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Cooper A, Edwards M, Davies F, Price D, Anderson P, Carson-Stevens A, Cooke M, Dale J, Donaldson L, Evans BA, Harrington B, Hepburn J, Hibbert P, Hughes TC, Porter A, Siriwardena AN, Watkins A, Snooks H, Edwards A. Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation. Emerg Med J 2024; 41:287-295. [PMID: 38649248 PMCID: PMC11041563 DOI: 10.1136/emermed-2023-213426] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. METHODS We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. RESULTS GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the 'right patients' are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. CONCLUSION GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew Cooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Barbara Harrington
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Julie Hepburn
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | | | - Alison Porter
- Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Alan Watkins
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Davies F, Edwards M, Price D, Anderson P, Carson-Stevens A, Choudhry M, Cooke M, Dale J, Donaldson L, Evans BA, Harrington B, Harris S, Hepburn J, Hibbert P, Hughes T, Hussain F, Islam S, Pockett R, Porter A, Siriwardena AN, Snooks H, Watkins A, Edwards A, Cooper A. Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation. Health Soc Care Deliv Res 2024; 12:1-152. [PMID: 38687611 DOI: 10.3310/jwqz5348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Background Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models. Objectives To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models. Design Mixed-methods realist evaluation. Methods Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development. Results General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models. Limitations The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored. Conclusion Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services. Future work The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. Study registration This study is registered as PROSPERO CRD42017069741. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Freya Davies
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Pippa Anderson
- Bangor Institute for Health and Medical Research, Bangor University, Wales, UK
| | | | - Mazhar Choudhry
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Matthew Cooke
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | - Jeremy Dale
- Professor of Clinical Systems Design, Warwick Medical School, Warwick, UK
| | | | - Bridie Angela Evans
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Shaun Harris
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Julie Hepburn
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Faris Hussain
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Saiful Islam
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Rhys Pockett
- Swansea Centre for Health Economics, School of Health and Social Care, Swansea University, Swansea, UK
| | - Alison Porter
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Helen Snooks
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Alan Watkins
- PRIME Centre Wales, Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff, UK
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Forster VJ, Aronson M, Zhang C, Chung J, Sudhaman S, Galati MA, Kelly J, Negm L, Ercan AB, Stengs L, Durno C, Edwards M, Komosa M, Oldfield LE, Nunes NM, Pedersen S, Wellum J, Siddiqui I, Bianchi V, Weil BR, Fox VL, Pugh TJ, Kamihara J, Tabori U. Biallelic EPCAM deletions induce tissue-specific DNA repair deficiency and cancer predisposition. NPJ Precis Oncol 2024; 8:69. [PMID: 38467830 PMCID: PMC10928233 DOI: 10.1038/s41698-024-00537-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/08/2024] [Indexed: 03/13/2024] Open
Abstract
We report a case of Mismatch Repair Deficiency (MMRD) caused by germline homozygous EPCAM deletion leading to tissue-specific loss of MSH2. Through the use of patient-derived cells and organoid technologies, we performed stepwise in vitro differentiation of colonic and brain organoids from reprogrammed EPCAMdel iPSC derived from patient fibroblasts. Differentiation of iPSC to epithelial-colonic organoids exhibited continuous increased EPCAM expression and hypermethylation of the MSH2 promoter. This was associated with loss of MSH2 expression, increased mutational burden, MMRD signatures and MS-indel accumulation, the hallmarks of MMRD. In contrast, maturation into brain organoids and examination of blood and fibroblasts failed to show similar processes, preserving MMR proficiency. The combined use of iPSC, organoid technologies and functional genomics analyses highlights the potential of cutting-edge cellular and molecular analysis techniques to define processes controlling tumorigenesis and uncovers a new paradigm of tissue-specific MMRD, which affects the clinical management of these patients.
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Affiliation(s)
- V J Forster
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Aronson
- Zane Cohen Centre, Sinai Health System and Faculty of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - C Zhang
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - J Chung
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - S Sudhaman
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - M A Galati
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - J Kelly
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - L Negm
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - A B Ercan
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - L Stengs
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - C Durno
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Edwards
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Komosa
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - N M Nunes
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - S Pedersen
- University Health Network, Toronto, ON, Canada
| | - J Wellum
- University Health Network, Toronto, ON, Canada
| | - I Siddiqui
- Department of Paediatric Laboratory Medicine and Pathobiology, Division of Pathology, The Hospital for Sick Children, Toronto, ON, Canada
| | - V Bianchi
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - B R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - V L Fox
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - T J Pugh
- University Health Network, Toronto, ON, Canada
| | - J Kamihara
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - U Tabori
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada.
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
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4
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Lombardi J, Stec E, Edwards M, Connell T, Sandor M. Comparison of mechanical properties and host tissue response to OviTex™ and Strattice™ surgical meshes: author reply. Hernia 2024; 28:281-282. [PMID: 37855939 PMCID: PMC10891220 DOI: 10.1007/s10029-023-02911-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 10/01/2023] [Indexed: 10/20/2023]
Affiliation(s)
- J Lombardi
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - E Stec
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - M Edwards
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - T Connell
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - M Sandor
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA.
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5
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Wilkinson DA, Edwards M, Shum C, Moinet M, Anderson NE, Benschop J, Nisa S. Molecular typing of Leptospira spp. in farmed and wild mammals reveals new host-serovar associations in New Zealand. N Z Vet J 2024; 72:1-9. [PMID: 37589061 DOI: 10.1080/00480169.2023.2248930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023]
Abstract
AIMS To apply molecular typing to DNA isolated from historical samples to determine Leptospira spp. infecting farmed and wild mammals in New Zealand. MATERIALS AND METHODS DNA samples used in this study were extracted from urine, serum or kidney samples (or Leptospira spp. cultures isolated from them) collected between 2007 and 2017 from a range of domestic and wildlife mammalian species as part of different research projects at Massey University. Samples were included in the study if they met one of three criteria: samples that tested positive with a lipL32 PCR for pathogenic Leptospira; samples that tested negative by lipL32 PCR but were recorded as positive to PCR for pathogenic Leptospira in the previous studies; or samples that were PCR-negative in all studies but were from animals with positive agglutination titres against serogroup Tarassovi. DNA samples were typed using PCR that targeted either the glmU or gyrB genetic loci. The resulting amplicons were sequenced and typed relative to reference sequences. RESULTS We identified several associations between mammalian hosts and Leptospira strains/serovars that had not been previously reported in New Zealand. Leptospira borgpetersenii strain Pacifica was found in farmed red deer (Cervus elaphus) samples, L. borgpetersenii serovars Balcanica and Ballum were found in wild red deer samples, Leptospira interrogans serovar Copenhageni was found in stoats (Mustela erminea) and brushtail possums (Trichosurus vulpecula), and L. borgpetersenii was found in a ferret (Mustela putorius furo). Furthermore, we reconfirmed previously described associations including dairy cattle with L. interrogans serovars Copenhageni and Pomona and L. borgpetersenii serovars Ballum, Hardjo type bovis and strain Pacifica, sheep with L. interrogans serovar Pomona and L. borgpetersenii serovar Hardjo type bovis, brushtail possum with L. borgpetersenii serovar Balcanica, farmed deer with L. borgpetersenii serovar Hardjo type bovis and hedgehogs (Erinaceus europaeus) with L. borgpetersenii serovar Ballum. CONCLUSIONS This study provides an updated summary of host-Leptospira associations in New Zealand and highlights the importance of molecular typing. Furthermore, strain Pacifica, which was first identified as Tarassovi using serological methods in dairy cattle in 2016, has circulated in animal communities since at least 2007 but remained undetected as serology is unable to distinguish the different genotypes. CLINICAL RELEVANCE To date, leptospirosis in New Zealand has been diagnosed with serological typing, which is deficient in typing all strains in circulation. Molecular methods are necessary to accurately type strains of Leptospira spp. infecting mammals in New Zealand.
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Affiliation(s)
- D A Wilkinson
- Molecular Epidemiology and Public Health Laboratory, Tāwharau Ora - School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - M Edwards
- The Royal (Dick) School of Veterinary Studies and the Roslin Institute, University of Edinburgh, Roslin, UK
| | - C Shum
- Molecular Epidemiology and Public Health Laboratory, Tāwharau Ora - School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - M Moinet
- Molecular Epidemiology and Public Health Laboratory, Tāwharau Ora - School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - N E Anderson
- The Royal (Dick) School of Veterinary Studies and the Roslin Institute, University of Edinburgh, Roslin, UK
| | - J Benschop
- Molecular Epidemiology and Public Health Laboratory, Tāwharau Ora - School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
| | - S Nisa
- Molecular Epidemiology and Public Health Laboratory, Tāwharau Ora - School of Veterinary Sciences, Massey University, Palmerston North, New Zealand
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6
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Van Cutsem E, Yaeger R, Delord JP, Tabernero J, Siu LL, Ducreux M, Siena S, Elez E, Kasper S, Zander T, Steeghs N, Murphy D, Edwards M, Wainberg ZA. Phase Ib/II Study of the Efficacy and Safety of Binimetinib (MEK162) Plus Panitumumab for Mutant or Wild-Type RAS Metastatic Colorectal Cancer. Oncologist 2023; 28:e1209-e1218. [PMID: 37597246 PMCID: PMC10712701 DOI: 10.1093/oncolo/oyad210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/08/2023] [Indexed: 08/21/2023] Open
Abstract
INTRODUCTION Activating RAS gene mutations occur in approximately 55% of patients with metastatic colorectal cancer (mCRC) and are associated with poorer clinical outcomes due to epidermal growth factor receptor (EGFR) blockade resistance. Combined EGFR and mitogen-activated protein kinase (MEK) inhibition may extend response to EGFR inhibition and overcome acquired resistance. This phase Ib/II dose escalation trial evaluated the safety and activity of dual inhibition with binimetinib (MEK1/2 inhibitor) and panitumumab (EGFR inhibitor [EGFRi]) in patients with RAS mutant or BRAF wild type (WT)/RAS WT mCRC. METHODS Phase Ib dose escalation started with binimetinib 45 mg twice daily plus panitumumab 6 mg/kg administered every 2 weeks. In the phase II study, patients with measurable mCRC were enrolled into 4 groups based on previous anti-EGFR monoclonal antibody therapy and RAS mutational status. RESULTS No patients in the phase Ib portion (n = 10) had a response; 70% of patients had stable disease. In the phase II portion (n = 43), overall response rate (ORR, confirmed) was 2.3% with one partial response in the RAS WT group, DCR was 30.2%, and median progression-free survival was 1.8 months (95%CI, 1.6-3.3). All patients experienced ≥1 adverse event, with the most common being diarrhea (71.7%), vomiting (52.8%), nausea (50.9%), fatigue (49.1%), dermatitis acneiform (43.4%), and rash (41.5%). Most patients required treatment interruption or dose reduction due to difficulties tolerating treatment. CONCLUSIONS The combination of binimetinib and panitumumab had substantial toxicity and limited clinical activity for patients with mutant or WT RAS mCRC, independent of EGFRi treatment history (Trial registration: NCT01927341).
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Affiliation(s)
- Eric Van Cutsem
- Digestive Oncology, University Hospitals Gasthuisberg, Leuven and KU Leuven, Leuven, Belgium
| | - Rona Yaeger
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jean-Pierre Delord
- Medical Oncology Department, Institut Claudius Regaud, IUCT-Oncopole, Toulouse, France
| | - Josep Tabernero
- Medical Oncology Department, Vall d’Hebron Campus Hospital and Institute of Oncology (VHIO), IOB-Quiron, UVic-UICC, Barcelona, Spain
| | - Lillian L Siu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Michel Ducreux
- Department of Medical Oncology, Gustave Roussy, Cancer Campus, Université Paris-Saclay, Villejuif, France
| | - Salvatore Siena
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
- Department of Oncology, Niguarda Cancer Center, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elena Elez
- Medical Oncology Department, Vall d’Hebron Campus Hospital and Institute of Oncology (VHIO), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Stefan Kasper
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, Essen, Germany
| | - Thomas Zander
- Department of Internal Medicine, Center for Integrated Oncology Aachen-Bonn-Cologne, University of Cologne, Duesseldorf, Germany
- Department of Internal Medicine I, Gastrointestinal Cancer Group Cologne (GCGC), University Clinic Cologne, Cologne, Germany
| | - Neeltje Steeghs
- Department of Medical Oncology and Clinical Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | | | - Zev A Wainberg
- Division of Hematology/Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Edwards M, Holland‐Hart D, Mann M, Seddon K, Buckle P, Longo M, Byrne A, Nelson A. Understanding how shared decision-making approaches and patient aids influence patients with advanced cancer when deciding on palliative treatments and care: A realist review. Health Expect 2023; 26:2109-2126. [PMID: 37448166 PMCID: PMC10632651 DOI: 10.1111/hex.13822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/09/2023] [Accepted: 07/01/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Patients with advanced incurable cancer face difficult decisions about palliative treatment options towards their end of life. However, they are often not provided with the appropriate information and support that is needed to make informed decisions. This review aimed to identify contexts and mechanisms associated with communication tools, patient decision-aids and shared decision-making (SDM) approaches that influence patient outcomes. METHODS We used a realist review method to search for published studies of patients (adults > 18) with advanced cancer who were expected to make a decision about palliative treatment and/or supportive care in consultation with healthcare practitioners. We appraised and synthesised literature describing the contexts of (when and how) decision aids and SDM approaches are used, and how these contexts interact with mechanisms (resources and reasoning) which impact patient outcomes. Stakeholders including academics, palliative healthcare professionals (HCPs) and people with lived experience of supporting people with advanced incurable cancer contributed to identifying explanatory accounts. These accounts were documented, analysed and consolidated to contribute to the development of a programme theory. RESULTS From the 33 included papers, we consolidated findings into 20 explanatory accounts to develop a programme theory that explains key contexts and mechanisms that influence patient and SDM. Contexts include underlying patients' and HCPs' attitudes and approaches. These need to be understood in relation to key mechanisms, including presenting information in multiple formats and providing adequate time and opportunities to prepare for and revisit decisions. Contexts influenced mechanisms which then influence the levels of patient decisional satisfaction, conflict and regret. CONCLUSIONS Our programme theory highlights mechanisms that are important in supporting shared treatment decisions for advanced noncurative cancer. The findings are informative for developing and evaluating interventions to improve understanding and involvement in SDM for patients with advanced incurable cancer. PATIENT AND PUBLIC CONTRIBUTION We included patient and public involvement (PPI) representatives in four stakeholder meetings. PPI helped to define the scope of the review, identify their unique experiences and perspectives, synthesise their perspectives with our review findings, make decisions about which theories we included in our programme theory and develop recommendations for policy and practice and future research.
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Affiliation(s)
- Michelle Edwards
- Division of Population Medicine, Marie Curie Palliative Care Research CentreCardiff UniversityCardiffWalesUK
| | - Daniella Holland‐Hart
- Division of Population Medicine, Marie Curie Palliative Care Research CentreCardiff UniversityCardiffWalesUK
| | - Mala Mann
- Division of Population Medicine, Marie Curie Palliative Care Research CentreCardiff UniversityCardiffWalesUK
| | - Kathy Seddon
- Marie Curie Palliative Care Research CentreWales Cancer Research CentreCardiffWalesUK
| | - Peter Buckle
- Marie Curie Palliative Care Research CentreWales Cancer Research CentreCardiffWalesUK
| | - Mirella Longo
- Division of Population Medicine, Marie Curie Palliative Care Research CentreCardiff UniversityCardiffWalesUK
| | - Anthony Byrne
- Division of Population Medicine, Marie Curie Palliative Care Research CentreCardiff UniversityCardiffWalesUK
| | - Annmarie Nelson
- Division of Population Medicine, Marie Curie Palliative Care Research CentreCardiff UniversityCardiffWalesUK
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Edwards M, Graziadio S, Shore J, Schmitz ND, Galvain T, Danker WA, Kocaman M, Pournaras DJ, Bowley DM, Hardy KJ. Plus Sutures for preventing surgical site infection: a systematic review of clinical outcomes with economic and environmental models. BMC Surg 2023; 23:300. [PMID: 37789307 PMCID: PMC10548560 DOI: 10.1186/s12893-023-02187-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 09/07/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Surgical site infections (SSIs) represent ~ 20% of all hospital-acquired infections in surgical patients and are associated with prolonged hospital stay, admission to intensive care, and mortality. We conducted a systematic review with economic and environmental models to assess whether triclosan-coated sutures (Plus Sutures) provide benefits over non-coated sutures in the reduction of SSI risk. METHODS Searches were conducted in fifteen databases. A total of 1,991 records were retrieved. Following deduplication and screening by two independent reviewers, 31 randomized controlled trials in adults and children were included in the review. Similarity of the studies was assessed by narrative review and confirmed by quantitative assessment. A fixed effects meta-analysis of SSI incidence model including all groups of patients estimated a risk ratio of 0.71 (95% confidence interval: 0.64 to 0.79) indicating those in the Plus Sutures group had a 29% reduction in the risk of developing an SSI compared with those in the control group (p < 0.001). Safety outcomes were analysed qualitatively. RESULTS The economic model estimated the use of Plus Sutures to result in average cost savings of £13.63 per patient. Plus Sutures remained cost-saving in all subgroup analyses with cost-savings ranging between £11 (clean wounds) and £140 (non-clean wounds). The environmental impact of SSI is substantial, and the model suggests that the introduction of Plus Sutures could result in potential environmental benefits. CONCLUSIONS The evidence suggests that Plus Sutures are associated with a reduced incidence of SSI across all surgery types alongside cost savings when compared with standard sutures.
