 years; 58.8% female. Pre-CSII HbA1c was 9.1 +/- 1.8%; CSII duration 4.3 years (interquartile range 2.6+/-7.2) and most recent HbA1c 8.2 +/- 1.2%. 82.4% (n = 98) had pre-CSII structured education. Almost all patients reported that CSII improved their quality of life (94.2%, n = 114) and reduced the frequency of hypoglycaemia (79.8%, n = 95). The majority felt confident to carbohydrate count (90.8%, n = 108); check blood glucose >4/day (80.1%, n = 105); test and adjust CSII basal rates (69.7%, n = 83; 80.7%, n = 96 respectively). A quarter did not feel confident to use sick day rules (26.9%, n = 32) or adjust their insulin:carbohydrate ratio (26%, n = 31). Many were not confident in the use of advanced bolus features (45.4%, n = 54) or exercising without upsetting blood glucose (33.6%, n = 40). 85.7% (n = 102) were satisfied with the quality of care received. Conclusions: CSII improved quality of life and, overall, users were confident to self-manage their diabetes. Use of advanced pump features, sick day rules and exercise were identified as areas to target in future education interventions.
    • Effects of late, repetitive remote ischaemic conditioning on myocardial strain in patients with acute myocardial infarction.

      Chitkara, Kamal
      Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied (38 receiving 4 weeks' daily CRIC, 35 controls receiving sham conditioning). Patients underwent cardiovascular magnetic resonance at baseline (5-7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain (longitudinal/circumferential, in infarct-related and remote territories). At both timepoints, there were no significant between-group differences in global indices (LV ejection fraction, infarct size, longitudinal/circumferential strain). However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group (from - 16.2 ± 5.2 at baseline to - 18.7 ± 6.3 at follow up, p = 0.0006) but not in corresponding segments of the control group (from - 15.5 ± 4.0 to - 15.2 ± 4.7, p = 0.81; for change: - 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively, p = 0.027). In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls (- 1.2 ± 4.4 versus - 2.5 ± 4.0, p = 0.038). In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: http://clinicaltrials.gov/show/NCT01664611 .
    • Efficacy of Isatuximab With Pomalidomide and Dexamethasone in Relapsed Myeloma: Results of a UK-Wide Real-World Dataset.

      Al-Kaisi, F
      Real-world data on the efficacy and tolerability of isatuximab with pomalidomide and dexamethasone (IsaPomDex) in relapsed/refractory myeloma patients have not been reported. In this UK-wide retrospective study, IsaPomDex outcomes were evaluated across 24 routine care cancer centers. The primary endpoint was overall response rate (ORR). Secondary endpoints included progression-free survival (PFS), duration of response (DOR) for patients who achieved an objective response (≥partial response [PR]), and adverse events (AEs). In a total cohort 107 patients, median follow up (interquartile range [IQR]) was 12.1 months (10.1-18.6 mo), median age (IQR) was 69 years (61-77). Median (IQR) Charlson Comorbidity Index (CCI) score was 3 (2-4); 43% had eGFR <60 mL/min. Median (IQR) number of prior therapies was 3 (3-3). Median (IQR) number of IsaPomDex cycles administered was 7 (3-13). ORR was 66.4%, with responses categorized as ≥ very good partial response: 31.8%, PR: 34.6%, stable disease: 15.9%, progressive disease: 15%, and unknown 2.8%. Median PFS was 10.9 months. Median DOR was 10.3 months. There was no statistical difference in median PFS by age (<65: 10.2 versus 65-74 13.2 versus ≥75: 8.5 mo, log-rank P = 0.4157), by CCI score (<4: 10.2 mo versus ≥4: 13.2, log-rank P = 0.6531), but inferior PFS was observed with renal impairment (≥60: 13.2 versus <60: 7.9 mo, log-rank P = 0.0408). Median OS was 18.8 months. After a median of 4 cycles, any grade AEs were experienced by 87.9% of patients. The most common ≥G3 AEs were neutropenia (45.8%), infections (18.7%), and thrombocytopenia (14%). Our UK-wide IsaPomDex study demonstrated encouraging efficacy outcomes in the real world, comparable to ICARIA-MM trial.
    • Electronic alerts for acute kidney injury.

