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Swerdlow A.J.,Institute of Cancer Research | Cooke R.,Institute of Cancer Research | Bates A.,Southampton General Hospital | Cunningham D.,Gastrointestinal Unit | And 13 more authors.
Journal of the National Cancer Institute | Year: 2014

Background: Modern treatment of Hodgkin's lymphoma (HL) has transformed its prognosis but causes late effects, including premature menopause. Cohort studies of premature menopause risks after treatment have been relatively small, and knowledge about these risks is limited.Methods: Nonsurgical menopause risk was analyzed in 2127 women treated for HL in England and Wales at ages younger than 36 years from 1960 through 2004 and followed to 2003 through 2012. Risks were estimated using Cox regression, modified Poisson regression, and competing risks. All statistical tests were two-sided.Results: During follow-up, 605 patients underwent nonsurgical menopause before age 40 years. Risk of premature menopause increased more than 20-fold after ovarian radiotherapy, alkylating chemotherapy other than dacarbazine, or BEAM (bis-chloroethylnitrosourea [BCNU], etoposide, cytarabine, melphalan) chemotherapy for stem cell transplantation, but was not statistically significantly raised after adriamycin, bleomycin, vinblastine, dacarbazine (ABVD). Menopause generally occurred sooner after ovarian radiotherapy (62.5% within five years of =5 Gy treatment) and BEAM (50.9% within five years) than after alkylating chemotherapy (24.2% within five years of =6 cycles), and after treatment at older than at younger ages. Cumulative risk of menopause by age 40 years was 81.3% after greater than or equal to 5Gy ovarian radiotherapy, 75.3% after BEAM, 49.1% after greater than or equal to 6 cycles alkylating chemotherapy, 1.4% after ABVD, and 3.0% after solely supradiaphragmatic radiotherapy. Tables of individualized risk information for patients by future period, treatment type, dose and age are provided.Conclusions: Patients treated with HL need to plan intended pregnancies using personalized information on their risk of menopause by different future time points. © The Author 2014. Published by Oxford University Press. All rights reserved. Source

Cloud G.,St. Georges Hospital | Rudd A.,Guys and St. Thomas
Clinical Medicine, Journal of the Royal College of Physicians of London | Year: 2013

Stroke is a common and devastating disease and, until very recently, was largely unrecognised as a preventable or treatable condition. Between 1998 and 2010, the National Sentinel Stroke Audit (NSSA) achieved 100% voluntary participation, collecting data on more than 60,000 patients from stroke services within England, Wales and Northern Ireland and becoming a benchmark for hospital stroke services. In this way it has informed stroke improvement at the local, regional and national levels and has overseen a radical change in stroke care within the NHS. This article describes the achievements of the NSSA and the lessons learned. © Royal College of Physicians, 2013. All rights reserved. Source

Morgan J.M.,University of Southampton | Dimitrov B.D.,University of Southampton | Gill J.,Guys and St. Thomas | Kitt S.,University of Southampton | And 10 more authors.
European Journal of Heart Failure | Year: 2014

Aims We wish to assess the clinical and cost-effectiveness of remote monitoring of heart failure patients with cardiac implanted electronic devices.Methods REM-HF is a multicentre, randomized, non-blinded, parallel trial designed to compare weekly remote monitoring-driven management with usual care for patients with cardiac implanted electronic devices (ICD, CRT-D, or CRT-P). The trial is event driven, and the final analysis will be performed when 546 events have been observed or the study is terminated at the interim analysis. We have randomized 1650 patients to be followed up for a minimum of 2 years. Patients will remain in the trial up to study termination. The first patient was randomized in September 2011 and the study is expected to complete in early 2016. The primary combined endpoint is time to first event of all-cause death or unplanned hospitalization for cardiovascular reasons. An economic evaluation will be performed, estimating the cost per quality-adjusted lifeyear, with direct costs estimated from the National Health Service perspective and quality of life assessed by the EQ-5D, Short-Form12, and Kansas City Cardiomyopathy Questionnaires. The study design has been informed by a feasibility study.Conclusion REM-HF is a multicentre randomized study that will provide important data on the effect of remote monitoring-driven management of implanted cardiac devices on morbidity and mortality, as well as the cost-effectiveness of this approach. Trial registration: UKCRN 10383. © 2014 European Society of Cardiology. Source