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Affiliation(s)
- M Edwards
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, York, YO10 5NQ, UK.
| | - S Graziadio
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, York, YO10 5NQ, UK
| | - J Shore
- York Health Economics Consortium, University of York, Enterprise House, Innovation Way, York, YO10 5NQ, UK
| | - N D Schmitz
- Johnson & Johnson MEDICAL GmbH, Robert-Koch-Strasse 1, 22851, Norderstedt, Germany
| | - T Galvain
- Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, NJ, USA
| | - W A Danker
- Ethicon Inc., 1000 US-202, Raritan, NJ, 08869, USA
| | - M Kocaman
- Johnson & Johnson Medical Limited, Berkshire, UK
| | - D J Pournaras
- Department of Bariatric and Metabolic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - D M Bowley
- University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - K J Hardy
- Derbyshire Pathology, University Hospitals Derby and Burton NHS Trust, Royal Derby Hospital, Derby, UK
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9
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Lombardi J, Stec E, Edwards M, Connell T, Sandor M. Comparison of mechanical properties and host tissue response to OviTex™ and Strattice™ surgical meshes. Hernia 2023; 27:987-997. [PMID: 37031315 PMCID: PMC10374700 DOI: 10.1007/s10029-023-02769-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/01/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE This study compared the in vitro/benchtop and in vivo mechanical properties and host biologic response to ovine rumen-derived/polymer mesh hybrid OviTex™ with porcine-derived acellular dermal matrix Strattice™ Firm. METHODS OviTex 2S Resorbable (OviTex 2S-R) and Strattice morphology were examined in vitro using histology and scanning electron microscopy; mechanical properties were assessed via tensile test; in vivo host biologic response and explant mechanics were evaluated in a rodent subcutaneous model. Separately, OviTex 1S Permanent (OviTex 1S-P) and Strattice were evaluated in a primate abdominal wall repair model. RESULTS OviTex 2S-R demonstrated layer separation, whereas Strattice retained its structural integrity and demonstrated higher maximum load than OviTex 2S-R out-of-package (124.8 ± 11.1 N/cm vs 37.9 ± 5.5 N/cm, p < 0.001), 24 h (55.7 ± 7.4 N/cm vs 5.6 ± 3.8 N/cm, p < 0.001), 48 h (45.3 ± 14.8 N/cm vs 2.8 ± 2.6 N/cm, p = 0.003), and 72 h (29.2 ± 10.5 N/cm vs 3.2 ± 3.1 N/cm, p = 0.006) following collagenase digestion. In rodents, inflammatory cell infiltration was observed between OviTex 2S-R layers, while Strattice induced a minimal inflammatory response. Strattice retained higher maximum load at 3 (46.3 ± 27.4 N/cm vs 9.5 ± 3.2 N/cm, p = 0.041) and 6 weeks (28.6 ± 14.1 N/cm vs 7.0 ± 3.0 N/cm, p = 0.029). In primates, OviTex 1S-P exhibited loss of composite mesh integrity whereas Strattice integrated into host tissue with minimal inflammation and retained higher maximum load at 1 month than OviTex 1S-P (66.8 ± 43.4 N/cm vs 9.6 ± 4.4 N/cm; p = 0.151). CONCLUSIONS Strattice retained greater mechanical strength as shown by lower susceptibility to collagenase degradation than OviTex 2S-R in vitro, as well as higher maximum load and improved host biologic response than OviTex 2S-R in rodents and OviTex 1S-P in primates.
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Affiliation(s)
- J Lombardi
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - E Stec
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - M Edwards
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - T Connell
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA
| | - M Sandor
- Allergan Aesthetics, an AbbVie Company, 4 Millennium Way, Branchburg, NJ, 08876, USA.
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10
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Goedegebuur J, Abbel D, Accassat S, Achterberg WP, Akbari A, Arfuch VM, Baddeley E, Bax JJ, Becker D, Bergmeijer B, Bertoletti L, Blom JW, Calvetti A, Cannegieter SC, Castro L, Chavannes NH, Coma-Auli N, Couffignal C, Edwards A, Edwards M, Enggaard H, Font C, Gava A, Geersing GJ, Geijteman ECT, Greenley S, Gregory C, Gussekloo J, Hoffmann I, Højen AA, van den Hout WB, Huisman MV, Jacobsen S, Jagosh J, Johnson MJ, Jørgensen L, Juffermans CCM, Kempers EK, Konstantinides S, Kroder AF, Kruip MJHA, Lafaie L, Langendoen JW, Larsen TB, Lifford K, van der Linden YM, Mahé I, Maiorana L, Maraveyas A, Martens ESL, Mayeur D, van Mens TE, Mohr K, Mooijaart SP, Murtagh FEM, Nelson A, Nielsen PB, Ording AG, Ørskov M, Pearson M, Poenou G, Portielje JEA, Raczkiewicz D, Rasmussen K, Trinks-Roerdink E, Schippers I, Seddon K, Sexton K, Sivell S, Skjøth F, Søgaard M, Szmit S, Trompet S, Vassal P, Visser C, van Vliet LM, Wilson E, Klok FA, Noble SIR. Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool. Thromb Res 2023; 228:54-60. [PMID: 37276718 DOI: 10.1016/j.thromres.2023.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs. METHODS The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe. RESULTS SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life. CONCLUSIONS We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.
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Affiliation(s)
- J Goedegebuur
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Abbel
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - S Accassat
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - W P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Akbari
- Swansea University, Swansea, Wales, United Kingdom
| | - V M Arfuch
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - E Baddeley
- Cardiff University, Cardiff, United Kingdom
| | - J J Bax
- Department of Medicine - Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Becker
- University Medical Center Mainz, Mainz, Germany
| | | | - L Bertoletti
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - A Calvetti
- Assistance Publique-Hopitaux de Paris, Paris, France
| | - S C Cannegieter
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - L Castro
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - N H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - N Coma-Auli
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - C Couffignal
- Hôpital Louis Mourier, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A Edwards
- Cardiff University, Cardiff, United Kingdom
| | - M Edwards
- Cardiff University, Cardiff, United Kingdom
| | - H Enggaard
- Aalborg University Hospital, Aalborg, Denmark
| | - C Font
- Department of Medical Oncology, Hospital Clinic Barcelona, Clinical Institute of Haematological and Oncological Diseases (ICMHO), IDIBAPS, Barcelona, Spain
| | - A Gava
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - G J Geersing
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | - E C T Geijteman
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - S Greenley
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - C Gregory
- Cardiff University, Cardiff, United Kingdom
| | - J Gussekloo
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - I Hoffmann
- Hôpital Bichat, APHP, Assistance Publique-Hopitaux de Paris, Paris, France
| | - A A Højen
- Aalborg University Hospital, Aalborg, Denmark
| | - W B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Jacobsen
- Aalborg University Hospital, Aalborg, Denmark
| | - J Jagosh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - M J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - L Jørgensen
- Aalborg University Hospital, Aalborg, Denmark
| | - C C M Juffermans
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
| | - E K Kempers
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - A F Kroder
- Todaytomorrow, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L Lafaie
- Department of Geriatrics and Gerontology, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | | | - T B Larsen
- Aalborg University Hospital, Aalborg, Denmark
| | - K Lifford
- Cardiff University, Cardiff, United Kingdom
| | - Y M van der Linden
- Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands; Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - I Mahé
- Department of Innovative Therapies in Haemostasis, Hôpital Louis Mourier, APHP, Paris, France
| | - L Maiorana
- Societa per l'Assistenza al Malato Oncologico Terminale Onlus (S.A.M.O.T.) Ragusa Onlus, Ragusa, Italy
| | - A Maraveyas
- Clinical Sciences Centre Hull York Medical School University of Hull, Hull, United Kingdom
| | - E S L Martens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - D Mayeur
- Centre Georges-François Leclerc, Dijon, France
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - K Mohr
- University Medical Center Mainz, Mainz, Germany
| | - S P Mooijaart
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - F E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - A Nelson
- Cardiff University, Cardiff, United Kingdom
| | - P B Nielsen
- Aalborg University Hospital, Aalborg, Denmark
| | - A G Ording
- Aalborg University Hospital, Aalborg, Denmark
| | - M Ørskov
- Aalborg University Hospital, Aalborg, Denmark
| | - M Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - G Poenou
- Department of Vascular and Therapeutical Medicine, Jean Monnet University, University Hospital of Saint-Étienne, Saint-Étienne, France
| | - J E A Portielje
- Department of Medicine - Internal medicine and Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Raczkiewicz
- Department of Medical Statistics, School of Public Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - K Rasmussen
- Aalborg University Hospital, Aalborg, Denmark
| | - E Trinks-Roerdink
- Julius Center for Health Sciences and Primary Care, Department of General Practice, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - K Seddon
- Wales Cancer Research Centre, Cardiff, UK
| | - K Sexton
- Cardiff University, Cardiff, United Kingdom
| | - S Sivell
- Cardiff University, Cardiff, United Kingdom
| | - F Skjøth
- Aalborg University Hospital, Aalborg, Denmark
| | - M Søgaard
- Aalborg University Hospital, Aalborg, Denmark
| | - S Szmit
- Department of Cardio-Oncology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - S Trompet
- Department of Medicine - Internal Medicine and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - P Vassal
- Department of Vascular and Therapeutical Medicine, University Hospital of Saint-Etienne, Saint-Étienne, France
| | - C Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - L M van Vliet
- Department of Health, Medicine and Neuropsychology, Leiden University, Leiden, the Netherlands
| | - E Wilson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Dummer R, Flaherty KT, Robert C, Arance A, B de Groot JW, Garbe C, Gogas HJ, Gutzmer R, Krajsová I, Liszkay G, Loquai C, Mandalà M, Schadendorf D, Yamazaki N, Pietro AD, Cantey-Kiser J, Edwards M, Ascierto PA. COLUMBUS 5-year update: a randomized, open-label, phase III trial of encorafenib plus binimetinib versus vemurafenib or encorafenib in patients with BRAF. Future Oncol 2023; 19:1091-1098. [PMID: 37309702 DOI: 10.2217/fon-2022-1258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
WHAT IS THIS SUMMARY ABOUT? Here, we summarize the 5-year results from part 1 of the COLUMBUS clinical study, which looked at the combination treatment of encorafenib plus binimetinib in people with a specific type of skin cancer called melanoma. Encorafenib (BRAFTOVI®) and binimetinib (MEKTOVI®) are medicines used to treat a type of melanoma that has a change in the BRAF gene, called advanced or metastatic BRAF V600-mutant melanoma. Participants with advanced or metastatic BRAF V600-mutant melanoma took either encorafenib plus binimetinib together (COMBO group), compared with encorafenib alone (ENCO group) or vemurafenib (ZELBORAF®) alone (VEMU group). WHAT WERE THE RESULTS? In this 5-year update, more participants in the COMBO group were alive for longer without their disease getting worse after 5 years than those in the VEMU and ENCO groups. Patients in the COMBO group were alive for longer without their disease getting worse when they: Had less advanced cancer Were able to do more daily activities Had normal lactate dehydrogenase (LDH) levels Had fewer organs with tumors before treatment After treatment, fewer participants in the COMBO group received additional anticancer treatment than participants in the VEMU and ENCO groups. The number of participants who reported severe side effects was similar for each treatment. The side effects caused by the drugs in the COMBO group decreased over time. WHAT DO THE RESULTS MEAN? Overall, this 5-year update confirmed that people with BRAF V600-mutant melanoma that has spread to other parts of the body and who took encorafenib plus binimetinib were alive for longer without their disease getting worse than those who took vemurafenib or encorafenib alone. Clinical Trial Registration: NCT01909453 (ClinicalTrials.gov).
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Affiliation(s)
| | | | | | - Ana Arance
- Hospital Clinic of Barcelona & IDIBAPS, Barcelona, Spain
| | | | - Claus Garbe
- University Hospital Tubingen, Tubingen, Germany
| | - Helen J Gogas
- National & Kapodistrian University of Athens, Athens, Greece
| | - Ralf Gutzmer
- Hannover Medical School, Hannover, & Ruhr-University Bochum, Minden Campus, Germany
| | | | | | - Carmen Loquai
- University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Dirk Schadendorf
- University Hospital Essen, West German Cancer Center & German Cancer Consortium, Partner Site Essen, Essen, Germany
| | | | | | | | | | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
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Tabernero J, Van Cutsem E, Garralda E, Tai D, De Braud F, Geva R, van Bussel MTJ, Fiorella Dotti K, Elez E, de Miguel MJ, Litwiler K, Murphy D, Edwards M, Morris VK. A Phase Ib/II Study of WNT974 + Encorafenib + Cetuximab in Patients With BRAF V600E-Mutant KRAS Wild-Type Metastatic Colorectal Cancer. Oncologist 2023; 28:230-238. [PMID: 36811382 PMCID: PMC10020809 DOI: 10.1093/oncolo/oyad007] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 12/01/2022] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND WNT974 is a small molecule inhibitor of Wnt signaling that specifically inhibits porcupine O-acyltransferase. This phase Ib dose--escalation study evaluated the maximum tolerated dose of WNT974 in combination with encorafenib and cetuximab in patients with BRAF V600E-mutant metastatic colorectal cancer with RNF43 mutations or RSPO fusions. PATIENTS AND METHODS Patients received once-daily encorafenib and weekly cetuximab, in addition to once-daily WNT974, in sequential dosing cohorts. In the first cohort, patients received 10-mg WNT974 (COMBO10), which was reduced in subsequent cohorts to 7.5-mg (COMBO7.5) or 5-mg (COMBO5) after dose-limiting toxicities (DLTs) were observed. Primary endpoints were incidence of DLTs and exposure to WNT974 and encorafenib. Secondary endpoints were anti-tumor activity and safety. RESULTS Twenty patients were enrolled (COMBO10, n = 4; COMBO7.5, n = 6; COMBO5, n = 10). DLTs were observed in 4 patients, including grade 3 hypercalcemia (COMBO10, n = 1; COMBO7.5, n = 1), grade 2 dysgeusia (COMBO10, n = 1), and lipase increased (COMBO10, n = 1). A high incidence of bone toxicities (n = 9) was reported, including rib fracture, spinal compression fracture, pathological fracture, foot fracture, hip fracture, and lumbar vertebral fracture. Serious adverse events were reported in 15 patients, most frequently bone fracture, hypercalcemia, and pleural effusion. The overall response rate was 10% and disease control rate 85%; most patients achieved stable disease as their best response. CONCLUSION Concerns surrounding the safety and lack of preliminary evidence of improved anti-tumor activity of WNT974 + encorafenib + cetuximab, compared with previous encorafenib + cetuximab data, ultimately led to study discontinuation. Phase II was not initiated. TRIAL REGISTRATION ClinicalTrials.gov, NCT02278133.
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Affiliation(s)
- Josep Tabernero
- Vall d’Hebron Hospital Campus, Vall d’Hebron Institute of Oncology (VHIO), UVic-UCC, IOB-Quiron, Barcelona, Spain
| | - Eric Van Cutsem
- University Hospitals Gasthuisberg Leuven and KU Leuven, Leuven, Belgium
| | - Elena Garralda
- START Madrid, Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - David Tai
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | | | - Ravit Geva
- Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Mark T J van Bussel
- Department of Clinical Pharmacology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Elena Elez
- Vall d’Hebron Barcelona Hospital Campus, Vall d’Hebron Institute of Oncology (VHIO), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Van Karlyle Morris
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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13
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Dummer R, Flaherty KT, Robert C, Arance A, de Groot JWB, Garbe C, Gogas HJ, Gutzmer R, Krajsová I, Liszkay G, Loquai C, Mandalà M, Schadendorf D, Yamazaki N, di Pietro A, Cantey-Kiser J, Edwards M, Ascierto PA. COLUMBUS 5-Year Update: A Randomized, Open-Label, Phase III Trial of Encorafenib Plus Binimetinib Versus Vemurafenib or Encorafenib in Patients With BRAF V600-Mutant Melanoma. J Clin Oncol 2022; 40:4178-4188. [PMID: 35862871 PMCID: PMC9916040 DOI: 10.1200/jco.21.02659] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Combination treatment with BRAF and MEK inhibitors has demonstrated benefits on progression-free survival (PFS) and overall survival (OS) and is a standard of care for the treatment of advanced BRAF V600-mutant melanoma. Here, we report the 5-year update from the COLUMBUS trial (ClinicalTrials.gov identifier: NCT01909453). METHODS Patients with locally advanced unresectable or metastatic BRAF V600-mutant melanoma, untreated or progressed after first-line immunotherapy, were randomly assigned 1:1:1 to encorafenib 450 mg once daily plus binimetinib 45 mg twice daily, vemurafenib 960 mg twice daily, or encorafenib 300 mg once daily. An updated analysis was conducted 65 months after the last patient was randomly assigned. RESULTS Five hundred seventy-seven patients were randomly assigned: 192 to encorafenib plus binimetinib, 191 to vemurafenib, and 194 to encorafenib. The 5-year PFS and OS rates with encorafenib plus binimetinib were 23% and 35% overall and 31% and 45% in those with normal lactate dehydrogenase levels, respectively. In comparison, the 5-year PFS and OS rates with vemurafenib were 10% and 21% overall and 12% and 28% in those with normal lactate dehydrogenase levels, respectively. The median duration of response with encorafenib plus binimetinib was 18.6 months, with disease control achieved in 92.2% of patients. In comparison, the median duration of response with vemurafenib was 12.3 months, with disease control achieved in 81.2% of patients. Long-term follow-up showed no new safety concerns, and results were consistent with the known tolerability profile of encorafenib plus binimetinib. Interactive visualization of the data presented in this article is available at COLUMBUS dashboard. CONCLUSION In this 5-year update of part 1 of the COLUMBUS trial, encorafenib plus binimetinib treatment demonstrated continued long-term benefits and a consistent safety profile in patients with BRAF V600-mutant melanoma.
