Cooper P.N.,Greater Manchester Neurosciences Center |
Westby M.,Guideline |
Pitcher D.W.,Worcestershire Royal Hospital |
Annals of Internal Medicine | Year: 2011
Description: Transient loss of consciousness (TLoC) is common and often leads to incorrect diagnosis, unnecessary investigation, or inappropriate choice of specialist referral. In August 2010, the National Institute for Health and Clinical Excellence published a guideline that addressed the initial assessment of and most appropriate specialist referral for persons who have experienced TLoC. The guideline focused on correct diagnosis and relevant specialist referral and did not make treatment recommendations. This synopsis describes the principal recommendations concerning assessment and referral of a patient with TLoC. Methods: The National Clinical Guideline Centre developed the guidelines by using the standard methodology of the National Institute for Health and Clinical Excellence. A multidisciplinary guideline panel generated review questions, discussed evidence, and formulated recommendations. The panel included a technical team from the National Clinical Guideline Centre, who reviewed and graded all relevant evidence identified from literature searches published in English up to November 2009 and performed healtheconomic modeling. Both guideline development and final modifications were informed by comments from stakeholders and the public. Recommendations: The panel made clear recommendations regarding the assessment of a person after TLoC, which emphasized the importance of clinical reasoning in diagnosis. Persons with uncomplicated faint, situational syncope, or orthostatic hypotension should receive electrocardiography but do not otherwise require immediate further investigation or specialist referral. Persons with features that suggest epilepsy should be referred for specialist neurologic assessment; brief seizure-like activity was recognized as a common occurrence during syncope that should not be regarded as indicating epilepsy. Persons with a suspected cardiac cause for TLoC or in whom TLoC is unexplained after initial assessment should receive specialist cardiovascular assessment. Guidance was provided on the appropriate choices of cardiovascular investigation, according to the presenting clinical circumstances. © 2011 American College of Physicians.
Crowther M.,Worcestershire Royal Hospital |
Lim W.,McMaster University |
Crowther M.A.,McMaster University
Blood | Year: 2010
Systematic reviews and meta-analyses are being increasingly used to summarize medical literature and identify areas in which research is needed. Systematic reviews limit bias with the use of a reproducible scientific process to search the literature and evaluate the quality of the individual studies. If possible the results are statistically combined into a meta-analysis in which the data are weighted and pooled to produce an estimate of effect. This article aims to provide the reader with a practical overview of systematic review and meta-analysis methodology, with a focus on the process of performing a review and the related issues at each step. © 2010 by The American Society of Hematology.
Neunert C.,University of Texas Southwestern Medical Center |
Lim W.,McMaster University |
Crowther M.,Worcestershire Royal Hospital |
Cohen A.,Children's Hospital of Philadelphia |
And 2 more authors.
Blood | Year: 2011
Immune thrombocytopenia (ITP) is commonly encountered in clinical practice. In 1996 the American Society of Hematology published a landmark guidance paper designed to assist clinicians in the management of this disorder. Since 1996 there have been numerous advances in the management of both adult and pediatric ITP. These changes mandated an update in the guidelines. This guideline uses a rigorous, evidence-based approach to the location, interpretation, and presentation of the available evidence. We have endeavored to identify, abstract, and present all available methodologically rigorous data informing the treatment of ITP. We provide evidence-based treatment recommendations using the GRADE system in those areas in which such evidence exists. We do not provide evidence in those areas in which evidence is lacking, or is of lower quality - interested readers are referred to a number of recent, consensus-based recommendations for expert opinion in these clinical areas. Our review identified the need for additional studies in many key areas of the therapy of ITP such as comparative studies of "front-line" therapy for ITP, the management of serious bleeding in patients with ITP, and studies that will provide guidance about which therapy should be used as salvage therapy for patients after failure of a first-line intervention. © 2011 by The American Society of Hematology.
