Background Antimicrobial resistance is a leading global public health threat, with inappropriate ... more Background Antimicrobial resistance is a leading global public health threat, with inappropriate use of antimicrobials in healthcare contributing to its development. Given this urgent need, we developed a complex ePrescribing-based Anti-Microbial Stewardship intervention (ePAMS+). Methods ePAMS+ includes educational and organisational behavioural elements, plus guideline-based clinical decision support to aid optimal antimicrobial use in hospital inpatients. ePAMS+ particularly focuses on prompt initiation of antimicrobials, followed by early review once test results are available to facilitate informed decision-making on stopping or switching where appropriate. A mixed-methods feasibility trial of ePAMS+ will take place in two NHS acute hospital care organisations. Qualitative staff interviews and observation of practice will respectively gather staff views on the technical component of ePAMS+ and information on their use of ePAMS+ in routine work. Focus groups will elicit staff an...
Odds Ratio for all-cause in hospital mortality associated with post index admission AKI. (DOCX 14... more Odds Ratio for all-cause in hospital mortality associated with post index admission AKI. (DOCX 14Â kb)
Cox regression for time to readmission from 1st admission dependent on AKI, excluding patients wh... more Cox regression for time to readmission from 1st admission dependent on AKI, excluding patients who died, and adjusted for age, gender, co-morbidity and CRP. (DOCX 21Â kb)
Comparison of comorbidities between the differing populations of patients: those who died in the ... more Comparison of comorbidities between the differing populations of patients: those who died in the first admission, those who survived and were readmitted and those who survived and werenâ t readmitted. (DOCX 15Â kb)
BACKGROUND This study describes the conversion within an existing electronic health record (EHR) ... more BACKGROUND This study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine–Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations. OBJECTIVE The aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable...
Background Electronic alerts (e-alerts) for Acute Kidney Injury (AKI) have been implemented into ... more Background Electronic alerts (e-alerts) for Acute Kidney Injury (AKI) have been implemented into a variety of different Electronic Health Records (EHR) systems worldwide in order to improve recognition and encourage early appropriate management of AKI. We were interested in the impact on patient safety, specialist referral and clinical management. Methods All patients admitted to our institution with AKI were included in the study. We studied AKI progression, dialysis dependency, length of hospital stay, emergency readmission, ICU readmission, and death, before and after the introduction of electronic alerts. The impact on prescription of high risk drugs, fluid administration, and referral to renal services was also analysed. Results After the introduction of the e-alert, progression to higher AKI stage, emergency readmission to hospital and death during admission were significantly reduced. More prescriptions were stopped for drugs that adversely affect renal function in AKI and th...
Cox regression for Post Discharge death after 90Â Days for AKI stage and adjusted for age, gender... more Cox regression for Post Discharge death after 90Â Days for AKI stage and adjusted for age, gender, co-morbidity and CRP. (DOCX 14Â kb)
Patients presenting to hospital with unplanned alcohol withdrawal in the United Kingdom are frequ... more Patients presenting to hospital with unplanned alcohol withdrawal in the United Kingdom are frequently admitted and managed with a fixed-dose benzodiazepine detoxification regimen. The West Midlands Poisons Unit (WMPU) offers an alternative to this with rapid supported discharge and subsequent elective inpatient detoxification, based on a symptom-triggered approach. Both management strategies are consistent with national recommendations though the relative effectiveness of each is unknown. The authors have retrospectively compared outcomes of patients admitted electively to WMPU with unplanned admissions at another hospital in the same city, University Hospitals Birmingham NHS Foundation Trust (UHB). Twenty consecutive admissions at each site were included in the study and followed up for at least one year. The total number of readmissions (13 vs. 47), the average number of readmissions per patient (0.7 ± 0.2 vs. 2.4 ± 1.7; p = .002) and the percentage of patients readmitted (40% vs. 100%) were significantly lower at WMPU compared with UHB. This study suggests that patients managed with an elective approach to alcohol detoxification, following work-up with a dedicated alcohol team in outpatient clinics, are readmitted to hospital with alcohol intoxication or withdrawal significantly less often when compared with patients managed following an unplanned admission.
