Publications by authors named "Robert M West"

95 Publications

Best practice in statistics: Use the Welch -test when testing the difference between two groups.

Authors:
Robert M West

Ann Clin Biochem 2021 Feb 9:4563221992088. Epub 2021 Feb 9.

Leeds Institute of Health Sciences, School of Medicine, 4468University of Leeds, Leeds, UK.

Clinical biochemists often wish to compare two groups of measurements. In order to do so, they must be familiar with Student's -test. This article provides guidance for the use of the Welch -test, with subtle but important differences and validity in a broader range of settings: advises the use of the Welch -test rather than Student's -test.
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http://dx.doi.org/10.1177/0004563221992088DOI Listing
February 2021

Mortality and Medical Complications of Subtrochanteric Fracture Fixation.

J Clin Med 2021 Feb 2;10(3). Epub 2021 Feb 2.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS1 3EX, UK.

The aim of this study was to define the incidence and investigate the associations with mortality and medical complications, in patients presenting with subtrochanteric femoral fractures subsequently treated with an intramedullary nail, with a special reference to advancement of age. A retrospective review, covering an 8-year period, of all patients admitted to a Level 1 Trauma Centre with the diagnosis of subtrochanteric fractures was conducted. Normality was assessed for the data variables to determine the further use of parametric or non-parametric tests. Logistic regression analysis was then performed to identify the most important associations for each event. A -value < 0.05 was considered significant. A total of 519 patients were included in our study (age at time of injury: 73.26 ± 19.47 years; 318 female). The average length of hospital stay was 21.4 ± 19.45 days. Mortality was 5.4% and 17.3% for 30 days and one year, respectively. Risk factors for one-year mortality included: Low albumin on admission (Odds ratio (OR) 4.82; 95% Confidence interval (95%CI) 2.08-11.19), dementia (OR 3.99; 95%CI 2.27-7.01), presence of pneumonia during hospital stay (OR 3.18; 95%CI 1.76-5.77) and Charlson comorbidity score (CCS) > 6 (OR 2.94; 95%CI 1.62-5.35). Regarding the medical complications following the operative management of subtrochanteric fractures, the overall incidence of hospital acquired pneumonia (HAP) was 18.3%. Patients with increasing CCS (CCS 6-8: OR 1.69; 95%CI 1.00-2.84/CCS > 8: OR 2.02; 95%CI 1.03-3.95), presence of asthma/chronic obstructive pulmonary disease (COPD) (OR 2.29; 95%CI 1.37-3.82), intensive care unit (ICU)/high dependency unit (HDU) stay (OR 3.25; 95%CI 1.77-5.96) and a length of stay of more than 21 days (OR 8.82; 95%CI 1.18-65.80) were at increased risk of this outcome. The incidence of post-operative delirium was found to be 10.2%. This was associated with pre-existing dementia (OR 4.03; 95%CI 0.34-4.16), urinary tract infection (UTI) (OR 3.85; 95%CI 1.96-7.56), need for an increased level of care (OR 3.16; 95%CI 1.38-7.25), pneumonia (OR 2.29; 95%CI 1.14-4.62) and post-operative deterioration of renal function (OR 2.21; 95%CI 1.18-4.15). The incidence of venous thromboembolism (VTE) was 3.7% (pulmonary embolism (PE): 8 patients; deep venous thrombosis (DVT): 11 patients), whilst the incidence of myocardial infarction (MI)/cerebrovascular accidents (CVA) was 4.0%. No evidence of the so called "weekend effect" was identified on both morbidity and mortality. Regression analysis of these complications did not reveal any significant associations. Our study has opened the field for the investigation of medical complications within the subtrochanteric fracture population. Early identification of the associations of these complications could help prognostication for those who are at risk of a poor outcome. Furthermore, these could be potential "warning shots" for clinicians to act early to manage and in some cases prevent these devastating complications that could potentially lead to an increased risk of mortality.
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http://dx.doi.org/10.3390/jcm10030540DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867276PMC
February 2021

Can CRP Levels Predict Infection in Presumptive Aseptic Long Bone Non-Unions? A Prospective Cohort Study.

J Clin Med 2021 Jan 22;10(3). Epub 2021 Jan 22.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds LS2 9JT, UK.

Nonunion remains a major complication of the management of long bone fractures. The primary aim of the present study was to investigate whether raised levels of C-reactive protein (CRP) and white blood cell count (WBC), in the absence of clinical signs, are correlated with positive intraoperative tissue cultures in presumptive aseptic long-bone nonunions. Infection was classified as positive if any significant growth of microorganisms was observed from bone/tissue samples sent from the theater at the time of revision surgery. Preoperatively all patients were investigated with full blood count, white blood count differential as well as C-reactive protein (CRP). A total of 105 consecutive patients (59 males) were included in the study, with an average age of 46.76 years (range 16-92 years) at the time of nonunion diagnosis. The vast majority were femoral (56) and tibial (37) nonunions. The median time from the index surgical procedure to the time of nonunion diagnosis was 10 months (range 9 months to 10 years). Positive cultures revealed a mixed growth of microorganisms, with coagulase-negative (56.4%) being the most prevalent microorganism, followed by (20.5%). , Methicillin-Resistant Staphylococcus aureus (MRSA), coliforms and micrococcus were present in the remainder of the cases (23.1%). Overall, the risk of infection with normal CRP levels (<10 mg/L) was 21/80 = 0.26. Elevated CRP levels (≥10 mg/L) increased the risk of infection to 0.72. The relative risk given a positive CRP test was RR = 0.72/0.26 = 2.74. Overall, the WBC count was found to be an unreliable marker to predict infection. Solid union was achieved in all cases after an average of 6.5 months (3-24 months) from revision surgery. In patients with presumed aseptic long bone nonunion and normal CRP levels, the risk of underlying low-grade indolent infection can be as high as 26%. Patients should be made aware of this finding, which can complicate their treatment course and outcomes.
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http://dx.doi.org/10.3390/jcm10030425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865495PMC
January 2021

Culturally adapted psychotherapies for depressed adults: A systematic review and meta-analysis.

J Affect Disord 2021 Jan 15;278:296-310. Epub 2020 Sep 15.

Faculty of Medicine and Health, Leeds Institute of Health Sciences, University of Leeds, UK.

Background: There is current debate about the effectiveness and generalizability of evidence-based psychological therapies in treatment of depression for diverse ethno-cultural groups. This has led to increasing interest in culturally adapted psychotherapies (CAPs).

Methods: Studies on CAPs for face-to-face treatment of depressed adults were identified using nine electronic database searches. Data on the process of adaptation was analysed using thematic analysis and treatment efficacy was assessed through meta-analysis of Randomized Controlled Trials.

