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Nicholson A.B.,South Tees Hospitals NHS Foundation Trust | Watson G.R.,South Tees Hospitals NHS Foundation Trust | Derry S.,University of Oxford | Wiffen P.J.,University of Oxford
Cochrane Database of Systematic Reviews | Year: 2017

Background: This is an updated review originally published in 2004 and first updated in 2007. This version includes substantial changes to bring it in line with current methodological requirements. Methadone is a synthetic opioid that presents some challenges in dose titration and is recognised to cause potentially fatal arrhythmias in some patients. It does have a place in therapy for people who cannot tolerate other opioids but should be initiated only by experienced practitioners. This review is one of a suite of reviews on opioids for cancer pain. Objectives: To determine the effectiveness and tolerability of methadone as an analgesic in adults and children with cancer pain. Search methods: For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, and clinicaltrials.gov, to May 2016, without language restriction. We also checked reference lists in relevant articles. Selection criteria: We sought randomised controlled trials comparing methadone (any formulation and by any route) with active or placebo comparators in people with cancer pain. Data collection and analysis: All authors agreed on studies for inclusion. We retrieved full texts whenever there was any uncertainty about eligibility. One review author extracted data, which were checked by another review author. There were insufficient comparable data for meta-analysis. We extracted information on the effect of methadone on pain intensity or pain relief, the number or proportion of participants with 'no worse than mild pain'. We looked for data on withdrawal and adverse events. We looked specifically for information about adverse events relating to appetite, thirst, and somnolence. We assessed the evidence using GRADE and created a 'Summary of findings' table. Main results: We revisited decisions made in the earlier version of this review and excluded five studies that were previously included. We identified one new study for this update. This review includes six studies with 388 participants. We did not identify any studies in children. The included studies differed so much in their methods and comparisons that no synthesis of results was feasible. Only one study (103 participants) specifically reported the number of participants with a given level of pain relief, in this case a reduction of at least 20% - similar in both the methadone and morphine groups. Using an outcome of 'no worse than mild pain', methadone was similar to morphine in effectiveness, and most participants who could tolerate methadone achieved 'no worse than mild pain'. Adverse event withdrawals with methadone were uncommon (12/202) and similar in other groups. Deaths were uncommon except in one study where the majority of participants died, irrespective of treatment group. For specific adverse events, somnolence was more common with methadone than with morphine, while dry mouth was more common with morphine than with methadone. None of the studies reported effects on appetite. We judged the quality of evidence to be low, downgraded due to risk of bias and sparse data. For specific adverse events, we considered the quality of evidence to be very low, downgraded due to risk of bias, sparse data, and indirectness, as surrogates for appetite, thirst and somnolence were used. There were no data on the use of methadone in children. Authors' conclusions: Based on low-quality evidence, methadone is a drug that has similar analgesic benefits to morphine and has a role in the management of cancer pain in adults. Other opioids such as morphine and fentanyl are easier to manage but may be more expensive than methadone in many economies. © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.


West R.M.,University of Leeds | Cattle B.A.,University of Leeds | Bouyssie M.,University of Leeds | Bouyssie M.,University Paul Sabatier | And 8 more authors.
European Heart Journal | Year: 2011

Aim s To quantify the determinants of primary percutaneous coronary intervention (PCI) performance in England and Wales between 2004 and 2007.Methods and resultsAll 8653 primary PCI cases admitted to acute hospitals in England and Wales as recorded in the Myocardial Ischaemia National Audit Project (MINAP) 20042007. We studied the impact of the volume of primary PCI cases (hospital volume) on door-to-balloon (DTB) times and the proportion of patients treated with primary PCI (hospital proportion) on 30-day mortality and employed regression analysis to identify reasons for DTB time variations with a multilevel component to express hospital variation. The proportion of patients receiving primary PCI increased from 5 in 2004 to 20 in 2007. Median DTB times reduced from 84 min in 2004 to 61 min in 2007. Median DTB times decreased as the number of primary PCI procedures increased. The 30-day all-cause mortality rate for hospitals performing primary PCI on >25 of ST-elevation myocardial infarction patients [5.0; 95 confidence interval (CI): 3.96.1] was almost double that of hospitals performing primary PCI on more than 75 (2.7; 95 CI: 2.03.5). Time-of-day, year of admission, sex, and diabetes significantly influenced DTB times. Hospital variation was evident by a hospital-level DTB time standard deviation of 12 min.Conclusion sThere was a large variation in DTB times between the best and worst performing hospitals. Although patient-related factors impacted upon DTB times, the volume and proportion of patients undergoing primary PCI were significantly associated with delay and early mortalityhospitals with the highest proportion of primary PCI had the lowest mortality. © 2010 The Author.