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Affiliation(s)
| | | | - Caroline Robert
- Gustave Roussy and Paris-Saclay University, Villejuif, France
| | - Ana Arance
- Hospital Clinic of Barcelona and IDIBAPS, Barcelona, Spain
| | | | - Claus Garbe
- University Hospital Tubingen, Tubingen, Germany
| | - Helen J Gogas
- National and Kapodistrian University of Athens, Athens, Greece
| | - Ralf Gutzmer
- Hannover Medical School, Hannover, and Ruhr-University Bochum, Minden Campus, Germany
| | | | | | - Carmen Loquai
- University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Dirk Schadendorf
- University Hospital Essen, West German Cancer Center and German Cancer Consortium, Partner Site Essen, Essen, Germany
| | | | | | | | | | - Paolo A Ascierto
- Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy
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Burns J, Mc Goldrick N, Sigerson D, Edwards M, Culshaw S, Clark C, Watling C, Braid R, O'Keefe E, Gorman M, Conway DI. A Health Inequalities Impact Assessment of the surveillance of COVID-19 in asymptomatic patients attending dental settings in Scotland. Community Dent Health 2022; 39:254-259. [PMID: 36283070 DOI: 10.1922/cdh_00170burns06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION A key aspect of the public health response to COVID-19 in Scotland was enhanced community surveillance, including testing in dental settings. Across Scotland, dental settings offered patients over 5-years-old the opportunity to participate in community surveillance of COVID-19. METHODS A Health Inequalities Impact Assessment (HIIA) was conducted to understand the differential impacts the programme would have on the population and to improve the accessibility of the programme. HIIA is a tool to allow the assessment, understanding, and mitigation of impacts on people of a proposed policy or practice. It fulfils an organisational duty to meet the requirements of the Equality Act and Fairer Scotland Duty. The HIIA was conducted rapidly in parallel with the programme development. An action research approach included an online workshop, consultation, review of population data and a literature search. RESULTS Adjustments were required to improve the programme's accessibility. Stakeholders, including dental teams from across Scotland were involved in the consultation and brought their front-line experience in different settings. Common issues identified included digital literacy and access, language and cultural barriers to participation, and issues relating to the implications of a positive COVID-19 result. Literature indicated limited evidence on the acceptability, accessibility, and equity of asymptomatic COVID-19 surveillance. CONCLUSION This HIIA was conducted during the COVID-19 pandemic. As an example of good practice in tackling inequalities in access to programmes it should represent the benchmark for other similar initiatives.
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Affiliation(s)
- J Burns
- Public Health, NHS Ayrshire and Arran, UK
| | | | | | - M Edwards
- Public Health, NHS Ayrshire and Arran, UK
| | - S Culshaw
- School of Medicine, Dentistry and Nursing, University of Glasgow, UK
| | | | | | | | - E O'Keefe
- Department of Public Health, NHS Fife, UK
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Evans BA, Carson‐Stevens A, Cooper A, Davies F, Edwards M, Harrington B, Hepburn J, Hughes T, Price D, Siriwardena NA, Snooks H, Edwards A. Implementing public involvement throughout the research process-Experience and learning from the GPs in EDs study. Health Expect 2022; 25:2471-2484. [PMID: 35894169 PMCID: PMC9615054 DOI: 10.1111/hex.13566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/26/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Public involvement in health services research is encouraged. Descriptions of public involvement across the whole research cycle of a major study are uncommon and its effects on research conduct are poorly understood. AIM This study aimed to describe how we implemented public involvement, reflect on process and effects in a large-scale multi-site research study and present learning for future involvement practice. METHOD We recorded public involvement roles and activities throughout the study and compared these to our original public involvement plan included in our project proposal. We held a group interview with study co-applicants to explore their experiences, transcribed the recorded discussion and conducted thematic analysis. We synthesized the findings to develop recommendations for future practice. RESULTS Public contributors' activities went beyond strategic study planning and management to include active involvement in data collection, analysis and dissemination. They attended management, scrutiny, planning and task meetings. They also facilitated public involvement through annual planning and review sessions, conducted a Public Involvement audit and coordinated public and patient input to stakeholder discussions at key study stages. Group interview respondents said that involvement exceeded their expectations. They identified effects such as changes to patient recruitment, terminology clarification and extra dissemination activities. They identified factors enabling effective involvement including team and leader commitment, named support contact, building relationships and demonstrating equality and public contributors being confident to challenge and flexible to meet researchers' timescales and work patterns. There were challenges matching resources to roles and questions about the risk of over-professionalizing public contributors. CONCLUSION We extended our planned approach to public involvement and identified benefits to the research process that were both specific and general. We identified good practice to support effective public involvement in health services research that study teams should consider in planning and undertaking research. PUBLIC CONTRIBUTION This paper was co-conceived, co-planned and co-authored by public contributors to contribute research evidence, based on their experiences of active involvement in the design, implementation and dissemination of a major health services research study.
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Affiliation(s)
- Bridie Angela Evans
- Swansea University Medical SchoolSwansea UniversitySwanseaUK
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
| | - Andrew Carson‐Stevens
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Alison Cooper
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Freya Davies
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Michelle Edwards
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | - Barbara Harrington
- Public Contributor, c/o Swansea University Medical SchoolSwansea UniversitySwanseaUK
| | - Julie Hepburn
- Public Contributor, c/o Swansea University Medical SchoolSwansea UniversitySwanseaUK
| | | | - Delyth Price
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
| | | | - Helen Snooks
- Swansea University Medical SchoolSwansea UniversitySwanseaUK
- Swansea University Medical School, PRIME Centre WalesSwansea UniversitySwanseaUK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, PRIME Centre WalesCardiff UniversityCardiffUK
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McFadzean IJ, Edwards M, Davies F, Cooper A, Price D, Carson-Stevens A, Dale J, Hughes T, Porter A, Harrington B, Evans B, Siriwardena N, Anderson P, Edwards A. Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'. BMC Emerg Med 2022; 22:155. [PMID: 36068508 PMCID: PMC9450363 DOI: 10.1186/s12873-022-00709-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/16/2022] [Indexed: 11/28/2022] Open
Abstract
Background It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand. Methods We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand. Results EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics. Conclusions Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00709-2.
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Affiliation(s)
- I J McFadzean
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales.
| | - M Edwards
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, Wales.
| | - F Davies
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - A Cooper
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - D Price
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - A Carson-Stevens
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - J Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Warwick, UK
| | - T Hughes
- John Radcliff Hospital, Oxford, UK
| | - A Porter
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - B Harrington
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
| | - B Evans
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - N Siriwardena
- School of Health and Social Care, University of Lincoln, Lincoln, UK
| | - P Anderson
- Swansea University Medical School, Swansea University, Swansea, Wales
| | - A Edwards
- PRIME Centre Wales, Cardiff University School of Medicine, Cardiff, Wales
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Pyle H, Lone A, Artami M, Edwards M, Raj P, Zhang B, Harris-Tryon T. 520 Skin-specific stearoyl-coenzyme A desaturase 1 knockout mice are colonized by saprophytic bacteria and fungi. J Invest Dermatol 2022. [DOI: 10.1016/j.jid.2022.05.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bateman KS, Stentiford GD, Kerr R, Hooper C, White P, Edwards M, Ross S, Hazelgrove R, Daumich C, Green MJ, Ivory D, Evans C, Bass D. Amoebic crab disease (ACD) in edible crab Cancer pagurus from the English Channel, UK. Dis Aquat Organ 2022; 150:1-16. [PMID: 35796507 DOI: 10.3354/dao03668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The genera Paramoeba and Neoparamoeba (Amoebozoa, Dactylopodida, Paramoebidae) include well-known opportunistic pathogens associated with fish (N. peruans; amoebic gill disease), lobsters, molluscs and sea urchins, but only rarely with crabs (grey crab disease of blue crabs). Following reports of elevated post-capture mortality in edible crabs Cancer pagurus captured from a site within the English Channel fishery in the UK, a novel disease (amoebic crab disease, ACD) was detected in significant proportions of the catch. We present histopathological, transmission electron microscopy and molecular phylogenetic data, showing that this disease is defined by colonization of haemolymph, connective tissues and fixed phagocytes by amoeboid cells, leading to tissue destruction and presumably death in severely diseased hosts. The pathology was strongly associated with a novel amoeba with a phylogenetic position on 18S rRNA gene trees robustly sister to Janickina pigmentifera (which groups within the current circumscription of Paramoeba/Neoparamoeba), herein described as Janickina feisti n. sp. We provide evidence that J. feisti is associated with ACD in 50% of C. pagurus sampled from the mortality event. A diversity of other paramoebid sequence types, clustering with known radiations of N. pemaquidensis and N. aestuarina and a novel N. aestuarina sequence type, was detected by PCR in most of the crabs investigated, but their detection was much less strongly associated with clinical signs of disease. The discovery of ACD in edible crabs from the UK is discussed relative to published historical health surveys for this species.
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Affiliation(s)
- K S Bateman
- International Centre of Excellence for Aquatic Animal Health, Centre for Environment, Fisheries and Aquaculture Science (Cefas), Barrack Road, The Nothe, Weymouth DT4 8UB, UK
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Kouli O, Murray V, Bhatia S, Cambridge WA, Kawka M, Shafi S, Knight SR, Kamarajah SK, McLean KA, Glasbey JC, Khaw RA, Ahmed W, Akhbari M, Baker D, Borakati A, Mills E, Thavayogan R, Yasin I, Raubenheimer K, Ridley W, Sarrami M, Zhang G, Egoroff N, Pockney P, Richards T, Bhangu A, Creagh-Brown B, Edwards M, Harrison EM, Lee M, Nepogodiev D, Pinkney T, Pearse R, Smart N, Vohra R, Sohrabi C, Jamieson A, Nguyen M, Rahman A, English C, Tincknell L, Kakodkar P, Kwek I, Punjabi N, Burns J, Varghese S, Erotocritou M, McGuckin S, Vayalapra S, Dominguez E, Moneim J, Salehi M, Tan HL, Yoong A, Zhu L, Seale B, Nowinka Z, Patel N, Chrisp B, Harris J, Maleyko I, Muneeb F, Gough M, James CE, Skan O, Chowdhury A, Rebuffa N, Khan H, Down B, Fatimah Hussain Q, Adams M, Bailey A, Cullen G, Fu YXJ, McClement B, Taylor A, Aitken S, Bachelet B, Brousse de Gersigny J, Chang C, Khehra B, Lahoud N, Lee Solano M, Louca M, Rozenbroek P, Rozitis E, Agbinya N, Anderson E, Arwi G, Barry I, Batchelor C, Chong T, Choo LY, Clark L, Daniels M, Goh J, Handa A, Hanna J, Huynh L, Jeon A, Kanbour A, Lee A, Lee J, Lee T, Leigh J, Ly D, McGregor F, Moss J, Nejatian M, O'Loughlin E, Ramos I, Sanchez B, Shrivathsa A, Sincari A, Sobhi S, Swart R, Trimboli J, Wignall P, Bourke E, Chong A, Clayton S, Dawson A, Hardy E, Iqbal R, Le L, Mao S, Marinelli I, Metcalfe H, Panicker D, R HH, Ridgway S, Tan HH, Thong S, Van M, Woon S, Woon-Shoo-Tong XS, Yu S, Ali K, Chee J, Chiu C, Chow YW, Duller A, Nagappan P, Ng S, Selvanathan M, Sheridan C, Temple M, Do JE, Dudi-Venkata NN, Humphries E, Li L, Mansour LT, Massy-Westropp C, Fang B, Farbood K, Hong H, Huang Y, Joan M, Koh C, Liu YHA, Mahajan T, Muller E, Park R, Tanudisastro M, Wu JJG, Chopra P, Giang S, Radcliffe S, Thach P, Wallace D, Wilkes A, Chinta SH, Li J, Phan J, Rahman F, Segaran A, Shannon J, Zhang M, Adams N, Bonte A, Choudhry A, Colterjohn N, Croyle JA, Donohue J, Feighery A, Keane A, McNamara D, Munir K, Roche D, Sabnani R, Seligman D, Sharma S, Stickney Z, Suchy H, Tan R, Yordi S, Ahmed I, Aranha M, El Sabawy D, Garwood P, Harnett M, Holohan R, Howard R, Kayyal Y, Krakoski N, Lupo M, McGilberry W, Nepon H, Scoleri Y, Urbina C, Ahmad Fuad MF, Ahmed O, Jaswantlal D, Kelly E, Khan MHT, Naidu D, Neo WX, O'Neill R, Sugrue M, Abbas JD, Abdul-Fattah S, Azlan A, Barry K, Idris NS, Kaka N, Mc Dermott D, Mohammad Nasir MN, Mozo M, Rehal A, Shaikh Yousef M, Wong RH, Curran E, Gardner M, Hogan A, Julka R, Lasser G, Ní Chorráin N, Ting J, Browne R, George S, Janjua Z, Leung Shing V, Megally M, Murphy S, Ravenscroft L, Vedadi A, Vyas V, Bryan A, Sheikh A, Ubhi J, Vannelli K, Vawda A, Adeusi L, Doherty C, Fitzgerald C, Gallagher H, Gill P, Hamza H, Hogan M, Kelly S, Larry J, Lynch P, Mazeni NA, O'Connell R, O'Loghlin R, Singh K, Abbas Syed R, Ali A, Alkandari B, Arnold A, Arora E, Azam R, Breathnach C, Cheema J, Compton M, Curran S, Elliott JA, Jayasamraj O, Mohammed N, Noone A, Pal A, Pandey S, Quinn P, Sheridan R, Siew L, Tan EP, Tio SW, Toh VTR, Walsh M, Yap C, Yassa J, Young T, Agarwal N, Almoosawy SA, Bowen K, Bruce D, Connachan R, Cook A, Daniell A, Elliott M, Fung HKF, Irving A, Laurie S, Lee YJ, Lim ZX, Maddineni S, McClenaghan