Recent Submissions

  • Salbutamol for analgesia in renal colic: study protocol for a prospective, randomised, placebo-controlled phase II trial (SARC).

    Johnson, Graham; Tabner, Andrew; Fakis, Apostolos; Sherman, R; Chester, V; Bedford, E
    BACKGROUND: Renal colic is the pain experienced by a patient when a renal calculus (kidney stone) causes partial or complete obstruction of part of the renal outflow tract. The standard analgesic regimes for renal colic are often ineffective; in some studies, less than half of patients achieve complete pain relief, and a large proportion of patients require rescue analgesia within 4 h. Current analgesic regimes are also associated with significant side effects including nausea, vomiting, drowsiness and respiratory depression. It has been hypothesised that beta adrenoreceptor agonists, such as salbutamol, may reduce the pain of renal colic. They have been shown to impact a number of factors that target the physiological causes of pain in renal colic (ureteric spasm and increased peristalsis, increased pressure at the renal pelvis and prostaglandin release with inflammation). There is biological plausibility and a body of evidence sufficient to suggest that this novel treatment for the pain of renal colic should be taken to a phase II clinical trial. The aim of this trial is to test whether salbutamol is an efficacious analgesic adjunct when added to the standard analgesic regime for patients presenting to the ED with subsequently confirmed renal colic. METHODS: A phase II, randomised, placebo-controlled trial will be performed in an acute NHS Trust in the East Midlands. Patients presenting to the emergency department with pain requiring IV analgesia and working diagnosis of renal colic will be randomised to receive standard analgesia ± a single intravenous injection of Salbutamol. Secondary study objectives will explore the feasibility of conducting a larger, phase III trial. DISCUSSION: The trial will provide important information about the efficacy of salbutamol as an analgesic adjunct in renal colic. It will also guide the development of a definitive phase III trial to test the cost and clinical effectiveness of salbutamol as an analgesic adjunct in renal colic. Salbutamol benefits from widespread use across the health service for multiple indications, extensive staff familiarity and a good side effect profile; therefore, its potential use for pain relief may have significant benefits for patient care. TRIAL REGISTRATION: ISRCTN Registry ISRCTN14552440 . Registered on 22 July 2019.
  • Trends in emergency department litigation within the NHS: a retrospective database analysis.

    Tabner, Andrew; Tilbury, Nicholas; Jones, Michael; Fakis, Apostolos; Evans, Nicola; Johnson, Graham
    The objectives of this study are to examine trends in litigation related to emergency department care within the NHS. The study is based on retrospective database analysis. NHS Resolution databases of litigation activity pertaining to Type I emergency departments within the NHS are used. The main outcome measures were number of claims, number of successful claims, costs associated with litigation and costs per claim, all in comparison to patterns of ED attendance numbers and inflation. The results showed that the annual cost of litigation relating to emergency department care within the NHS has increased from £25.5 million in 2005/6 to £161.9 million in 2017/18. Mean cost per claim has increased from £58,252 in 2005/6 to £168,966 in 2017/18. The number of claims received has increased significantly; the proportion of these which were successful has remained constant. Therefore, it was concluded that the costs of litigation are increasing disproportionately to inflation and attendance numbers. Multiple potential causes are discussed, with significant implications for clinical practice.
  • Azithromycin versus standard care in patients with mild-to-moderate COVID-19 (ATOMIC2): an open-label, randomised trial.

