James N.D.,University of Birmingham |
Hussain S.A.,University of Birmingham |
Hussain S.A.,University of Liverpool |
Hall E.,Institute of Cancer Research |
And 10 more authors.
New England Journal of Medicine | Year: 2012
BACKGROUND:Radiotherapy is an alternative to cystectomy in patients with muscle-invasive bladder cancer. In other disease sites, synchronous chemoradiotherapy has been associated with increased local control and improved survival, as compared with radiotherapy alone. METHODS:In this multicenter, phase 3 trial, we randomly assigned 360 patients with muscle-invasive bladder cancer to undergo radiotherapy with or without synchronous chemotherapy. The regimen consisted of fluorouracil (500 mg per square meter of body-surface area per day) during fractions 1 to 5 and 16 to 20 of radiotherapy and mitomycin C (12 mg per square meter) on day 1. Patients were also randomly assigned to undergo either whole-bladder radiotherapy or modified-volume radiotherapy (in which the volume of bladder receiving full-dose radiotherapy was reduced) in a partial 2-by-2 factorial design (results not reported here). The primary end point was survival free of locoregional disease. Secondary end points included overall survival and toxic effects. RESULTS:At 2 years, rates of locoregional disease-free survival were 67% (95% confidence interval [CI], 59 to 74) in the chemoradiotherapy group and 54% (95% CI, 46 to 62) in the radiotherapy group. With a median follow-up of 69.9 months, the hazard ratio in the chemoradiotherapy group was 0.68 (95% CI, 0.48 to 0.96; P = 0.03). Five-year rates of overall survival were 48% (95% CI, 40 to 55) in the chemoradiotherapy group and 35% (95% CI, 28 to 43) in the radiotherapy group (hazard ratio, 0.82; 95% CI, 0.63 to 1.09; P = 0.16). Grade 3 or 4 adverse events were slightly more common in the chemoradiotherapy group than in the radiotherapy group during treatment (36.0% vs. 27.5%, P = 0.07) but not during follow-up (8.3% vs. 15.7%, P = 0.07). CONCLUSIONS:Synchronous chemotherapy with fluorouracil and mitomycin C combined with radiotherapy significantly improved locoregional control of bladder cancer, as compared with radiotherapy alone, with no significant increase in adverse events. (Funded by Cancer Research U.K.; BC2001 Current Controlled Trials number, ISRCTN68324339.). Copyright © 2012 Massachusetts Medical Society.
News Article | November 1, 2016
Hundreds of planned operations and outpatient appointments have been cancelled across Lincolnshire after an NHS computer network was attacked. Northern Lincolnshire and Goole NHS Foundation Trust (NLAG) said systems were infected with a virus on Sunday, with it treated as a "major incident". The trust, which runs hospitals in Goole, Grimsby and Scunthorpe, said the measures would remain into Tuesday. United Lincolnshire Hospitals NHS Trust (ULHT) also had to cancel operations. Dr Karen Dunderdale, NLAG deputy chief executive, said: "A virus infected our electronic systems yesterday, and we have taken the decision, following expert advice, to shut down the majority of our systems so we can isolate and destroy it. "Our main priority is patient safety. All adult patients should presume their appointment/procedure has been cancelled unless they are contacted. Those who turn up will be turned away." The trust added that inpatients would be cared for and discharged as soon as they were medically fit, with major trauma cases and high risk women in labour being diverted to neighbouring hospitals. It said: "We are reviewing the situation on an hourly basis. Our clinicians will continue to see, treat and operate on those patients who would be at significant clinical risk should their treatment be delayed." Further updates will be posted on the trust website. ULHT shares four of its clinical IT systems and said it had to cancel operations "unless there is a clinical reason not to". Mark Brassington, chief operating officer at ULHT, said: "We have a plan in place to minimise risks to patients which includes reverting to manual systems. "The biggest impact on the trust is in processing of blood tests, access to historical test results and availability of blood for blood transfusions. "Our number one priority is keeping patients safe so we are cancelling all planned operations tomorrow unless there is a clinical reason not to."