RE, Muthuganesan V, Ravichandran P, Roberts N, Shaji S, Solt S, Toshney E, Arnold C, Baker O, Belais F, Bojanic C, Byrne M, Chau CYC, De Soysa S, Eldridge M, Fairey M, Fearnhead N, Guéroult A, Ho JSY, Joshi K, Kadiyala N, Khalid S, Khan F, Kumar K, Lewis E, Magee J, Manetta-Jones D, Mann S, McKeown L, Mitrofan C, Mohamed T, Monnickendam A, Ng AYKC, Ortu A, Patel M, Pope T, Pressling S, Purohit K, Saji S, Shah Foridi J, Shah R, Siddiqui SS, Surman K, Utukuri M, Varghese A, Williams CYK, Yang JJ, Billson E, Cheah E, Holmes P, Hussain S, Murdock D, Nicholls A, Patel P, Ramana G, Saleki M, Spence H, Thomas D, Yu C, Abousamra M, Brown C, Conti I, Donnelly A, Durand M, French N, Goan R, O'Kane E, Rubinchik P, Gardiner H, Kempf B, Lai YL, Matthews H, Minford E, Rafferty C, Reid C, Sheridan N, Al Bahri T, Bhoombla N, Rao BM, Titu L, Chatha S, Field C, Gandhi T, Gulati R, Jha R, Jones Sam MT, Karim S, Patel R, Saunders M, Sharma K, Abid S, Heath E, Kurup D, Patel A, Ali M, Cresswell B, Felstead D, Jennings K, Kaluarachchi T, Lazzereschi L, Mayson H, Miah JE, Reinders B, Rosser A, Thomas C, Williams H, Al-Hamid Z, Alsadoun L, Chlubek M, Fernando P, Gaunt E, Gercek Y, Maniar R, Ma R, Matson M, Moore S, Morris A, Nagappan PG, Ratnayake M, Rockall L, Shallcross O, Sinha A, Tan KE, Virdee S, Wenlock R, Donnelly HA, Ghazal R, Hughes I, Liu X, McFadden M, Misbert E, Mogey P, O'Hara A, Peace C, Rainey C, Raja P, Salem M, Salmon J, Tan CH, Alves D, Bahl S, Baker C, Coulthurst J, Koysombat K, Linn T, Rai P, Sharma A, Shergill A, Ahmed M, Ahmed S, Belk LH, Choudhry H, Cummings D, Dixon Y, Dobinson C, Edwards J, Flint J, Franco Da Silva C, Gallie R, Gardener M, Glover T, Greasley M, Hatab A, Howells R, Hussey T, Khan A, Mann A, Morrison H, Ng A, Osmond R, Padmakumar N, Pervaiz F, Prince R, Qureshi A, Sawhney R, Sigurdson B, Stephenson L, Vora K, Zacken A, Cope P, Di Traglia R, Ferarrio I, Hackett N, Healicon R, Horseman L, Lam LI, Meerdink M, Menham D, Murphy R, Nimmo I, Ramaesh A, Rees J, Soame R, Dilaver N, Adebambo D, Brown E, Burt J, Foster K, Kaliyappan L, Knight P, Politis A, Richardson E, Townsend J, Abdi M, Ball M, Easby S, Gill N, Ho E, Iqbal H, Matthews M, Nubi S, Nwokocha JO, Okafor I, Perry G, Sinartio B, Vanukuru N, Walkley D, Welch T, Yates J, Yeshitila N, Bryans K, Campbell B, Gray C, Keys R, Macartney M, Chamberlain G, Khatri A, Kucheria A, Lee STP, Reese G, Roy choudhury J, Tan WYR, Teh JJ, Ting A, Kazi S, Kontovounisios C, Vutipongsatorn K, Amarnath T, Balasubramanian N, Bassett E, Gurung P, Lim J, Panjikkaran A, Sanalla A, Alkoot M, Bacigalupo V, Eardley N, Horton M, Hurry A, Isti C, Maskell P, Nursiah K, Punn G, Salih H, Epanomeritakis E, Foulkes A, Henderson R, Johnston E, McCullough H, McLarnon M, Morrison E, Cheung A, Cho SH, Eriksson F, Hedges J, Low Z, May C, Musto L, Nagi S, Nur S, Salau E, Shabbir S, Thomas MC, Uthayanan L, Vig S, Zaheer M, Zeng G, Ashcroft-Quinn S, Brown R, Hayes J, McConville R, French R, Gilliam A, Sheetal S, Shehzad MU, Bani W, Christie I, Franklyn J, Khan M, Russell J, Smolarek S, Varadarassou R, Ahmed SK, Narayanaswamy S, Sealy J, Shah M, Dodhia V, Manukyan A, O'Hare R, Orbell J, Chung I, Forenc K, Gupta A, Agarwal A, Al Dabbagh A, Bennewith R, Bottomley J, Chu TSM, Chu YYA, Doherty W, Evans B, Hainsworth P, Hosfield T, Li CH, McCullagh I, Mehta A, Thaker A, Thompson B, Virdi A, Walker H, Wilkins E, Dixon C, Hassan MR, Lotca N, Tong KS, Batchelor-Parry H, Chaudhari S, Harris T, Hooper J, Johnson C, Mulvihill C, Nayler J, Olutobi O, Piramanayagam B, Stones K, Sussman M, Weaver C, Alam F, Al Rawi M, Andrew F, Arrayeh A, Azizan N, Hassan A, Iqbal Z, John I, Jones M, Kalake O, Keast M, Nicholas J, Patil A, Powell K, Roberts P, Sabri A, Segue AK, Shah A, Shaik Mohamed SA, Shehadeh A, Shenoy S, Tong A, Upcott M, Vijayasingam D, Anarfi S, Dauncey J, Devindaran A, Havalda P, Komninos G, Mwendwa E, Norman C, Richards J, Urquhart A, Allan J, Cahya E, Hunt H, McWhirter C, Norton R, Roxburgh C, Tan JY, Ali Butt S, Hansdot S, Haq I, Mootien A, Sanchez I, Vainas T, Deliyannis E, Tan M, Vipond M, Chittoor Satish NN, Dattani A, De Carvalho L, Gaston-Grubb M, Karunanithy L, Lowe B, Pace C, Raju K, Roope J, Taylor C, Youssef H, Munro T, Thorn C, Wong KHF, Yunus A, Chawla S, Datta A, Dinesh AA, Field D, Georgi T, Gwozdz A, Hamstead E, Howard N, Isleyen N, Jackson N, Kingdon J, Sagoo KS, Schizas A, Yin L, Aung E, Aung YY, Franklin S, Han SM, Kim WC, Martin Segura A, Rossi M, Ross T, Tirimanna R, Wang B, Zakieh O, Ben-Arzi H, Flach A, Jackson E, Magers S, Olu abara C, Rogers E, Sugden K, Tan H, Veliah S, Walton U, Asif A, Bharwada Y, Bowley D, Broekhuizen A, Cooper L, Evans N, Girdlestone H, Ling C, Mann H, Mehmood N, Mulvenna CL, Rainer N, Trout I, Gujjuri R, Jeyaraman D, Leong E, Singh D, Smith E, Anderton J, Barabas M, Goyal S, Howard D, Joshi A, Mitchell D, Weatherby T, Badminton R, Bird R, Burtle D, Choi NY, Devalia K, Farr E, Fischer F, Fish J, Gunn F, Jacobs D, Johnston P, Kalakoutas A, Lau E, Loo YNAF, Louden H, Makariou N, Mohammadi K, Nayab Y, Ruhomaun S, Ryliskyte R, Saeed M, Shinde P, Sudul M, Theodoropoulou K, Valadao-Spoorenberg J, Vlachou F, Arshad SR, Janmohamed AM, Noor M, Oyerinde O, Saha A, Syed Y, Watkinson W, Ahmadi H, Akintunde A, Alsaady A, Bradley J, Brothwood D, Burton M, Higgs M, Hoyle C, Katsura C, Lathan R, Louani A, Mandalia R, Prihartadi AS, Qaddoura B, Sandland-Taylor L, Thadani S, Thompson A, Walshaw J, Teo S, Ali S, Bawa JH, Fox S, Gargan K, Haider SA, Hanna N, Hatoum A, Khan Z, Krzak AM, Li T, Pitt J, Tan GJS, Ullah Z, Wilson E, Cleaver J, Colman J, Copeland L, Coulson A, Davis P, Faisal H, Hassan F, Hughes JT, Jabr Y, Mahmoud Ali F, Nahaboo Solim ZN, Sangheli A, Shaya S, Thompson R, Cornwall H, De Andres Crespo M, Fay E, Findlay J, Groves E, Jones O, Killen A, Millo J, Thomas S, Ward J, Wilkins M, Zaki F, Zilber E, Bhavra K, Bilolikar A, Charalambous M, Elawad A, Eleni A, Fawdon R, Gibbins A, Livingstone D, Mala D, Oke SE, Padmakumar D, Patsalides MA, Payne D, Ralphs C, Roney A, Sardar N, Stefanova K, Surti F, Timms R, Tosney G, Bannister J, Clement NS, Cullimore V, Kamal F, Lendor J, McKay J, Mcswiggan J, Minhas N, Seneviratne K, Simeen S, Valverde J, Watson N, Bloom I, Dinh TH, Hirniak J, Joseph R, Kansagra M, Lai CKN, Melamed N, Patel J, Randev J, Sedighi T, Shurovi B, Sodhi J, Vadgama N, Abdulla S, Adabavazeh B, Champion A, Chennupati R, Chu K, Devi S, Haji A, Schulz J, Testa F, Davies P, Gurung B, Howell S, Modi P, Pervaiz A, Zahid M, Abdolrazaghi S, Abi Aoun R, Anjum Z, Bawa G, Bhardwaj R, Brown S, Enver M, Gill D, Gopikrishna D, Gurung D, Kanwal A, Kaushal P, Khanna A, Lovell E, McEvoy C, Mirza M, Nabeel S, Naseem S, Pandya K, Perkins R, Pulakal R, Ray M, Reay C, Reilly S, Round A, Seehra J, Shakeel NM, Singh B, Vijay Sukhnani M, Brown L, Desai B, Elzanati H, Godhaniya J, Kavanagh E, Kent J, Kishor A, Liu A, Norwood M, Shaari N, Wood C, Wood M, Brown A, Chellapuri A, Ferriman A, Ghosh I, Kulkarni N, Noton T, Pinto A, Rajesh S, Varghese B, Wenban C, Aly R, Barciela C, Brookes T, Corrin E, Goldsworthy M, Mohamed Azhar MS, Moore J, Nakhuda S, Ng D, Pillay S, Port S, Abdullah M, Akinyemi J, Islam S, Kale A, Lewis A, Manjunath T, McCabe H, Misra S, Stubley T, Tam JP, Waraich N, Chaora T, Ford C, Osinkolu I, Pong G, Rai J, Risquet R, Ainsworth J, Ayandokun P, Barham E, Barrett G, Barry J, Bisson E, Bridges I, Burke D, Cann J, Cloney M, Coates S, Cripps P, Davies C, Francis N, Green S, Handley G, Hathaway D, Hurt L, Jenkins S, Johnston C, Khadka A, McGee U, Morris D, Murray R, Norbury C, Pierrepont Z, Richards C, Ross O, Ruddy A, Salmon C, Shield M, Soanes K, Spencer N, Taverner S, Williams C, Wills-Wood W, Woodward S, Chow J, Fan J, Guest O, Hunter I, Moon WY, Arthur-Quarm S, Edwards P, Hamlyn V, McEneaney L, N D G, Pranoy S, Ting M, Abada S, Alawattegama LH, Ashok A, Carey C, Gogna A, Haglund C, Hurley P, Leelo N, Liu B, Mannan F, Paramjothy K, Ramlogan K, Raymond-Hayling O, Shanmugarajah A, Solichan D, Wilkinson B, Ahmad NA, Allan D, Amin A, Bakina C, Burns F, Cameron F, Campbell A, Cavanagh S, Chan SMZ, Chapman S, Chong V, Edelsten E, Ekpete O, El Sheikh M, Ghose R, Hassane A, Henderson C, Hilton-Christie S, Husain M, Hussain H, Javid Z, Johnson-Ogbuneke J, Johnston A, Khalil M, Leung TCC, Makin I, Muralidharan V, Naeem M, Patil P, Ravichandran S, Saraeva D, Shankey-Smith W, Sharma N, Swan R, Waudby-West R, Wilkinson A, Wright K, Balasubramanian A, Bhatti S, Chalkley M, Chou WK, Dixon M, Evans L, Fisher K, Gandhi P, Ho S, Lau YB, Lowe S, Meechan C, Murali N, Musonda C, Njoku P, Ochieng L, Pervez MU, Seebah K, Shaikh I, Sikder MA, Vanker R, Alom J, Bajaj V, Coleman O, Finch G, Goss J, Jenkins C, Kontothanassis A, Liew MS, Ng K, Outram M, Shakeel MM, Tawn J, Zuhairy S, Chapple 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G, Raheel F, Rajaseharan A, Ramgopal A, Risbrooke C, Selvaratnam K, Sethunath G, Tabassum R, Taylor J, Thakker A, Wijesingha N, Wybrew R, Yasin T, Ahmed Osman A, Alfadhel S, Carberry E, Chen JY, Drake I, Glen P, Jayasuriya N, Kawar L, Myatt R, Sinan LOH, Siu SSY, Tjen V, Adeboyejo O, Bacon H, Barnes R, Birnie C, D'Cunha Kamath A, Hughes E, Middleton S, Owen R, Schofield E, Short C, Smith R, Wang H, Willett M, Zimmerman M, Balfour J, Chadwick T, Coombe-Jones M, Do Le HP, Faulkner G, Hobson K, Shehata Z, Beattie M, Chmielewski G, Chong C, Donnelly B, Drusch B, Ellis J, Farrelly C, Feyi-Waboso J, Hibell I, Hoade L, Ho C, Jones H, Kodiatt B, Lidder P, Ni Cheallaigh L, Norman R, Patabendi I, Penfold H, Playfair M, Pomeroy S, Ralph C, Rottenburg H, Sebastian J, Sheehan M, Stanley V, Welchman J, Ajdarpasic D, Antypas A, Azouaghe O, Basi S, Bettoli G, Bhattarai S, Bommireddy L, Bourne K, Budding J, Cookey-Bresi R, Cummins T, Davies G, Fabelurin C, Gwilliam R, Hanley J, Hird A, Kruczynska A, Langhorne B, Lund J, Lutchman I, McGuinness R, Neary M, Pampapathi S, Pang E, Podbicanin S, Rai N, Redhouse White G, Sujith J, Thomas P, Walker I, Winterton R, Anderson P, Barrington M, Bhadra K, Clark G, Fowler G, Gibson C, Hudson S, Kaminskaite V, Lawday S, Longshaw A, MacKrill E, McLachlan F, Murdeshwar A, Nieuwoudt R, Parker P, Randall R, Rawlins E, Reeves SA, Rye D, Sirkis T, Sykes B, Ventress N, Wosinska N, Akram B, Burton L, Coombs A, Long R, Magowan D, Ong C, Sethi M, Williams G, Chan C, Chan LH, Fernando D, Gaba F, Khor Z, Les JW, Mak R, Moin S, Ng Kee Kwong KC, Paterson-Brown S, Tew YY, Bardon A, Burrell K, Coldwell C, Costa I, Dexter E, Hardy A, Khojani M, Mazurek J, Raymond T, Reddy V, Reynolds J, Soma A, Agiotakis S, Alsusa H, Desai N, Peristerakis I, Adcock A, Ayub H, Bennett T, Bibi F, Brenac S, Chapman T, Clarke G, Clark F, Galvin C, Gwyn-Jones A, Henry-Blake C, Kerner S, Kiandee M, Lovett A, Pilecka A, Ravindran R, Siddique H, Sikand T, Treadwell K, Akmal K, Apata A, Barton O, Broad G, Darling H, Dhuga Y, Emms L, Habib S, Jain R, Jeater J, Kan CYP, Kathiravelupillai A, Khatkar H, Kirmani S, Kulasabanathan K, Lacey H, Lal K, Manafa C, Mansoor M, McDonald S, Mittal A, Mustoe S, Nottrodt L, Oliver P, Papapetrou I, Pattinson F, Raja M, Reyhani H, Shahmiri A, Small O, Soni U, Aguirrezabala Armbruster B, Bunni J, Hakim MA, Hawkins-Hooker L, Howell KA, Hullait R, Jaskowska A, Ottewell L, Thomas-Jones I, Vasudev A, Clements B, Fenton J, Gill M, Haider S, Lim AJM, Maguire H, McMullan J, Nicoletti J, Samuel S, Unais MA, White N, Yao PC, Yow L, Boyle C, Brady R, Cheekoty P, Cheong J, Chew SJHL, Chow R, Ganewatta Kankanamge D, Mamer L, Mohammed B, Ng Chieng Hin J, Renji Chungath R, Royston A, Sharrad E, Sinclair R, Tingle S, Treherne K, Wyatt F, Maniarasu VS, Moug S, Appanna T, Bucknall T, Hussain F, Owen A, Parry M, Parry R, Sagua N, Spofforth K, Yuen ECT, Bosley N, Hardie W, Moore T, Regas C, Abdel-Khaleq S, Ali N, Bashiti H, Buxton-Hopley R, Constantinides M, D'Afflitto M, Deshpande A, Duque Golding J, Frisira E, Germani Batacchi M, Gomaa A, Hay D, Hutchison R, Iakovou A, Iakovou D, Ismail E, Jefferson S, Jones L, Khouli Y, Knowles C, Mason J, McCaughan R, Moffatt J, Morawala A, Nadir H, Neyroud F, Nikookam Y, Parmar A, Pinto L, Ramamoorthy R, Richards E, Thomson S, Trainer C, Valetopoulou A, Vassiliou A, Wantman A, Wilde S, Dickinson M, Rockall T, Senn D, Wcislo K, Zalmay P, Adelekan K, Allen K, Bajaj M, Gatumbu P, Hang S, Hashmi Y, Kaur T, Kawesha A, Kisiel A, Woodmass M, Adelowo T, Ahari D, Alhwaishel K, Atherton R, Clayton B, Cockroft A, Curtis Lopez C, Hilton M, Ismail N, Kouadria M, Lee L, MacConnachie A, Monks F, Mungroo S, Nikoletopoulou C, Pearce L, Sara X, Shahid A, Suresh G, Wilcha R, Atiyah A, Davies E, Dermanis A, Gibbons H, Hyde A, Lawson A, Lee C, Leung-Tack M, Li Saw Hee J, Mostafa O, Nair D, Pattani N, Plumbley-Jones J, Pufal K, Ramesh P, Sanghera J, Saram S, Scadding S, See S, Stringer H, Torrance A, Vardon H, Wyn-Griffiths F, Brew A, Kaur G, Soni D, Tickle A, Akbar Z, Appleyard T, Figg K, Jayawardena P, Johnson A, Kamran Siddiqui Z, Lacy-Colson J, Oatham R, Rowlands B, Sludden E, Turnbull C, Allin D, Ansar Z, Azeez Z, Dale VH, Garg J, Horner A, Jones S, Knight S, McGregor C, McKenna J, McLelland T, Packham-Smith A, Rowsell K, Spector-Hill I, Adeniken E, Baker J, Bartlett M, Chikomba L, Connell B, Deekonda P, Dhar M, Elmansouri A, Gamage K, Goodhew R, Hanna P, Knight J, Luca A, Maasoumi N, Mahamoud F, Manji S, Marwaha PK, Mason F, Oluboyede A, Pigott L, Razaq AM, Richardson M, Saddaoui I, Wijeyendram P, Yau S, Atkins W, Liang K, Miles N, Praveen B, Ashai S, Braganza J, Common J, Cundy A, Davies R, Guthrie J, Handa I, Iqbal M, Ismail R, Jones C, Jones I, Lee KS, Levene A, Okocha M, Olivier J, Smith A, Subramaniam E, Tandle S, Wang A, Watson A, Wilson C, Chan XHF, Khoo E, Montgomery C, Norris M, Pugalenthi PP, Common T, Cook E, Mistry H, Shinmar HS, Agarwal G, Bandyopadhyay S, Brazier B, Carroll L, Goede A, Harbourne A, Lakhani A, Lami M, Larwood J, Martin J, Merchant J, Pattenden S, Pradhan A, Raafat N, Rothwell E, Shammoon Y, Sudarshan R, Vickers E, Wingfield L, Ashworth I, Azizi S, Bhate R, Chowdhury T, Christou A, Davies L, Dwaraknath M, Farah Y, Garner J, Gureviciute E, Hart E, Jain A, Javid S, Kankam HK, Kaur Toor P, Kaz R, Kermali M, Khan I, Mattson A, McManus A, Murphy M, Nair K, Ngemoh D, Norton E, Olabiran A, Parry L, Payne T, Pillai K, Price S, Punjabi K, Raghunathan A, Ramwell A, Raza M, Ritehnia J, Simpson G, Smith W, Sodeinde S, Studd L, Subramaniam M, Thomas J, Towey S, Tsang E, Tuteja D, Vasani J, Vio M, Badran A, Adams J, Anthony Wilkinson J, Asvandi S, Austin T, Bald A, Bix E, Carrick M, Chander B, Chowdhury S, Cooper Drake B, Crosbie S, D Portela S, Francis D, Gallagher C, Gillespie R, Gravett H, Gupta P, Ilyas C, James G, Johny J, Jones A, Kinder F, MacLeod C, Macrow C, Maqsood-Shah A, Mather J, McCann L, McMahon R, Mitham E, Mohamed M, Munton E, Nightingale K, O'Neill K, Onyemuchara I, Senior R, Shanahan A, Sherlock J, Spyridoulias A, Stavrou C, Stokes D, Tamang R, Taylor E, Trafford C, Uden