    Johnson, Graham
    BACKGROUND: The antibacterial, anti-inflammatory, and antiviral properties of azithromycin suggest therapeutic potential against COVID-19. Randomised data in mild-to-moderate disease are not available. We assessed whether azithromycin is effective in reducing hospital admission in patients with mild-to-moderate COVID-19. METHODS: This prospective, open-label, randomised superiority trial was done at 19 hospitals in the UK. We enrolled adults aged at least 18 years presenting to hospitals with clinically diagnosed, highly probable or confirmed COVID-19 infection, with fewer than 14 days of symptoms, who were considered suitable for initial ambulatory management. Patients were randomly assigned (1:1) to azithromycin (500 mg once daily orally for 14 days) plus standard care or to standard care alone. The primary outcome was death or hospital admission from any cause over the 28 days from randomisation. The primary and safety outcomes were assessed according to the intention-to-treat principle. This trial is registered at (NCT04381962) and recruitment is closed. FINDINGS: 298 participants were enrolled from June 3, 2020, to Jan 29, 2021. Three participants withdrew consent and requested removal of all data, and three further participants withdrew consent after randomisation, thus, the primary outcome was assessed in 292 participants (145 in the azithromycin group and 147 in the standard care group). The mean age of the participants was 45·9 years (SD 14·9). 15 (10%) participants in the azithromycin group and 17 (12%) in the standard care group were admitted to hospital or died during the study (adjusted OR 0·91 [95% CI 0·43-1·92], p=0·80). No serious adverse events were reported. INTERPRETATION: In patients with mild-to-moderate COVID-19 managed without hospital admission, adding azithromycin to standard care treatment did not reduce the risk of subsequent hospital admission or death. Our findings do not support the use of azithromycin in patients with mild-to-moderate COVID-19. FUNDING: National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Pfizer.
  • Improving the percentage of HIV tests offered to patients admitted to an acute hospital trust with community-acquired pneumonia

    McGuinness, Rachel; Keevil, H; Sharif, Adam; Lau, Ting Kwan; Crookes, William; Bhamm, Roma; Ali, Salma; Payne, Victoria; Hollinshead, Leanna; Cundy, Karen; et al. (2020-12)
    Young people and adults diagnosed with an HIV indicator condition should be offered an HIV test (NICE [National Institute of Clinical Excellence] guidance). Community-acquired pneumonia (CAP) is considered to be an HIV indicator condition as it has an undiagnosed HIV prevalence of 0.76%. We observed however, that the offer of HIV testing to patients with radiologically diagnosed CAP remained low even after a senior respiratory physician review. Our aim was to improve the percentage of patients being offered an HIV test with CAP requiring hospital admission across four acute medical wards at Royal Derby Hospital within 12 months. We identified several key steps in the process. These included the identification of CAP, the role of the medical clerking team and the respiratory infections nursing team that manage pneumonia admissions. After collecting baseline data and staff interviews, we conducted seven plan-do-study-act (PDSA) interventions. These included; iterative communication, educational interventions, system changes that involved a direct HIV test offering by our respiratory infection team and the addition of an HIV test to the electronic CAP bundle. Data collected from 177 patients were analysed over a period of one year. The main outcome measure of the project 'Did patients with a diagnosis of CAP on admission have a documented HIV test offered?' improved from 28% during the first cycle of data collection to 76.4% during the final cycle. Patients were more likely to be offered an HIV test if they had no comorbidity compared with those with a diagnosis of asthma or chronic obstructive pulmonary disease. Our most impactful PDSA interventions were the respiratory infection nurses directly offering an HIV test to patients and adding HIV to the electronic ordering CAP bundle. Our quality improvement programme has shown that educational, communication and system changes can help improve the uptake of HIV testing. Education on HIV testing is now part of our induction programme for new doctors and we are using a new CAP bundle to help streamline the request of HIV testing at the first clinician clerking. Our dedicated respiratory infection nursing team also ensures that patients with CAP have a documented offer of an HIV test.
  • Toxicological analysis of George's marvellous medicine: literature review

    Johnson, Graham (2020-12)
    Objective: To analyse the therapeutic effects and toxicity of the eponymous concoction described in Roald Dahl's book George's Marvellous Medicine. Design: Literature review. Setting: Two literature loving households in England. Participants: George Kranky and grandma Kranky. Main outcome measures: Clinical and toxic effects of the individual ingredients checked against those listed in ToxBase, the National Poisons Information Service's poisons database. Results: The medicine contained 34 ingredients. The most common toxic effect identified on ToxBase was nausea and vomiting (16 ingredients, 47%). Potentially life threatening effects were associated with 13 (38%) ingredients, including depression of the central nervous system, kidney injury, convulsions, cardiac toxicity, and mucosal erosion. The effects described in the book were accurate initially but then diverted from the most likely clinical outcome (death). Conclusions: Although Dahl ought to be applauded for his initial accuracy about the toxicology of the ingredients in George's marvellous medicine, the overall effect would be fatal catastrophic physiological collapse. Scientific exploration and experimentation should be encouraged in children, although any medicinal ingredients need to be checked for potential toxicity before being administered-to grandmas or anyone else.
  • Handheld electronic device use in patient care: the emergency department patient perspective-a cross-sectional survey.

