• Language matters. Addressing the use of language in the care of people with diabetes: position statement of the English Advisory Group.

      Wilmot, Emma (2018-06)
      The language used by healthcare professionals can have a profound impact on how people living with diabetes, and those who care for them, experience their condition and feel about living with it day-to-day. At its best, good use of language, both verbal and written, can lower anxiety, build confidence, educate and help to improve self-care. Conversely, poor communication can be stigmatizing, hurtful and undermining of self-care and can have a detrimental effect on clinical outcomes. The language used in the care of those with diabetes has the power to reinforce negative stereotypes, but it also has the power to promote positive ones. The use of language is controversial and has many perspectives. The development of this position statement aimed to take account of these as well as the current evidence base. A working group, representing people with diabetes and key organizations with an interest in the care of people with diabetes, was established to review the use of language. The work of this group has culminated in this position statement for England. It follows the contribution of Australia and the USA to this important international debate. The group has set out practical examples of language that will encourage positive interactions with those living with diabetes and subsequently promote positive outcomes. These examples are based on a review of the evidence and are supported by a simple set of principles.
    • LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-masked, randomised controlled trial.

      Game, Frances (2018-09)
      BACKGROUND: The LeucoPatch device uses bedside centrifugation without additional reagents to generate a disc comprising autologous leucocytes, platelets, and fibrin, which is applied to the surface of the wound. We aimed to test the effectiveness of LeucoPatch on the healing of hard-to-heal foot ulcers in people with diabetes. METHODS: This was a multicentre, international, observer-masked, randomised controlled trial of people with diabetes and a hard-to-heal foot ulcer done in 32 specialist diabetic foot clinics in three countries (UK, Denmark, and Sweden). After a 4-week run-in period, those with a reduction in ulcer area of less than 50% were randomly allocated (1:1) by computer-generated, web-based randomisation (block sizes of two, four, and six) to either prespecified good standard care alone or care plus weekly application of LeucoPatch. The primary outcome was the proportion of ulcers that healed within 20 weeks assessed in the intention-to-treat population (all participants with post-randomisation data collected), defined as complete epithelialisation (confirmed by an observer who was masked to randomisation group), and remained healed for 4 weeks. This trial is registered with the ISRCTN registry, number 27665670, and ClinicalTrials.gov, number NCT02224742. FINDINGS: Between Aug 30, 2013, and May 3, 2017, 269 participants were randomly allocated to receive treatment (137 to receive standard care and 132 to receive LeucoPatch). The mean age was 61·9 years (SD 11·6), 217 (82%) were men, and 222 (83%) had type 2 diabetes. In the LeucoPatch group, 45 (34%) of 132 ulcers healed within 20 weeks versus 29 (22%) of 134 ulcers in the standard care group (odds ratio 1·58, 96% CI 1·04-2·40; p=0·0235) by intention-to-treat analysis. Time to healing was shorter in the LeucoPatch group (p=0·0246) than in the standard care group. No difference in adverse events was seen between the groups. The most common serious adverse event (SAE) was diabetic foot infection (24 events in the LeucoPatch group [24% of all SAEs] and 20 in the standard care group [27% of all SAEs]. There were no device-related adverse events. INTERPRETATION: The use of LeucoPatch is associated with significant enhancement of healing of hard-to-heal foot ulcers in people with diabetes. FUNDING: Reapplix ApS.
    • LIMPRINT in Specialist Lymphedema Services in United Kingdom, France, Italy, and Turkey.

