To assess patients’ knowledge of their drug therapy for neovascular macular degeneration and to identify which aspects of the drug they considered most important if given the option of switching to an alternative drug.
Prospective questionnaire survey.
A total of 126 patients attending our hospital service for intravitreal ranibizumab therapy for neovascular macular degeneration.
Main outcome measures
Using a questionnaire, patients were asked questions pertaining to aspects of drug therapy in neovascular macular degeneration. Fields covered included drug names, knowledge of alternative drugs, cost of drugs and their views on switching to another drug.
Eighty (63.5%) had heard of Lucentis (ranibizumab) and 31 (24.6%) were aware of Avastin (bevacizumab). Of the latter 31 patients, 20 did not have a preference between Avastin and Lucentis. These patients felt that the factors they would consider important for them to consider switching were effectiveness (10, 50%), specialist recommendation (8, 40%), safety (2, 10%) and cost (0).
Introducing a cheaper, off-label alternative in the therapy of macular degeneration in the presence of a licensed option has been extensively debated. Many patients have no knowledge of this controversial issue but it is likely that efficacy and recommendation by clinicians are more important than cost to patients who may consider switching to the off-label Avastin.
To investigate the rate of death caused by pulmonary embolism (PE) and the antemortem performance in diagnosis and treatment of PE.
A systematic search of cases involving fatal PE via PowerPath® (Sunquest) followed by chart review.
An academic medical centre located in San Diego, United States of America.
Postmortem cases with pathological findings of PE.
Main outcome measures
After data collection and collation, the data were subject to analysis.
From 2002 to 2012, PE was identified as the mechanism of death in 108 of 982 cases (11%, 95% CI 9.01–12.99%) at an institution with an average autopsy rate of 30% ± 0.07%. Excluding cases where care was withheld (by advance directive) or unavailable, 29 of 108 were eligible for antemortem treatment for PE. In 31% (nine of 29) of these cases the diagnosis of PE was considered antemortem. Only three of 29 were given thrombolytics despite only one case being contraindicated.
The rate of PE-related death is consistent with most other autopsy series and major epidemiologic studies despite advances in system wide deep venous thrombosis prophylaxis. The results validate previous studies that this diagnosis is often missed but probably improving compared to historical standards. Even when the diagnosis is considered, however, thrombolytics are not routinely given, even without contraindications. The cause of this failure to treat may require further study with comparison to patients that were treated to determine the utilization of this treatment. It also underscores the continued difficulty in the diagnosis of this disease.
Placebo appears to be a real neurobiological phenomenon that has evolved through the selection pressure to be able to heal ourselves. The complex language and social structures of humans means that we can attribute meaning to therapeutic encounters with culturally sanctioned authority figures and we can use our attachment to such figures to generate hope for recovery. Different mechanisms may be involved in the neurobiological aspect of placebo including anxiety, learning, conditioning as well as individual genetic variation. Examination of the published work shows that while some trials do seem to indicate a specific mode of action for homeopathic remedies other trials do not and this is an issue that needs to be addressed at the trial design stage. A clinical trial that includes both a placebo group and a non-participating control arm is the most powerful design for separating the non-specific and polymorphic placebo effect from the specific effects of trial medication. The control variables in a trial of homeopathic medication should also include the process of consultation as this may assume a meaning for the individual that can also be associated with a placebo effect.
To investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the ‘August effect’.
Quantitative retrospective observational study of routinely collected data on junior doctor workload.
Two large teaching hospitals in England.
Task level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals.
Main outcome measures
Number and type of tasks requested by nurses, time to completion of tasks by junior doctors.
There was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10−9).
This study suggests that the ‘August effect’ is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity.
Light therapy is still used to treat a number of common diseases in Russia. The practice is firmly anchored in history: Soviet clinical practice was divorced from the emerging field of evidence-based medicine. Medical researchers were cut off from international medical research and scientific literature, with much Soviet scientific activity based on a particular socialist ideology. In this study, the use of light therapy serves as a case study to explore tensions between international evidence-based medicine and practices developed in isolation under the Soviet Union, the legacy of which is to the detriment of many patients today. We used four different search methods to uncover scientific and grey literature, both historical and contemporary. We assessed the changing frequency of publications over time and contrasted the volume of literature on light therapy with more orthodox treatments such as statins and painkillers. Our search found an increasing number and comparatively large body of scientific publications on light therapy in the Russian language, and many publications emanating from prestigious Russian institutions. Combined with our analysis of the historical literature and our appraisal of 22 full text articles, this leads us to suggest that light therapy entered mainstream Soviet medical practice before the Stalinist period and still occupies an important position in contemporary Russian clinical practice. We propose that this outdated treatment survives in Russia in part due to the political, economic and social forces that helped to popularize it during Soviet times, and by the seeming justification offered by poorly executed studies.