    Tilbury, N; Johnson, Graham; Rusk, Zoe; Byrne, C; Shergill, M; Churchman, A; Tabner, Andrew (2020-09)
    BACKGROUND: Staff use of smartphones and tablets in the healthcare setting is increasingly prevalent, but little is known about whether this use is acceptable to patients. Staff are concerned that the use of handheld electronic devices (HEDs) may be negatively misconstrued by patients. The HED can be a valuable tool, offering the emergency clinician access to a wealth of resources; it is therefore vital that patient views are addressed during their widespread adoption into clinical practice. METHODS: Patients, or those accompanying them, within the ED of the Royal Derby Hospital between April and June 2017 were asked to complete a survey consisting of 22 questions. Data collection took place to include all times of day and every day of the week. Every eligible individual within the department during a data collection period was approached. RESULTS: A total of 438 respondents successfully completed the survey with a response rate of 92%. Only 2% of those who observed staff using HEDs during their ED visit thought that they were being used for non-clinical purposes. 339 (78%) agreed that staff should be allowed to use HEDs in the workplace. Concerns expressed by respondents included devices being used for non-clinical purposes and data security. The main suggestion by respondents was that the purpose of the HEDs should be explained to patients to avoid misinterpretation. CONCLUSION: Our survey shows that the majority of survey respondents felt that clinical staff should be allowed to use HEDs in the workplace and that many of the concerns raised could be addressed with adequate patient information and clear governance.
  • Mitigating the Psychological Impact of COVID-19 on Healthcare Workers: A Digital Learning Package.

    Johnson, Graham; Tabner, Andrew (2020-04)
    The coronavirus pandemic (COVID-19) will undoubtedly have psychological impacts for healthcare workers, which could be sustained; frontline workers will be particularly at risk. Actions are needed to mitigate the impacts of COVID-19 on mental health by protecting and promoting the psychological wellbeing of healthcare workers during and after the outbreak. We developed and evaluated a digital learning package using Agile methodology within the first three weeks of UK outbreak. This e-package includes evidence-based guidance, support and signposting relating to psychological wellbeing for all UK healthcare employees. A three-step rapid development process included public involvement activities (PPIs) (STEP 1), content and technical development with iterative peer review (STEP 2), and delivery and evaluation (STEP 3). The package outlines the actions that team leaders can take to provide psychologically safe spaces for staff, together with guidance on communication and reducing social stigma, peer and family support, signposting others through psychological first aid (PFA), self-care strategies (e.g., rest, work breaks, sleep, shift work, fatigue, healthy lifestyle behaviours), and managing emotions (e.g., moral injury, coping, guilt, grief, fear, anxiety, depression, preventing burnout and psychological trauma). The e-package includes advice from experts in mental wellbeing as well as those with direct pandemic experiences from the frontline, as well as signposting to public mental health guidance. Rapid delivery in STEP 3 was achieved via direct emails through professional networks and social media. Evaluation included assessment of fidelity and implementation qualities. Essential content was identified through PPIs (n = 97) and peer review (n = 10) in STEPS 1 and 2. The most important messages to convey were deemed to be normalisation of psychological responses during a crisis, and encouragement of self-care and help-seeking behaviour. Within 7 days of completion, the package had been accessed 17,633 times, and healthcare providers had confirmed immediate adoption within their health and wellbeing provisions. Evaluation (STEP 3, n = 55) indicated high user satisfaction with content, usability and utility. Assessment of implementation qualities indicated that the package was perceived to be usable, practical, low cost and low burden. Our digital support package on 'psychological wellbeing for healthcare workers' is free to use, has been positively evaluated and was highly accessed within one week of release. It is available here: Supplementary Materials. This package was deemed to be appropriate, meaningful and useful for the needs of UK healthcare workers. We recommend provision of this e-package to healthcare workers alongside wider strategies to support their psychological wellbeing during and after the COVID-19 pandemic.
  • Increased Risk of Acute Pancreatitis with Codeine Use in Patients with a History of Cholecystectomy.