C, Waddington C, Yassin D, Zaman M, Bangi S, Cheng T, Chew D, Hussain N, Imani-Masouleh S, Mahasivam G, McKnight G, Ng HL, Ota HC, Pasha T, Ravindran W, Shah K, Vishnu K S, Zaman S, Carr W, Cope S, Eagles EJ, Howarth-Maddison M, Li CY, Reed J, Ridge A, Stubbs T, Teasdaled D, Umar R, Worthington J, Dhebri A, Kalenderov R, Alattas A, Arain Z, Bhudia R, Chia D, Daniel S, Dar T, Garland H, Girish M, Hampson A, Kyriacou H, Lehovsky K, Mullins W, Omorphos N, Vasdev N, Venkatesh A, Waldock W, Bhandari A, Brown G, Choa G, Eichenauer CE, Ezennia K, Kidwai Z, Lloyd-Thomas A, Macaskill Stewart A, Massardi C, Sinclair E, Skajaa N, Smith M, Tan I, Afsheen N, Anuar A, Azam Z, Bhatia P, Davies-kelly N, Dickinson S, Elkawafi M, Ganapathy M, Gupta S, Khoury EG, Licudi D, Mehta V, Neequaye S, Nita G, Tay VL, Zhao S, Botsa E, Cuthbert H, Elliott J, Furlepa M, Lehmann J, Mangtani A, Narayan A, Nazarian S, Parmar C, Shah D, Shaw C, Zhao Z, Beck C, Caldwell S, Clements JM, French B, Kenny R, Kirk S, Lindsay J, McClung A, McLaughlin N, Watson S, Whiteside E, Alyacoubi S, Arumugam V, Beg R, Dawas K, Garg S, Lloyd ER, Mahfouz Y, Manobharath N, Moonesinghe R, Morka N, Patel K, Prashar J, Yip S, Adeeko ES, Ajekigbe F, Bhat A, Evans C, Farrugia A, Gurung C, Long T, Malik B, Manirajan S, Newport D, Rayer J, Ridha A, Ross E, Saran T, Sinker A, Waruingi D, Allen R, Al Sadek Y, Alves do Canto Brum H, Asharaf H, Ashman M, Balakumar V, Barrington J, Baskaran R, Berry A, Bhachoo H, Bilal A, Boaden L, Chia WL, Covell G, Crook D, Dadnam F, Davis L, De Berker H, Doyle C, Fox C, Gruffydd-Davies M, Hafouda Y, Hill A, Hubbard E, Hunter A, Inpadhas V, Jamshaid M, Jandu G, Jeyanthi M, Jones T, Kantor C, Kwak SY, Malik N, Matt R, McNulty P, Miles C, Mohomed A, Myat P, Niharika J, Nixon A, O'Reilly D, Parmar K, Pengelly S, Price L, Ramsden M, Turnor R, Wales E, Waring H, Wu M, Yang T, Ye TTS, Zander A, Zeicu C, Bellam S, Francombe J, Kawamoto N, Rahman MR, Sathyanarayana A, Tang HT, Cheung J, Hollingshead J, Page V, Sugarman J, Wong E, Chiong J, Fung E, Kan SY, Kiang J, Kok J, Krahelski O, Liew MY, Lyell B, Sharif Z, Speake D, Alim L, Amakye NY, Chandrasekaran J, Chandratreya N, Drake J, Owoso T, Thu YM, Abou El Ela Bourquin B, Alberts J, Chapman D, Rehnnuma N, Ainsworth K, Carpenter H, Emmanuel T, Fisher T, Gabrel M, Guan Z, Hollows S, Hotouras A, Ip Fung Chun N, Jaffer S, Kallikas G, Kennedy N, Lewinsohn B, Liu FY, Mohammed S, Rutherfurd A, Situ T, Stammer A, Taylor F, Thin N, Urgesi E, Zhang N, Ahmad MA, Bishop A, Bowes A, Dixit A, Glasson R, Hatta S, Hatt K, Larcombe S, Preece J, Riordan E, Fegredo D, Haq MZ, Li C, McCann G, Stewart D, Baraza W, Bhullar D, Burt G, Coyle J, Deans J, Devine A, Hird R, Ikotun O, Manchip G, Ross C, Storey L, Tan WWL, Tse C, Warner C, Whitehead M, Wu F, Court EL, Crisp E, Huttman M, Mayes F, Robertson H, Rosen H, Sandberg C, Smith H, Al Bakry M, Ashwell W, Bajaj S, Bandyopadhyay D, Browlee O, Burway S, Chand CP, Elsayeh K, Elsharkawi A, Evans E, Ferrin S, Fort-Schaale A, Iacob M, I K, Impelliziere Licastro G, Mankoo AS, Olaniyan T, Otun J, Pereira R, Reddy R, Saeed D, Simmonds O, Singhal G, Tron K, Wickstone C, Williams R, Bradshaw E, De Kock Jewell V, Houlden C, Knight C, Metezai H, Mirza-Davies A, Seymour Z, Spink D, Wischhusen S. Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study. Lancet Digit Health 2022; 4:e520-e531. [PMID: 35750401 DOI: 10.1016/s2589-7500(22)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. METHODS We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). FINDINGS In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). INTERPRETATION In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. FUNDING British Journal of Surgery Society.
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Dummer R, Pathan N, Zhu Z, Robert C, Arance A, de Groot JWB, Garbe C, Gogas HJ, Gutzmer R, Krajsová I, Liszkay G, Loquai C, Mandala M, Schadendorf D, Yamazaki N, Edwards M, Cantey-Kiser J, di Pietro A, Deng S, Ascierto PA, Flaherty K. Abstract 6403: Molecular correlates of clinical benefit from circulating tumor DNA (ctDNA): Analysis of the COLUMBUS study. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-6403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: In the randomized, two-part, phase 3 COLUMBUS study (NCT01909453), encorafenib (enco) + binimetinib (bini) and enco alone improved 5-year progression-free survival (PFS) and overall survival (OS) vs vemurafenib (vem) in patients (pts) with advanced BRAF V600E/K-mutant melanoma. ctDNA offers a less invasive alternative to tissue biopsy for identifying mutations in pts with advanced melanoma and may have prognostic value. We evaluated whether ctDNA from pts enrolled in COLUMBUS Part 1 correlate with pts’ efficacy outcomes.
Methods: In COLUMBUS Part 1, 577 pts were randomized 1:1:1 to enco + bini, enco, or vem. 650 plasma samples were collected at baseline (Cycle 0 or Cycle 1 Day 1; all arms) and during treatment (Cycle 2 Day 1 [C2D1]; enco + bini and enco arms); 426 samples from COLUMBUS Part 1 were successfully analyzed using the GuardantOMNI assay. Analyses were exploratory with no multiplicity adjustments.
Results: Survival outcomes in the biomarker cohort were similar to those in the intent-to-treat population. ctDNA was detected in 279 (96%) pts at baseline and 107 (79%) pts at C2D1. 92% concordance was observed between two plasma genomics assays (Inostics and Guardant) and 75% between tumor and plasma with respect to BRAF mutation status. BRAF V600 variant allele frequency (VAF) at baseline was prognostic for PFS and OS (P<0.0001) in the enco + bini arm. Treatment with enco + bini and enco sharply reduced BRAF V600 VAF (P<0.0001). Decrease in BRAF V600 VAF was more pronounced in responders than in non-responders. Greater clinical benefit was observed in pts with complete ctDNA clearance at C2D1, among whom 12% and 58% had a complete or partial response, respectively, vs 9% and 48%, respectively, for those without complete ctDNA clearance. In the enco + bini arm, high tumor mutational burden (≥10 per megabase) at C2D1, but not at baseline, was associated with shorter PFS (P<0.0001) and OS (P=0.0151). The most frequently detected alterations at baseline were BRAF (79%), TERT (53%), LRP1B (21%), TP53 (17%), and PREX2 (14%). BRAF gene had the most significant decrease from baseline to C2D1 (51.6% difference; P<0.0001), followed by TERT (41.6% difference; P<0.0001), GRIN2A (16.3% difference; P=0.0152), and ROS1 (12.2% difference; P=0.0437) in pts who received enco + bini. FGFR1 mutations were found to be most associated with a lack of BRAF V600 clearance (P=0.0005). Further analyses of molecular correlates of response and resistance are underway.
Conclusions: These exploratory analyses of Part 1 of the COLUMBUS study suggested that treatment with enco + bini significantly reduced BRAF V600 VAF, which was prognostic for PFS and OS at both baseline and C2D1. ctDNA provides a powerful tool for understanding the molecular basis for response and resistance to treatment and may impact future treatment decisions.
Citation Format: Reinhard Dummer, Nuzhat Pathan, Zhou Zhu, Caroline Robert, Ana Arance, Jan Willem B. de Groot, Claus Garbe, Helen J. Gogas, Ralf Gutzmer, Ivana Krajsová, Gabriella Liszkay, Carmen Loquai, Mario Mandala, Dirk Schadendorf, Naoya Yamazaki, Michelle Edwards, Jean Cantey-Kiser, Alessandra di Pietro, Shibing Deng, Paolo A. Ascierto, Keith Flaherty. Molecular correlates of clinical benefit from circulating tumor DNA (ctDNA): Analysis of the COLUMBUS study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 6403.
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Affiliation(s)
| | | | | | - Caroline Robert
- 4Gustave Roussy and Paris-Saclay University, Villejuif, France
| | - Ana Arance
- 5Hospital Clinic of Barcelona and IDIBAPS, Barcelona, Spain
| | | | - Claus Garbe
- 7University Hospital Tubingen, Tubingen, Germany
| | - Helen J. Gogas
- 8National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Carmen Loquai
- 12University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Logan AM, Reid I, Yogarajah M, Wang C, Greenwood N, Edwards M, Jarman H, Nirmalananthan N. Migraine in the emergency department: A retrospective evaluation of the characteristics of attendances in a major city hospital in the United Kingdom. Cephalalgia Reports 2022. [DOI: 10.1177/25158163221084325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Detailed Emergency Department attendance data for migraine are needed for service redesign. Methods: A service evaluation was undertaken, classifying adult emergency department headache attendances using the International Classification of Headache Disorders migraine C-E criteria, evaluating attendance characteristics. Results: Migraine/Probable migraine diagnosis was documented in 58% but coded in 24% attendances by ED clinicians. 29% of patients used no analgesia before attending, 43% attended ≥4 days after onset and 19% arrived by ambulance. Conclusion: This evaluation highlights sub-optimal acute management and discrepancy between migraine coding and diagnosis contributing to underreporting. We recommend further evaluation of identified cohorts and headache proforma use.
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Affiliation(s)
- A-M Logan
- Neurology Department, Atkinson Morley Regional Neurosciences Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - I Reid
- Neurology Department, Atkinson Morley Regional Neurosciences Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - M Yogarajah
- Neurology Department, Atkinson Morley Regional Neurosciences Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - C Wang
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - N Greenwood
- Faculty of Health, Social Care and Education, Kingston University and St George’s University of London, London, UK
| | - M Edwards
- Molecular and Clinical Sciences Research Institute, St George’s University of London, London, UK
| | - H Jarman
- Emergency Department Clinical Research Unit, St George’s University Hospital NHS Foundation Trust, London, UK
| | - N Nirmalananthan
- Neurology Department, Atkinson Morley Regional Neurosciences Centre, St George’s University Hospitals NHS Foundation Trust, London, UK
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22
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Parikh A, Vieira MC, Li B, Lamarre N, Abraham A, Parzynski C, Edwards M. EPR22-117: Evaluation of the Influence of the BRAF V600E Mutation and of the Microsatellite Instability on the Overall Survival (OS) of Metastatic CRC Patients Based on Real World Data. J Natl Compr Canc Netw 2022. [DOI: 10.6004/jnccn.2021.7264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Aparna Parikh
- 1 Massachusetts General Hospital Cancer Center, Boston, MA
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23
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Edwards M, Cooper A, Hughes T, Davies F, Price D, Anderson P, Evans B, Carson-Stevens A, Dale J, Hibbert P, Harrington B, Hepburn J, Niroshan Siriwardena A, Snooks H, Edwards A. The effectiveness of primary care streaming in emergency departments on decision-making and patient flow and safety - A realist evaluation. Int Emerg Nurs 2022; 62:101155. [PMID: 35339107 DOI: 10.1016/j.ienj.2022.101155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 11/28/2022]
Abstract
Primary care streaming was implemented in UK Emergency Departments (EDs) to manage an increasing demand for urgent care. We aimed to explore its effectiveness in EDs with different primary care models and identify contexts and mechanisms that influenced outcomes: streaming patients to the most appropriate clinician or service, ED flow and patient safety. METHOD We observed streaming and interviewed ED and primary care staff during case study visits to 10 EDs in England. We used realist methodology, synthesising a middle-range theory with our qualitative data to refine and create a set of theories that explain relationships between contexts, mechanisms and outcomes. RESULTS Mechanisms contributing to the effectiveness of primary care streaming were: quality of decision-making, patient flow, redeploying staff, managing patients across streams, the implementation of governance protocols, guidance, training, service evaluation and quality improvement efforts. Experienced nurses and good teamworking and strategic and operational management were key contextual factors. CONCLUSION We recommend service improvement strategies, operational management, monitoring, evaluation and training to ensure that ED nurses stream patients presenting at an ED seeking urgent care to the most appropriate clinicians for their needs in a safe and efficient manner.
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Affiliation(s)
- Michelle Edwards
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK.
| | - Alison Cooper
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Thomas Hughes
- Emergency Department, John Radcliffe Hospital, Oxford, UK
| | - Freya Davies
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Delyth Price
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Pippa Anderson
- Swansea Centre for Health Economics, College of Human and Health Sciences, Swansea University, Swansea. UK
| | - Bridie Evans
- Swansea University Medical School, Swansea University, Swansea, UK
| | | | - Jeremy Dale
- Academic Primary Care, Warwick University, Coventry, UK
| | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Australia
| | - Barbara Harrington
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Julie Hepburn
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
| | | | - Helen Snooks
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, UK
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Lewis G, Spaulding A, Borkar S, Dinh T, Colibaseanu D, Edwards M. Caprini assessment utilization and impact on patient safety in gynecologic surgery. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.12.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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25
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Parvizian MK, Zhang M, Edwards M, Bhoey P, Hookey L, Rodrigues D. A102 INDICATION FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND ASSOCIATION WITH HEMORRHAGE: A SYSTEMATIC REVIEW AND META-ANALYSIS. J Can Assoc Gastroenterol 2022. [DOI: 10.1093/jcag/gwab049.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Hemorrhage is a complication associated with up to 2% of cases of Endoscopic Retrograde Cholangiopancreatography (ERCP), most commonly following sphincterotomy. Studies investigating risk factors associated with hemorrhage, such as ERCP indication, have been conflicting.
Aims
We performed a systematic review and meta-analysis to determine the association between the indication for ERCP and ERCP-associated hemorrhage.