Armstrong R.G.,United Lincolnshire Hospitals NHS Trust |
West J.,University of Nottingham |
Card T.R.,University of Nottingham |
Card T.R.,Kings Mill Hospital
American Journal of Gastroenterology | Year: 2010
OBJECTIVES: Azathioprine is an accepted treatment of inflammatory bowel disease (IBD), but concerns exist regarding its carcinogenic potential. Studies in renal transplant and rheumatology patients have reported an increased cancer risk. In IBD, studies suggest a small increased risk of lymphoma and protection against colorectal cancer, but the overall risk of malignancy has not been established. METHODS: We conducted a nested case-control study using the General Practice Research Database. Records of IBD patients were examined for azathioprine prescriptions and cancers. Prescriptions per year of follow-up were grouped for analysis. Azathioprine use was compared between IBD cases (with a diagnosed cancer) and IBD controls (without). Results: Overall, 15,471 patients with IBD and over 1 year of appropriate data were identified. Among these, 392 developed cancer, of whom 10.5% received at least one prescription for azathioprine, compared with 1,914 (12.7%) of the controls. Analyzing the occurrence of any cancer against azathioprine prescription showed a nonsignificant protective effect (odds ratio (OR)0.92, 95% confidence interval (CI)=0.79-1.06). Correction for the effects of age and smoking removed this effect (OR=1.04, 95% CI=0.89-1.21). Diagnosis of lymphoma was associated with ever use of azathioprine with OR of 3.22, CI=1.01-10.18. Conclusions: We found evidence of an increased risk of lymphoma, which is consistent with previous studies. We found no overall increase in risk of cancer in individuals with IBD who had taken azathioprine. Our study does not show a need for azathioprine cessation in the medium term in IBD because of the risk of malignancy. © 2010 by the American College of Gastroenterology.
Sreedharan A.,United Lincolnshire Hospitals NHS Trust
Cochrane database of systematic reviews (Online) | Year: 2010
BACKGROUND: There is conflicting evidence regarding the clinical efficacy of proton pump inhibitors (PPI) initiated before endoscopy for upper gastrointestinal bleeding. OBJECTIVES: To systematically review evidence from randomised controlled trials (RCTs) of PPI treatment initiated before endoscopy for upper gastrointestinal bleeding. SEARCH STRATEGY: We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE and CINAHL databases and major conference proceedings to September 2005, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model. Searches were re-run in February 2006 and October 2008. SELECTION CRITERIA: We selected randomised controlled trials (RCTs), of hospitalised participants with unselected upper gastrointestinal bleeding, undergoing active treatment with a proton pump inhibitor PPI (oral or intravenous) and control treatment with either placebo, histamine-2 receptor antagonist (H2RA) or no treatment prior to endoscopy. Outcomes were assessed at 30 days and included mortality, rebleeding and surgery. Also assessed were stigmata of recent haemorrhage (SRH; active bleeding, non bleeding visible vessel or adherent clot) at index endoscopy, length of hospital stay, blood transfusion requirements and requirement for endoscopic therapy at index endoscopy. DATA COLLECTION AND ANALYSIS: At least two review authors assessed eligibility criteria and extracted data regarding outcomes and factors affecting methodological quality. MAIN RESULTS: Six RCTs comprising 2223 participants were included. There was no statistical heterogeneity among trials for dichotomous outcomes. There were no statistically significant differences in mortality, rebleeding or surgery between PPI and control treatment. Unweighted pooled mortality rates were 6.1% and 5.5% respectively (odds ratio (OR)1.12; 95% CI 0.72 to 1.73). Unweighted pooled rebleeding rates were 13.9% and 16.6% respectively (OR 0.81; 95%CI 0.61 to 1.09). Pooled rates for surgery were 9.9% and 10.2% respectively (OR 0.96 95% CI 0.68 to 1.35). PPI treatment compared to control significantly reduced the proportion of participants with SRH at index endoscopy; unweighted pooled rates were 37.2% and 46.5% respectively (OR 0.67; 95% CI 0.54 to 0.84). However, this result was not robust to sensitivity analysis. PPI treatment compared to control significantly reduced endoscopic therapy at index endoscopy; unweighted pooled rates were 8.6% and 11.7% respectively (OR 0.68; 95% CI 0.50 to 0.93). For continuous outcomes (length of hospital stay and blood transfusion requirements), quantitative analysis could not be performed. AUTHORS' CONCLUSIONS: PPI treatment initiated before endoscopy for upper gastrointestinal bleeding might reduce the proportion of participants with SRH at index endoscopy and significantly reduces requirement for endoscopic therapy during index endoscopy. However, there is no evidence that PPI treatment affects clinically important outcomes, namely mortality, rebleeding or need for surgery.