Results: Fifteen studies were included in the review, of which eight were included in a meta-analysis. Cognitive Behavioural Therapy and Behavioural Activation were commonly selected approaches for CAPs, mainly based on their strong evidence base for effectiveness. Twelve studies reported the adaptation process that follows all or some phases recommended by the Medical Research Council Framework for developing complex interventions. A meta-analysis of 16 RCTs, which included eight studies from the current review and eight studies from an earlier review (Chowdhary et al. (2014), demonstrated a statistically significant benefit in favour of CAPs, reducing symptom burden [standardized mean difference -0.63, 95% confidence interval -0.87 to -0.39]. Subgroup analysis showed a larger effect when the intervention was for the majority ethnic group in a population, rather than a minority group.

Limitations: Some studies did not report all relevant information, and in the subgroup analysis only three studies were of minority groups.

Conclusions: CAPs were confirmed to be more efficacious than control treatments. This supports the continued development and evaluation of culturally adapted psychotherapies for depression.
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http://dx.doi.org/10.1016/j.jad.2020.09.051DOI Listing
January 2021

Should Radiation Exposure be an Issue of Concern in Children with Multiple Trauma?

Ann Surg 2020 Jul 24. Epub 2020 Jul 24.

Leeds Orthopaedic Trauma Sciences, LIRMM, Leeds University, Leeds, UK.

Objective: The aims of this study were 3-fold: first, establish the level of radiation exposure experienced by the pediatric trauma patients; second, model the level of risk of developing fatal carcinogenesis; and third, test whether pattern of injury was predictive of the level of exposure.

Summary Background Data: There are certain conditions that cause children to be exposed to increased radiation, that is, scoliosis, where level of radiation exposure is known. The extent that children are exposed to radiation in the context of multiple traumas remains unclear.

Methods: Patients below the age of 16 years and with an Injury Severity Score (ISS) ≥10, treated by a Major Trauma Center for the period January 2008 to December 2018 were identified. The following data were extracted for the year following the patient's injury: number, doses, and type of radiological examination.The sex and age of the patient was taken into account in the calculation of the risk of developing a carcinogenesis.

Results: The median radiation dose of the 425 patients identified in the 12 months following injury, through both CT and radiographs, was 24.3 mSv. Modeling the predictive value of pattern of injury and other relevant clinical values, ISS was proportionately predictive of cumulative dose received.

Conclusion: A proportion of younger polytrauma patients were exposed to high levels of radiation that in turn mean an increased risk of carcinogenesis. However, the ISS, age, injury pattern, and length of hospital stay are predictive of both risks, enabling monitoring and patient advisement of the risks.
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http://dx.doi.org/10.1097/SLA.0000000000004204DOI Listing
July 2020

Oral glucocorticoids and incidence of hypertension in people with chronic inflammatory diseases: a population-based cohort study.

CMAJ 2020 03;192(12):E295-E301

Leeds Institute of Biomedical and Clinical Sciences (Mebrahtu); Leeds Institute of Cardiovascular and Metabolic Medicine (Morgan), School of Medicine, University of Leeds; NIHR Biomedical Research Centre (Morgan, Stewart), Leeds Teaching Hospitals NHS Trust, Chapel Allerton Hospital; Leeds Institute of Health Sciences, (West, Pujades-Rodriguez), School of Medicine; Dean's office, Faculty of Medicine & Health (Stewart), University of Leeds, Leeds, UK

Background: Only a few population-based studies have examined the association between glucocorticoids and hypertension, with inconsistent results. We aimed to investigate the effect of oral glucocorticoids on incidence of hypertension in adults with chronic inflammatory diseases.

Methods: We analyzed electronic health records from 389 practices in England during 1998-2017 of adults diagnosed with any of 6 chronic inflammatory diseases but with no previous diagnosis of hypertension. We used glucocorticoid prescription data to construct time-variant daily and cumulative variables of prednisolone-equivalent dose (cumulated from 1 year before the start of follow-up) and estimated incidence rates and adjusted hazard ratios (HRs) for hypertension using Cox regression analysis.

Results: Among 71 642 patients in the cohort, 24 896 (34.8%) developed hypertension during a median follow-up of 6.6 years. The incidence rate of hypertension was 46.7 (95% confidence interval [CI] 46.0-47.3) per 1000 person-years. Incidence rates increased with higher cumulative glucocorticoid prednisolone-equivalent dose, from 44.4 per 1000 person-years in periods of nonuse to 45.3 per 1000 person-years for periods with between > 0.0 and 959.9 mg (HR 1.14, 95% CI 1.09-1.19), to 49.3 per 1000 person-years for periods with 960-3054.9 mg (HR 1.20, 95% CI 1.14-1.27), and to 55.6 per 1000 person-years for periods with ≥ 3055 mg (HR 1.30, 95% CI 1.25-1.35). Cumulative effects were seen for the 6 diseases studied, but dose-response effects were not found for daily dose.

Interpretation: Cumulative dose of oral glucocorticoids was associated with increased incidence of hypertension, suggesting that blood pressure should be monitored closely in patients routinely treated with these drugs. Given that glucocorticoids are widely prescribed, the associated health burden could be high. ClinicalTrials. gov, no. NCT03760562.
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http://dx.doi.org/10.1503/cmaj.191012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101178PMC
March 2020

Understanding patterns of care for musculoskeletal patients using routinely collected National Health Service data from general practices in England.

Health Informatics J 2020 12 16;26(4):2470-2484. Epub 2020 Mar 16.

NIHR Leeds Musculoskeletal Biomedical Research Centre, University of Leeds.

Musculoskeletal conditions are extremely common and represent a costly and growing problem in the United Kingdom. Understanding patterns of care and how they vary between individual patients and patient groups is necessary for effective and efficient disease management. In this article, we present a novel approach to understanding patterns of care for musculoskeletal patients in which trajectories are constructed from clinical and administrative data that are routinely collected by clinicians and healthcare professionals. Our approach is applied to routinely collected National Health Service data for musculoskeletal patients who were registered to a set of general practices in England and highlights both known and previously unreported variations in the prescribing of opioid analgesics by gender and presence of pre-existing depression. We conclude that the application of our approach to routinely collected National Health Service data can extend the dimensions over which patterns of care can be understood for musculoskeletal patients and for patients with other long-term conditions.
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http://dx.doi.org/10.1177/1460458220907431DOI Listing
December 2020

How, in what contexts, and why do quality dashboards lead to improvements in care quality in acute hospitals? Protocol for a realist feasibility evaluation.

BMJ Open 2020 02 25;10(2):e033208. Epub 2020 Feb 25.

School of Health Sciences, University of Manchester, Manchester, Greater Manchester, UK.

Introduction: National audits are used to monitor care quality and safety and are anticipated to reduce unexplained variations in quality by stimulating quality improvement (QI). However, variation within and between providers in the extent of engagement with national audits means that the potential for national audit data to inform QI is not being realised. This study will undertake a feasibility evaluation of QualDash, a quality dashboard designed to support clinical teams and managers to explore data from two national audits, the Myocardial Ischaemia National Audit Project (MINAP) and the Paediatric Intensive Care Audit Network (PICANet).