    Tabner, Andrew (2019-08)
    BACKGROUND: Codeine has a spasmodic effect on sphincter of Oddi and is suspected to cause acute pancreatitis in patients with a history of cholecystectomy. AIMS: To assess the association between codeine use and acute pancreatitis in patients with a previous cholecystectomy. METHODS: We conducted a retrospective nested case-control study using the 2005-2015 MarketScan® Commercial Claims and Encounters Database. The cohort included patients aged 18-64; cohort entry began 365 days after cholecystectomy. Odds ratios (ORs) and 95% CIs for acute pancreatitis hospitalization were estimated comparing use of codeine with non-use of codeine. In a secondary analysis, use of codeine was compared with an active comparator: use of non-steroidal anti-inflammatory drugs (NSAIDs). RESULTS: Of the 664,083 patients included in the cohort, 1707 patients were hospitalized for acute pancreatitis (incidence 1.1 per 1000 person-years) and were matched to 17,063 controls. Compared with non-use of codeine, use of codeine was associated with an increased risk of acute pancreatitis (OR 2.67; 95% CI 1.63, 4.36), particularly elevated in the first 15 days of codeine use (OR 5.37; 95% CI 2.70, 10.68). Compared with use of NSAIDs, use of codeine was also associated with an increased risk of acute pancreatitis (OR 2.64; 95% CI 1.54, 4.52). CONCLUSION: Codeine is associated with an increased risk of acute pancreatitis in patients who have previously undergone cholecystectomy; greater clinician awareness of this association is needed.
  • Novel use of Cytosorb™ haemadsorption to provide biochemical control in liver impairment.

    Madhavan, D; Austin, Andrew; Morris, C (2019-05)
    We describe the use of Cytosorb™, a synthetic extracorporeal haemoperfusion adsorption column, in the management of two patients with drug induced cholestasis and a third with alcoholic hepatitis and subsequent acute on chronic liver failure. Cytosorb was used in these patients to remove bilirubin and bile acids by supporting impaired excretory hepatic function, alleviating symptoms with the intention of serving as a bridge to endogenous recovery. The first two cases demonstrate favourable biochemical and symptomatic responses; the third case demonstrated a good biochemical response but subsequently died from the complications of multiple organ failure. These cases suggest Cytosorb™ be evaluated as an adjunct to support liver excretory functions in other arenas, such as acute liver failure or overdose. It remains unclear whether extracorporeal therapies removing liver toxins allow faster or more complete spontaneous recovery of endogenous function.
  • The cost of diagnostic uncertainty: a prospective economic analysis of febrile children attending an NHS emergency department.