Zachariah D.,Portsmouth Hospitals NHS Trust | Taylor J.,Royal Infirmary | Rowell N.,South Tees Hospitals NHS Foundation Trust | Spooner C.,Servier Laboratories Ltd | Kalra P.R.,Portsmouth Hospitals NHS Trust
Journal of Geriatric Cardiology | Year: 2015

Chronic heart failure (CHF) is predominantly seen in older patients, and therefore real life medicine often requires the extrapolation of findings from trials conducted in much younger populations. Prescribing patterns and potential benefits in the elderly are heavily influenced by polypharmacy and co-morbid pathologies. Increasing longevity may become less relevant in the frail elderly, whereas improving quality of life (QoL) often becomes priority; the onus being on improving wellbeing, maintaining independence for longer, and delaying institutionalisation. Specific studies evaluating elderly patients with CHF are lacking and little is known regarding the tolerability and side-effect profile of evidence based drug therapies in this population. There has been recent interest on the impact of heart rate in patients with symptomatic CHF. Ivabradine, with selective heart rate lowering capabilities, is of benefit in patients with CHF and left ventricular systolic dysfunction in sinus rhythm, resulting in reduction of heart failure hospitalisation and cardiovascular death. This manuscript will focus on CHF and the older patient and will discuss the impact of heart rate, drug therapies and tolerability. It will also highlight the unmet need for specific studies that focus on patient-centred study end points rather than mortality targets that characterise most therapeutic trials. An on-going study evaluating the impact of ivabradine on QoL that presents a unique opportunity to evaluate the tolerability and impact of an established therapy on a wide range of real life, older patients with CHF will be discussed. © 2015 JGC All rights reserved; www.jgc301.com.


Close H.,Durham University | Reilly J.,Durham University | Reilly J.,West Park Hospital | Mason J.M.,Durham University | And 4 more authors.
PLoS ONE | Year: 2014

Objective: Lithium users are offered routine renal monitoring but few studies have quantified the risk to renal health. The aim of this study was to assess the association between use of lithium carbonate and incidence of renal failure in patients with bipolar disorder. Methods: This was a retrospective cohort study using the General Practice Research Database (GPRD) and a nested validation study of lithium exposure and renal failure. A cohort of 6360 participants aged over 18 years had a first recorded diagnosis of bipolar disorder between January 1, 1990 and December 31, 2007. Data were examined from electronic primary care records from 418 general practices across the UK. The primary outcome was the hazard ratio for renal failure in participants exposed to lithium carbonate as compared with non-users of lithium, adjusting for age, gender, co-morbidities, and poly-pharmacy. Results: Ever use of lithium was associated with a hazard ratio for renal failure of 2.5 (95% confidence interval 1.6 to 4.0) adjusted for known renal risk factors. Absolute risk was age dependent, with patients of 50 years or older at particular risk of renal failure: Number Needed to Harm (NNH) was 44 (21 to 150). Conclusions: Lithium is associated with an increased risk of renal failure, particularly among the older age group. The absolute risk of renal failure associated with lithium use remains small. © 2014 Close et al.