Methods And Analysis: Realist evaluation, which involves building, testing and refining theories of how an intervention works, provides an overall framework for this feasibility study. Realist hypotheses that describe how, in what contexts, and why QualDash is expected to provide benefit will be tested across five hospitals. A controlled interrupted time series analysis, using key MINAP and PICANet measures, will provide preliminary evidence of the impact of QualDash, while ethnographic observations and interviews over 12 months will provide initial insight into contexts and mechanisms that lead to those impacts. Feasibility outcomes include the extent to which MINAP and PICANet data are used, data completeness in the audits, and the extent to which participants perceive QualDash to be useful and express the intention to continue using it after the study period.

Ethics And Dissemination: The study has been approved by the University of Leeds School of Healthcare Research Ethics Committee. Study results will provide an initial understanding of how, in what contexts, and why quality dashboards lead to improvements in care quality. These will be disseminated to academic audiences, study participants, hospital IT departments and national audits. If the results show a trial is feasible, we will disseminate the QualDash software through a stepped wedge cluster randomised trial.
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http://dx.doi.org/10.1136/bmjopen-2019-033208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044920PMC
February 2020

Liaison psychiatry-measurement and evaluation of service types, referral patterns and outcomes (LP-MAESTRO): a protocol.

BMJ Open 2019 11 24;9(11):e032179. Epub 2019 Nov 24.

Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK.

Introduction: We describe the protocol for a project that will use linkage of routinely collected NHS data to answer a question about the nature and effectiveness of liaison psychiatry services in acute hospitals in England.

Methods And Analysis: The project will use three data sources: (1) Hospital Episode Statistics (HES), a database controlled by NHS Digital that contains patient data relating to emergency department (ED), inpatient and outpatient episodes at hospitals in England; (2) ResearchOne, a research database controlled by The Phoenix Partnership (TPP) that contains patient data relating to primary care provided by organisations using the SystmOne clinical information system and (3) clinical databases controlled by mental health trusts that contain patient data relating to care provided by liaison psychiatry services. We will link patient data from these sources to construct care pathways for patients who have been admitted to a particular hospital and determine those patients who have been seen by a liaison psychiatry service during their admission.Patient care pathways will form the basis of a matched cohort design to test the effectiveness of liaison intervention. We will combine healthcare utilisation within care pathways using cost figures from national databases. We will compare the cost of each care pathway and the impact of a broad set of health-related outcomes to obtain preliminary estimates of cost-effectiveness for liaison psychiatry services. We will carry out an exploratory incremental cost-effectiveness analysis from a whole system perspective.

Ethics And Dissemination: Individual patient consent will not be feasible for this study. Favourable ethical opinion has been obtained from the NHS Research Ethics Committee (North of Scotland) (REF: 16/NS/0025) for Work Stream 2 (phase 1) of the Liaison psychiatry-measurement and evaluation of service types, referral patterns and outcomes study. The Confidentiality Advisory Group at the Health Research Authority determined that Section 251 approval under Regulation 5 of the Health Service (Control of Patient Information) Regulations 2002 was not required for the study 'on the basis that there is no disclosure of patient identifiable data without consent' (REF: 16/CAG/0037).Results of the study will be published in academic journals in health services research and mental health. Details of the study methodology will also be published in an academic journal. Discussion papers will be authored for health service commissioners.
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http://dx.doi.org/10.1136/bmjopen-2019-032179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887012PMC
November 2019

Defective Proliferation and Osteogenic Potential with Altered Immunoregulatory phenotype of Native Bone marrow-Multipotential Stromal Cells in Atrophic Fracture Non-Union.

Sci Rep 2019 11 22;9(1):17340. Epub 2019 Nov 22.

Leeds Institute of Rheumatic and Musculoskeletal Medicine, School of Medicine, University of Leeds, Leeds, UK.

Bone marrow-Multipotential stromal cells (BM-MSCs) are increasingly used to treat complicated fracture healing e.g., non-union. Though, the quality of these autologous cells is not well characterized. We aimed to evaluate bone healing-related capacities of non-union BM-MSCs. Iliac crest-BM was aspirated from long-bone fracture patients with normal healing (U) or non-united (NU). Uncultured (native) CD271highCD45low cells or passage-zero cultured BM-MSCs were analyzed for gene expression levels, and functional assays were conducted using culture-expanded BM-MSCs. Blood samples were analyzed for serum cytokine levels. Uncultured NU-CD271highCD45low cells significantly expressed fewer transcripts of growth factor receptors, EGFR, FGFR1, and FGRF2 than U cells. Significant fewer transcripts of alkaline phosphatase (ALPL), osteocalcin (BGLAP), osteonectin (SPARC) and osteopontin (SPP1) were detected in NU-CD271CD45 cells. Additionally, immunoregulation-related markers were differentially expressed between NU- and U-CD271CD45 cells. Interestingly, passage-zero NU BM-MSCs showed low expression of immunosuppressive mediators. However, culture-expanded NU and U BM-MSCs exhibited comparable proliferation, osteogenesis, and immunosuppression. Serum cytokine levels were found similar for NU and U groups. Collectively, native NU-BM-MSCs seemed to have low proliferative and osteogenic capacities; therefore, enhancing their quality should be considered for regenerative therapies. Further research on distorted immunoregulatory molecules expression in BM-MSCs could potentially benefit the prediction of complicated fracture healing.
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http://dx.doi.org/10.1038/s41598-019-53927-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874596PMC
November 2019

Bedside breath tests in children with abdominal pain: a prospective pilot feasibility study.

Pilot Feasibility Stud 2019 5;5:121. Epub 2019 Nov 5.

3Leeds Teaching Hospitals Trust, Leeds, UK.

Background: There is no definitive method of accurately diagnosing appendicitis before surgery. We evaluated the feasibility of collecting breath samples in children with abdominal pain and gathered preliminary data on the accuracy of breath tests.

Methods: We conducted a prospective pilot study at a large tertiary referral paediatric hospital in the UK. We recruited 50 participants with suspected appendicitis, aged between 5 and 15 years. Five had primary diagnosis of appendicitis. The primary outcome was the number of breath samples collected. We also measured the number of samples processed within 2 h and had CO ≥ 3.5%. Usability was assessed by patient-reported pain pre- and post-sampling and user-reported sampling difficulty. Logistic regression analysis was used to predict appendicitis and evaluated using the area under the receiver operator characteristic curve (AUROC).

Results: Samples were collected from all participants. Of the 45 samples, 36 were processed within 2 h. Of the 49 samples, 19 had %CO ≥ 3.5%. No difference in patient-reported pain was observed ( = 0.24). Sampling difficulty was associated with patient age ( = 0.004). The logistic regression model had AUROC = 0.86.

Conclusions: Breath tests are feasible and acceptable to patients presenting with abdominal pain in clinical settings. We demonstrated adequate data collection with no evidence of harm to patients. The AUROC was better than a random classifier; more specific sensors are likely to improve diagnostic performance.

Trial Registration: ClinicalTrials.gov, NCT03248102. Registered 14 Aug 2017.
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http://dx.doi.org/10.1186/s40814-019-0502-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833160PMC
November 2019

Lower Urinary Tract Infections: Management, Outcomes and Risk Factors for Antibiotic Re-prescription in Primary Care.