Methods
A systematic search of MEDLINE, EMBASE, and CENTRAL was done from inception until September 2021 for studies reporting on factors associated with ERCP-associated hemorrhage (both immediate and delayed) in adults. Exclusion criteria included: pediatric patients, no outcome of interest, did not investigate hemorrhage risk factors, inappropriate study design (basic science, reviews, and case reports/series), or if no English text was available. A DerSimonian and Laird random-effects meta-analysis was performed to generate pooled Odds Ratios (OR) with 95% Confidence Intervals (CIs) for each procedural indication in relation to hemorrhage.
Results
952 records were identified of which 17 were included in our quantitative analysis. Common indications included acute cholangitis, choledocholithiasis, Sphincter of Oddi dysfunction (SOD), acute pancreatitis, chronic pancreatitis, and malignancy-associated duct obstruction. Rates of hemorrhage varied in the included studies (median 2.2%; IQR 1.7–6.9). Sphincterotomy rates also differed in the included studies (median 100%; IQR 71.1–100). Five studies did not report on antiplatelet or anticoagulant use with the remaining reporting varying rates of antiplatelet (median 8.3%; IQR 0–26.5) and anticoagulant (median 0.8%; IQR 0–2.25) use. Hemorrhage was significantly associated with acute cholangitis (OR 2.48; 95% CI 1.62–3.78) and choledocholithiasis (OR 1.76; 95% CI 1.06–2.94) but not SOD (OR 1.38; 95% CI 0.74–2.58), malignancy (OR 0.68; 95% CI 0.29–1.59), acute pancreatitis (OR 1.08; 95% CI 0.30–3.82), or chronic pancreatitis (OR 0.56; 95% CI 0.16–1.99).
Conclusions
Acute cholangitis and choledocholithiasis were associated with increased hemorrhage, whereas SOD, malignancy, acute pancreatitis, and chronic pancreatitis were not. Providers should consider procedural indication when counselling patients on hemorrhage risk in ERCP.
Funding Agencies
None
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Affiliation(s)
| | - M Zhang
- McMaster University, Hamilton, ON, Canada
| | - M Edwards
- Medicine, Queen’s University, Kingston, ON, Canada
| | - P Bhoey
- Medicine, Queen’s University, Kingston, ON, Canada
| | - L Hookey
- Medicine, Queen’s University, Kingston, ON, Canada
| | - D Rodrigues
- Medicine, Queen’s University, Kingston, ON, Canada
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Price D, Edwards M, Davies F, Cooper A, McFadzean J, Carson-Stevens A, Cooke M, Dale J, Evans BA, Harrington B, Hepburn J, Siriwardena AN, Snooks H, Edwards A. Patients’ experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation. BMC Emerg Med 2022; 22:12. [PMID: 35065616 PMCID: PMC8783419 DOI: 10.1186/s12873-021-00562-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/07/2021] [Indexed: 12/03/2022] Open
Abstract
Background Patient experience is an important outcome and indicator of healthcare quality, and patient reported experiences are key to improving quality of care. While patient experience in emergency departments (EDs) has been reported in research, there is limited evidence about patients’ specific experiences with primary care services located in or alongside EDs. We aim to identify theories about patient experience and acceptability of being streamed to a primary care clinician in an ED. Methods Using theories from a rapid realist review as a basis, we interviewed 24 patients and 106 staff members to generate updated theories about patient experience and acceptability of streaming to primary care services in EDs. Feedback from 56 stakeholders, including clinicians, policymakers and patient and public members, as well as observations at 13 EDs, also contributed to the development of these theories, which we present as a programme theory. Results We found that patients had no expectations or preferences for which type of clinician they were seen by, and generally found being streamed to a primary care clinician in the ED acceptable. Clinicians and patients reported that patients generally found primary care streaming acceptable if they felt their complaint was dealt with suitably, in a timely manner, and when clinicians clearly communicated the need for investigations, and how these contributed to decision-making and treatment plans. Conclusions From our findings, we have developed a programme theory to demonstrate that service providers can expect that patients will be generally satisfied with their experience of being streamed to, and seen by, primary care clinicians working in these services. Service providers should consider the potential advantages and disadvantages of implementing primary care services at their ED. If primary care services are implemented, clear communication is needed between staff and patients, and patient feedback should be sought.
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27
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Stanford-Edwards C, Edwards M, Selby A, Lewis R, Powell C, Nicholas O. Creating a Sustainable Future of Radiotherapy Following COP26: A Case for Lung Stereotactic Ablative Radiotherapy Over Surgery? Clin Oncol (R Coll Radiol) 2021; 34:e105-e106. [PMID: 34895991 DOI: 10.1016/j.clon.2021.11.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/26/2021] [Indexed: 11/03/2022]
Affiliation(s)
- C Stanford-Edwards
- Swansea Bay University Health Board, South West Wales Cancer Centre, Swansea, UK; The University of Manchester, Manchester, UK.
| | - M Edwards
- Swansea Bay University Health Board, South West Wales Cancer Centre, Swansea, UK
| | - A Selby
- Swansea Bay University Health Board, South West Wales Cancer Centre, Swansea, UK
| | - R Lewis
- Swansea Bay University Health Board, South West Wales Cancer Centre, Swansea, UK
| | - C Powell
- Swansea Bay University Health Board, South West Wales Cancer Centre, Swansea, UK
| | - O Nicholas
- Swansea Bay University Health Board, South West Wales Cancer Centre, Swansea, UK; Swansea University Medical School, Swansea, UK
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28
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Cooper A, Carson-Stevens A, Edwards M, Davies F, Donaldson LJ, Anderson P, Cooke M, Dale J, Evans BA, Harrington B, Hepburn J, Hibbert P, Hughes T, Porter A, Siriwardena AN, Snooks H, Edwards A. Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation. Br J Gen Pract 2021; 71:e931-e940. [PMID: 34048363 PMCID: PMC8544118 DOI: 10.3399/bjgp.2021.0090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/17/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Increasing pressure on emergency services has led to the development of different models of care delivery including GPs working in or alongside emergency departments (EDs), but with a lack of evidence for patient safety outcomes. AIM This study aimed to explore how care processes work and how patient safety incidents associated with GPs working in ED settings may be mitigated. DESIGN AND SETTING Realist methodology with a purposive sample of 13 EDs in England and Wales with different GP service models. The study sought to understand the relationship between contexts, mechanisms, and outcomes to develop theories about how and why patient safety incidents may occur, and how safe care was perceived to be delivered. METHOD Qualitative data were collected (observations, semi-structured audio-recorded staff interviews, and local patient safety incident reports). Data were coded using 'if, then, because' statements to refine initial theories developed from an earlier rapid realist literature review and analysis of a sample of national patient safety incident reports. RESULTS The authors developed a programme theory to describe how safe patient care was perceived to be delivered in these service models, including: an experienced streaming nurse using local guidance and early warning scores; support for GPs' clinical decision making, with clear governance processes relevant to the intended role (traditional GP approach or emergency medicine approach); and strong clinical leadership to promote teamwork and improve communication between services. CONCLUSION The findings of this study can be used as a focus for more in-depth human factors investigations to optimise work conditions in this complex care delivery setting.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Freya Davies
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Matthew Cooke
- Division of Health Sciences, Warwick Medical School, Coventry, UK
| | - Jeremy Dale
- Division of Health Sciences, Warwick Medical School, Coventry, UK
| | | | | | | | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Australia
| | | | - Alison Porter
- Institute of Life Science 2, Swansea University Medical School, Swansea, UK
| | | | - Helen Snooks
- Institute of Life Science 2, Swansea University Medical School, Swansea, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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29
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Stapelberg NJC, Bowman C, Woerwag-Mehta S, Walker S, Davies A, Hughes I, Michel K, Pisani AR, Van Engelen H, Delos M, Hageman T, Fullerton-Smith K, Krishnaiah R, McDowell S, Cameron A, Scales TL, Dillon C, Gigante T, Heddle C, Mudge N, Zappa A, Edwards M, Gutjahr S, Joshi H, Turner K. A lived experience co-designed study protocol for a randomised control trial: the Attempted Suicide Short Intervention Program (ASSIP) or Brief Cognitive Behavioural Therapy as additional interventions after a suicide attempt compared to a standard Suicide Prevention Pathway (SPP). Trials 2021; 22:723. [PMID: 34674732 PMCID: PMC8529364 DOI: 10.1186/s13063-021-05658-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022] Open
Abstract
Background Despite being preventable, suicide is a leading cause of death and a major global public health problem. For every death by suicide, many more suicide attempts are undertaken, and this presents as a critical risk factor for suicide. Currently, there are limited treatment options with limited underpinning research for those who present to emergency departments with suicidal behaviour. The aim of this study is to assess if adding one of two structured suicide-specific psychological interventions (Attempted Suicide Short Intervention Program [ASSIP] or Brief Cognitive Behavioural Therapy [CBT] for Suicide Prevention) to a standardised clinical care approach (Suicide Prevention Pathway [SPP]) improves the outcomes for consumers presenting to a Mental Health Service with a suicide attempt. Methods This is a randomised controlled trial with blinding of those assessing the outcomes. People who attempt suicide or experience suicidality after a suicide attempt, present to the Gold Coast Mental Health and Specialist Services, are placed on the Suicide Prevention Pathway (SPP), and meet the eligibility criteria, are offered the opportunity to participate. A total of 411 participants will be recruited for the study, with 137 allocated to each cohort (participants are randomised to SPP, ASSIP + SPP, or CBT + SPP). The primary outcomes of this study are re-presentation to hospitals with suicide attempts. Presentations with suicidal ideation will also be examined (in a descriptive analysis) to ascertain whether a rise in suicidal ideation is commensurate with a fall in suicide attempts (which might indicate an increase in help-seeking behaviours). Death by suicide rates will also be examined to ensure that representations with a suicide attempt are not due to participants dying, but due to a potential improvement in mental health. For participants without a subsequent suicide attempt, the total number of days from enrolment to the last assessment (24 months) will be calculated. Self-reported levels of suicidality, depression, anxiety, stress, resilience, problem-solving skills, and self- and therapist-reported level of therapeutic engagement are also being examined. Psychometric data are collected at baseline, end of interventions, and 6,12, and 24 months. Discussion This project will move both ASSIP and Brief CBT from efficacy to effectiveness research, with clear aims of assessing the addition of two structured psychological interventions to treatment as usual, providing a cost-benefit analysis of the interventions, thus delivering outcomes providing a clear pathway for rapid translation of successful interventions. Trials registration ClinicalTrials.govNCT04072666. Registered on 28 August 2019
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Affiliation(s)
- Nicolas J C Stapelberg
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia.,Faculty Health Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - Candice Bowman
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia.
| | - Sabine Woerwag-Mehta
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia.,Faculty Health Sciences and Medicine, Bond University, 14 University Drive, Robina, Queensland, 4226, Australia
| | - Sarah Walker
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Angela Davies
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia.,Lived Experience Suicide Prevention Research Advisory Committee (this committee was convened specifically for this study and is supported by the Gold Coast Mental Health and Specialist Services Peer Workers), Southport, Australia
| | - Ian Hughes
- Office for Research Governance and Development, Gold Coast Health, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Konrad Michel
- University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Anthony R Pisani
- Departments of Psychiatry and Pediatrics, University of Rochester, 300 Crittenden Blvd., BOX PSYCH, Rochester, NY, 14642, USA
| | - Heidy Van Engelen
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Mia Delos
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Tamara Hageman
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Kim Fullerton-Smith
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Ravikumar Krishnaiah
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Sarah McDowell
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Alison Cameron
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Trudy-Lee Scales
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Cherie Dillon
- Lived Experience Suicide Prevention Research Advisory Committee (this committee was convened specifically for this study and is supported by the Gold Coast Mental Health and Specialist Services Peer Workers), Southport, Australia
| | - Titta Gigante
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia.,Lived Experience Suicide Prevention Research Advisory Committee (this committee was convened specifically for this study and is supported by the Gold Coast Mental Health and Specialist Services Peer Workers), Southport, Australia
| | - Cindy Heddle
- Lived Experience Suicide Prevention Research Advisory Committee (this committee was convened specifically for this study and is supported by the Gold Coast Mental Health and Specialist Services Peer Workers), Southport, Australia
| | - Natalie Mudge
- Lived Experience Suicide Prevention Research Advisory Committee (this committee was convened specifically for this study and is supported by the Gold Coast Mental Health and Specialist Services Peer Workers), Southport, Australia
| | - Anne Zappa
- Lived Experience Suicide Prevention Research Advisory Committee (this committee was convened specifically for this study and is supported by the Gold Coast Mental Health and Specialist Services Peer Workers), Southport, Australia
| | - Michelle Edwards
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia.,Lived Experience Suicide Prevention Research Advisory Committee (this committee was convened specifically for this study and is supported by the Gold Coast Mental Health and Specialist Services Peer Workers), Southport, Australia
| | - Sigi Gutjahr
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Hitesh Joshi
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
| | - Kathryn Turner
- Department of Mental Health and Specialist Services Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland, 4215, Australia
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30
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Faderani R, Monks M, Peprah D, Colori A, Allen L, Amphlett A, Edwards M. 183 Improving Wellbeing Among UK Doctors Redeployed During Thecovid-19 Pandemic. Br J Surg 2021. [PMCID: PMC8524497 DOI: 10.1093/bjs/znab259.445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background In response to the COVID-19, the NHS has implemented significant workforce changes to manage the increased and changing demand on healthcare services. We aimed to investigate the impact of such changes on the wellbeing of redeployed doctors. Method We conducted a survey at three NHS trusts over 2 weeks during the peak of the pandemic, asking redeployed doctors to rate their morale, work–life balance, perceived support and safety, and to voice concerns. Results 172 redeployed doctors responded to the survey. On exploring morale, 114 (66.3%) respondents felt confident in their new role, 113 (65.7%) felt satisfied or neutral with their new role and only 54 (31.4%) felt stressed at work. 114 (66.3%) doctors felt valued by their team and 136 (79%) felt valued by the general public. 111 (64.5%) had noticed an increase in the length of breaks and 153 (89%) felt that their rotas provided sufficient respite. 95 respondents (55.2%) did not feel confident in the Public Health personal protective equipment (PPE) guidance and similarly 94 (54.7%) did not feel safe while wearing PPE. The three most common concerns were training opportunities – 105 (61%), PPE – 99 (57.6%) and family health – 95 (55.2%). Conclusions Our findings suggest that, among the doctors surveyed, morale is higher than might be expected, with doctors feeling valued, confident, and well rested in their new role. Concerns about training opportunities/career progression, PPE and family safety need to be addressed to minimise the adverse effects on doctor’s wellbeing due to redeployment.
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Affiliation(s)
- R Faderani
- University Hospital of Wales, Cardiff, United Kingdom
| | - M Monks
- Royal Free Hospital, London, United Kingdom
| | - D Peprah
- University College London Hospital, London, United Kingdom
| | - A Colori
- University College London Hospital, London, United Kingdom
| | - L Allen
- University Hospital of Wales, Cardiff, United Kingdom
| | - A Amphlett
- The Royal Free Hospital, London, United Kingdom
| | - M Edwards
- University Hospital of Wales, Cardiff, United Kingdom
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Altell T, Massa E, Edwards M. 1373 Semi-Elective Trauma Patients Pathway and Medical Clerking Proforma, Closed Loop Audit. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Introduction
Semi-elective Trauma care is a service provided by the Trauma and Orthopaedic department for patients who sustain fractures to the upper and lower limbs requiring surgical intervention, are still ambulatory and can be cared for safely at home until the date of operation.
Aim
To assess patients’ referral pathway and clerking documentation against the Standards for the Clinical Structure and Content of Patient Records, published by the RCSEng.
Method
We performed a closed loop audit on the clerking documentation and the referral pathway for these patients. We collected data retrospectively for three months, assessing the clerking documentation against the guidelines. The data was analysed and presented at our Clinical Governance meeting. We then implemented the Semi-Elective Trauma Pathway and the Medical Clerking Proforma. Afterwards, data was collected prospectively to complete the audit cycle.
Results
A sum of 181 patient were included. Before the use of our changes, only 36% of patients had a complete clerking documentation, with two cases of near misses, and no comprehensive referral pathway for these patients. Post implementation of the Pathway and the Clerking Proforma, 88% of patients had complete clerking documentation, no near misses and 95% of them went properly through the pathway we introduced.
Conclusions
These patients present an important part of any trauma list. This Audit shows that having a comprehensive referral pathway and a clerking proforma will make sure that patients will have full medical history taken and are ready for the operation on the day of surgery and decrease the number of near misses.