      Selby, Nicholas (2013-11)
      PURPOSE OF REVIEW: Acute kidney injury (AKI) is extremely common in hospitalized patients and its presence infers a poorer chance of survival, longer hospital stays and an increased risk of subsequent chronic kidney disease. Recent reports have suggested that standards of care for patients with AKI are often suboptimal and that this contributes to poor outcomes. In an attempt to address delays in diagnosing AKI, there has been increasing interest in e-alert systems for AKI. This review aims to discuss recent developments in e-alert methodologies, as well as examining the evidence to support their effectiveness. RECENT FINDINGS: Several e-alert systems for AKI have been reported, including more recent descriptions of hospital-wide systems that apply current diagnostic criteria and run sustainably in routine clinical practice. Evidence is accumulating to show their impact in altering physician behaviour and triggering earlier intervention. Emerging data suggest that in combination with other service improvement strategies, this may translate into improved patient outcomes. SUMMARY: The current ad-hoc development of e-alert systems needs to be addressed by arriving at consensus around the way in which these systems should apply diagnostic criteria, particularly with respect to selection of baseline creatinine value. Enhancements in IT provision may provide the only durable solution to this, while at the same time facilitating wider uptake. Wider use will allow for further study of the value of e-alerts, including their use in other settings such as primary care.
    • Elevated serum free pregnancy-associated plasma protein-A independently predicts mortality in haemodialysis patients but is not associated with recurrent haemodialysis-induced ischaemic myocardial injury.

      Jefferies, Helen (2015-03)
      BACKGROUND/AIMS: Pregnancy-associated plasma protein-A (PAPP-A) is a putative marker of atheroma instability and ischaemic myocardial stress prior to necrosis. Total PAPP-A (tPAPP-A) levels in acute coronary syndromes predict adverse outcomes. However, free PAPP-A (fPAPP-A) predominates in the circulation. Ischaemic haemodialysis (HD)-induced cardiac injury (myocardial stunning) is common and is associated with markers of myocardial necrosis, inflammation, cardiovascular events and mortality. Coronary plaque instability in pathophysiology of HD-induced myocardial stunning has not been studied. We aimed to investigate the relationship of fPAPP-A with stunning and mortality. METHODS: 130 prevalent patients from two HD centres (Finland and UK) were studied. Pre-HD free, complexed and total PAPP-A were measured by immunoassay. A subset of 62 patients underwent echocardiography to assess HD-induced myocardial stunning. The mean duration of follow-up was 407 ± 98 days. RESULTS: fPAPP-A was elevated (median: 3.45 mIU/l) and correlated with dialysis vintage (r = 0.391, p < 0.001), cardiac troponin T (cTnT; r = 0.29, p = 0.001) and cardiac troponin I (cTnI; r = 0.22, p = 0.01). PAPP-A was not related to stunning. Dialysis vintage and cTnT independently predicted Ln fPAPP-A (model R = 0.463). fPAPP-A, cTnT and age independently predicted death (Nagelkerke R(2) = 0.362). CONCLUSIONS: fPAPP-A, a novel predictor of HD-related mortality, demonstrates better prognostic power than tPAPP-A. Coronary plaque instability may contribute to sub-lethal myocardial injury, but may not be critical in pathogenesis of HD-induced ischaemic cardiac injury.
    • Emphysema- and airway-dominant COPD phenotypes defined by standardised quantitative computed tomography.

      Subramanian, Deepak (2016-05)
      EvA (Emphysema versus Airway disease) is a multicentre project to study mechanisms and identify biomarkers of emphysema and airway disease in chronic obstructive pulmonary disease (COPD). The objective of this study was to delineate objectively imaging-based emphysema-dominant and airway disease-dominant phenotypes using quantitative computed tomography (QCT) indices, standardised with a novel phantom-based approach.441 subjects with COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages 1-3) were assessed in terms of clinical and physiological measurements, laboratory testing and standardised QCT indices of emphysema and airway wall geometry.QCT indices were influenced by scanner non-conformity, but standardisation significantly reduced variability (p<0.001) and led to more robust phenotypes. Four imaging-derived phenotypes were identified, reflecting "emphysema-dominant", "airway disease-dominant", "mixed" disease and "mild" disease. The emphysema-dominant group had significantly higher lung volumes, lower gas transfer coefficient, lower oxygen (PO2 ) and carbon dioxide (PCO2 ) tensions, higher haemoglobin and higher blood leukocyte numbers than the airway disease-dominant group.The utility of QCT for phenotyping in the setting of an international multicentre study is improved by standardisation. QCT indices of emphysema and airway disease can delineate within a population of patients with COPD, phenotypic groups that have typical clinical features known to be associated with emphysema-dominant and airway-dominant disease.
    • Encouraging reduction of activity amongst patients with diabetic foot ulcers.