EClinicalMedicine 2019 Sep 12;14:23-31. Epub 2019 Aug 12.

Leeds Institute for Data Analytics, School of Medicine, University of Leeds, UK.

Background: Urinary tract infections (UTIs) are major drivers of antibiotic prescribing in primary care. Inappropriate antibiotic prescribing for UTIs likely drives antibiotic resistance. We aimed to describe current investigation and antibiotic treatment to examine opportunities for improved antimicrobial stewardship.

Methods: We identified a cohort of all patients with lower UTI diagnosis between 2011 and 2015 in the 390 primary care practices contributing data to ResearchOne in England. We examined investigation, antibiotic treatment and antibiotic re-prescription within 28 days according to guideline-defined patient groups. We assessed risk factors for re-prescription using mixed-effect logistic regression.

Findings: In total, 494,675 UTIs were diagnosed in 300,354 patients. Median age was 54 years, and 83.3% were women. Same-day antibiotic was prescribed for 85.7% of UTIs; 56.8% were treated with trimethoprim, and urine sampling was undertaken in 25.0%. The antibiotic re-prescription rate was low (17,430, 4.1%) and increased slightly over time in men (from 5.2% in 2011 to 6.2% in 2015). Overall, 21.1% of pre-prescription were for the same antibiotic. The percentage of adults with recurrent UTIs ranged from 1.0% in 18-64 year-old men to 2.6% in women ≥ 65 years. The risk of antibiotic re-prescription increased with age, calendar year, recent antibiotic prescribing and treatment with antibiotic other than trimethoprim or nitrofurantoin.

Interpretation: Most patients diagnosed with lower UTI in primary care receive same-day empirical antibiotics with little diversity in choice of agent. The antibiotic re-prescription rate is low. Microbiological investigation and re-prescription of the same antibiotic given for the initial episode happened in one quarter of UTIs.

Funding: UK National Health Service Improvement.
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http://dx.doi.org/10.1016/j.eclinm.2019.07.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833446PMC
September 2019

Quality of life trajectories in survivors of acute myocardial infarction: a national longitudinal study.

Heart 2020 01 7;106(1):33-39. Epub 2019 Nov 7.

Leeds Institute of Cardiovascular and Metabolic Medicine/Leeds Institute of Data Analytics, University of Leeds, Leeds, UK.

Aim: To define trajectories of perceived health-related quality of life (HRQoL) among survivors of acute myocardial infarction (AMI) and identify factors associated with trajectories.

Methods: Data on HRQoL among 9566 survivors of AMI were collected from 77 National Health Service hospitals in England between 1 November 2011 and 24 June 2015. Longitudinal HRQoL was collected using the EuroQol five-dimension questionnaire measured at hospitalisation, 1, 6 and 12 months post-AMI. Trajectories of perceived HRQoL post-MI were determined using multilevel regression analysis and latent class growth analysis (LCGA).

Results: One or more percieved health problems in mobility, self-care, usual activities, pain/discomfort and anxiety/depression was reported by 69.1% (6607/9566) at hospitalisation and 59.7% (3011/5047) at 12 months. Reduced HRQoL was associated with women (-4.07, 95% CI -4.88 to -3.25), diabetes (-2.87, 95% CI -3.87 to -1.88), previous AMI (-1.60, 95% CI -2.72 to -0.48), previous angina (-1.72, 95% CI -2.77 to -0.67), chronic renal failure (-2.96, 95% CI -5.08 to -0.84; -3.10, 95% CI -5.72 to -0.49), chronic obstructive pulmonary disease (-3.89, 95% CI -5.07 to -2.72) and cerebrovascular disease (-2.60, 95% CI -4.24 to -0.96). LCGA identified three subgroups of HRQoL which we labelled: improvers (68.1%), non-improvers (22.1%) and dis-improvers (9.8%). Non-improvers and dis-improvers were more likely to be women, non-ST-elevation myocardial infarction (NSTEMI) and have long-term health conditions, compared with improvers.

Conclusions: Quality of life improves for the majority of survivors of AMI but is significantly worse and more likely to decline for women, NSTEMI and those with long-term health conditions. Assessing HRQoL both in hospital and postdischarge may be important in determining which patients could benefit from tailored interventions.

Trial Registration: NCT01808027 and NCT01819103.
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http://dx.doi.org/10.1136/heartjnl-2019-315510DOI Listing
January 2020

Patient and implant survival following intraoperative periprosthetic femoral fractures during primary total hip arthroplasty: an analysis from the national joint registry for England, Wales, Northern Ireland and the Isle of Man.

Bone Joint J 2019 10;101-B(10):1199-1208

Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK.

Aims: We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls.

Patients And Methods: This retrospective cohort study compared 4831 hips with IOPFF and 48 154 propensity score matched primary THAs without IOPFF implanted between 2004 and 2016, which had been recorded on a national joint registry. Implant and patient survival rates were compared between groups using Cox regression.

Results: Ten-year stem survival was worse in the IOPFF group (p < 0.001). Risk of revision for aseptic loosening increased 7.2-fold following shaft fracture and almost 2.8-fold after trochanteric fracture (p < 0.001). Risk of periprosthetic fracture of the femur revision increased 4.3-fold following calcar-crack and 3.6-fold after trochanteric fracture (p < 0.01). Risk of instability revision was 3.6-fold after trochanteric fracture and 2.4-fold after calcar crack (p < 0.001). Risk of 90-day mortality following IOPFF without revision was 1.7-fold and 4.0-fold after IOPFF with early revision surgery uncomplicated THA (p < 0.001).

Conclusion: IOPFF increases risk of stem revision and mortality up to ten years following surgery. The risk of revision depends on IOPFF subtype and mortality risk increases with subsequent revision surgery. Surgeons should carefully diagnose and treat IOPFF to minimize fracture progression and implant failure. Cite this article: 2019;101-B:1199-1208.
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http://dx.doi.org/10.1302/0301-620X.101B10.BJJ-2018-1596.R1DOI Listing
October 2019

What predicts mortality in the elderly patient presenting as a trauma call? A report from a Major Trauma Centre.

Surgeon 2020 Jun 28;18(3):142-149. Epub 2019 Aug 28.

Trauma and Orthopaedic Department, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, United Kingdom. Electronic address:

Purpose: Within the UK there is a continued expansion of the population over the age of 65, this currently accounts for 17.8% of the British population. We review the impact that centralization of Major Trauma has had, as well as analysing for significant predictors of poor outcome.

Method: All patients presenting to Leeds Major Trauma Centre as a 'Major Trauma' who were equal to or over the age of 65 were included in this study. Prospectively collected data from the Trauma Audit Research Network (TARN) was collated to include the above data set from the 1st April 2012 - 1st April 2016. The 1st April 2012 represents the commencement of the Major Trauma Network within Yorkshire. To allow more quantative assessment of patients' co-morbidities, they were coded as per Charlson Co-morbidity Index for analysis.