Introduction : Au cours des dernières années, l'utilisation des portfolios en tant qu'outil d'app... more Introduction : Au cours des dernières années, l'utilisation des portfolios en tant qu'outil d'apprentissage et d'évaluation est devenue une pratique de plus en plus répandue au sein des programmes de formation des professionnels de santé. Malgré le nombre croissant de publications qui rend compte de cette tendance, il manque une synthèse claire des données probantes qui en documente les effets éducatifs chez les étudiants au cours du cursus pré-gradué dans le milieu des professions de santé. Tel est l'objet de la présente contribution qui expose RÉFÉRENCES
Background: ePrescribing systems have considerable potential for improving healthcare quality and... more Background: ePrescribing systems have considerable potential for improving healthcare quality and safety. With growing expectations about the benefits of such systems, there is evidence of widespread plans to implement these systems in hospitals in England where hitherto they have had a low uptake. Given the international drive away from developing homegrown to systems to procuring commercial applications, we aimed to identify available ePrescribing systems in England and to use the findings to develop a taxonomy of the systems offered by suppliers. Methods and Findings: We undertook a scoping review of the published and grey literature, and conducted expert interviews with vendors, healthcare organisations and national ePrescribing experts in order to identify the spectrum of available systems, identify and map their key features, and then iteratively develop and validate a taxonomy of commercial ePrescribing systems available to English hospitals. There is a wide range of available systems including 13 hospital-wide applications and a range of specialty systems. These commercial applications can be grouped into four sub-categories: standalone systems, modules within integrated systems, functionalities spread over several modules, and specialty systems. The findings also reveal that apart from four packaged applications (two of which are specialty systems), all other systems have none or less than two live implementations across England. Conclusions: The wide range of products developed in the last few years by different national and international suppliers, and the low uptake of these products by English hospitals indicate that the English ePrescribing market is still in its infancy. This market is undergoing rapid cycles of change, both with respect to the number of suppliers and their diversity of offerings. Constant renewal of knowledge is needed on the status of this evolving market, encompassing the products development and adoption, to assist implementation decisions and facilitate market maturity.
Background: Entering the clinical environment is potentially stressful for junior medical student... more Background: Entering the clinical environment is potentially stressful for junior medical students. Aims: We evaluated first-year medical student feedback on a peer-mentored 'Hospital Orientation Day' designed to provide insight into future clinical training. Method: Using a mixed methodology approach data were collected from first-year medical students. Responses to a questionnaire were used to develop a topic guide for focus groups held the next academic year. The questionnaire was completed by 230 firstyear students and 32 second years participated in the interviews. Thematic analysis was used to draw conclusions. Results: Analysis of questionnaire responses indicated that students gained insight into future learning. Focus groups then generated five themes: (1) entering the hospital without fear, (2) linking the present with the future, (3) understanding the culture of learning in the clinical years, (4) a 'Backstage Pass' to the clinical world and (5) peer mentors make or break the day. Conclusions: Using peer mentors during the Hospital Orientation Day allowed insight into future learning. We highlight the importance of student Mentors in the success of hospital orientation. To maximise the benefits for first years, we recommend a mentor selection procedure, mentor training opportunities and incentives to optimise mentor performance.
Summary Monitoring of patients taking antihypertensive treatment can identify potential adverse d... more Summary Monitoring of patients taking antihypertensive treatment can identify potential adverse drug reactions (ADRs). However, published guidelines give divergent or incomplete recommendations on monitoring for ADRs. Using a predetermined strategy, we undertook a systematic review to identify hypertension guidelines published from January 2001 to October 2011 with recommendations for monitoring for ADRs. We screened 88 abstracts and 187 web-based guidelines, and identified 19 published guidelines on monitoring the biochemical effects of antihypertensive drug therapy. We then produced a set of practical clinical guidelines, synthesized from those recommendations. Our recommendations are designed to provide efficient monitoring. They reduce the number of tests to a minimum consistent with safe practice and align monitoring schedules, so that creatinine, potassium and sodium concentrations are measured at the same times in all cases. The instructions for biochemical monitoring in curr...