      Game, Frances (2018-07)
      Background: Recommendations published by the international working group of the diabetic foot (2015) advise that patients should limit standing and walking to facilitate optimal wound healing. Aims: To assess the feasibility and acceptability of wearing a pedometer to record step counts and daily walking patterns. To examine the relationship between step count and wound healing. Methods: Ten attendees of the diabetic foot clinic at Royal Derby Hospital were invited to use a pedometer (Omron HJ-203) for a 4-week period. Results: The majority of participants (n=9) wore the pedometer on a daily basis. A weak negative correlation was found between wound size reduction and mean daily step count (Spearman's rank -0.057, p=0.0091). Reduced wound size was associated with smaller variations in daily step count (<6.75 fold). Conclusions: The pedometer was acceptable to participants and feasible to use as demonstrated by high uptake in daily use. Strategies may be needed to help achieve and sustain reductions in walking behaviour over time and in the context of competing health beliefs and the demands of work and family life.
    • Endobronchial metastasis of mixed Mullerian tumour of the uterus.

      Baskaran, Vadsala; Pugh, Laura; Berg, Robert; Anderson, John (2017-12)
      Endobronchial metastasis occurs in only 2%-5% of non-pulmonary cancers. Here we report on an 84-year-old woman who presented with breathlessness and light-headedness while on holiday in Australia, 2 years post-treatment for endometrial cancer. Initial CT pulmonary angiogram identified a soft tissue mass in the left hemithorax. A chest radiograph performed after repatriation was consistent with a large left pleural effusion, but bedside ultrasound showed a lobulated mass involving the left hemidiaphragm. A pleural procedure in the traditional 'triangle of safety' would have resulted in inadvertent puncture of the underlying mass. Serial imaging confirmed the mass was rapidly progressing, and metastatic malignant mixed Mullerian endometrial carcinoma was diagnosed by endobronchial biopsy. A tunnelled intrapleural catheter was inserted for symptom relief, and the patient deteriorated and died at home 2 weeks later. To our knowledge, this is the first case of endobronchial metastasis from malignant mixed Mullerian tumour of the uterus.
    • Endoscopic ampullectomy for papillary tumors: A single-center experience

      Guerra, Maria (2015)
      Introduction: Ampullary adenoma is an uncommon, pre-cancerous lesion arising from the duodenal papilla. Endoscopic ampullectomy may be proposed in patients with smaller lesions without invasive carcinoma. There are aspects on the diagnosis and the management of ampullary tumors which are not well established. Objetive: To evaluate the efficacy and safety of endoscopic ampullectomy for assessing the correct diagnosis and treatment of ampullary tumors. Patients and methods: All ampullary tumors with lesion size less than 3 cm, without macroscopic features of malignancy, identified from May 2000 to December 2014, were included in the study. Thirteen endoscopic ampullectomies were undertaken in 9 males (69.2%) and 4 females (30.7%) with a mean age of 71. No endoscopic ultrasound was performed prior to the endoscopic resection. Clinical history, imaging assessment, preoperative histology, complications and followup were reviewed. Results: The resection was achieved in one piece for 12 patients (92.3%). A pancreatic stent was inserted in 10 patients. There was no mortality but three complications occurred: 1 acute pancreatitis (7.6%), 2 post ampullectomy bleeding (15.3%). The definitive histological results included: adenoma with low-grade dysplasia (5); adenoma with high-grade dysplasia or in situ carcinoma (2); and invasive carcinoma (6). The resection was sufficient and complete in 53.8%, 6 patients required additional surgery. The median follow-up was 25.8 months. Conclusion: Endoscopic ampullectomy is an effective procedure for assessing the diagnosis of ampullary neoplasms, and for subsequent therapeutic management in selected patients. Bleeding and pancreatitis are the most common complications.Copyright © 2015 Journal of Interventional Gastroenterology.
    • Endoscopic ampullectomy: a technical review

      Guerra, Maria (2016-05)
      This article provides a practical review to undertaking safe endoscopic ampullectomy and highlights some of the common difficulties with this technique as well as offering strategies to deal with these challenges. We conducted a review of studies regarding endoscopic ampullectomy for ampullary neoplasms with special focus on techniques. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. The optimal technique for endoscopic ampullectomy is dependent on the lesions size. En bloc resection is recommended for lesions confined to the papilla. There is no significant evidence to support the submucosal injection before ampullectomy. There is no consensus regarding the optimal current and power output for endoscopic ampulectomy. The benefits of a thermal adjunctive therapy remain controversial. A prophylactic pancreatic stent reduces the incidence and severity of pancreatitis post-ampullectomy. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure for papillary adenomas in experienced endoscopist and it can avoid the need for surgical intervention.
    • Endotoxaemia in haemodialysis: a novel factor in erythropoetin resistance?