      Keeley, Vaughan (2019-04)
      Background: There is no standardized international model for specialist lymphedema services, which covers the types of lymphedema treated and the treatments provided. The aim of this study was to provide a profile of patients attending specialist lymphedema services in different countries to explore similarities and differences. Methods and Results: The LIMPRINT core tool was used in specialist lymphedema services in the United Kingdom, France, Italy, and Turkey. Services in Turkey saw a slightly younger age group, with a higher proportion of female patients reflecting a particular focus on breast cancer-related lymphedema. There were higher levels of obesity and restricted mobility in patients in the United Kingdom compared with other countries. Italy and France saw the highest percentage of patients with primary lymphedema. Diabetes was a common comorbidity in the United Kingdom and Turkey. The United Kingdom saw the largest number of patients with lower limb lymphedema. Conclusions: The results show a wide range of complexity of patients treated in specialist lymphedema services. Some of the differences between countries may reflect different stages in the evolution of specialist lymphedema services, rather than a true difference in prevalence, with those with "younger" services treating a high proportion of patients with cancer and those with more established services treating a wider range of different types of lymphedema, including more elderly people with multiple comorbidities.
    • LIMPRINT: Estimation of the Prevalence of Lymphoedema/Chronic Oedema in Acute Hospital in In-Patients.

      Keeley, Vaughan (2019-04)
      Background: To estimate the prevalence of lymphedema/chronic edema (CO) and wounds in acute hospital inpatients in five different countries. Methods and Results: A point-prevalence study was carried out during working day periods in six general hospitals in four countries (Denmark, France, United Kingdom, and Australia) and one hospital oncology inpatient unit in one other country (Ireland). The study used validated clinical tools for the assessment and collection of data. Data were collected by expert clinicians through interviews and physical examination of the patients present in the wards. A total of 1905 patients could be included and investigated among the 3041 total bed occupancy in the seven hospitals. Lymphedema/CO was present in 723 of them (38%). Main risk factors associated with CO were age, morbid obesity, and heart failure, as well as chair bound immobility and neurological deficiency. History of cellulitis was frequent in patients with CO and wounds (24.8%) and CO alone (14.1%) compared to the 1.5% prevalence in patients without CO. Conclusion: Lymphedema/CO is very frequent in patients hospitalized in hospital acute wards. It is strongly associated with obesity, venous insufficiency, and heart failure. Our results strongly suggest a hidden health care burden and cost linked to CO independently of chronic wounds.
    • LIMPRINT: The UK Experience-Subjective Control of Swelling in Patients Attending Specialist Lymphedema Services.

      Keeley, Vaughan (2019-04)
      Background and Study Design: This study was undertaken as part of the UK LIMPRINT international study to determine the number of people with chronic edema (CO) and its impact on health services. Overall 7436 with CO were recruited in the main UK study from a range of health settings. Methods and Results: Factors relating to subjective control of arm and leg CO were defined in the UK. A total of 1565 patients were included in the study with exclusions for: no limb swelling or not recorded (1669), having concurrent arm/leg CO (272), control of assessment missing (5) and professional being unsure of control status of CO (325). Arm swelling occurred in 953 (18.5%) with leg CO in 4212 (81.5%). Poor control was found in 1430 (27.2%) and good control in 3735 (72.3%). Control of arm swelling was worse in men and control increased overall in those aged over 45 years. In contrast control of CO worsened in those with leg CO with increasing age and multiple co-morbidities. Obesity and cellulitis, particularly an episode in the last year were associated with poor control. Independent risk factors for arm CO were : obesity, neurological disease and cellulitis in the last year and for leg CO, obesity, poor mobility, heart disease, presence of a wound, cellulitis in the last year and duration of swelling. Conclusion: Control of CO within specialized centers is complex due to sociodemographic and clinical comorbidities.
    • Locking hemodialysis catheters with Trimethoprim-Ethanol-Ca-EDTA to prevent bloodstream infections. A randomized, evaluator blinded clinical trial.