Bell C.,Worcestershire Royal Hospital |
Rowe I.F.,Worcestershire Royal Hospital
Musculoskeletal Care | Year: 2011
Objectives. To investigate how well recognized the association between rheumatoid arthritis (RA) and excess cardiovascular (CV) risk is within primary care and the current assessment strategies being employed by general practitioners (GPs). Methods. Questionnaires were sent to all 376 GPs in the Worcestershire Primary Care Trust. Results. Thirty-two per cent of GPs identified RA as an independent risk factor for CV disease. Fifteen per cent and 34%, respectively, assessed their RA patients for primary and secondary prevention of their CV risks. Of those GPs who made an assessment, 18.4% adjusted the calculated risk derived from standard charts. The frequency of assessment was greater among GPs who had received a form of education about the association between CV disease and RA. However, of the GPs identifying this susceptibility, only 40% performed any form of primary prevention risk assessment. Conclusions. At present, the excess risk of CV disease conferred by RA is under-recognized and under-assessed in primary care. Currently, educational resources on this topic targeted at GPs are lacking and may in part account for our findings. However, even when GPs did identify the risk of CV disease in RA or had received education about it, this did not consistently change their clinical management. Further work to promote knowledge and management strategies for CV disease in RA is therefore needed to improve the care of patients with this condition. © 2010 John Wiley & Sons, Ltd.
Jha S.,Sheffield Teaching Hospitals |
Moran P.,Worcestershire Royal Hospital
International Urogynecology Journal and Pelvic Floor Dysfunction | Year: 2011
Introduction and hypothesis: The objective of this study was to assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and the changes in management since this survey was first conducted 5 years ago. Methods: A postal questionnaire survey was sent to practising consultant gynaecologists in UK hospitals. They included urogynaecologists in tertiary centres, gynaecologists with a designated special interest in urogynaecology, and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire sent 5 years ago. Results: Two hundred and eighteen responses were received of which 190 were completed. For anterior vaginal wall prolapse, anterior colporrhaphy was still the procedure of choice in 71% of respondents. There was a significant rise in graft usage, particularly synthetic graft for recurrent prolapse (56%). A Burch was being performed by only 1% compared to 11% 5 years ago. In women with uterovaginal prolapse, the procedure of choice was still a vaginal hysterectomy and repair (82%). Thirty-five percent of respondents would operate in women whose family was incomplete. In women with posterior vaginal wall prolapse, the procedure of choice was posterior colporrhaphy with midline fascial plication in 66%, marginally less than the previous (75%). For vault prolapse, 73% of respondents would operate, and 43% would perform urodynamics prior to surgery. The procedure of choice was an abdominal sacrocolpopexy (44%), slightly greater than 5 years ago when it was 38%. Conclusions: Basic trends in prolapse surgery remain unchanged. The increase in the use of grafts is in patients with recurrent prolapse. © 2010 The International Urogynecological Association.
Gilbody J.,Worcestershire Royal Hospital
Journal of Bone and Joint Surgery - Series B | Year: 2011
Aseptic loosening of the acetabular component continues to be the most common indication for revision of total hip replacements in younger patients. Early in the evolution of the cemented hip, arthroplasty surgeons switched from removal to retention of the acetabular subchondral bone plate, theorising that unfavourable mechanical forces were the cause of loosening at the bone-cement interface. It is now known that the cause of aseptic loosening is probably biological rather than mechanical and removing the subchondral bone plate may enhance biological fixation of cement to bone. With this in mind, perhaps it is time to revive removal of the subchondral bone as a standard part of acetabular preparation. © 2011.
Crowther M.,Worcestershire Royal Hospital |
Crowther M.A.,McMaster University
Arteriosclerosis, Thrombosis, and Vascular Biology | Year: 2015
The direct thrombin inhibitor dabigatran and the anti-Xa agents rivaroxaban, edoxaban, and apixaban are a new generation of oral anticoagulants. Their advantage over the vitamin K antagonists is the lack of the need for monitoring and dose adjustment. Their main disadvantage is currently the absence of a specific reversal agent. Dabigatran's, unlike the anti-Xa agents, absorption can be reduced by activated charcoal if administered shortly after ingestion and it can be removed from the blood with hemodialysis. Prothrombin complex concentrate, activated prothrombin complex concentrate, and recombinant factor VIIa all show some activity in reversing the anticoagulant effect of these drugs but this is based on ex vivo, animal, and volunteer studies. It is unclear, which, if any, of these drugs is the most suitable for emergency reversal. Three novel molecules (idarucizumab, andexanet, and PER977) may provide the most effective and safest way of reversal. These agents are currently in premarketing studies. © 2015 American Heart Association, Inc.