Dudley N.J.,United Lincolnshire Hospitals NHS Trust
Ultrasound | Year: 2013
Estimated fetal weight is used in fetal growth monitoring and, if accurately estimated, may provide a sensitive screening tool for the small-for-gestational-age fetus, which may then proceed to further investigations. There is considerable evidence, however, that ultrasound-estimated fetal weight is inaccurate. The aim of this study was to review the literature on the efficacy of estimated fetal weight in the early prediction of low birthweight. Seven studies met the inclusion criteria. Most studies used an estimated fetal weight threshold of the 10th percentile, where sensitivity for predicting small-for-gestational-age infants in low-risk groups is low and specificity is high. The sensitivity of estimated fetal weight is higher where the prevalence of small-for-gestational-age is higher or a higher detection threshold is used. Fetal weight estimation is more sensitive and specific than other measures in detecting small-for-gestational-age, but is limited by large random errors. Random errors reduce sensitivity with less effect on specificity. High sensitivity is useful where further discriminatory tests are available; this may be the case here, where Doppler ultrasound is of proven value in high-risk groups. High specificity is required where invasive or expensive procedures will be performed on the selected group. In order to achieve sensitivity approaching 100%, a threshold 3 standard deviations of estimated fetal weight error above the 10th percentile of fetal weight is required. Smaller random errors will allow the threshold to be reduced and will increase specificity.
Dudley N.J.,United Lincolnshire Hospitals NHS Trust |
Gibson N.M.,University of Nottingham
Ultrasound | Year: 2014
Ultrasound scanner preset programmes are factory set or tailored to user requirements. Scanners may, therefore, have different settings for the same application, even on similar equipment in a single department. The aims of this study were: (1) to attempt to match the performance of two scanners, where one was preferred and (2) to assess differences between six scanners used for breast ultrasound within our organisation. The Nottingham Ultrasound Quality Assurance software was used to compare imaging performance. Images of a Gammex RMI 404GS test object were collected from six scanners, using default presets, factory presets and settings matched to a preferred scanner. Resolution, low contrast performance and high contrast performance were measured. The performance of two scanners was successfully matched, where one had been preferred. Default presets varied across the six scanners, three different presets being used. The most used preset differed in settings across the scanners, most notably in the use of different frequency modes. The factory preset was more consistent across the scanners, the main variation being in dynamic range (55-70 dB). Image comparisons showed significant differences, which were reduced or eliminated by adjustment of settings to match a reference scanner. It is possible to match scanner performance using the Nottingham Ultrasound Quality Assurance software as a verification tool. Ultrasound users should be aware that scanners may not behave in a similar fashion, even with apparently equivalent presets. It should be possible to harmonise presets by consensus amongst users.