Paleri V.,Newcastle Upon Tyne Hospitals NHS Foundation Trust | Wight R.G.,South Tees Hospitals NHS Foundation Trust | Silver C.E.,Yeshiva University | Haigentz Jr. M.,Yeshiva University | And 6 more authors.
Oral Oncology | Year: 2010

Comorbidity, the presence of additional illnesses unrelated to the tumor, has a significant impact on the prognosis of patients with head and neck cancer. In these patients, tobacco and alcohol abuse contributes greatly to comorbidity. Several instruments have been used to quantify comorbidity including Adult Comorbidity Evaluation 27 (ACE 27), Charlson Index (CI) and Cumulative Illness Rating Scale. The ACE 27 and CI are the most frequently used indices. Information on comorbidity at the time of diagnosis can be abstracted from patient records. Self-reporting is less reliable than record review. Functional status is not a reliable substitute for comorbidity evaluation as a prognostic measure. Severity as well as the presence of a condition is required for a good predictive instrument. Comorbidity increases mortality in patients with head and neck cancer, and this effect is greater in the early years following treatment. In addition to reducing overall survival, many studies have shown that comorbidity influences disease-specific survival negatively, most likely because patients with high comorbidity tend to have delay in diagnosis, often presenting with advanced stage tumors, and the comorbidity may also prompt less aggressive treatment. The impact of comorbidity on survival is greater in younger than in older patients, although it affects both. For specific tumor sites, comorbidity has been shown to negatively influence prognosis in oral, oropharyngeal, laryngeal and salivary gland tumors. Several studies have reported higher incidence and increased severity of treatment complications in patients with high comorbidity burden. Studies have demonstrated a negative impact of comorbidity on quality of life, and increased cost of treatment with higher degree of comorbidity. Our review of the literature suggests that routine collection of comorbidity data will be important in the analysis of survival, quality of life and functional outcomes after treatment as comorbidity has an impact on all of the above. These data should be integrated with tumor-specific staging systems in order to develop better instruments for prognostication, as well as comparing results of different treatment regimens and institutions. © 2010 Elsevier Ltd. All rights reserved.


Jameson S.S.,London School of Hygiene and Tropical Medicine | Baker P.N.,London School of Hygiene and Tropical Medicine | Charman S.C.,London School of Hygiene and Tropical Medicine | Deehan D.J.,London School of Hygiene and Tropical Medicine | And 6 more authors.
Journal of Bone and Joint Surgery - Series B | Year: 2012

We compared thromboembolic events, major haemorrhage and death after knee replacement in patients receiving either aspirin or low-molecular-weight heparin (LMWH). Data from the National Joint Registry for England and Wales were linked to an administrative database of hospital admissions in the English National Health Service. A total of 156 798 patients between April 2003 and September 2008 were included and followed for 90 days. Multivariable risk modelling was used to estimate odds ratios adjusted for baseline risk factors (AOR). An AOR < 1 indicates that risk rates are lower with LMWH than with aspirin. In all, 36 159 patients (23.1%) were prescribed aspirin and 120 639 patients (76.9%) were prescribed LMWH. We found no statistically significant differences between the aspirin and LMWH groups in the rate of pulmonary embolism (0.49% vs 0.45%, AOR 0.88 (95% confidence interval (CI) 0.74 to 1.05); p = 0.16), 90-day mortality (0.39% vs 0.45%, AOR 1.13 (95% CI 0.94 to 1.37); p = 0.19) or major haemorrhage (0.37% vs 0.39%, AOR 1.01 (95% CI 0.83 to 1.22); p = 0.94). There was a significantly greater likelihood of needing to return to theatre in the aspirin group (0.26% vs 0.19%, AOR 0.73 (95% CI 0.58 to 0.94); p = 0.01). Between patients receiving LMWH or aspirin there was only a small difference in the risk of pulmonary embolism, 90-day mortality and major haemorrhage. These results should be considered when the existing guidelines for thromboprophylaxis after knee replacement are reviewed. ©2012 British Editorial Society of Bone and Joint Surgery.