    Desai, Henal (2019-03)
    A lack of prompt and definitive diagnostics makes it difficult to distinguish viral from potentially life-threatening bacterial causes, necessitating a cautious approach. This may result in extended periods of observation, additional radiography, and the precautionary use of antibiotics (ABs) prior to evidence of bacterial foci. This study examines resource use, service costs, and health outcomes. METHODS: We studied an all-year prospective, comprehensive, and representative cohort of 6518 febrile children (aged < 16 years), attending Alder Hey Children's Hospital, an NHS-affiliated paediatric care provider in the North West of England, over a 1-year period. Performing a time-driven and activity-based micro-costing, we estimated the economic impact of managing paediatric febrile illness, with focus on nurse/clinician time, investigations, radiography, and inpatient stay. Using bootstrapped generalised linear modelling (GLM, gamma, log), we identified the patient and healthcare provider characteristics associated with increased resource use, applying retrospective case-note identification to determine rates of potentially avoidable AB prescribing. RESULTS: Infants aged less than 3 months incurred significantly higher resource use than any other age group, at £1000.28 [95% CI £82.39-£2993.37] per child, (p < 0.001), while lesser experienced doctors exhibited 3.2-fold [95% CI 2.0-5.1-fold] higher resource use than consultants (p < 0.001). Approximately 32.4% of febrile children received antibiotics, and 7.1% were diagnosed with bacterial infections. Children with viral illnesses for whom antibiotic prescription was potentially avoidable incurred 9.9-fold [95% CI 6.5-13.2-fold] cost increases compared to those not receiving antibiotics, equal to an additional £1352.10 per child, predominantly resulting from a 53.9-h increase in observation and inpatient stay (57.1 vs. 3.2 h). Bootstrapped GLM suggested that infants aged below 3 months and those prompting a respiratory rate 'red flag', treatment by lesser experienced doctors, and Manchester Triage System (MTS) yellow or higher were statistically significant predictors of higher resource use in 100% of bootstrap simulations. CONCLUSION: The economic impact of diagnostic uncertainty when managing paediatric febrile illness is significant, and the precautionary use of antibiotics is strongly associated with increased costs. The use of ED resources is highest among infants (aged less than 3 months) and those infants managed by lesser experienced doctors, independent of clinical severity. Diagnostic advances which could increase confidence to withhold antibiotics may yield considerable efficiency gains in these groups, where the perceived risks of failing to identify potentially life-threatening bacterial infections are greatest.
  • Smoking cessation in the emergency department: a qualitative exploration of staff attitudes

    Johnson, Graham (2018)
    Emergency departments see uniquely large numbers of patients across all demographic groups who are more likely to smoke and who attend with acute health concerns that can provide an impetus for behaviour change. Despite this potential opportunity, no smoking cessation programme in any UK emergency department yet exists. This study sought to identify perceived barriers and facilitators for emergency department smoking cessation activity, as well as potential modes of intervention, by exploring staff attitudes. Methods 16 members of staff from the Emergency Department, Derby NHS Teaching Hospital were purposively sampled to include a spectrum of clinical and non-clinical roles, grades, and employment duration. Semi-structured interviews were conducted within the department, and thematically analysed with dual-coding for validity under an interpretivist paradigm. Findings Three themes were identified: roles of emergency departments, effects of smoking, and scope for intervention. Effects were described in individual-health and department-management contexts, with belief that reducing patient smoking would benefit both. Health promotion was seen as theoretically part of, and practically achievable within, the emergency department role. Lack of organisational support was a key barrier. Staff practice included occasional ad-hoc smoking cessation activity, but nothing routine. Those who did not incorporate smoking cessation into their practice felt that lack of training and support, rather than time, stopped them from doing so. Interpretation Support for emergency department smoking cessation was found in the face of major barriers. Options to address these barriers were suggested, highlighting a willingness to engage. Complex interventions appeared impractical, and no single approach seemed universally applicable to emergency department environments. This study addresses the paucity of evidence around emergency department attitudes towards smoking cessation by providing a unique and in-depth picture of staff in the study department. It also balances clinical and population health viewpoints and has potential to inform promising prevention strategies in the emerging population-focused health-care structures. However, the study might not be generalisable to other emergency departments. Further research exploring patient attitudes would be a valuable next step.
  • UK national audit of safety checks for radiology interventions.

    Cozens, Neil (2018-11)
    OBJECTIVE:: To re-audit the use of safety checklists in radiology departments in NHS departments throughout the UK. METHODS:: This audit was performed on behalf of The Royal College of Radiologists Audit Committee in 2016 and was sent to radiology audit leads at every NHS department in the UK to determine the use of safety checks in various modalities and subspecialties. Free form text boxes gathered data on problems with checklist implementation. RESULTS:: 109/177 (62%) trusts responded. 48% of respondents used safety checklists for all radiological procedures in all modalities. 50% used checklists for some procedures. 2% did not use a checklist. Checklist use had increased since the previous audit (98% 2016, compared to 94% in 2012) but implementation for different procedures remains variable. For example, in ultrasound guided fine needle and breast stereotactic procedures (49%), use has not increased since 2012. CONCLUSION:: Reasons for not using checklists include a perception that intervention suite checklists were not appropriate for minor procedures and the limited flexibility of radiology information systems (RIS). The limitations of checklists are discussed. ADVANCES IN KNOWLEDGE:: Our re-audit shows that in spite of increased bimplementation, use of safety checks is variable. Local ownership and RIS flexibility are needed to support the culture of safety processes in radiology departments.
  • Acute ‘pathological haematoma’ without significant antecedent trauma as an unusual presentation of undiagnosed malignancy