Sreedharan A.,United Lincolnshire Hospitals NHS Trust
Cochrane database of systematic reviews (Online) | Year: 2011
The majority of oesophageal and gastro-oesophageal cancers are diagnosed at an advanced stage and palliative treatment is the realistic management option for most patients. The optimal intervention for the palliation of dysphagia in these patients has not been established. To systematically analyse and summarise the efficacy of different interventions used in the palliation of dysphagia in primary oesophageal carcinoma. We undertook a search according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and CINAHL and major conference proceedings up to August 2005. The literature search was re-run in August 2006 and March 2007. Randomised controlled trials (RCTs) in patients with inoperable or unresectable primary oesophageal cancer who underwent palliative treatment. We included rigid plastic intubation, self-expanding metallic stent (SEMS) insertion, brachytherapy, external beam radiotherapy, chemotherapy, oesophageal bypass surgery, chemical and thermal ablation therapy, either head-to-head or in combination. The primary outcome was dysphagia improvement. Secondary outcomes included recurrent dysphagia, technical success, procedure related mortality, 30-day mortality, adverse effects and quality of life. One author assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting risk of bias. We included 2542 patients from 40 studies. SEMS insertion is safer and more effective than plastic tube insertion. Thermal and chemical ablative therapy provide comparable dysphagia palliation but have an increased requirement for re-interventions and adverse effects. Anti-reflux stents provide comparable dysphagia palliation to conventional metal stents. Some anti-reflux stents might reduce gastro-oesophageal reflux compared to conventional metal stents. Brachytherapy might be a suitable alternative to SEMS in providing a survival advantage and possibly a better quality of life. Self-expanding metal stent insertion is safe, effective and quicker in palliating dysphagia compared to other modalities. However, high-dose intraluminal brachytherapy is a suitable alternative and might provide additional survival benefit with a better quality of life. Self-expanding metal stent insertion and brachytherapy provide comparable palliation to endoscopic ablative therapy but are preferable due to the reduced requirement for re-interventions. Rigid plastic tube insertion, dilatation alone or in combination with other modalities, chemotherapy alone, combination chemoradiotherapy and bypass surgery are not recommended for palliation of dysphagia due to a high incidence of delayed complications and recurrent dysphagia.
Birch D.,United Lincolnshire Hospitals NHS Trust
Nursing Older People | Year: 2016
This is the third in a short series that presents case study examples of the application of comprehensive geriatric assessment (CGA) in different clinical settings. CGA is a holistic assessment model, which is designed to determine a frail older person's medical and mental health status, as well as functional, social and environmental issues. When undertaken by nurses, it can enable individualised care planning. The case study presented explores the application of CGA with an 89-year-old patient with complex health and social care needs. It demonstrates how a hospital admission was avoided and the patient's health outcomes improved, by using a nurse-led systematic approach to assessment and by careful consideration of CGA domains. © 2016 RCNi Ltd.
McKechnie A.J.,United Lincolnshire Hospitals NHS Trust
British Journal of Oral and Maxillofacial Surgery | Year: 2014
See-and-treat surgery has been described as an efficient means of streamlining specialist diagnosis and treatment, and is commonly employed in gynaecology to reduce the delay between cytological screening and definitive treatment of cervical neoplasia. Relatively young patients with predominantly benign skin lesions have been treated in see-and-treat clinics but only in the context of referrals from primary care. The author describes the treatment of tertiary referrals for facial skin malignancies under local anaesthesia at these clinics, and analyses their acceptability to patients. A total of 100 consecutive patients were included. Data on age, coexisting conditions, diagnosis, site and size of lesion, operation, and outcomes including complications and completeness of excision, were collected. A questionnaire seeking patients' opinions was also used. Ninety patients were treated and 98 lesions were removed, 94% of which were malignant. The complete excision rate was 95%. There were no complications, and 98% of patients were satisfied with the service. See-and-treat surgery is an effective, safe, and acceptable means of providing surgical management of facial skin malignancies. © 2014 The British Association of Oral and Maxillofacial Surgeons.
Turner P.,United Lincolnshire Hospitals NHS Trust |
Kane R.,University of Lincoln |
Jackson C.,University of Lincoln
British Journal of Health Care Management | Year: 2013
This article examines the implementation and efficacy of the enterprise culture: the policy to produce within the NHS the resource utilisation, quality and efficiency improvements demonstrated by leading private organisations. The article also considers the framework underpinning private sector best practice and offers a critical view of how it is reflected in the enterprise culture. The article concludes that despite some success in centralised measures, the enterprise culture does not meet the necessary framework to truly reproduce private sector improvements.