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Affiliation(s)
- T Altell
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - E Massa
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - M Edwards
- King's College Hospital NHS Foundation Trust, London, United Kingdom
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Dummer R, Flaherty K, Robert C, Arance A, de Groot J, Garbe C, Gogas H, Gutzmer R, Krajsová I, Liszkay G, Loquai C, Mandala M, Schadendorf D, Yamazaki N, Zohren F, Edwards M, Ascierto P. 1041MO 5-year update on COLUMBUS: A randomized phase III trial of encorafenib (enco) + binimetinib (bini) versus enco or vemurafenib (vem) in patients (pts) with BRAF V600-mutant melanoma. Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.1426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Edwards M, Cooper A, Stevens AC, Edwards A, Hughes T, Snooks H, Anderson P, Porter A, Evans B, Dale J, Cooke M, Hibbert P, Siriwardena AN. PP18 Is there provider induced demand at emergency departments with primary care services? Patient, local and wider system factors described to influence demand for primary care in emergency departments: realist evaluation. Arch Emerg Med 2021. [DOI: 10.1136/emermed-2021-999.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundEvidence from evaluations of emergency departments (EDs) with co-located primary care services suggests that they influence additional demand for non-urgent care (provider-induced demand). In a realist review of the literature on the effects of primary care services in EDs we proposed a theory that when primary care services are distinct at an ED they may encourage additional primary care demand and when primary care clinicians work indistinctly in the ED there is no additional demand. We aimed to explore evidence for this theory and explain contexts, mechanisms and outcomes that influence such demand.MethodsWe used realist evaluation methodology and carried out observations of key processes. We interviewed 23 patients, 21 ED clinical directors, 26 other ED staff members and 26 GPs at 13 EDs (England & Wales). Field notes and audio-recorded interviews were transcribed and analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to provider induced demand.ResultsEDs with distinct primary care services were perceived to attract more demand for primary care than EDs where primary care clinicians worked indistinctly because the primary care service was visible, widely known about, enabled direct access, and received NHS 111 referrals. Other influences on demand were patients’ experiences of accessing primary care, the capacity for urgent care in the community, location of the ED and public transport links, service design and developments (new buildings, renovations) and population characteristics (unfamiliarity with local healthcare services, not registered with a GP or different cultural perceptions of seeking health care).ConclusionsA range of patient, local-system and wider-system factors contribute to additional demand at an ED with co-located primary care services. Our findings can inform providers and policymakers in developing strategies to limit the effect of these influences on additional demand.
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Edwards M, Cooper A, Davies F, Stevens AC, Edwards A, Hughes T, Snooks H, Anderson P, Porter A, Evans B, Dale J, Cooke M, Hibbert P, Siriwardena AN. PP19 Primary care streaming in emergency departments- contexts and mechanisms associated with perceived effectiveness outcomes: a realist evaluation. Arch Emerg Med 2021. [DOI: 10.1136/emermed-2021-999.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundRecent policy has encouraged emergency departments (EDs) to deploy nurses to stream patients from the ED front door to GPs working in a separate GP service operating within or alongside an ED. We aimed to describe mechanisms relating to effectiveness of streaming in different primary care service models identified in EDs. We explored perceptions of whether patients were perceived to be appropriately streamed to emergency care, primary care, other hospital services or community primary care services; and effects on patient flow (waiting times and length of stay in the ED); and safe streaming outcomes.MethodsWe used realist evaluation methodology to explore perceived streaming effectiveness. We visited 13 EDs with different primary care service models (purposively selected across England & Wales; 8 streamed primary care patients to a primary care clinician) and carried out observations of triage/streaming and patient flow and interviews with key members of staff (consultants, GPs, nurses). Field notes and audio-recorded interviews were transcribed and analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to streaming effectiveness.ResultsWe identified five contexts (nurses’ knowledge and experience, streaming guidance, teamwork and communication, operational management and strategic management) that facilitated mechanisms that influenced the effectiveness of streaming (streaming to an appropriate service, patient flow, delivering safe care). We integrated a middle range psychological theory (cognitive continuum theory) with our findings to recommend a focus for training nurses in streaming and service improvements.ConclusionsWe identified key mechanisms relating to the effectiveness of primary care streaming in different models of service. We recommend a collaborative approach to service development, guidance and training (including input from ED clinicians and primary care clinicians) and a range of training strategies that are suitable for less experienced junior nurses and more experienced senior nurses and nurse practitioners.
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Nash TM, Elahwal M, Edwards M. Adaptation of the vein cuff in distal arterial anastomosis (Brighton Sock). Ann R Coll Surg Engl 2021; 103:537-538. [PMID: 34192499 DOI: 10.1308/rcsann.2021.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- T M Nash
- Royal Sussex County Hospital, Brighton, UK
| | - M Elahwal
- Royal Sussex County Hospital, Brighton, UK
| | - M Edwards
- Royal Sussex County Hospital, Brighton, UK
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Conway D, Culshaw S, Edwards M, Clark C, Watling C, Robertson C, Braid R, O’Keefe E, McGoldrick N, Burns J, Provan S, VanSteenhouse H, Hay J, Gunson R. SARS-CoV-2 Positivity in Asymptomatic-Screened Dental Patients. J Dent Res 2021; 100:583-590. [PMID: 33779355 PMCID: PMC8138329 DOI: 10.1177/00220345211004849] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Enhanced community surveillance is a key pillar of the public health response to coronavirus disease 2019 (COVID-19). Asymptomatic carriage of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a potentially significant source of transmission, yet remains relatively poorly understood. Disruption of dental services continues with significantly reduced capacity. Ongoing precautions include preappointment and/or at appointment COVID-19 symptom screening and use of enhanced personal protective equipment (PPE). This study aimed to investigate SARS-CoV-2 infection in dental patients to inform community surveillance and improve understanding of risks in the dental setting. Thirty-one dental care centers across Scotland invited asymptomatic-screened patients aged over 5 y to participate. Following verbal consent and completion of sociodemographic and symptom history questionnaire, trained dental teams took a combined oropharyngeal and nasal swab sample using standardized Viral Transport Medium-containing test kits. Samples were processed by the Lighthouse Lab and patients informed of their results by SMS/email with appropriate self-isolation guidance in the event of a positive test. All positive cases were successfully followed up by the national contact tracing program. Over a 13-wk period (from August 3, 2020, to October 31, 2020), 4,032 patients, largely representative of the population, were tested. Of these, 22 (0.5%; 95% CI, 0.5%-0.8%) tested positive for SARS-CoV-2. The positivity rate increased over the period, commensurate with uptick in community prevalence identified across all national testing monitoring data streams. To our knowledge, this is the first report of a COVID-19 testing survey in asymptomatic-screened patients presenting in a dental setting. The positivity rate in this patient group reflects the underlying prevalence in community at the time. These data are a salient reminder, particularly when community infection levels are rising, of the importance of appropriate ongoing infection prevention control and PPE vigilance, which is relevant as health care team fatigue increases as the pandemic continues. Dental settings are a valuable location for public health surveillance.
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Affiliation(s)
- D.I. Conway
- School of Medicine, Dentistry, Nursing,
University of Glasgow, Glasgow, UK
- Public Health Scotland, Glasgow,
UK
| | - S. Culshaw
- School of Medicine, Dentistry, Nursing,
University of Glasgow, Glasgow, UK
| | - M. Edwards
- Department of Public Health, NHS
Ayrshire and Arran, Ayr, UK
| | - C. Clark
- Public Health Scotland, Glasgow,
UK
| | | | - C. Robertson
- Public Health Scotland, Glasgow,
UK
- Mathematics and Statistics, Strathclyde
University, Glasgow, UK
| | - R. Braid
- Public Health Scotland, Glasgow,
UK
| | - E. O’Keefe
- Public Health Department, NHS Fife,
Leven, UK
| | | | - J. Burns
- Public Health Department, NHS Fife,
Leven, UK
| | - S. Provan
- Oral Health Directorate, NHS Greater
Glasgow & Clyde, Glasgow, UK
| | | | - J. Hay
- Lighthouse Lab in Glasgow, Glasgow,
UK
| | - R. Gunson
- West of Scotland Specialist Virology
Centre, Glasgow Royal Infirmary, Glasgow, UK
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Altell T, Massa E, Edwards M. 421 Intrapelvic Protrusion of a Femoral Head in A Ceramic-on-Ceramic Total Hip Replacement, A Case Report. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Ceramic on ceramic bearing in Total Hip Replacement (THR) is associated with a low but evident risk of ceramic linear fracture, which can lead to catastrophic failure if not diagnosed and treated early.
Case presentation:
A 59-year-old male patient, who underwent a ceramic-on-ceramic THR 8 years ago, presented to our centre with a five-week history of right hip pain, after he suddenly twisted his upper body and felt a sharp pain in his groin. Prior to the injury he had an excellent functional level with the prosthesis.
His examination findings confirmed a reduced range of movement with pain in the groin on internal and external rotation. X-ray and CT of the hip confirmed a ceramic liner fracture with protrusion of the femoral head into the pelvis. A revision THR was subsequently performed.
Discussion
The usual pattern of liner fracture in this type of bearings is that the femoral head stays contained inside the metal cup. In our case, the ceramic femoral head uniquely fractured the liner and passed into the pelvis. To the best of our knowledge, this is the third reported case in literature where a ceramic femoral head protrudes through the metal cup into the pelvis.
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Affiliation(s)
- T Altell
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - E Massa
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - M Edwards
- King's College Hospital NHS Foundation Trust, London, United Kingdom
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Edwards M, Laing R. 226 Management of Liver Trauma: Outcomes at One of Europe's Most Active HPB and Liver Transplant Centres. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
The management of liver trauma (LT) has gradually moved away from surgery and more towards conservative or interventional radiological management. Positive outcomes depend upon careful selection for non-operative management, and to avoid surgical intervention in all grade I-III injuries unless haemodynamically unstable following resuscitation. This study investigated the management of all LT patients over a 12-month period at our institution.
Method
We undertook a retrospective study of all patients admitted with LT in 2019 (n = 60). We assessed records to determine the grade of LT (I-VI), concurrent injuries, their management, length of stay and outcomes.
Results
Of the 60 patients admitted with LT, 43 were male (72%) and 41 patients (68%) sustained injuries to multiple organs. 53/60 patients (88%) sustained injuries classified as grade 3 or below. In patients with multiple organ injuries, 7/41 (17%) underwent intervention compared to 7/12 (58%) in those with isolated LT. No deaths were recorded in patients with LT, and 6 people died in the multiple injury group (mortality 10%). Any form of intervention was associated with a doubling in average length of stay.
Conclusions
Non-operative management underpins most isolated LT care; if this fails or is associated with multiple organ traumas, morbidity and mortality rise dramatically.
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Affiliation(s)
- M Edwards
- University Hospitals Birmingham, Birmingham, United Kingdom
| | - R Laing
- University Hospitals Birmingham, Birmingham, United Kingdom
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Brant H, Voss S, Morton K, Cooper A, Edwards M, Price D, Gaughan J, Edwards A, Benger J. Current provision of general practitioner services in or alongside emergency departments in England. Emerg Med J 2021; 38:780-783. [PMID: 33619158 PMCID: PMC8461443 DOI: 10.1136/emermed-2020-210539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND In 2017, general practitioners in or alongside the emergency department (GPED), an approach that employs GPs in or alongside the ED to address increasing ED demand, was advocated by the National Health Service in England and supported by capital funding. However, little is known about the models of GPED that have been implemented. METHODS Data were collected at two time points: September 2017 and December 2019, on the GPED model in use (if any) at 163/177 (92%) type 1 EDs in England. Models were categorised according to a taxonomy as 'inside/integrated', 'inside/parallel', 'outside/onsite' or 'outside/offsite'. Multiple data sources used included: on-line surveys, interviews, case study data and publicly available information. RESULTS An increase of EDs using GPED was observed from 81% to 95% over the study period. 'Inside/parallel' was the most frequently used model: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The adoption of 'inside/integrated' models fell from 26% (38/149) to 9% (15/159). Capital funding was received by 87% (142/163) of the EDs sampled. We identified no significant difference between the GPED model adopted and observable characteristics of EDs of annual attendance, 4-hour wait, rurality and deprivation within the population served. CONCLUSION The majority of EDs in England have now adopted GPED. The availability of capital funding to finance structural changes so that separate GP services can be provided may explain the rise in parallel models and the decrease in integrated models. Further research is required to understand the relative effectiveness of the various models of GPED identified.
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Affiliation(s)
- Heather Brant
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Sarah Voss
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Katherine Morton
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Michelle Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Delyth Price
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - James Gaughan
- Centre for Health Economics, University of York, York, North Yorkshire, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Kopetz S, Grothey A, Ciardiello F, Desai J, Kim TW, Maughan T, Van Cutsem E, Wasan HS, Yaeger R, Yoshino T, Gollerkeri A, Edwards M, Rodriguez Lizaso M, Tabernero J. Global BRAF testing practices in metastatic colorectal cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.3_suppl.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
128 Background:The BRAF V600E mutation is a marker of poor prognosis in patients with metastatic colorectal cancer (mCRC). Targeted therapy, such as encorafenib plus cetuximab, is approved in the US/Europe for the treatment (tx) of BRAF V600E-mutated mCRC and demonstrated improved survival vs historical standard of care (SOC). Determining BRAF mutation status in mCRC is recommended by NCCN and ESMO guidelines although adherence to guidelines may not be uniform. This report’s objective is to communicate global survey results of mCRC BRAF testing practices. Identifying regions where BRAF testing is not SOC may help identify where education efforts are needed improve effective tx decision making. Methods: Oncology tx centers were identified from a registry and public information. Centers were selected for research experience, historic data quality, and estimated mCRC patients. A BRAF testing practices survey using an online platform of verified centers was conducted March-August 2020; 395 centers/38 countries have responded thus far. Results: Respondents indicated BRAF-mutation testing is performed as SOC for patients with mCRC in most regions; Eastern Europe and South America are exceptions: only 47% (45/95) and 45% (9/20) of centers, respectively routinely performed mutation testing. Most test tumor tissue, few test both tumor tissue or blood, and none conduct blood mutation testing only. Most regions perform BRAF testing at initial diagnosis or confirmation of advanced disease. Individual country statistics will be presented. Conclusions: BRAF testing has global variability, impacting tx decisions. Increased awareness and routine testing may lead to informed decisions regarding targeted therapies, such as encorafenib plus cetuximab where approved, in patients with BRAF V600E-mutant mCRC. [Table: see text]
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Affiliation(s)
- Scott Kopetz
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | - Jayesh Desai
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Tae Won Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Tim Maughan
- MRC Oxford Institute for Radiation Oncology, University of Oxford, Oxford, United Kingdom
| | - Eric Van Cutsem
- University Hospital Gasthuisberg and University of Leuven, Leuven, Belgium
| | - Harpreet Singh Wasan
- Hammersmith Hospital, Division of Cancer, Imperial College London, London, United Kingdom
| | - Rona Yaeger
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | | | | | - Josep Tabernero
- Vall d’Hebron University Hospital and Institute of Oncology (VIHO), Barcelona, Spain
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Freynhagen R, Elling C, Radic T, Sohns M, Liedgens H, James D, McCool R, Edwards M. Safety of tapentadol compared with other opioids in chronic pain treatment: network meta-analysis of randomized controlled and withdrawal trials. Curr Med Res Opin 2021; 37:89-100. [PMID: 33032466 DOI: 10.1080/03007995.2020.1832977] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the relative safety of oral tapentadol PR and other opioid analgesics for moderate or severe chronic pain in adults, we conducted a systematic review and network meta-analysis (NMA). METHODS A systematic review was conducted to identify randomized controlled trials (RCTs) and randomized withdrawal trials of tapentadol with other WHO stage II and III opioid analgesics in patients with moderate or severe chronic pain. Searches were conducted in MEDLINE, EMBASE, PubMed, Cochrane databases and trial registries. Feasibility assessment evaluated the trials' suitability for NMA. Outcomes assessed were overall AEs, overall serious adverse events, constipation, nausea, dizziness, somnolence, headache, and discontinuation due to AEs. Randomized withdrawal trials were analyzed separately to other RCTs. RESULTS Searches conducted in April 2019 identified 16,604 records. Following screening and feasibility assessment, 29 RCTs and 19 randomized withdrawal trials were identified and included in the NMA. Consistent with existing research, evidence from RCTs suggested that tapentadol is associated with relatively lower odds of adverse events occurring than most active comparators. The withdrawal trial data were less clear, with higher uncertainty around the results, and results that appear to contradict the RCT evidence. There are a number of trial design factors that may be affecting these results. CONCLUSIONS RCT evidence suggests that tapentadol can be a useful treatment option for patients suffering from chronic pain and in need of an opioid analgesic. Opioids should be prescribed by a qualified physician only after other analgesics have been considered, taking side effects and misuse risk into account.