    Cozens, Neil; Sharp, Jerry; Minhas, Honeyia (2012-07)
    The authors report two cases of malignancy that presented initially with acute haematomas without any history of significant trauma. The first case was a 31-year-old male who presented with a large haematoma in the anterior triangle of the neck following minor trauma during a rugby match. This was shown to be due to haemorrhage into an undiagnosed papillary thyroid tumour. The second case was a 41-year-old male who developed a spontaneous sternocleidomastoid haematoma after laying flagstones and without any history of direct trauma. This was due to haemorrhage into a nodal deposit of non-Hodgkin’s lymphoma. These cases highlight that sudden onset haematomas without obvious explanation may be the result of underlying malignancy. In such instances further investigation must be considered and re examination of the patient is essential after the haematoma has resolved.
  • Patients with learning disabilities should be considered at high risk of cervical spine injury.

    Byrne, C; Johnson, Graham; Tabner, Graham; Hewitt, Susanne (2018-10)
  • Training in emergency medicine.

    Boden, Dan (2018-09)
    One of the key challenges faced in emergency medicine is to provide effective training so that clinicians feel valued and supported in the roles they undertake. While there are numerous areas of exemplar practice nationally this article details two areas of particular focus for the Royal College of Emergency Medicine: supporting trainees' return to formal training programmes and developing specialty and associate specialist doctors in emergency medicine.
  • Emergency tracheostomy management: Are we appropriately trained?

    Paschou, Vasiliki; Hassan, A (2018-07)
    The aim of this audit was to assess the level of competency and adequacy of training, among the nursing staff in Royal Derby Hospital Intensive Care Unit and compare it to the national guidelines [1, 2]. The tracheostomy equipment availability, as well as the bedside presence of the emergency management algorithms were also assessed and compared to the national guidelines. Methods Bedside data collection was performed from 10 April 2017 to 24 April 2017. Twenty bedside assessments of appropriate equipment and algorithm leaflet availability were performed. Each nurse caring for an individual patient answered a 'competency questionnaire' regarding tracheostomy management during an Emergency. Their level of training as well as time intervals since the last training session were determined. Results All surveyed staff had in-house teaching and bedside training, 30% had a formal course and only 75% had a competency assessment. Time intervals since the last training were very variable, ranging from less than 1 year up to 18 years. All bedside elective and emergency equipment was available, except from the daily tracheostomy checklist. Bedside algorithms were not available in any of the 20 cases. Eighty percent of staff were not aware about the emergency management algorithms and 100% of them admitted their willingness to attend a refresher teaching session on emergency management of tracheostomy. Discussion Although training had been given to all nursing staff who looked after tracheostomy patients, the level of training was very variable and inconsistent. Nursing staff should keep skills and knowledge up to date through regular teaching sessions and competency assessments. Bedside emergency equipment was available at all times but completion of a daily tracheostomy checklist at the beginning of every shift can guarantee maintenance of safe practice. The algorithms should be coupled with bed-head signs, allowing essential information to be clearly displayed and immediately available to responders in an emergency, Including key details, the nature and date of the tracheostomy, method of forming the stoma and the function of any stay sutures. As a result of the audit finding, nurses' training has been reviewed, a regular teaching programme has been scheduled and a tracheostomy checklist has been initiated.
  • Eccentric exercise increases circulating fibroblast activation protein but not bioactive fibroblast growth factor 21 in healthy humans.