To develop a list of prescribing indicators specific for the hospital setting that would facilita... more To develop a list of prescribing indicators specific for the hospital setting that would facilitate the prospective collection of high-severity and/or high-frequency prescribing errors, which are also amenable to electronic clinical decision support. METHODS A two-stage consensus technique (electronic Delphi) was carried out with 20 experts across England. Participants were asked to score prescribing errors using a five-point Likert scale for their likelihood of occurrence and the severity of the most likely outcome. These were combined to produce risk scores, from which median scores were calculated for each indicator across the participants in the study. The degree of consensus between the participants was defined as the proportion that gave a risk score in the same category as the median. Indicators were included if a consensus of 80% or more was achieved. RESULTS A total of 80 prescribing errors were identified by consensus as being high or extreme risk. The most common drug classes named within the indicators were antibiotics (n = 13), antidepressants (n = 8), nonsteroidal anti-inflammatory drugs (n = 6) and opioid analgesics (n = 6). The most frequent error type identified as high or extreme risk were those classified as clinical contraindications (n = 29 of 80).
This is an observational study of heat-related illness in UK Service Personnel deployed into summ... more This is an observational study of heat-related illness in UK Service Personnel deployed into summer conditions in Northern Kuwait and Southern Iraq. Among 622 hospitalisations reported during a 9-week period at the historical British Military Hospital, Shaibah, 303 consecutive admissions are reviewed in detail. Several clinical syndromes attributable to thermal stress were observed. These ranged from self-limiting debility to life-threatening failures of homeostasis, with 5.0% developing a critical care requirement. Hyponatraemia was a commonly occurring electrolyte disturbance by which, relative to the local reference range, a majority of heat-attributed admissions were affected. Reductions in measured serum sodium could be profound (<125 mmol/L in 20.1% of all heat-related casualties). Hypokalaemia was observed in half of cases, though only a minority were affected by severely low potassium (<2.5 mmol/L in 4.0%). Despite preventive measures prescribed on hospital discharge, ...
Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease. When fully ... more Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease. When fully expressed, it is characterized by inflammatory soft tissue changes, exophthalmos, ocular dysmotility causing diplopia, and, rarely, sight-threatening dysthyroid optic neuropathy (DON). The prevalence of GO among Graves' patients seems lately declining, probably due to early diagnosis, early intervention on risk factors associated with its occurrence or progression (smoking, uncontrolled thyroid dysfunction), early correction of hyper and hypothyroidism. Only about 25-30% of newly diagnosed Graves' hyperthyroids are affected with GO, which is usually mild and rarely progressive. Assessment of activity and severity of GO according to standardized criteria is fundamental to plan management. The European Thyroid Association and the European Group on Graves' Orbitopathy (EUGOGO) have recently published the first guideline on management of GO. Mild GO usually requires only a watchful strategy, in addition to local measures (eye drops, ointments) and removal of risk factors. Intravenous glucocorticoids (ivGCs) are the first-line treatment for moderate-to-severe and active GO, as demonstrated by randomized clinical trials. When ivGCs fail or GO recurs after treatment withdrawal, options include a second course of ivGCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab. Evidence that the any of the above treatment be effective in the context of a poor response to a first course of ivGCs is limited and should be investigated in larger studies. In addition to rituximab, ongoing investigations are exploring the role of other biologics targeting, e.g., the IGF-1 receptor or the IL-6 receptor, and results will probably available in 1-2 years. When GO has been treated medically and is inactive, rehabilitative surgery (orbital decompression, squint surgery, eyelid surgery) is often needed.