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Affiliation(s)
- R Freynhagen
- Department of Anaesthesiology, Critical Care Medicine, Pain Medicine & Palliative Care, Benedictus Krankenhaus Tutzing, Pain Center Lake Starnberg, Academic Teaching Hospital Technische Universität München, Munich, Germany
- Department of Anaesthesiology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - C Elling
- Grünenthal GmbH, Aachen, Germany
| | - T Radic
- Grünenthal GmbH, Aachen, Germany
| | - M Sohns
- Grünenthal GmbH, Aachen, Germany
| | | | - D James
- Quantics Biostatistics, Edinburgh, UK
| | - R McCool
- York Health Economics Consortium, York, UK
| | - M Edwards
- York Health Economics Consortium, York, UK
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Brinkler R, Edwards M. In reply: Questionnaire translation and questionnaire validation are not the same. Int J Obstet Anesth 2020; 45:166. [PMID: 33413964 DOI: 10.1016/j.ijoa.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022]
Affiliation(s)
- R Brinkler
- Department of Anaesthesia, Royal National Orthopaedic Hospital, London, UK.
| | - M Edwards
- Department of Anaesthesia, North Shore Hospital, Auckland, New Zealand
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Choudrhey M, Edwards M, Cooper A, Anderson P, Hughes T, Carson-Stevens A, Porter A, Adrian E. 188 Senior clinical and business managers’perspectives on how different mechanisms and models of employing general practitioners in or alongside Emergency Departments influence wider system outcomes. Arch Emerg Med 2020. [DOI: 10.1136/emj-2020-rcemabstracts.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Aims/Objectives/BackgroundWe aim to examine senior managers’ perspectives on funding mechanisms used to implement the policy and experiences of success or challenges in introducing models of using GPs in or alongside emergency departments. Health policy in England has advocated the use of primary care clinicians at emergency departments to address pressures from rising attendances. However, implementing large systemic changes such as placing GPs in or alongside emergency departments requires significant funding, consideration of the opportunity costs of the alternative uses of such funding, an available workforce and evidence of how it should be used. Our findings will inform policy adaptation and service development to improve the healthcare provided to patients by providing new evidence of the reported experiences of adopting models of using GPs in or alongside emergency departments.Methods/DesignThe perspectives of senior clinical, business and finance managers with responsibility for emergency department services and on-site primary care service implementation were investigated in semi-structured interviews with 31 managers at 12 type-1 emergency departments in England and Wales. Emergency departments operated one of three GP models or had prior experience of implementing a GP model. Interviews were thematically analysed.Results/ConclusionsSuccessful GPs models in emergency departments were perceived to be reliant on well-organised and unified funding mechanisms, appropriate staffing and governance, and consideration of population demands and needs. Funding mechanisms and the flow of funds were reported as complex, the most efficient mechanisms were described at departments where funding was unified, in collaboration with health and community care services. Staffing with local, experienced GPs was important. There were also cautions from experiences with private locum providers. Our findings contribute to debates about implementing policy on how primary care clinicians are effectively and safely deployed in emergency departments and how local context should be considered.
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Edwards M, Edwards M, Cooper A, Davies F, Stevens AC, Hughes T, Anderson P, Edwards A. 192 Primary care streaming in emergency departments- contexts and mechanisms associated with perceived effectiveness outcomes: a realist evaluation. Arch Emerg Med 2020. [DOI: 10.1136/emj-2020-rcemabstracts.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Aims/Objectives/BackgroundRecent policy has encouraged emergency departments (EDs) to deploy nurses to stream patients from the ED front door to GPs working in a separate GP service operating within or alongside an ED. We aim to describe mechanisms relating to effectiveness of streaming in different primary care service models identified in emergency departments. We explored whether patients were appropriately streamed to emergency care, primary care, other hospital services or community primary care services; patient flow (including effects on waiting times and length of stay in the emergency department); and safe streaming outcomes. We sought suggestions for quality improvements relating to streamingMethods/DesignA realist evaluation methodology was used to explore perceived streaming effectiveness. We visited 13 emergency departments (purposively selected across England & Wales; 8 streamed primary care patients to a primary care clinician) and carried out observations of triage/streaming and patient flow and interviews with key members of staff (consultants, GPs, nurses).Field notes from observations and audio-recorded interviews were transcribed verbatim and were analysed by creating context, mechanism and outcome configurations to refine and develop theories relating to streaming effectiveness.Results/ConclusionsWe identified five contexts (nurses’ knowledge and experience, streaming guidance, teamwork and communication, operational management and strategic management) that facilitated mechanisms that influenced the effectiveness of streaming (streaming to an appropriate service, patient flow, delivering safe care). We integrated a middle range psychological theory with our findings to recommend a focus for training nurses in streaming and service improvements. We recommend a collaborative approach to service development, guidance and training (including input from emergency department clinicians, primary care clinicians) and a range of training strategies that are suitable for less experienced junior nurses and more experienced senior nurses and nurse practitioners.
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Edwards M, Price D, Hepburn J, Harrington B, Evans B, Cooper A, Edwards A. 207 Patients’motivations and expectations when seeking urgent care at emergency departments and acceptability of primary care streaming: a realist study. Arch Emerg Med 2020. [DOI: 10.1136/emj-2020-rcemabstracts.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Aims/Objectives/BackgroundWe aim to explain the contexts and mechanisms that influence patients’ motivations and expectations when accessing urgent care at an ED and their acceptability of being streamed to a primary care clinician working in or alongside the ED. Recent healthcare policy has encouraged the implementation of primary care services in or alongside emergency departments whereby patients with low acuity illness are streamed to a primary care clinician after a brief initial assessment. Our findings describe patients’ motivations, expectations, and acceptability of primary care streaming and their level of satisfaction.Methods/DesignWe recruited 24 patients to be interviewed after visiting an emergency department for one of five low acuity complaints. 12 patients were streamed to ED clinicians and 11 were streamed to primary care clinicians. We carried out semi-structured realist style interviews by telephone and carried out a realist analysis to create theories to explain motivations to attend, acceptability of streaming and satisfaction with care.Results/ConclusionsMotivations for attending the ED included patients’ perception of their complaint as an emergency which needed immediate treatment, and previous experience of receiving care at the ED. Acceptability of primary care streaming was related to patients’ past experiences accessing primary care services, their trust in initial assessment processes and their expectation to be seen by ‘expert clinicians’ on the ‘same day’. When patients’ expectations of waiting times, level of investigations and general quality of care were met or exceeded, they reported acceptability to being streamed to a primary care clinician and were satisfied with their care. Understanding why patients attend the ED for urgent care needs and their experience of primary care streaming is essential to addressing increasing ED demand and improving efficiency.
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Edwards M, Cooper A, Freya D, Carson-Stevens A, Hughes T, Siriwardena N, Snooks H, Edwards A. 191 A classification of primary care pathways in emergency departments: a multi-methods study comprising cross-sectional survey; site visits with observations; semi-structured and informal interviews. Arch Emerg Med 2020. [DOI: 10.1136/emj-2020-rcemabstracts.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Aims/Objectives/BackgroundWe aim to describe and classify the predominant streaming pathways on arrival in Emergency Departments (EDs) in England and Wales and explain how they operate in different models of emergency department primary care services. Recent policy has encouraged a method whereby nurses stream from the emergency department front door to GPs working in a separate GP service operating within or alongside an ED. However, there is variation in methods of assessing and streaming patients on arrival at EDs. Conflated terminology causes difficulties in assessing relative performance, improving quality or gathering evidence about safety, clinical effectiveness. Our findings present a new classification of current streaming pathways from emergency departments to primary care services.Methods/DesignWe used a multi-stage method approach, including an online survey completed by 77 EDs across England & Wales, interviews with 21 clinical leads, and finally, undertaking case studies of 13 EDs. Qualitative data were triangulated and analysed using a framework analysis approach.Results/ConclusionsThe most common ED pathways to primary care services were: front door streaming before ED registration; streaming inside the ED; or without streaming but GPs selecting patients. Pathways were often adapted, to suit local circumstances such as department layout, patient demand levels, skill mix and interests of GPs practitioners and the accessibility of community primary care services. Pathways to redirect patients with non-urgent primary care problems to community primary care services were also used, with local variation in protocols based on staffing, patient demand and links to community primary care services. Local clinical leads and managers need to consider which pathway(s) may best suit their local context and needs. Consistency of terminology used to describe pathways between EDs and primary care services is necessary for multi-site evaluation, quality improvement and performance measurement.
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Edwards M, Cooper A, Davies F, Carson-Stevens A, Hughes T, Porter A, Snooks H, Edwards A. 206 Emergency department clinical leads’ experiences of implementing primary care services where GPs work in or alongside emergency departments in the UK: a qualitative study. Arch Emerg Med 2020. [DOI: 10.1136/emj-2020-rcemabstracts.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Aims/Objectives/BackgroundWe aim to describe ED clinical leads’ experiences of implementing and delivering ‘primary care services’ and ‘emergency medicine services’ where GPs were integrated into the ED team. NHS England policy has promoted services in which patients presenting to EDs with non-urgent problems are directed to general practitioners (GPs) and other primary care clinicians working within or alongside EDs to address increasing demand. Our findings describe variation in the ways that these primary care services are implemented and the ways in which GPs work within them. We also highlight successes and challenges in implementing such services.Methods/DesignWe conducted interviews with ED clinical leads in England (n=19) and Wales (n=2). We used framework analysis to analyse interview transcripts and explore differences across ‘primary care services’, ‘emergency medicine services’ and emergency departments without primary care services.Results/ConclusionsIn EDs with separate primary care services, success was reported with a distinct workforce of primary care clinicians, who improved waiting times and flow by seeing primary care-type patients in a timely way, using fewer investigations, and enabling ED doctors to focus on more acutely unwell patients. Some challenges were: aligning services with the policy guidance, inconsistent demand for primary care, accessible community primary care services, difficulties recruiting GPs, lack of funding, difficulties agreeing governance protocols and establishing effective streaming pathways. Where GPs were integrated into an ED workforce success was reported as managing the demand for both emergency and primary care and reducing admissions.To support successful and sustainable primary care services in or alongside EDs, policy makers and commissioners should consider varied ways that GPs can be employed to manage local demand and also local contextual factors such as the ability to recruit and retain GPs, sustainable funding, clear governance frameworks, training, support and guidance for all staff.
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Brant H, Voss S, Cooper A, Edwards M, Price D, Gaughan J, Edwards A, Benger J. 198 Current provision of general practitioner services in or alongside emergency departments in England. Arch Emerg Med 2020. [DOI: 10.1136/emj-2020-rcemabstracts.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Aims/Objectives/BackgroundOne approach to addressing increasing demand in emergency departments (EDs) has been the co-location of general practitioners (GPs) in or alongside the emergency department (ED), known as GPED. This approach was both advocated by the National Health Service (NHS) and supported by capital funding in 2017. However, little is known about the models of GPED that have been implemented as a result.Methods/DesignWe collected data on the model of GPED in use (if any) at 163/177 (92%) of type one EDs in England at two time points: September 2017 and December 2019. Multiple data sources were used including: on-line surveys; interviews; case study data; publicly available information. Models were classified according to an iteratively developed taxonomy as Inside/integrated, Inside/parallel, Outside/onsite, Outside/offsite.Results/ConclusionsThe proportion of EDs using GPED increased from 81% to 95% over the study period. The most common model was ‘Inside/parallel’ to the ED: 30% (44/149) in 2017, rising to 49% (78/159) in 2019. The number of Inside/integrated models dropped from 26% (38/149) to 9% (15/159). 23 sites commenced and four sites ceased GPED provision. 87% (142/163) of the EDs sampled were awarded capital funding. We identified no association between the type of GPED model adopted and the observable characteristics of EDs such as annual attendance, rurality of location and deprivation within the population served.The majority of EDs in England have now adopted GPED. The increase in Inside/parallel models and the reduction in Inside/integrated models is likely to be related to the availability of capital funding to finance structural changes to EDs so that separate GP services could be provided. Further research is required to understand the relative effectiveness of the various models of GPED identified.
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King CE, Kermode A, Saxena G, Carvelli P, Edwards M, Creagh-Brown BC. Postoperative continuous non-invasive cardiac output monitoring on the ward: a feasibility study. J Clin Monit Comput 2020; 35:1349-1356. [PMID: 33094826 PMCID: PMC8542541 DOI: 10.1007/s10877-020-00601-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/29/2020] [Indexed: 12/19/2022]
Abstract
Postoperative hypotension is common (occurring in one third of patients) and is associated with worse clinical outcomes. The LiDCO CNAP (continuous non-invasive arterial pressure) device measures haemodynamics but has not been widely adopted in ward environments. Improved early detection of hypotension by CNAP might guide interventions to improve clinical outcomes. We aimed to find the proportion of patients who tolerated LiDCO CNAP for 12 h postoperatively, to unmask episodes of hypotension detected by continuous monitoring and to characterise the haemodynamic profile at the time of hypotension. In this feasibility study, patients undergoing major elective surgery were continuously postoperatively monitored using CNAP. Haemodynamic data gathered from CNAP, including nSVRI (nominal systemic vascular resistance index), nSVI (nominal stroke volume index), SVV (stroke volume variation) and blood pressure, were analysed using Microsoft Excel and GraphPad Prism 8. 104 patients (age (mean ± sd): 68 ± 14, male (56%)) had CNAP sited postoperatively. 39% tolerated the CNAP device for at least 12 h. Within the 104 patients a mean of 81.2 min of hypotension detected by CNAP was not detected by usual care. The proportion of low/normal/high nSVI was 71%, 27% and 2%, nSVRI was 43%, 17% and 40%, respectively. CNAP monitoring was not tolerated for 12 h in the majority of patients. There were many episodes of hypotension unmasked through continuous monitoring. Based on the advanced haemodynamic data provided it is possible that the underlying cause of a third of postoperative hypotensive episodes is vasodilation rather than hypovolaemia.Trial registry number: NCT04010058 (ClinicalTrials.gov) Date of registration: 08/07/2019.
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Affiliation(s)
- C E King
- Medical Student, Faculty of Medicine, University of Southampton, Southampton, UK
| | - A Kermode
- Surrey Perioperative Anaesthesia Critical Care Collaborative Research Group (SPACeR), Royal Surrey County Hospital, Egerton Road, Guildford, UK
| | - G Saxena
- Surrey Perioperative Anaesthesia Critical Care Collaborative Research Group (SPACeR), Royal Surrey County Hospital, Egerton Road, Guildford, UK
| | - P Carvelli
- Surrey Perioperative Anaesthesia Critical Care Collaborative Research Group (SPACeR), Royal Surrey County Hospital, Egerton Road, Guildford, UK
| | - M Edwards
- Department of Anaesthesia, Southampton General Hospital, Tremona Road, Southampton, UK
| | - B C Creagh-Brown
- Surrey Perioperative Anaesthesia Critical Care Collaborative Research Group (SPACeR), Royal Surrey County Hospital, Egerton Road, Guildford, UK. .,Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey, UK.
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Wilker J, Humphries S, Rosas-Sotomayor JC, Gómez Cerna M, Torkamaneh D, Edwards M, Navabi A, Pauls KP. Genetic Diversity, Nitrogen Fixation, and Water Use Efficiency in a Panel of Honduran Common Bean ( Phaseolus vulgaris L.) Landraces and Modern Genotypes. Plants (Basel) 2020; 9:plants9091238. [PMID: 32961677 PMCID: PMC7569834 DOI: 10.3390/plants9091238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 01/09/2023]
Abstract
Common bean (Phaseolus vulgaris L.) provides critical nutrition and a livelihood for millions of smallholder farmers worldwide. Beans engage in symbiotic nitrogen fixation (SNF) with Rhizobia. Honduran hillside farmers farm marginal land and utilize few production inputs; therefore, bean varieties with high SNF capacity and environmental resiliency would be of benefit to them. We explored the diversity for SNF, agronomic traits, and water use efficiency (WUE) among 70 Honduran landrace, participatory bred (PPB), and conventionally bred bean varieties (HON panel) and 6 North American check varieties in 3 low-N field trials in Ontario, Canada and Honduras. Genetic diversity was measured with a 6K single nucleotide polymorphism (SNP) array, and phenotyping for agronomic, SNF, and WUE traits was carried out. STRUCTURE analysis revealed two subpopulations with admixture between the subpopulations. Nucleotide diversity was greater in the landraces than the PPB varieties across the genome, and multiple genomic regions were identified where population genetic differentiation between the landraces and PPB varieties was evident. Significant differences were found between varieties and breeding categories for agronomic traits, SNF, and WUE. Landraces had above average SNF capacity, conventional varieties showed higher yields, and PPB varieties performed well for WUE. Varieties with the best SNF capacity could be used in further participatory breeding efforts.
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Affiliation(s)
- Jennifer Wilker
- Department of Plant Agriculture, University of Guelph, Guelph, ON N1G 2W1, Canada; (J.W.); (D.T.); (M.E.)
| | - Sally Humphries
- Department of Sociology and Anthropology, University of Guelph, Guelph, ON N1G 2W1, Canada;
| | - Juan Carlos Rosas-Sotomayor
- Departamento de Ciencia y Producción Agropecuaria, Escuela Agrícola Panamericana, Zamorano, Tegucigalpa 11101, Honduras;
| | - Marvin Gómez Cerna
- Fundación para la Investigación Participativa con Agricultores de Honduras, La Ceiba, Atlántida 561, Honduras;
| | - Davoud Torkamaneh
- Department of Plant Agriculture, University of Guelph, Guelph, ON N1G 2W1, Canada; (J.W.); (D.T.); (M.E.)
| | - Michelle Edwards
- Department of Plant Agriculture, University of Guelph, Guelph, ON N1G 2W1, Canada; (J.W.); (D.T.); (M.E.)
| | - Alireza Navabi
- Department of Plant Agriculture, University of Guelph, Guelph, ON N1G 2W1, Canada; (J.W.); (D.T.); (M.E.)
| | - K. Peter Pauls
- Department of Plant Agriculture, University of Guelph, Guelph, ON N1G 2W1, Canada; (J.W.); (D.T.); (M.E.)
- Correspondence: ; Tel.: +1-519-824-4120 (ext. 54136)
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