      Fluck, Richard (2018-10)
      Background: Central line associated bloodstream infections(CLABSI) often result from intraluminal microbial colonization and are associated with morbidity, mortality, and substantial costs. The use of antimicrobial catheter lock solutions may reduce the incidence of CLABSI. Methods: Patients undergoing hemodialysis through a prevalent central venous catheter(CVC) were randomly assigned to have their CVC locked between dialysis sessions with an antimicrobial catheter lock solution containing trimethoprim 5 mg/mL, Ethanol 25% and Ca-EDTA 3%(Investigational Medical Device, IMD) or heparin 5,000 U/mL(Active Control Heparin, ACH). Exit site care was standardized by protocol-driven use of skin antiseptics and occlusive dressings. The composite primary endpoint consisted of the incidence of CLABSI and the use ofintra-catheter thrombolytic treatment(TT). Given the viscosity and odor of the IMD, blinding was impossible. Therefore, the incidence of CLABSI was adjudicated by a blinded endpoint committee. Results: 270 patients on hemodialysis were enrolled and followed for a total of 43,738 CVC days. Despite the low CLABSI incidence of 0.41/1,000 CVC days in patients randomized to ACH, the IMD further reduced the incidence 4.56-fold to 0.09/1,000 CVC days(P<0.03). The product was well tolerated, and the frequency and severity of adverse events were comparable between groups. Intracatheter instillation of thrombolytics was more frequent in patients receiving the IMD (12% ACH, 40% IMD;P<0.001) but rates of catheter removal did not differ(13% in ACH and 11% in IMD). Overall dialysis adequacy was comparable between groups. Conclusions: In patients on chronic hemodialysis, a trimethoprim, ethanol and Ca-EDTA Lock solution significantly reduced the incidence of CLABSI.
    • Locoregional recurrence of breast cancer presenting as upper limb venous thromboembolism

      Lingam, Krishna (2017-08)
      Locoregional recurrence of breast cancer is a major concern for both patient and oncologist. Presentation as venous thromboembolism (VTE) carries risk of delayed diagnosis and has a poor prognosis. Here we describe, for the first time in the literature, a delayed diagnosis of local recurrence of infiltrative inflammatory breast cancer presenting as extensive deep venous thrombosis of the upper arm veins. This case demonstrates the need for a high level of vigilance for recurrence of malignancy in patients with no concurrent risk factors for VTE and atypical clinical progression in order to reach a timely diagnosis.
    • Long Term Outcomes after Acute Kidney Injury: Lessons from the ARID Study.

      Horne, Kerry; Shardlow, Adam; Selby, Nicholas (2015-09)
      The high incidence and poor short-term outcomes of acute kidney injury (AKI) have focused attention on this global healthcare issue. Concurrently, the long-term effects of AKI are increasingly appreciated, namely, increased risk of subsequent chronic kidney disease, end stage kidney disease requiring renal replacement therapies and a higher rate of cardiovascular events. Whilst there is little doubt about the strength of these associations, knowledge gaps remain. To address some of these, the AKI Risk In Derby study commenced in 2013. This is a prospective case-control study investigating the long-term effects of AKI in a general hospitalized population (including those with less severe AKI). This review will summarize the background and rationale of this study, its design and methodology, as well as the 1-year outcome results from a preceding pilot study.
    • Long-Term Follow-Up of Complete Versus Lesion-Only Revascularization in

      Kelly, Damian (2019-12)
      BACKGROUND: Randomized trials have shown that complete revascularization in patients with ST-segment elevation myocardial infarction (MI) with multivessel disease results in lower major adverse cardiovascular events (MACE) (all-cause death, MI, ischemia-driven revascularization, heart failure). OBJECTIVES: The goal of this study was to determine whether the benefits of complete revascularization are sustained long-term and their impact on hard endpoints. METHODS: CvLPRIT (Complete versus Lesion-only Primary PCI Trial) was a randomized trial of complete inpatient revascularization versus infarct-related artery revascularization only at the index admission. Randomized patients have been followed longer-term. The components of the original primary endpoint were collected from physical and electronic patient records, and from local databases for all readmissions. RESULTS: The median follow-up (achieved in >90% patients) from randomization to first event or last follow-up was 5.6 years (0.0 to 7.3 years). The primary MACE endpoint rate at this time point was 24.0% in the complete revascularization group but 37.7% of the infarct-related artery-only group (hazard ratio: 0.57; 95% confidence interval: 0.37 to 0.87; p = 0.0079). The composite endpoint of all-cause death/MI was 10.0% in the complete revascularization group versus 18.5% in the infarct-related artery-only group (hazard ratio: 0.47; 95% confidence interval: 0.25 to 0.89; p = 0.0175). In a landmark analysis (from 12 months to final follow-up), there was no significant difference between MACE, death/MI, and individual components of the primary endpoint. CONCLUSIONS: Long-term follow-up of the CvLPRIT trial shows that the significantly lower rate of MACE in the complete revascularization group, previously seen at 12 months, is sustained to a median of 5.6 years. A significant difference in composite all-cause death/MI favoring the complete revascularization was also observed. (Complete versus Lesion-only Primary PCI Trial; ISRCTN70913605).
    • Long-term outcomes after AKI-a major unmet clinical need.