Background The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision ... more Background The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision Support (CDS) has been found to have some unintended consequences. The aim of this study is to explore pharmacists and physicians perceptions of their interprofessional communication in the context of the technology and whether electronic messaging and CDS has an impact on this. Method This qualitative study was conducted in two acute hospitals: the University Hospitals Birmingham NHS Foundation Trust (UHBFT) and Guy's and St Thomas' NHS Foundation Trust (GSTH). UHBFT use an established locally developed CPOE system that can facilitate pharmacist-physician communication with the ability to assign a message directly to an electronic prescription. In contrast, GSTH use a more recently implemented commercial system where such communication is not possible. Focus groups were conducted with pharmacists and physicians of varying grades at both hospitals. Focus group data were transcribed and analysed thematically using deductive and inductive approaches, facilitated by NVivo 10. Results Three prominent themes emerged during the study: increased communication load; impaired decision-making; and improved workflow. CPOE and CDS were found to increase the communication load for the pharmacist owing to a reduced ability to amend electronic prescriptions, new types of prescribing errors, and the provision of technical advice relating to the use of the system. Decision-making was found to be affected, owing to the difficulties faced by pharmacists and physicians when trying to determine the context of prescribing
Acute Kidney Injury (AKI) has evoked much interest over the past decade and is reported to be ass... more Acute Kidney Injury (AKI) has evoked much interest over the past decade and is reported to be associated with high inpatient mortality. Preventable death and increased readmission rates related to AKI have been the focus of considerable interest. We studied hospital acquired AKI in all emergency hospital admissions, except transfers from ICU to ICU or patients known to renal services, to ascertain mortality and readmission rates, and trackable modifiable factors for death, using cox regression and Kaplan Meier survival curves. Data was extracted from the electronic patient records and a series of case notes reviewed. Admissions were included between April 2006 and March 2010 (and patients followed up until September 2011). Overall incidence of AKI was 2.2%, (AKI stage 1, 61%, stage 2,27% and stage 3, 12%). In patients who sustain in-hospital AKI, 34% die in hospital, 42% are dead at 90 days and 48% at 1 year post discharge, compared to 12% 1 year mortality in patients without AKI. I...
Background Antimicrobial resistance is a leading global public health threat, with inappropriate ... more Background Antimicrobial resistance is a leading global public health threat, with inappropriate use of antimicrobials in healthcare contributing to its development. Given this urgent need, we developed a complex ePrescribing-based Anti-Microbial Stewardship intervention (ePAMS+). Methods ePAMS+ includes educational and organisational behavioural elements, plus guideline-based clinical decision support to aid optimal antimicrobial use in hospital inpatients. ePAMS+ particularly focuses on prompt initiation of antimicrobials, followed by early review once test results are available to facilitate informed decision-making on stopping or switching where appropriate. A mixed-methods feasibility trial of ePAMS+ will take place in two NHS acute hospital care organisations. Qualitative staff interviews and observation of practice will respectively gather staff views on the technical component of ePAMS+ and information on their use of ePAMS+ in routine work. Focus groups will elicit staff an...
Odds Ratio for all-cause in hospital mortality associated with post index admission AKI. (DOCX 14... more Odds Ratio for all-cause in hospital mortality associated with post index admission AKI. (DOCX 14Â kb)
Cox regression for time to readmission from 1st admission dependent on AKI, excluding patients wh... more Cox regression for time to readmission from 1st admission dependent on AKI, excluding patients who died, and adjusted for age, gender, co-morbidity and CRP. (DOCX 21Â kb)
Comparison of comorbidities between the differing populations of patients: those who died in the ... more Comparison of comorbidities between the differing populations of patients: those who died in the first admission, those who survived and were readmitted and those who survived and werenâ t readmitted. (DOCX 15Â kb)
BACKGROUND This study describes the conversion within an existing electronic health record (EHR) ... more BACKGROUND This study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine–Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations. OBJECTIVE The aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable...