Heslehurst N.,Northumbria University | Russell S.,University of Teesside | McCormack S.,University of Teesside | Sedgewick G.,South Tees Hospitals NHS Foundation Trust | And 2 more authors.
Midwifery | Year: 2013

Objective: to explore midwives' perceptions of their training and education requirements in relation to maternal obesity. Design: an interpretive constructionist approach used focus groups and broad discussion topics to allow midwives to identify their own personal and professional needs. Data analysis incorporated researcher and data triangulation (transcripts, debrief notes, and observers' notes), using a thematic content analysis approach. Setting and participants: participants included 46 community and hospital-based midwives from all NHS Trusts providing maternity services in Northeast England, UK. Eleven focus groups took place in midwives' place of work. Sampling was determined by data saturation. Findings: three main themes were identified: discussing obesity, weight management, and practicalities of training. Midwives' justification for the need for training was centrally connected to all themes, and there were strong views on the need for training and education, and the potential benefits to their practice. Issues relating to obesity communication were most prominent. Midwives' uncertainty about effective obesity communication and management, and concerns of a negative impact on the midwife-woman relationship, are key barriers to their practice. Key conclusions and implications for practice: the provision of a systematic approach to training and education is endorsed by midwives, and would provide the required level of knowledge and skills to deliver the recommended standard of care appropriate to their practice. It is clear that midwives require both training and education, although there are challenges to midwives' engagement with effective continuous professional development largely outside their control. Realistic models of training and education are required to address midwives' needs, and these should be thoroughly evaluated for impact on midwifery practice, and on obese women's health and well-being. © 2012 Elsevier Ltd.


Khan S.K.,South Tees Hospitals NHS Foundation Trust | Karuppaiah K.,South Tees Hospitals NHS Foundation Trust | Bajwa A.S.,South Tees Hospitals NHS Foundation Trust
Annals of the Royal College of Surgeons of England | Year: 2012

INTRODUCTION: Informed consent is an ethical and legal prerequisite for major surgical procedures. Recent literature has identified 'poor consent' as a major cause of litigation in trauma cases. We aimed to investigate the patient and process factors that influence consent information recall in mentally competent patients (abbreviated mental test score [AMTS] £6) presenting with neck of femur (NOF) fractures. METHODS: A prospective study was conducted at a tertiary unit. Fifty NOF patients (cases) and fifty total hip replacement (THR) patients (controls) were assessed for process factors (adequacy and validity of consent) as well as patient factors (comprehension and retention) using consent forms and structured interview proformas. RESULTS: The two groups were matched for ASA (American Society of Anesthesiologists) grade and AMTS. The consent forms were adequate in both groups but scored poorly for validity in the NOF group. Only 26% of NOF patients remembered correctly what surgery they had while only 48% recalled the risks and benefits of the procedure. These results were significantly poorer than in THR patients (p=0.0001). CONCLUSIONS: This study confirms that NOF patients are poor at remembering the information conveyed to them at the time of consent when compared with THR patients despite being intellectually and physiologically matched. We suggest using preprinted consent forms (process factors), information sheets and visual aids (patient factors) to improve retention and recall.


Cormack S.M.,South Tees Hospitals NHS Foundation Trust
BMJ case reports | Year: 2012

This report describes the case of a 71-year-old lady who was diagnosed with a Stanford type A dissecting aortic aneurysm which resulted in paraplegia secondary to spinal artery injury at T12 level. She had surgical repair with a tube graft. At a routine review CT scan 2 years postdissection, she presents with asymptomatic but significant dilation, of maximum diameter 78 mm, of the superior part of the ascending thoracic aorta, extending into the arch, suggestive of false aneurysm formation at the surgical anastomoses. There was also thrombosis of the false lumen in the distal arch and descending thoracic aorta. She is a candidate for urgent resection of the aortic arch and reimplantation of the brachiocephalic vessels.


Cheesman M.,South Tees Hospitals NHS Foundation Trust | Maund A.,South Tees Hospitals NHS Foundation Trust
Anaesthesia and Intensive Care Medicine | Year: 2016

The perioperative management of ruptured abdominal aortic aneurysms (RAAA) remains a core anaesthetic competency. Changes such as service centralization, aneurysm screening and the developing role of emergency endovascular aneurysm repair (EVAR) are altering the demands upon anaesthetists. Whereas previously on-site general anaesthesia for resuscitative open aneurysm repair (OAR) was standard, now transfer, choice of surgical technique and options for anaesthetic management may need to be considered. We present the key components of emergency anaesthesia for both OAR and EVAR and describe clinical dilemmas arising at preoperative and intraoperative stages. © 2016 Elsevier Ltd.

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