      Harrison, Laura; Burton, James; McIntyre, Christopher (2012-07)
      BACKGROUND/OBJECTIVES: Translocated endotoxin derived from intestinal bacteria is a driver of systemic inflammation and oxidative stress. Severe endotoxaemia is an underappreciated, but characteristic finding in haemodialysis (HD) patients, and appears to be driven by acute repetitive dialysis induced circulatory stress. Resistance to erythropoietin (EPO) has been identified as a predictor of mortality risk, and associated with inflammation and malnutrition. This study aims to explore the potential link between previously unrecognised endotoxaemia and EPO Resistance Index (ERI) in HD patients. METHODOLOGY/PRINCIPAL FINDINGS: 50 established HD patients were studied at a routine dialysis session. Data collection included weight, BMI, ultrafiltration volume, weekly EPO dose, and blood sampling pre and post HD. ERI was calculated as ratio of total weekly EPO dose to body weight (U/kg) to haemoglobin level (g/dL). Mean haemoglobin (Hb) was 11.3±1.3 g/dL with a median EPO dose of 10,000 [IQR 7,500-20,000] u/wk and ERI of 13.7 [IQR 6.9-23.3] ((U/Kg)/(g/dL)). Mean pre-HD serum ET levels were significantly elevated at 0.69±0.30 EU/ml. Natural logarithm (Ln) of ERI correlated to predialysis ET levels (r = 0.324, p = 0.03) with a trend towards association with hsCRP (r = 0.280, p = 0.07). Ln ERI correlated with ultrafiltration volume, a driver of circulatory stress (r = 0.295, p = 0.046), previously identified to be associated with increased intradialytic endotoxin translocation. Both serum ET and ultrafiltration volume corrected for body weight were independently associated with Ln ERI in multivariable analysis. CONCLUSIONS: This study suggests that endotoxaemia is a significant factor in setting levels of EPO requirement. It raises the possibility that elevated EPO doses may in part merely be identifying patients subjected to significant circulatory stress and suffering the myriad of negative biological consequences arising from sustained systemic exposure to endotoxin.
    • Endotoxemia in Peritoneal Dialysis Patients: A Pilot Study to Examine the Role of Intestinal Perfusion and Congestion.

      Harrison, Laura (2017-01)
      Endotoxemia is common in advanced chronic kidney disease and is particularly severe in those receiving dialysis. In hemodialysis patients, translocation from the bowel occurs as a consequence of recurrent circulatory stress leading to a reduction in circulating splanchnic volume and increased intestinal permeability. Peritoneal dialysis (PD) patients are often volume expanded and have continuous direct immersion of bowel in fluid; these may also be important factors in endotoxin translocation and would suggest different therapeutic strategies to improve it. The mechanisms leading to endotoxemia have never been specifically studied in PD. In this study, 17 subjects (8 PD patients, 9 healthy controls) underwent detailed gastrointestinal and cardiac magnetic resonance imaging during fasted and fed states. Gross splanchnic perfusion was assessed by quantification of superior mesenteric artery flow. Magnetic resonance imaging findings were correlated to endotoxemia, markers of hydration status and cardiac structure and function.
    • Epidemiology and aetiology of dialysis-treated end-stage kidney disease in Libya.