Background Electronic alerts (e-alerts) for Acute Kidney Injury (AKI) have been implemented into ... more Background Electronic alerts (e-alerts) for Acute Kidney Injury (AKI) have been implemented into a variety of different Electronic Health Records (EHR) systems worldwide in order to improve recognition and encourage early appropriate management of AKI. We were interested in the impact on patient safety, specialist referral and clinical management. Methods All patients admitted to our institution with AKI were included in the study. We studied AKI progression, dialysis dependency, length of hospital stay, emergency readmission, ICU readmission, and death, before and after the introduction of electronic alerts. The impact on prescription of high risk drugs, fluid administration, and referral to renal services was also analysed. Results After the introduction of the e-alert, progression to higher AKI stage, emergency readmission to hospital and death during admission were significantly reduced. More prescriptions were stopped for drugs that adversely affect renal function in AKI and th...
Cox regression for Post Discharge death after 90Â Days for AKI stage and adjusted for age, gender... more Cox regression for Post Discharge death after 90Â Days for AKI stage and adjusted for age, gender, co-morbidity and CRP. (DOCX 14Â kb)
Patients presenting to hospital with unplanned alcohol withdrawal in the United Kingdom are frequ... more Patients presenting to hospital with unplanned alcohol withdrawal in the United Kingdom are frequently admitted and managed with a fixed-dose benzodiazepine detoxification regimen. The West Midlands Poisons Unit (WMPU) offers an alternative to this with rapid supported discharge and subsequent elective inpatient detoxification, based on a symptom-triggered approach. Both management strategies are consistent with national recommendations though the relative effectiveness of each is unknown. The authors have retrospectively compared outcomes of patients admitted electively to WMPU with unplanned admissions at another hospital in the same city, University Hospitals Birmingham NHS Foundation Trust (UHB). Twenty consecutive admissions at each site were included in the study and followed up for at least one year. The total number of readmissions (13 vs. 47), the average number of readmissions per patient (0.7 ± 0.2 vs. 2.4 ± 1.7; p = .002) and the percentage of patients readmitted (40% vs. 100%) were significantly lower at WMPU compared with UHB. This study suggests that patients managed with an elective approach to alcohol detoxification, following work-up with a dedicated alcohol team in outpatient clinics, are readmitted to hospital with alcohol intoxication or withdrawal significantly less often when compared with patients managed following an unplanned admission.
Introduction : Au cours des dernières années, l'utilisation des portfolios en tant qu'outil d'app... more Introduction : Au cours des dernières années, l'utilisation des portfolios en tant qu'outil d'apprentissage et d'évaluation est devenue une pratique de plus en plus répandue au sein des programmes de formation des professionnels de santé. Malgré le nombre croissant de publications qui rend compte de cette tendance, il manque une synthèse claire des données probantes qui en documente les effets éducatifs chez les étudiants au cours du cursus pré-gradué dans le milieu des professions de santé. Tel est l'objet de la présente contribution qui expose RÉFÉRENCES
Background: ePrescribing systems have considerable potential for improving healthcare quality and... more Background: ePrescribing systems have considerable potential for improving healthcare quality and safety. With growing expectations about the benefits of such systems, there is evidence of widespread plans to implement these systems in hospitals in England where hitherto they have had a low uptake. Given the international drive away from developing homegrown to systems to procuring commercial applications, we aimed to identify available ePrescribing systems in England and to use the findings to develop a taxonomy of the systems offered by suppliers. Methods and Findings: We undertook a scoping review of the published and grey literature, and conducted expert interviews with vendors, healthcare organisations and national ePrescribing experts in order to identify the spectrum of available systems, identify and map their key features, and then iteratively develop and validate a taxonomy of commercial ePrescribing systems available to English hospitals. There is a wide range of available systems including 13 hospital-wide applications and a range of specialty systems. These commercial applications can be grouped into four sub-categories: standalone systems, modules within integrated systems, functionalities spread over several modules, and specialty systems. The findings also reveal that apart from four packaged applications (two of which are specialty systems), all other systems have none or less than two live implementations across England. Conclusions: The wide range of products developed in the last few years by different national and international suppliers, and the low uptake of these products by English hospitals indicate that the English ePrescribing market is still in its infancy. This market is undergoing rapid cycles of change, both with respect to the number of suppliers and their diversity of offerings. Constant renewal of knowledge is needed on the status of this evolving market, encompassing the products development and adoption, to assist implementation decisions and facilitate market maturity.