Results: 1167 patients presented within the above timeframe. Mean age was 79.5 (range 65-103.5). Mean ISS was 14.8 of the entire cohort. Mortality was 12.9% of the entire cohort. The leading mechanisms of injury were from low energy falls <2m-59.89%, Fall >2m-23.05% and Road Traffic Collision - 16.45%.

Conclusion: Mortality rates since the commencement of the Major Trauma Network within this age group have reduced. This is likely secondary to centralization of major trauma. Variables found to be statistically significant with increased mortality were increasing age, head injury, presence of Chronic Lung Disease, presence of metastases, decreased GCS and increased ISS.
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http://dx.doi.org/10.1016/j.surge.2019.07.008DOI Listing
June 2020

Non-pharmacological interventions for post-stroke emotionalism (PSE) within inpatient stroke settings: a theory of planned behavior survey.

Top Stroke Rehabil 2020 01 28;27(1):15-24. Epub 2019 Aug 28.

The Medical School, University of East Anglia, Norwich, UK.

: Post-stroke emotionalism (PSE) is common. Trials of antidepressants for PSE suggest only modest clinical benefit and risk of side effects. There have been no trials of non-pharmacological treatments for PSE; in fact, little is known about the non-pharmacological treatments actually provided to PSE sufferers in clinical practice.: To determine the non-pharmacological interventions provided by stroke professionals, their perceived effectiveness, and the factors associated with the intention to provide them.: Focus groups and published sources of information were used to construct a comprehensive list of non-pharmacological approaches for PSE. This was followed by a national (online) survey of 220 UK stroke clinicians from nursing, medicine, and the allied health professions to investigate the approaches used in clinical practice, using Theory of Planned Behavior components to determine the factors associated with intention to provide them.: Most respondents reported high intention to provide non-pharmacological interventions from the list that was constructed. Offering reassurance and talking to patients about goals were the commonest interventions, and distraction and tensing facial muscles least common. Respondents who perceived others to hold them professionally responsible for carrying out non-pharmacological approaches were more likely to use them, as were respondents who held more positive attitudes.: Our survey data reveal that stroke clinicians report regular use of non-pharmacological interventions for PSE. There is a pressing need for well-conducted clinical trials to evaluate the effectiveness of these approaches.
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http://dx.doi.org/10.1080/10749357.2019.1654241DOI Listing
January 2020

Leeds-Genoa Non-Union Index: a clinical tool for asessing the need for early intervention after long bone fracture fixation.

Int Orthop 2020 01 22;44(1):161-172. Epub 2019 Aug 22.

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon wing, Level D, LS13EX, Leeds, West Yorkshire, UK.

Aim Of The Study: The aim of this case-control study was to develop a clinical decision rule to support assessment of the risk of long-bone non-union and plan for appropriate early intervention.

Methods: Two hundred patients (100 cases and 100 controls) were recruited. Risk factors identified to contribute to the development of non-union were recorded and analysed with a multivariable logistic regression model. Tabulation of the outcome (non-union/union) against each risk factor in turn (univariable analysis) was carried out. Odds ratios and confidence intervals were derived using Wald's method. A receiver-operator curve was calculated and the area under the curve was computed. Having established the eight most important risk factors, a non-union risk index was developed as the count of the risk factors present in each patient.

Results: The five risk factors for non-union with greater effect size were post-surgical fracture gap > 4 mm (odds ratio (OR) = 11.97 95% CI (4.27, 33.53)), infection superficial/deep (OR 10.16 (2.44, 42.36)), not optimum mechanical stability (OR 10.06 (3.75, 26.97)), displacement > 75% of shaft width (OR 6.81 (2.21, 20.95)), and site of fracture-tibia (OR 4.33 (1.32, 14.14)). The ROC curve for the non-union index was 0.924, sensitivity 91%, specificity 77%.

Conclusions: The non-union index derived from counting risk factors predicts union for 0-4 risk factors and non-union for 5-8 risk factors. It can be readily applied and can guide clinicians about the risk of development of long-bone non-union. It can become a powerful aid for assessing fracture fixation outcome and to support early intervention.
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http://dx.doi.org/10.1007/s00264-019-04376-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6938791PMC
January 2020

Risk Factors for Intraoperative Periprosthetic Femoral Fractures During Primary Total Hip Arthroplasty. An Analysis From the National Joint Registry for England and Wales and the Isle of Man.

J Arthroplasty 2019 12 9;34(12):3065-3073.e1. Epub 2019 Jul 9.

Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), School of Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, United Kingdom; Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom; Leeds Musculoskeletal Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom.

Background: The aim of this study is to estimate risk factors for intraoperative periprosthetic femoral fractures (IOPFF) and each anatomic subtype (calcar crack, trochanteric fracture, femoral shaft fracture) during primary total hip arthroplasty.

Methods: This retrospective cohort study included 793,823 primary total hip arthroplasties between 2004 and 2016. Multivariable regression modeling was used to estimate relative risk of patient, surgical, and implant factors for any IOPFF and for all anatomic subtypes of IOPFF. Clinically important interactions were assessed using multivariable regression.

Results: Patient factors significantly increasing the risk of fracture were female gender, American Society of Anesthesiologists grade 3 to 5, and preoperative diagnosis including avascular necrosis of the hip, previous trauma, inflammatory disease, pediatric disease, and previous infection. Overall risk of IOPFF associated with age was greatest in patients below 50 years and above 80 years. Risk of any fracture reduced with computer-guided surgery and in non-National Health Service hospitals. Nonposterior approaches increased the risk of shaft and trochanteric fracture only. Cementless implants significantly increased the risk of only calcar cracks and shaft fractures and not trochanteric fractures.

Conclusion: Fracture risk increases in patients younger than 50 and older than 80 years, females, American Society of Anesthesiologists grade 3 to 5, and indications other than primary osteoarthritis. Large cumulative reduction in IOPFF risk may occur with use of cemented implants, posterior approach, and computer-guided surgery.

Level Of Evidence: Level 3b (cohort study).
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http://dx.doi.org/10.1016/j.arth.2019.06.062DOI Listing
December 2019

Statistics on mortality following acute myocardial infarction in 842 897 Europeans.

Cardiovasc Res 2020 01;116(1):149-157

Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.

Aims: To compare ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) mortality between Sweden and the UK, adjusting for background population rates of expected death, case mix, and treatments.

Methods And Results: National data were collected from hospitals in Sweden [n = 73 hospitals, 180 368 patients, Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART)] and the UK [n = 247, 662 529 patients, Myocardial Ischaemia National Audit Project (MINAP)] between 2003 and 2013. There were lower rates of revascularization [STEMI (43.8% vs. 74.9%); NSTEMI (27.5% vs. 43.6%)] and pharmacotherapies at time of hospital discharge including [aspirin (82.9% vs. 90.2%) and (79.9% vs. 88.0%), β-blockers (73.4% vs. 86.4%) and (65.3% vs. 85.1%)] in the UK compared with Sweden, respectively. Standardized net probability of death (NPD) between admission and 1 month was higher in the UK for STEMI [8.0 (95% confidence interval 7.4-8.5) vs. 6.7 (6.5-6.9)] and NSTEMI [6.8 (6.4-7.2) vs. 4.9 (4.7-5.0)]. Between 6 months and 1 year and more than 1 year, NPD remained higher in the UK for NSTEMI [2.9 (2.5-3.3) vs. 2.3 (2.2-2.5)] and [21.4 (20.0-22.8) vs. 18.3 (17.6-19.0)], but was similar for STEMI [0.7 (0.4-1.0) vs. 0.9 (0.7-1.0)] and [8.4 (6.7-10.1) vs. 8.3 (7.5-9.1)].