Jackson T.L.,Kings College London | Williamson T.H.,Guys and St. Thomas
Retina | Year: 2015

Purpose: To report pragmatic outcomes from a database study of epiretinal membrane surgery. Methods: Prospective anonymized clinical audit data from electronic medical records were pooled over 10 years into a national database, from 1,131 primary epiretinal membrane operations, by 69 surgeons, in 16 U.K. vitreoretinal units. Results: The median age of 1,131 patients was 71.6 years. A pars plana vitrectomy and epiretinal membrane peel were combined with internal limiting membrane peel in 17.0% of operations, and cataract surgery in 49.9%. Use of general anesthesia declined from 94.1% in 2001 to 28.9% in 2010. One or more intraoperative complication occurred in 9.8% (8.1% excluding cataract surgery complications). The median preoperative logarithm of the minimum angle of resolution (logMAR) visual acuity improved from 0.60 to 0.30 (Snellen 20/80-20/40) after a median follow-up of 7.0 months; 41.7% of eyes improved ≥0.30 logMAR units (approximately 2 Snellen's lines). The percentages of eyes undergoing subsequent surgery were 3.3%, 1.0%, 0.4%, and 0.8% for epiretinal membrane, retinal detachment, macular hole, and other vitreoretinal indications, respectively. Excluding pseudophakic eyes, 51.7%, 73.2%, and 76.2% of eyes underwent cataract surgery within 1 year, 2 year, and 3 years respectively. Conclusion: These results may help vitreoretinal surgeons to benchmark their surgical outcomes, and patients to assess the risks and benefits of surgery. Copyright © by Ophthalmic Communications Society, Inc. Source

Bristowe K.,Kings College London | Shepherd K.,Kings College | Bryan L.,Kings College London | Brown H.,St. Christophers Hospice | And 5 more authors.
Palliative Medicine | Year: 2014

Background: In recent years, the End-Stage Kidney Disease population has increased and is ever more frail, elderly and co-morbid. A care-focused approach needs to be incorporated alongside the disease focus, to identify those who are deteriorating and improve communication about preferences and future care. Yet many renal professionals feel unprepared for such discussions. Aim: To develop and pilot a REnal specific Advanced Communication Training (REACT) programme to address the needs of End- Stage Kidney Disease patients and renal professionals. Design: Two-part study: (1) development of the REnal specific Advanced Communication Training programme informed by multiprofessional focus group and patient survey and (2) piloting of the programme. Setting/participants: The REnal specific Advanced Communication Training programme was piloted with 16 participants (9 renal nurses/health-care assistants and 7 renal consultants) in two UK teaching hospitals. Results: The focus group identified the need for better information about end-of-life phase, improved awareness of patient perspectives, skills to manage challenging discussions, 'hands on' practice in a safe environment and follow-up to discuss experiences. The patient survey demonstrated a need to improve communication about concerns, treatment plans and decisions. The developed REnal specific Advanced Communication Training programme was acceptable and feasible and was associated with a non-significant increase in confidence in communicating about end-of-life issues (pre-training: 6.6/10, 95% confidence interval: 5.7-7.4; post-training: 6.9/10, 95% confidence interval: 6.1-7.7, unpaired t-test - p = 0.56), maintained at 3 months. Conclusion: There is a need to improve end-of-life care for End-Stage Kidney Disease patients, to enable them to make informed decisions about future care. Challenges include prioritising communication training among service providers. © The Author(s) 2013. Source

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