Background: Entering the clinical environment is potentially stressful for junior medical student... more Background: Entering the clinical environment is potentially stressful for junior medical students. Aims: We evaluated first-year medical student feedback on a peer-mentored 'Hospital Orientation Day' designed to provide insight into future clinical training. Method: Using a mixed methodology approach data were collected from first-year medical students. Responses to a questionnaire were used to develop a topic guide for focus groups held the next academic year. The questionnaire was completed by 230 firstyear students and 32 second years participated in the interviews. Thematic analysis was used to draw conclusions. Results: Analysis of questionnaire responses indicated that students gained insight into future learning. Focus groups then generated five themes: (1) entering the hospital without fear, (2) linking the present with the future, (3) understanding the culture of learning in the clinical years, (4) a 'Backstage Pass' to the clinical world and (5) peer mentors make or break the day. Conclusions: Using peer mentors during the Hospital Orientation Day allowed insight into future learning. We highlight the importance of student Mentors in the success of hospital orientation. To maximise the benefits for first years, we recommend a mentor selection procedure, mentor training opportunities and incentives to optimise mentor performance.
Summary Monitoring of patients taking antihypertensive treatment can identify potential adverse d... more Summary Monitoring of patients taking antihypertensive treatment can identify potential adverse drug reactions (ADRs). However, published guidelines give divergent or incomplete recommendations on monitoring for ADRs. Using a predetermined strategy, we undertook a systematic review to identify hypertension guidelines published from January 2001 to October 2011 with recommendations for monitoring for ADRs. We screened 88 abstracts and 187 web-based guidelines, and identified 19 published guidelines on monitoring the biochemical effects of antihypertensive drug therapy. We then produced a set of practical clinical guidelines, synthesized from those recommendations. Our recommendations are designed to provide efficient monitoring. They reduce the number of tests to a minimum consistent with safe practice and align monitoring schedules, so that creatinine, potassium and sodium concentrations are measured at the same times in all cases. The instructions for biochemical monitoring in curr...
To develop a list of prescribing indicators specific for the hospital setting that would facilita... more To develop a list of prescribing indicators specific for the hospital setting that would facilitate the prospective collection of high-severity and/or high-frequency prescribing errors, which are also amenable to electronic clinical decision support. METHODS A two-stage consensus technique (electronic Delphi) was carried out with 20 experts across England. Participants were asked to score prescribing errors using a five-point Likert scale for their likelihood of occurrence and the severity of the most likely outcome. These were combined to produce risk scores, from which median scores were calculated for each indicator across the participants in the study. The degree of consensus between the participants was defined as the proportion that gave a risk score in the same category as the median. Indicators were included if a consensus of 80% or more was achieved. RESULTS A total of 80 prescribing errors were identified by consensus as being high or extreme risk. The most common drug classes named within the indicators were antibiotics (n = 13), antidepressants (n = 8), nonsteroidal anti-inflammatory drugs (n = 6) and opioid analgesics (n = 6). The most frequent error type identified as high or extreme risk were those classified as clinical contraindications (n = 29 of 80).
This is an observational study of heat-related illness in UK Service Personnel deployed into summ... more This is an observational study of heat-related illness in UK Service Personnel deployed into summer conditions in Northern Kuwait and Southern Iraq. Among 622 hospitalisations reported during a 9-week period at the historical British Military Hospital, Shaibah, 303 consecutive admissions are reviewed in detail. Several clinical syndromes attributable to thermal stress were observed. These ranged from self-limiting debility to life-threatening failures of homeostasis, with 5.0% developing a critical care requirement. Hyponatraemia was a commonly occurring electrolyte disturbance by which, relative to the local reference range, a majority of heat-attributed admissions were affected. Reductions in measured serum sodium could be profound (<125 mmol/L in 20.1% of all heat-related casualties). Hypokalaemia was observed in half of cases, though only a minority were affected by severely low potassium (<2.5 mmol/L in 4.0%). Despite preventive measures prescribed on hospital discharge, ...
Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease. When fully ... more Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease. When fully expressed, it is characterized by inflammatory soft tissue changes, exophthalmos, ocular dysmotility causing diplopia, and, rarely, sight-threatening dysthyroid optic neuropathy (DON). The prevalence of GO among Graves' patients seems lately declining, probably due to early diagnosis, early intervention on risk factors associated with its occurrence or progression (smoking, uncontrolled thyroid dysfunction), early correction of hyper and hypothyroidism. Only about 25-30% of newly diagnosed Graves' hyperthyroids are affected with GO, which is usually mild and rarely progressive. Assessment of activity and severity of GO according to standardized criteria is fundamental to plan management. The European Thyroid Association and the European Group on Graves' Orbitopathy (EUGOGO) have recently published the first guideline on management of GO. Mild GO usually requires only a watchful strategy, in addition to local measures (eye drops, ointments) and removal of risk factors. Intravenous glucocorticoids (ivGCs) are the first-line treatment for moderate-to-severe and active GO, as demonstrated by randomized clinical trials. When ivGCs fail or GO recurs after treatment withdrawal, options include a second course of ivGCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab. Evidence that the any of the above treatment be effective in the context of a poor response to a first course of ivGCs is limited and should be investigated in larger studies. In addition to rituximab, ongoing investigations are exploring the role of other biologics targeting, e.g., the IGF-1 receptor or the IL-6 receptor, and results will probably available in 1-2 years. When GO has been treated medically and is inactive, rehabilitative surgery (orbital decompression, squint surgery, eyelid surgery) is often needed.
Background The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision ... more Background The implementation of Computerised Physician Order Entry (CPOE) and Clinical Decision Support (CDS) has been found to have some unintended consequences. The aim of this study is to explore pharmacists and physicians perceptions of their interprofessional communication in the context of the technology and whether electronic messaging and CDS has an impact on this. Method This qualitative study was conducted in two acute hospitals: the University Hospitals Birmingham NHS Foundation Trust (UHBFT) and Guy's and St Thomas' NHS Foundation Trust (GSTH). UHBFT use an established locally developed CPOE system that can facilitate pharmacist-physician communication with the ability to assign a message directly to an electronic prescription. In contrast, GSTH use a more recently implemented commercial system where such communication is not possible. Focus groups were conducted with pharmacists and physicians of varying grades at both hospitals. Focus group data were transcribed and analysed thematically using deductive and inductive approaches, facilitated by NVivo 10. Results Three prominent themes emerged during the study: increased communication load; impaired decision-making; and improved workflow. CPOE and CDS were found to increase the communication load for the pharmacist owing to a reduced ability to amend electronic prescriptions, new types of prescribing errors, and the provision of technical advice relating to the use of the system. Decision-making was found to be affected, owing to the difficulties faced by pharmacists and physicians when trying to determine the context of prescribing
Acute Kidney Injury (AKI) has evoked much interest over the past decade and is reported to be ass... more Acute Kidney Injury (AKI) has evoked much interest over the past decade and is reported to be associated with high inpatient mortality. Preventable death and increased readmission rates related to AKI have been the focus of considerable interest. We studied hospital acquired AKI in all emergency hospital admissions, except transfers from ICU to ICU or patients known to renal services, to ascertain mortality and readmission rates, and trackable modifiable factors for death, using cox regression and Kaplan Meier survival curves. Data was extracted from the electronic patient records and a series of case notes reviewed. Admissions were included between April 2006 and March 2010 (and patients followed up until September 2011). Overall incidence of AKI was 2.2%, (AKI stage 1, 61%, stage 2,27% and stage 3, 12%). In patients who sustain in-hospital AKI, 34% die in hospital, 42% are dead at 90 days and 48% at 1 year post discharge, compared to 12% 1 year mortality in patients without AKI. I...
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Papers by Jamie Coleman