To explore how participation in an online support community may impact upon the experience of inflammatory bowel disease (IBD).
An online survey.
Study participants recruited through 35 IBD online communities.
A total of 249 males and females aged 16–69 years, living with either Crohn’s disease (65.9%) or ulcerative colitis (26.1%) or awaiting formal diagnosis (8%).
Patients reported being members for an average of two years, with the majority accessing the community on a daily (46.9%) or weekly (40%) basis. Spending on average four hours per week online, approximately two-thirds of members posted between one and five messages per week. Members joined to find others in a similar situation and to obtain and share information and emotional support. Through participation members accessed a wealth of knowledge about all aspects of living with IBD and this was helpful in terms of accepting their illness and learning to manage it. The community also helped members see their illness more positively as well as contributing to an improvement in subjective wellbeing. However, some negatives aspects were noted.
Online support communities may provide a useful shared space through which IBD patients may seek and provide both informational and emotional support. Many of these benefits may not be available through traditional healthcare. Whilst online support communities may be beneficial for those who choose to participate in them, they are not without limitations. Health professionals should be aware of the potential benefits and limitations of online communities.
Zoonoses involve infections and infestations transmissible from animals to humans. Zoonoses are a major global threat. Exposure to zoonotic pathogens exists in various settings including encroachment on nature; foreign travel; pet keeping; bushmeat consumption; attendance at zoological parks, petting zoos, school ‘animal contact experiences’, wildlife markets, circuses, and domesticated and exotic animal farms. Under-ascertainment is believed to be common and the frequency of some zoonotic disease appears to be increasing. Zoonoses include direct, indirect and aerosolized transmission. Improved awareness of zoonoses in the hospital environment may be important to the growing need for prevention and control. We reviewed relevant literature for the years 2000 to present and identified a significant need for the promotion of awareness and management of zoonoses in the hospital environment. This article provides a new decision-tree, as well as staff and patient guidance on the prevention and control of zoonoses associated with hospitals.
To evaluate the appropriateness of proton pump inhibitor (PPI) prescribing by conducting an audit of medical inpatients against recommended guidelines.
Questionnaire-based study. All medical wards were audited and different information was documented by patients' medical records review (both hospital visit notes and general practitioner's letters) and short interview, where we asked them to name the clinical reason for using PPI.
This study was carried out in the setting of a regional hospital (537-bed, secondary care referral centre) in Ireland.
The study participants were all consecutive medical patients admitted to the medical wards at Waterford Regional Hospital, Waterford.
Main outcome measures
The appropriateness of PPI usage in our regional hospital by assessing the level of its prescribing against published guidelines (NICE, 2000).
During the audit period, 205 consecutive medical inpatients were assessed. Seventy-nine percent (162 out of 205) of the studied patients were found to be using PPI. For 45% (n = 73) of patients, there was no documentation of valid indication for being on PPI. Overall, 64% of patients were prescribed PPI by hospital doctors, either during their current or previous admissions. We noted that 31% (n = 51) of patients were taking PPI for ≥2 years and another 25% of patients were using PPI for about one year. Only 12% (n = 20) of patients had undergone endoscopy procedures.
Inappropriate use of PPI remains common in hospital practice. The risks of using long-term PPI must be weighed against the benefits.
Operative vaginal delivery has been described since the Middle Ages. During this time, however, labour would be sustained over several days and intrapartum death almost inevitable. In these circumstances, intervention involving the use of surgical instruments or even kitchen utensils would serve purely as an attempt to avoid maternal mortality. The establishment of forceps-assisted delivery as a means of avoiding both maternal and neonatal morbidity was initiated in the 16th century by the Chamberlen family and later developed over several centuries by leading obstetricians of the time including Simpson, Barnes and Keilland. The evolution of forceps is a fascinating story which is rich in history. Despite the development of Ventouse and the increasing use of Caesarean section for difficult delivery, forceps remain an integral part of obstetric practice. The striking resemblance of modern day forceps to the original instruments used by the Chamberlens is a testament to both the family's ingenuity and enterprise as well as the subsequent pioneering obstetricians who followed in their footsteps.