Conclusion: Short-term mortality following STEMI and NSTEMI was higher in the UK compared with Sweden. Mid- and longer-term mortality remained higher in the UK for NSTEMI but was similar for STEMI. Differences in mortality may be due to differential use of guideline-indicated treatments.
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http://dx.doi.org/10.1093/cvr/cvz197DOI Listing
January 2020

Towards UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE): protocol for an evaluation of the requirements for arthroplasty follow-up, and the production of consensus-based recommendations.

BMJ Open 2019 06 25;9(6):e031351. Epub 2019 Jun 25.

NIHR Leeds Biomedical Research Centre, Leeds, UK.

Introduction: Hip and knee arthroplasties have revolutionised the management of degenerative joint diseases and, due to an ageing population, are becoming increasingly common. Follow-up of joint prostheses is to identify problems in symptomatic or asymptomatic patients due to infection, osteolysis, bone loss or potential periprosthetic fracture, enabling timely intervention to prevent catastrophic failure at a later date. Early revision is usually more straight-forward surgically and less traumatic for the patient. However, routine long-term follow-up is costly and requires considerable clinical time. Therefore, some centres in the UK have curtailed this aspect of primary hip and knee arthroplasty services, doing so without an evidence base that such disinvestment is clinically or cost-effective.

Methods: Given the timeline from joint replacement to revision, conducting a randomised controlled trial (RCT) to determine potential consequences of disinvestment in hip and knee arthroplasty follow-up is not feasible. Furthermore, the low revision rates of modern prostheses, less than 10% at 10 years, would necessitate thousands of patients to adequately power such a study. The huge variation in follow-up practice across the UK also limits the generalisability of an RCT. This study will therefore use a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations as to how, when and on whom follow-up should be conducted. Four interconnected work packages will be completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from five national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document which includes a stratification algorithm to determine appropriate follow-up care for an individual patient.

Ethics And Dissemination: Favourable ethical opinion has been obtained for WP2a (RO-HES) (220520) and WP2B (220316) from the National Research Ethics Committee. Following advice from the Confidentiality Advisory Group (17/CAG/0122), data controllers for the data sets used in WP2a (RO-HES) - NHS Digital and The Phoenix Partnership - confirmed that Section 251 support was not required as no identifiable data was flowing into or out of these parties. Application for approval of WP2a (RO-HES) from the Independent Group Advising on the Release of Data (IGARD) at NHS Digital is in progress (DARS-NIC-147997). Section 251 support (17/CAG/0030) and NHS Digital approval (DARS-NIC-172121-G0Z1H-v0.11) have been obtained for WP2a (NJR-HES-PROMS). ISAC (11_050MnA2R2) approval has been obtained for WP2a (CPRD-HES).
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http://dx.doi.org/10.1136/bmjopen-2019-031351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6597629PMC
June 2019

Organisation and delivery of liaison psychiatry services in general hospitals in England: results of a national survey.

BMJ Open 2018 09 1;8(8):e023091. Epub 2018 Sep 1.

Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

Objectives: To describe the current provision of hospital-based liaison psychiatry services in England, and to determine different models of liaison service that are currently operating in England.

Design: Cross-sectional observational study comprising an electronic survey followed by targeted telephone interviews.

Setting: All 179 acute hospitals with an emergency department in England.

Participants: 168 hospitals that had a liaison psychiatry service completed an electronic survey. Telephone interviews were conducted for 57 hospitals that reported specialist liaison services additional to provision for acute care.

Measures: Data included the location, service structures and staffing, working practices, relations with other mental health service providers, policies such as response times and funding. Model 2-based clustering was used to characterise the services. Telephone interviews identified the range of additional liaison psychiatry services provided.

Results: Most hospitals (141, 79%) reported a 7-day service responding to acute referrals from the emergency department and wards. However, under half of hospitals had 24 hours access to the service (78, 44%). One-third of hospitals (57, 32%) provided non-acute liaison work including outpatient clinics and links to specialist hospital services. 156 hospitals (87%) had a multidisciplinary service including a psychiatrist and mental health nurses. We derived a four-cluster model of liaison psychiatry using variables resulting from the electronic survey; the salient features of clusters were staffing numbers, especially nursing; provision of rapid response 24 hours 7-day acute services; offering outpatient and other non-acute work, and containing age-specific teams for older adults.

Conclusions: This is the most comprehensive study to date of liaison psychiatry in England and demonstrates the wide availability of such services nationally. Although all services provide an acute assessment function, there is no uniformity about hours of coverage or expectation of response times. Most services were better characterised by the model we developed than by current classification systems for liaison psychiatry.
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http://dx.doi.org/10.1136/bmjopen-2018-023091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6120655PMC
September 2018

Access to hospital and community palliative care for patients with advanced cancer: A longitudinal population analysis.

PLoS One 2018 8;13(8):e0200071. Epub 2018 Aug 8.

St Gemma's Academic Unit of Palliative Care, Leeds Institute of Health Sciences, Level 10, Clarendon Way, University of Leeds, Leeds, United Kingdom.

Background: The UK National Health Service is striving to improve access to palliative care for patients with advanced cancer however limited information exists on the level of palliative care support currently provided in the UK. We aimed to establish the duration and intensity of palliative care received by patients with advanced cancer and identify which cancer patients are missing out.

Methods: Retrospective cancer registry, primary care and secondary care data were obtained and linked for 2474 patients who died of cancer between 2010 and 2012 within a large metropolitan UK city. Associations between the type, duration, and amount of palliative care by demographic characteristics, cancer type, and therapies received were assessed using Chi-squared, Mann-Whitney or Kruskal-Wallis tests. Multinomial multivariate logistic regression was used to assess the odds of receiving community and/or hospital palliative care compared to no palliative care by demographic characteristics, cancer type, and therapies received.

Results: Overall 64.6% of patients received palliative care. The average palliative care input was two contacts over six weeks. Community palliative care was associated with more palliative care events (p<0.001) for a longer duration (p<0.001). Patients were less likely to receive palliative care if they were: male (p = 0.002), aged 80 years or over (p<0.05), diagnosed with lung cancer (p<0.05), had not received an opioid prescription (p<0.001), or had not received chemotherapy (p<0.001). Patients given radiotherapy were more likely to receive community only palliative care compared to no palliative care (Odds Ratio = 1.49, 95% Confidence Interval = 1.16-1.90).