      Selby, Nicholas; Taal, Maarten (2019-01)
      In this issue of Kidney International, a comprehensive systematic review and meta-analysis provides an up-to-date picture of the long-term risks of death, chronic kidney disease (CKD), and end-stage kidney disease (ESKD) that follow an episode of acute kidney injury (AKI). Results confirm the significant event rate of these adverse outcomes following AKI and demonstrate that AKI severity and the clinical setting in which AKI occurs are important determinants of risk. In this commentary we discuss the implications of this study and how the results signal some key priorities for future research in an area of substantial clinical need.
    • Long-Term Outcomes in Patients with Acute Kidney Injury.

      Noble, Rebecca; Lucas, BJ; Selby, Nicholas (2020-02)
      The long-term sequelae of AKI have received increasing attention so that its associations with a number of adverse outcomes, including higher mortality and development of CKD, are now widely appreciated. These associations take on particular importance when considering the high incidence of AKI, with a lack of proven interventions and uncertainties around optimal care provision meaning that the long-term sequelae of AKI present a major unmet clinical need. In this review, we examine the published data that inform our current understanding of long-term outcomes following AKI and discuss potential knowledge gaps, covering long-term mortality, CKD, progression to ESKD, proteinuria, cardiovascular events, recurrent AKI, and hospital readmission.
    • Longitudinal Trends in Quality of Life and Physical Function in Frail Older Dialysis Patients: A Comparison of Assisted Peritoneal Dialysis and In-center Hemodialysis

      Fluck, Richard (2019-01)
      BACKGROUND: In-center hemodialysis (HD) has been the standard treatment for older dialysis patients, but reports suggest an associated decline in physical and cognitive function. Cross-sectional data suggest that assisted peritoneal dialysis (aPD), an alternative treatment, is associated with quality of life (QoL) outcomes that are comparable to in-center HD. We compared longitudinal changes in QoL between modalities. METHODS: We enrolled 106 aPD patients, matched with 100 HD patients from 20 renal centers in England and Northern Ireland. Patients were assessed quarterly for 2 years using the Hospital Anxiety and Depression Scale (HADS), SF-12 physical and mental scores, symptom score, Illness Intrusiveness Rating Scale (IIRS), Barthel's score, and the Renal Treatment Satisfaction Questionnaire (RTSQ). Mixed model analysis was used to assess the impact of dialysis modality on these outcomes during follow-up. P values were adjusted for multiple significance testing. RESULTS: Multivariate analysis showed no difference in any of the outcome measures between aPD and HD. Longitudinal trends in outcomes were also not significantly different. Higher age at baseline was associated with lower IIRS and RTSQ scores during follow-up. One-hundred and twenty-five (60.6%) patients dropped out of the study: 59 (28.6%) died, 61 (29.6%) withdrew during follow-up, and 5 (2.5%) were transplanted. CONCLUSIONS: Quality of life outcomes in frail older aPD patients were equivalent to those receiving in-center HD. Assisted PD is thus a valid alternative to HD for older people with end-stage kidney disease (ESKD) wishing to dialyze at home.
    • Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association

      Game, Frances (2018-08)
      Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.
    • Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association.