Often considered no more than an historical curiosity, writer’s cramp remains an important disability in the workplace and the mechanism, which has puzzled the best medical minds for generations, remains contentious. A remarkable range of hypotheses has been put forward to try and explain a disability which periodically reached epidemic and economically worrying levels, but in the end medical opinion has accepted the explanation put forward by neurologists Sheehy and Marsden in 1983 that this was caused by a form of focal dystonia. However, the majority of the historical descriptions of writer’s cramp do not fit the classical parameters of focal dystonia and are more accurately described as a progressive forearm muscle fatigue. Today’s keyboard operators continue to complain of symptoms identical to their clerical forebears demonstrating that this is a problem which has evolved but not disappeared; this has the paradoxical advantage that modern research techniques enable this complaint to be revisited. The result shows that two varieties of writer’s cramp have always existed and while focal dystonia remains a valid explanation for a minority of cases, the much more common fatigue-based complaint is better explained by chronic compartment syndrome of the forearm.
A standardised terminology for describing medical devices can enable safe and unambiguous exchange of information. Proposed changes to EU-wide medical devices regulations mandate the use of such a system. This article reviews two important classification systems for medical devices in the UK. The Global Medical Device Nomenclature (GMDN) provides a classification system specifically for medical devices and diagnostics, and facilitates data exchange between manufacturers and regulators. SNOMED CT is the terminology of choice in the NHS for communicating, sharing and storing information about patients’ healthcare episodes. Harmonisation of GMDN and SNOMED CT will encourage use of single terminology throughout the lifetime of a device; from regulatory approval through clinical use and post-marketing surveillance. Manufacturers will be required to register medical devices with a European device database (Eudamed) and to fit certain devices with a Unique Device Identifier; both are efforts to improve transparency and traceability of medical devices. Successful implementation of these elements depends on having a consistent nomenclature for medical devices.
To characterize paediatric presentations of stabbing to emergency departments across London and to audit existing referral rates to the police and social services against the new standard set by the General Medical Council.
Retrospective multi-centre service evaluation/audit.
All emergency departments within London.
Patients under 18 years of age presenting to emergency departments with non-accidental stabbing between 1 April 2007 and 30 April 2009.
Main outcome measures
Patient age, nature of assault, assailant, injuries and management. Rates of documented referral to police and social services, as mandated by GMC guidance.
A total of 381 presentations were identified from 20 out of the 32 hospitals in London, 160 of whom were less than 16 years old. The majority were seen only by emergency department staff and only a minority (28%) were admitted. Three died in the departments. A knife was the commonest weapon and the limbs the most common site of injury. Referrals to police were documented in only 30% of patients (43% if <16 years old) and to social services in 16% (31% if <16 years old) of those discharged. In the majority, there was no documentation (police 64%, social services 79%).
A significant number of paediatric stabbings present to emergency departments across London. The majority of these are discharged directly from departments. Of those discharged, documentation regarding referral rates to Police and Social Services was poor, and documented referral rates low. This study covered a period prior to the introduction of new General Medical Council guidance and a repeat audit to assess subsequent documented referrals is required.
Skin lesions are extremely common, with 54% of the UK population being affected by skin disease annually. As such, dermatological conditions can be brought to light following admission to hospital for different underlying conditions, with 57% of the dermatological diagnoses made on the hospital wards, unrelated to previous patient history or reasons for admission. The role of the dermatologist is therefore comprehensive and inherently important in the hospital. General practitioners play an integral role in managing skin conditions in the community, with up to 24% of consultations relating to skin disease, referring patients to dermatology mainly for the management of more complex conditions, and diagnosis of certain skin lesions. It is therefore essential to further analyse these roles and to better understand the extent of inpatient and outpatient activity to better plan the provision of dermatological services whether in the community, or in the hospital.
There have been concerns about the potential increases in operating time associated with the use of individually wrapped presterilized small orthopaedic implants compared with our traditional method of screw banks. We set out to quantify this theory.
Prospective experimental study.
Orthopaedic Surgical Trainees and Theatre Scrub team.
Main outcome measure
The time taken to complete the operation.
The use of prepacked and sterilized implants added 2 min 56 s to the use of a bank with a full complement of normal screws that required tapping and 3 min 58 s if self-tapping screws were used (P < 0.001).
Using individually wrapped presterilized small orthopaedic implants increases operating time.