      Alashek, Wiam; McIntyre, Christopher; Taal, Maarten (2012-06)
      BACKGROUND: The extent and the distribution of end stage kidney disease (ESKD) in Libya have not been reported despite provision of dialysis over 4 decades. This study aimed to develop the first comprehensive description of the epidemiology of dialysis-treated ESKD in Libya. METHODS: Structured demographic and clinical data were obtained regarding all adult patients treated at all maintenance dialysis facilities (n=39) in Libya from May to September 2009. Subsequently data were collected prospectively on all new patients who started dialysis from September 2009 to August 2010. Population estimates were obtained from the Libyan national statistics department. The age and gender breakdown of the population in each region was obtained from mid-2009 population estimates based on 2006 census data. RESULTS: The prevalence of dialysis-treated ESKD was 624 per million population (pmp). 85% of prevalent patients were aged <65 years and 58% were male. The prevalence of ESKD varied considerably with age with a peak at 55-64 years (2475 pmp for males; 2197 pmp for females). The annual incidence rate was 282 pmp with some regional variation and a substantially higher rate in the South (617 pmp). The most common cause of ESKD among prevalent and incident patients was diabetes. Other important causes were glomerulonephritis, hypertensive nephropathy and congenital or hereditary diseases.CONCLUSIONS: Libya has a relatively high prevalence and incidence of dialysis-treated ESKD. As the country prepares to redevelop its healthcare system it is hoped that these data will guide strategies for the prevention of CKD and planning for the provision of renal replacement therapy.
    • Epidemiology of coeliac disease in a single centre in Southern Derbyshire 1958-2014

      Holmes, Geoffrey (2017-09)
      OBJECTIVE To determine trends in diagnosis of coeliac disease (CD) in patients attending a single centre 1958-2014 and provide figures for prevalence and incidence in those born in Derby city over 4 decades. To explore a link between deprivation and prevalence and characteristics of CD in Asians.DESIGNAn unselected, consecutive series of 2410 adult patients with CD diagnosed in the catchment area of the Derby hospitals was identified. 1077 born within Derby city identified by postcodes was used to determine changes in prevalence and incidence over 4 decades. 191 patients were Asian. Population numbers were obtained from National Census information.RESULTSIn the quinquennium 2010-2014, 20 times more patients were diagnosed than during 1975-1979. 27% were diagnosed at ≥60 years. A paucity of diagnoses in young men was observed. Women were diagnosed most often in age band ≥35<45, 15 years earlier than men. The largest increase in diagnosis rates occurred in young women and the elderly. In 2014, overall prevalence was 1:188; women 1:138. 4.6% of the variation was attributed to deprivation. Diagnosis rates in Asians increased markedly although only 5% were diagnosed at ≥60 years, much lower than for whites.CONCLUSIONSThe dramatic increase in number of patients with CD presents challenges for follow-up and new models of care need to be explored. Healthcare workers should be alert to the diagnosis in young men and elderly Asians. A dedicated coeliac clinic is an excellent facility to increase diagnosis rates.
    • Epidemiology of Staphylococcus aureus bacteraemia amongst patients receiving dialysis for established renal failure in England in 2009 to 2011: a joint report from the Health Protection Agency and the UK Renal Registry.

      Crowley, Lisa; Wilson, J; Guy, R; Pitcher, David; Fluck, Richard (2012-09)
      INTRODUCTION: Infection remains one of the leading causes of death in patients with end-stage renal failure (ESRF) receiving dialysis. Since April 2007, all centres providing renal replacement therapy in England have been required to provide additional data on patients with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. From January 2011 this has also been required for patients with Methicillin Sensitive Staphylococcus Aureus (MSSA). MRSA data for 2009-2011 and the first 6 months of MSSA data are reported. METHODS: Potential bacteraemia were identified by the Health Protection Agency based on clinical details provided and the clinical setting. The records were 'shared' with the parent renal centre who then complete the additional data on the HCAI-DCS website. Centres were also contacted by phone and email as a further validation step. RESULTS: From April 2009-2010 there were 77 confirmed episodes of MRSA bacteraemia at a median rate of 0.25 per 100 prevalent dialysis patients. This number decreased to 61 episodes between April 2010-2011 at a median rate of 0 per 100 prevalent dialysis patients. Overall there has been an 82% reduction in absolute episodes since the first year of mandatory reporting in 2007. The incidence of bacteraemia in patients with a central venous catheter was approximately six fold higher than in those with an AV fistula. From 1st January to 30th June 2011 there were 160 episodes of MSSA bacteraemia with a rate of 1.06 episodes per 100 dialysis patients, again the risk was six fold higher in patients with a CVC. CONCLUSIONS: Overall rates of MRSA bacteraemia in dialysis patients continued to fall although there remained variation between renal centres. Initial data from the early days of MSSA reporting suggested high rates of infection and an even greater variation between renal centres. This requires confirmation from future data collection.