    Ghasemi, R (2018-04)
    NEW FINDINGS: What is the central question of this study? The role of FGF21 as an exercise-induced myokine remains controversial. The aim of this study was to determine whether eccentric exercise would augment the release of FGF21 and/or its regulatory enzyme Fibroblast Activation Protein (FAP) from skeletal muscle tissue into the systemic circulation of healthy human volunteers. What is the main finding and its importance? Eccentric exercise does not release total or bioactive FGF21 from human skeletal muscle. However, exercise releases its regulatory enzyme FAP from tissue(s) other than muscle, which may play a role in the inactivation of FGF21. ABSTRACT: The primary aim of the current investigation was to determine whether eccentric exercise would augment the release of the novel myokine, Fibroblast Growth Factor 21 (FGF21) and/or its regulatory enzyme Fibroblast Activation Protein (FAP) from skeletal muscle tissue into the systemic circulation of healthy human volunteers. Physically active young healthy male volunteers [age 25.0 ± 10.7 years; body mass index (BMI) 23.1 ± 7.9 kg/m2 ] completed 3 sets of 25 repetitions (with 5 min rest in between) of single-leg maximal eccentric contractions using their non-dominant leg, whilst the dominant leg served as a control. Arterialised blood samples from a hand vein and deep venous blood samples from the common femoral vein of the exercised leg, along with blood flow of the superficial femoral artery using Doppler ultrasound, were obtained before and after each exercise bout and every 20 minutes during the 3 h recovery period. Muscle biopsy samples were taken at baseline, immediately and 3 h and 48 h post-exercise. The main findings from this study showed there was no significant increase in total or bioactive FGF21 secreted from skeletal muscle into the systemic circulation in response to exercise. Furthermore, skeletal muscle FGF21 protein content was unchanged in response to exercise. However, there was a significant increase in arterialised and venous FAP concentrations with no apparent contribution to its release from the exercised leg. These findings raise the possibility that the elevated levels of FAP may play a role in the inactivation of FGF21 during exercise.
  • Tracheostomy on the intensive care unit - a two-month network-wide snapshot

    Stewart, Paul (2014-04)
    Tracheostomy is a common and invasive procedure performed on the intensive care unit and has significant associated complications. Current evidence is insufficient to clearly guide practice. We conducted a two-month prospective service evaluation of tracheostomy within our local critical care network. We found 80 tracheostomies were performed during this time. Tracheostomy was performed at a median of six days after commencement of invasive ventilation, most commonly using the Ciaglia technique. Eighteen tracheostomies (23%) were performed surgically. The facilitation of weaning from invasive ventilation was the most common indication for tracheostomy. The median (IQR) time from tracheostomy to completion of weaning from mechanical ventilation was seven (4-11) days and from tracheostomy to decannulation was 14 (9-26) days. Eleven patients (14%) sustained complications possibly relating to tracheostomy insertion, three of whom subsequently died, although tracheostomy insertion was only possibly linked to one of these deaths. While our sample is small, it benchmarks a UK critical care network's tracheostomy practice in the UK.
  • Frequency of stepping down antibiotics and nebuliser treatment is lower at weekends compared to weekdays: an observational study.

    Lacey, J; Skelly, Robert; Norwood, Mark; Sturrock, Nigel (2017-12)
    We hypothesised that delays in providing non-urgent medication step-downs at weekends to medical management may be associated with increased length of stay. In a novel use of electronic prescribing data, we analysed emergency admissions from a busy acute medical hospital over 52 weeks from November 2014 to October 2015. The main outcomes of interest were switching from intravenous antibiotics to oral antibiotics and stopping nebulised bronchodilators. The rate of switching from intravenous to oral antibiotics was lower on Saturdays and Sundays compared with weekdays, and the rate of stopping nebulised bronchodilators was similarly lower at weekends (p<0.001). Median length of stay was shorter in those whose antibiotic treatment was stepped down at weekends compared with weekdays (4 days versus 5 days, p<0.001). Reduced medication step-downs at weekends may represent a bottleneck in patient flow. Electronic prescribing data are a valuable resource for future health services research.

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