      Game, Frances (2018-08)
      Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.
    • Management of Inpatient macroscopic haematuria: a typical urology emergency with a high mortality.

      Pavithran, A
      OBJECTIVE: To review the in-patient (IP) management patterns and 30-day outcomes of patients admitted with macroscopic haematuria (MH) over a 1-year-period in a single-institution, aiming to clarify management for such cases in the future. METHODS: Retrospective cohort study was conducted on all patients admitted with MH in a single-institution over 1-year, excluding patients not requiring an overnight stay. A case note review was performed for patient demographics, MH investigations, and management. RESULTS: A total of 120 patients were admitted with MH over a span of 1-year. 89% (107/120) were males, with an average age of 78 years (36-97 years), an average ASA of 3, mean length-of-stay (LOS) was 5 days (1-31days) and 68% (82/120) had pre-existing urological conditions. 62% (74/120) required bladder irrigation for a mean duration of 3 days (1-16days). 10% (12/120) required an emergency rigid cystoscopy and washout to manage the bleeding, of which 4% (5/12) had malignancy noted. Over 8% (10/120) patients discharged had unplanned readmissions within 30 days. The 1-year mortality for this cohort was 23% (28/120) of which 21% (6/28) died within 30 days from discharge. CONCLUSION: IP MH affects a vulnerable patient cohort. There is no specific pathway guiding the inpatient management of MH; therefore, research is required to produce standardized pathways for managing MH, considering the high-risk patient cohort, the prolonged LOS, and high one-year mortality rate.
    • Management of the temporomandibular joint in inflammatory arthritis: Involvement of surgical procedures.

      O'Connor, Rory (2017-06)
      Many conditions may affect the temporomandibular joint (TMJ), but its incidence in individual joint diseases is low. However, inflammatory arthropathies, particularly rheumatoid and psoriatic arthritis and ankylosing spondylitis, appear to have a propensity for affecting the joint. Symptoms include pain, restriction in mouth opening, locking, and noises, which together can lead to significant impairment. Jaw rest, a soft diet, a bite splint, and medical therapy, including disease-modifying antirheumatic drugs (DMARDs) and simple analgesia, are the bedrock of initial treatment and will improve most symptoms in most patients. Symptom deterioration does not necessarily follow disease progression, but when it does, TMJ arthroscopy and arthrocentesis can help modulate pain, increase mouth opening, and relieve locking. These minimally invasive procedures have few complications and can be repeated. Operations to repair or remove a damaged intra-articular disc or to refine joint anatomy are used in select cases. Total TMJ replacement is reserved for patients where joint collapse or fusion has occurred or in whom other treatments have failed to provide adequate symptomatic control. It yields excellent outcomes and is approved by the National Institute of Health and Care Excellence (NICE), UK. Knowledge of the assessment and treatment of the TMJ, which differs from other joints affected by inflammatory arthritis due to its unique anatomy and function, is not widespread outside of the field of oral and maxillofacial surgery. The aim of this article is to highlight the peculiarities of TMJ disease secondary to rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis and how to best manage these ailments, which should help guide when referral to a specialist TMJ surgeon is appropriate.
    • Managing patients with delusional infestations in an integrated Psychodermatology clinic is much more cost effective than a general dermatology or primary care setting

      Mohandas, Padma (2016-09)
      Delusional Infestation (DI) is a condition whereby patients hold a fixed, false belief of being infested with living organisms (1) . Patients classically present with excoriated skin at various stages of the healing process, together with evidence of their infestation (the specimen sign(2) ) such as skin debris, insects or insect parts.. Patients also complain of a variety of cutaneous symptoms such as crawling, itching, burning and soreness. DI may occur as a primary disorder or as a consequence of medical illness(3) . A significant proportion of patients also have other associated dermato-psychological problems such as body dysmorphophobia, obsessive compulsive disorder and nodular prurigo. Sufferers often experience significant morbidity and reduction in quality of life.