Powell J.B.,Worcestershire Royal Hospital |
Gach J.E.,West Dermatology
Clinical and Experimental Dermatology | Year: 2015
Background Elderly patients present with a unique spectrum of dermatoses that pose particular management opportunities and challenges, which will be increasingly encountered in dermatological practice. The skin of elderly patients differs from that of younger patients not only in appearance but also in structure, physiology and response to ultraviolet (UV) radiation. However, little is known about the safety and efficacy of phototherapy in elderly patients and how phototherapy is currently being utilized to treat them. Aim To investigate the safety, efficacy and utilization of phototherapy in elderly patients. Methods In January 2014, we analysed all patients recently referred for, currently receiving or recently having completed a course of phototherapy at a university teaching hospital in England (UK). Results In total, 249 patients were identified; 37 (15%) were over the age of 65 years (the WHO definition of an elderly or older person). The dermatoses being treated were psoriasis (51%), eczema (11%), nodular prurigo (11%), pruritus (11%), Grover disease (5%) and others (11%). One patient with dementia was deemed not safe to embark on phototherapy, and five patients were yet to start. The remaining 31 elderly patients received 739 individual phototherapy treatments: 88% narrowband (NB)-UVB and 12% systemic, bath and hand/foot psoralen UVA (PUVA). The acute adverse event (AE) rate was 1.89%, all occurring in those receiving NB-UVB. No severe acute AEs occurred. Of those who completed their course of phototherapy, 80% achieved a clear/near clear or moderate response, while just two patients (8%) had minimal response and two (8%) had worsening of the disease during treatment. Of those receiving NB-UVB for psoriasis, 91% achieved a clear or near-clear response. Conclusions In this small survey, the first of its kind to focus on elderly patients, phototherapy appears to be well-tolerated, safe and efficacious in the short term. Further thought and investigation should be given to delivering phototherapy to an ageing population. © 2015 British Association of Dermatologists.
Hull P.,Worcestershire Royal Hospital
Hand surgery : an international journal devoted to hand and upper limb surgery and related research : journal of the Asia-Pacific Federation of Societies for Surgery of the Hand | Year: 2010
Distal radius fractures are common, and surgeons have in their armament a variety of ways of treating them. In this study, 50 orthopaedic surgeons in the UK were shown five clinical scenarios and radiographs from patients with various fracture patterns of the distal radius, and were asked for their preferred management. There was a wide variation in the preferred treatment for each scenario presented. Across all of the cases, 52% of surgeons preferred to use a volar locking-plate compared with 21% who chose fixation with Kirschner wires. There was very little consensus among surgeons with regard to the optimal method of fixation for patients sustaining dorsally displaced fractures of the distal radius. This disagreement is not surprising as there is currently no high level evidence to guide surgeons as to the best management option for this common and potentially debilitating injury.
Nyamekye I.,Worcestershire Royal Hospital |
Merker L.,Worcestershire Royal Hospital
Phlebology | Year: 2012
Iliofemoral DVT constitutes approximately 20-25% of lower limb DVT and represents a specific subgroup of patients at highest risk for post-thrombotic syndrome (PTS). Anticoagulation alone has no significant thrombolytic activity and has not impact on PTS prevention. Early thrombus removal has reduced PTS in uncontrolled reports and reviews but major trials are awaited. The optimal timing for treatment appear to be thrombus, <2 weeks old and, methods for thrombus removal include direct open or suction thrombectomy, catheter directed thrombolysis (CDT), with or without percutaneous mechanical thrombectomy (PMT) devices. Three principle types of PMT device are in use (rotational, rheolytic and ultrasound enhanced devices) and are combined with CDT in pharmocomechanical thrombolysis (PhMT) to enhance early thrombus removal. These devices have individual device specific attributes and side effects that are additional to the bleeding complications of thrombolysis. A number of additional interventions may be utilised to the improve results of CDT and PhMT. IVC filter deployment to reduce periprocedural PE, is supported by little evidence unless an indication for its use already exists. However, balloon venoplasty and vein stents undoubtedly vein patency after treatment. Early thrombus removal comes with additional upfront costs derived from devices, imaging and critical care bed usage. However, significant potential savings from reduction in PTS and rethrombosis rates may reduce overall societal costs. This review focuses on iliofemoral thrombosis, however, the less commonly encountered but clinically important subclavian vein thrombosis is also discussed.