Conclusion: Timely supportive care for cancer patients is advocated but these results suggest that older patients and those who do not receive anti-cancer treatment or opioid analgesics miss out. These patients should be targeted for assessment to identify unmet needs which could benefit from palliative care input.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200071PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082504PMC
January 2019

Fixation of periprosthetic or osteoporotic distal femoral fractures with locking plates: a pilot randomised controlled trial.

Int Orthop 2019 05 25;43(5):1193-1204. Epub 2018 Jul 25.

Academic Department of Trauma and Orthopaedic, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing Level D, Leeds, West Yorkshire, LS13EX, UK.

Introduction: We hypothesised that the use of a polyaxial locking plate design offers the same clinical benefits as a monoaxial locking plate system following distal femoral osteoporotic/periprosthetic fracture fixation.

Method: A multicentre prospective randomised pilot trial was conducted. Inclusion criteria were patients over 60 years with a displaced osteoporotic or periprosthetic distal femoral fracture. Details documented included time to union, complications, reinterventions and functional outcomes according to the Oxford knee score and EuroQol EQ-5D. Analysis of factors influencing an early fracture healing response was performed between those with clear features of radiological callus formation at three months. Statistical analysis was performed using a logistic regression model with multiple covariates assessed for each plate system (1:1 ratio) over a follow-up period of one year.

Results: Forty patients (34 females) with a mean age of 77 (60-99) were recruited. Four patients deceased within the first six months. Twenty-five patients united by the six month follow-up. Six more patients progressed to union between six and nine months. Five patients developed non-union (two patients had implant failure; one in each group) and all underwent revision surgery. Malunion was evident in two cases, one with 15° of valgus (monoaxial plate), and one with 12° of recurvatum (polyaxial plate). Between the two plate systems, statistical analysis revealed no significant differences in most of the recorded parameters. Radiological features of early bone healing were present when the surgical approach was smaller (p = 0.015), and when a greater working length of the bridging plate was present (p = 0.016).

Conclusion: Both plate systems demonstrated good union rates and limited implant related complications. Good reduction, mechanically sound construct and respect of the local fracture biology was more important than the particular plate design characteristics.
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http://dx.doi.org/10.1007/s00264-018-4061-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6470115PMC
May 2019

A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation.

Eur Heart J 2018 08;39(32):2975-2983

Clinical and Population Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.

Aims: To determine whether changing patterns of anticoagulant use in atrial fibrillation (AF) have impacted on stroke rates in England.

Methods And Results: English national databases, 2006-2016, were interrogated to assess stroke admissions and oral anticoagulant use. The number of patients with known AF increased linearly from 692 054 to 983 254 (prevalence 1.29% vs. 1.71%). Hospital episodes of AF-related stroke/100 000 AF patients increased from 80/week in 2006 to 98/week in 2011 and declined to 86/week in 2016 (2006-2011 difference 18.0, 95% confidence interval (CI) 17.9-18.1, 2011-2016 difference -12.0, 95% CI -12.1 to -11.9). Anticoagulant use amongst patients with CHA2DS2-VASc ≥2 increased from 48.0% to 78.6% and anti-platelet use declined from 42.9% to 16.1%; the greatest rate of change occurred in the second 5 year period (for anticoagulants 2006-2011 difference 4.8%, 95% CI 4.5-5.1%, 2011-2016 difference 25.8%, 95% CI 25.5-26.1%). After adjustment for AF prevalence, a 1% increase in anticoagulant use was associated with a 0.8% decrease in the weekly rate of AF-related stroke (incidence rate ratio 0.992, 95% CI 0.989-0.994). Had the use of anticoagulants remained at 2009 levels, 4068 (95% CI 4046-4089) more strokes would have been predicted in 2015/2016.

Conclusion: Between 2006 and 2016, AF prevalence and anticoagulant use in England increased. From 2011, hospitalized AF-related stroke rates declined and were significantly associated with increased anticoagulant uptake.
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http://dx.doi.org/10.1093/eurheartj/ehy411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110195PMC
August 2018

Older age is associated with less cancer treatment: a longitudinal study of English cancer patients.

Age Ageing 2018 11;47(6):833-840

St Gemma's Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Level 10, Worsley Building, Clarendon Way, Leeds, UK.

Background: making informed decisions about cancer care provision for older cancer patients can be challenging and complex. Evidence suggests cancer care varies by age, however the relationship between age and care experiences from diagnosis to death for cancer patients within the UK has not previously been examined in detail.

Patients And Methods: retrospective cohort linking cancer registry and secondary care data for 13,499 adult cancer patients who died between January 2005 and December 2011. Cancer therapies (chemotherapy, radiotherapy, surgery), hospital palliative care referrals, hospital admissions and place of death were compared between age groups using multivariable regression models. Trends in cancer care over time, overall and within age groups were also assessed.

Results: compared with adult patients under 60 years, patients aged 80 years and over were less likely to receive chemotherapy, radiotherapy, a hospital palliative care referral; or be admitted to hospital but were more likely to die in a care home. Overall, the percentage of patients receiving chemotherapy, surgery, hospital palliative care referrals and hospital admissions have increased while deaths in hospital have decreased. Deaths at home have increased for patients aged 80 years and over.

Conclusion: older patients are less likely to receive cancer therapies or hospital palliative care before death. Further research is needed to identify the extent to which these results reflect unmet need.
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http://dx.doi.org/10.1093/ageing/afy094DOI Listing
November 2018

PROMs for Pain in Adult Cancer Patients: A Systematic Review of Measurement Properties.

Pain Pract 2019 01 4;19(1):93-117. Epub 2018 Jul 4.

Leeds institute of Health Sciences, School of Medicine, University of Leeds, Leeds, U.K.

Context: Pain is one of the most devastating symptoms for cancer patients. One third of patients who experience pain do not receive effective treatment. A key barrier to effective pain management is lack of routine measurement and monitoring of pain. Patient-reported outcome measures (PROMs) are recommended for measuring cancer pain. However, evidence to guide the selection of the most appropriate measure to identify and monitor cancer pain is limited. A systematic review of measurement properties of PROMs for pain in cancer patients is needed to identify the best validated measure for adoption to an electronic platform.

Objectives: To systematically review measurement properties of PROMs used for adult cancer patients to measure pain and, as a secondary goal, to investigate the evidence of validated mobile health (mHealth) applications used to measure pain (registration number: CRD42017065575).

Methods: Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were systematically searched in March 2018 for studies examining measurement properties for PROMs for pain in adult cancer patients. The methodological quality of the studies and their results were appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and specific measurement properties criteria, respectively.

Results: Sixteen studies evaluating 8 instruments were included. No studies using a PROM in an mHealth application were identified. The methodological quality of the measurement properties ranged between poor and fair. No instrument showed strong positive evidence for all the evaluated measurement properties. Based on the available evidence, the Brief Pain Inventory-Short Form (BPI-SF) had the strongest evidence to support its selection for the measurement of cancer pain.

Conclusion: The BPI-SF was the best performing measure across all properties evaluated through COSMIN. Better quality validation studies of PROMs for cancer pain are needed to explore the full range of measurement properties. Utilizing mHealth applications to measure pain in cancer patients is an innovative approach worthy of further investigation.
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http://dx.doi.org/10.1111/papr.12711DOI Listing
January 2019

Association between glucocorticoid therapy and incidence of diabetes mellitus in polymyalgia rheumatica and giant cell arteritis: a systematic review and meta-analysis.

RMD Open 2018 28;4(1):e000521. Epub 2018 Feb 28.

Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.

Background: Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are almost always treated with glucocorticoids (GCs), but long-term GC use is associated with diabetes mellitus (DM). The absolute incidence of this complication in this patient group remains unclear.

Objective: To quantify the absolute risk of GC-induced DM in PMR and GCA from published literature.

Methods: We identified literature from inception to February 2017 reporting diabetes following exposure to oral GC in patients with PMR and/or GCA without pre-existing diabetes. A random-effects meta-analysis was performed to summarise the findings.

Results: 25 eligible publications were identified. In studies of patients with GCA, mean cumulative GC dose was almost 1.5 times higher than in studies of PMR (8.2 g vs 5.6 g), with slightly longer treatment duration and longer duration of follow-up (6.4 years vs 4.4 years). The incidence proportion (cumulative incidence) of patients who developed new-onset DM was 6% (95% CI 3% to 9%) for PMR and 13% (95% CI 9% to 17%) for GCA. Based on UK data on incidence rate of DM in the general population, the expected background incidence rate of DM over 4.4 years in patients with PMR and 6.4 years in patients with GCA (follow-up duration) would be 4.8% and 7.0%, respectively. Heterogeneity between studies was high (I=79.1%), as there were differences in study designs, patient population, geographical locations and treatment. Little information on predictors of DM was found.

Conclusion: Our meta-analysis produced plausible estimates of DM incidence in patients with PMR and GCA, but there is insufficient published data to allow precise quantification of DM risk.
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http://dx.doi.org/10.1136/rmdopen-2017-000521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845432PMC
February 2018

Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study.

BMJ Open 2018 01 31;8(1):e018284. Epub 2018 Jan 31.

Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

Objectives: This study aimed to establish the association between timing and provision of palliative care (PC) and quality of end-of-life care indicators in a population of patients dying of cancer.

Setting: This study uses linked cancer patient data from the National Cancer Registry, the electronic medical record system used in primary care (SystmOne) and the electronic medical record system used within a specialist regional cancer centre. The population resided in a single city in Northern England.

Participants: Retrospective data from 2479 adult cancer decedents who died between January 2010 and February 2012 were registered with a primary care provider using the SystmOne electronic health record system, and cancer was certified as a cause of death, were included in the study.

Results: Linkage yielded data on 2479 cancer decedents, with 64.5% who received at least one PC event. Decedents who received PC were significantly more likely to die in a hospice (39.4% vs 14.5%, P<0.005) and less likely to die in hospital (23.3% vs 40.1%, P<0.05), and were more likely to receive an opioid (53% vs 25.2%, P<0.001). PC initiated more than 2 weeks before death was associated with avoiding a hospital death (≥2 weeks, P<0.001), more than 4 weeks before death was associated with avoiding emergency hospital admissions and increased access to an opioid (≥4 weeks, P<0.001), and more than 33 weeks before death was associated with avoiding late chemotherapy (≥33 weeks, no chemotherapy P=0.019, chemotherapy over 4 weeks P=0.007).

Conclusion: For decedents with advanced cancer, access to PC and longer duration of PC were significantly associated with better end-of-life quality indicators.
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http://dx.doi.org/10.1136/bmjopen-2017-018284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829853PMC
January 2018

Good practice or positive action? Using Q methodology to identify competing views on improving gender equality in academic medicine.

BMJ Open 2017 Aug 22;7(8):e015973. Epub 2017 Aug 22.

Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

Objectives: The number of women entering medicine has increased significantly, yet women are still under-represented at senior levels in academic medicine. To support the gender equality action plan at one School of Medicine, this study sought to (1) identify the range of viewpoints held by staff on how to address gender inequality and (2) identify attitudinal barriers to change.

Design: Q methodology. 50 potential interventions representing good practice or positive action, and addressing cultural, organisational and individual barriers to gender equality, were ranked by participants according to their perception of priority.

Setting: The School of Medicine at the University of Leeds, UK.

Participants: Fifty-five staff members were purposively sampled to represent gender and academic pay grade.

Results: Principal components analysis identified six competing viewpoints on how to address gender inequality. Four viewpoints favoured positive action interventions: (1) support careers of women with childcare commitments, (2) support progression of women into leadership roles rather than focus on women with children, (3) support careers of all women rather than just those aiming for leadership, and (4) drive change via high-level financial and strategic initiatives. Two viewpoints favoured good practice with no specific focus on women by (5) recognising merit irrespective of gender and (6) improving existing career development practice. No viewpoint was strongly associated with gender, pay grade or role; however, latent class analysis identified that female staff were more likely than male to prioritise the setting of equality targets. Attitudinal barriers to the setting of targets and other positive action initiatives were identified, and it was clear that not all staff supported positive action approaches.

Conclusions: The findings and the approach have utility for those involved in gender equality work in other medical and academic institutions. However, the impact of such initiatives needs to be evaluated in the longer term.
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http://dx.doi.org/10.1136/bmjopen-2017-015973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629690PMC
August 2017

Implementation of a standardized protocol to manage elderly patients with low energy pelvic fractures: can service improvement be expected?

Int Orthop 2017 09 21;41(9):1813-1824. Epub 2017 Jul 21.

Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, UK.

Purpose: The incidence of low energy pelvic fractures (FPFs) in the elderly is increasing. Comorbidities, decreased bone-quality, problematic fracture fixation and poor compliance represent some of their specific difficulties. In the absence of uniform management, a standard operating procedure (SOP) was introduced to our unit, aiming to improve the quality of services provided to these patients.

Methods: A cohort study was contacted to test the impact of (1) using a specific clinical algorithm and (2) using different antiosteoporotic drugs. Multivariate regression analysis was used to determine prognostic factors. Study endpoints were the time-to-healing, length-of-stay, return to pre-injury mobility, union status, mortality and complications.

Results: A total of 132 elderly patients (≥65 years) admitted during the period 2012-2014 with FPFs were enrolled. High-energy fractures, acetabular fractures, associated trauma affecting mobility, pathological pelvic lesions and operated FPFs were used as exclusion criteria. The majority of included patients were females (108/132; 81.8%), and the mean age was 85.8 years (range 67-108). Use of antiosteoporotics was associated with a shorter time of healing (p = 0.036). Patients treated according to the algorithm showed a significant protection against malunion (p < 0.001). Also, adherence to the algorithm allowed more patients to return to their pre-injury mobility status (p = 0.039).

Conclusions: The use of antiosteoporotic medication in elderly patients with fragility pelvic fractures was associated with faster healing, whilst the adherence to a structured clinical pathway led to less malunions and non-unions and return to pre-injury mobility state.
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http://dx.doi.org/10.1007/s00264-017-3567-2DOI Listing
September 2017