To determine overall survival and factors predicting survival after immunosuppressive therapy in patients with acquired aplastic anaemia.
Retrospective.
Tertiary care hospital.
120 adults diagnosed as having acquired aplastic anaemia between 1 January 1996 and 31 December 2009.
Anti-thymocyte globulin (ATG) followed by ciclosporin was administered to all patients for 15–18 months as the initial treatment. Haematological response was assessed 6 months after ATG administration and 6-monthly thereafter. Platelets were transfused if levels were <10 x 103/l and for symptomatic bleeding. Transfusions of red blood cells were given for haemoglobin levels <70 g/l or symptomatic anaemia. Febrile neutropenia was managed with antibiotics, with the addition of antifungal agents after 3–4 days of unresponsive fever. Granulocyte colony-stimulating factor was administered at a dose of 5 µg/kg/day (maximum 300 µg/day) subcutaneously for infective episodes.
Primary outcome: overall survival. Secondary outcome: response to immunosuppressive therapy, failure-free survival, relapse and clonal evolutions. The response and relapse criteria were defined in accordance with the British Council for Standards in Haematology guidelines.
Overall response at 6 months after initiation of treatment was 85.8% (103/120). Overall survival at 76 months was 83.4%. Overall survival correlated with presence of response (complete response or partial response) at 6 months after ATG administration (HR=0.021, 95% CI 0.006 to 0.079, p<0.001). The occurrence of infectious complications adversely affected the overall survival (HR=5.71, 95% CI 1.22 to 26.77, p=0.027). Six patients relapsed. There were no deaths or adverse events 12 months after treatment among responders.
In our study, overall survival was 83.4% at a median follow-up of 76 months. The two variables that significantly affected overall survival were response to therapy at 6 months and occurrence of infectious complications.
An under-recognised complication of permanent pacemakers is an increase in tricuspid regurgitation (TR) due to interference with the tricuspid valve apparatus, which can cause right ventricular (RV) dysfunction and right heart failure. We use a recent case to illustrate this phenomenon and highlight this as a differential diagnosis in patients with right heart failure and previously implanted pacemaker or defibrillator.
A 61 year old lady was referred for transthoracic echocardiography (TTE) after presenting with exertional dyspnoea. Two years previously she had undergone aortic valve replacement and subsequently required a permanent pacemaker for persistent junctional bradycardia. Clinical examination revealed an elevated venous pressure with prominent V waves and peripheral oedema. TTE showed RV dilatation and new severe TR (A). Trans-oesophageal echocardiography (TOE) was requested to elucidate the exact mechanism of TR. Two-dimensional TOE revealed that the RV pacing lead prevented complete leaflet co-aptation (B) resulting in severe central TR (C)....]]>
Patients frequently use secure web portals to access their medical record and communicate with their doctors, though few institutions currently train residents for electronic communication. We sought to develop a curriculum for secure messaging between patients and resident physicians, and to assess resident attitudes before and after the curriculum.
In 2011, we developed a curriculum for patient–doctor secure messaging using a web-based patient portal within an internal medicine residency programme. We asked all residents to perform a self-assessment of skills, and report attitudes toward electronic communication at the beginning and end of the experience (9 months apart). We enrolled residents who practiced at the hospital-based clinic site into the patient portal, and recorded usage statistics.
The completed survey response rate was 108/159 (68%). At baseline, 57% of residents had used traditional email with patients, and most residents felt that the portal would increase work for providers but benefit patients. Postintervention questionnaires demonstrated no significant changes among all respondents, but residents who used the portal perceived improvements in care. Most residents were concerned about professional liability. More residents felt comfortable writing electronic messages to patients after the curriculum (80% to 91%, p=0.01).
Implementing a patient web portal and secure messaging in a residency clinic is feasible and may improve the work and educational experience of trainees. Residents were initially sceptical of secure messaging being an additional burden to their work, but this was not realised among residents who used the portal.
Chikungunya virus (CHIKV), transmitted to humans from infected mosquitoes, causes acute fever, arthralgia and rash. There is increasing evidence that it also causes longer-term rheumatic symptoms. In a circumscribed part of Mauritius where infectivity was high, a cohort of inhabitants was surveyed with the objectives of assessing the prevalence of and risk factors for chronic musculoskeletal symptoms and for a rheumatoid arthritis-like condition at 27.5 months after initial infection.
Participants were recruited May–November 2008 and invited to complete a questionnaire. CHIKV was diagnosed clinically. The primary outcomes for the analyses were (a) self-reported ongoing musculoskeletal symptoms and (b) fulfilment of modified diagnostic criteria for rheumatoid arthritis. Risk factors for these outcomes were explored in univariate analyses using logistic regression. Subsequently, multivariate logistic regression was used to identify factors that were independently associated with the outcomes.
173 individuals were identified with CHIKV, of whom 136 (78.6%) reported persisting musculoskeletal symptoms 27.5 months after infection. Persistent symptoms were associated with older age at time of infection, female gender and baseline symmetrical distribution of joint symptoms. We found that 5% of those infected with CHIKV fulfilled a modified version of the American College of Rheumatology criteria for rheumatoid arthritis 27.5 months after infection.
CHIKV is associated with a high prevalence of persistent rheumatic symptoms. Physicians need to be aware of CHIKV as a cause of acute and chronic rheumatic symptoms.
In patients with a hyperlucent lung, radiological differentiation between a pneumothorax and a giant bulla is not always definitive. This may result in a chest tube insertion into a pulmonary bulla with devastating results or a delay in initiating appropriate treatment for pneumothorax. Usually, distinctions between the pleural line of a pneumothorax and the bulla wall can be made by computed tomography (CT). In addition, the double wall sign of pneumothorax (parallel bulla wall and chest wall outlined by air outside the bulla) is useful in recognising the coexistence of bullae and pneumothoraces.
A 38-year-old man who had smoked half a packet of cigarettes a day for more than 20 years presented with sudden onset of chest pain...]]>
Hepatitis C virus (HCV) is associated with neuropsychiatric complaints. Previous studies have associated cognitive alterations with HCV infection but have often included confounding factors in their samples. This study compares the cognitive performance between patients with HCV infection (HCV patients) and a control group while excluding other factors that may cause cognitive impairment.
This cross-sectional study was conducted from March 2010 through June 2011. HCV infected patients and healthy individuals between the ages of 18 and 80 years were considered eligible. The exclusion criteria included well established causes of cognitive impairment such as depression and cirrhosis. Study participants underwent neuropsychological testing involving measures of attention, memory, abstraction, visuoconstructive abilities, and executive function.
Of 138 initial patients, 47 were excluded because of their medical records, three refused to participate, 23 did not attend the consultation, and 32 were excluded because of having Beck Depression Inventory (BDI) scores >11. In all, 33 patients underwent neuropsychological testing; however, three were excluded because of having hypothyroidism, and one was excluded because of having a cobalamin deficiency. For the control group, of the 33 healthy individuals that were selected, four were excluded because of having BDI scores >11. Thus, the final analysis included 29 HCV patients and 29 control participants. The groups did not differ in education, age, or gender. No statistically significant differences were found between the groups regarding cognitive performance.
In this study using strict selection criteria, there was no evidence of an association between HCV infection and cognitive impairment.
To assess the impact of a 7-week public bowel cancer awareness campaign pilot by reviewing the number of 2-week referrals from general practitioners (GPs) to hospital, endoscopic procedures and new cancers diagnosed throughout the five acute hospitals in The Peninsular Cancer Network, UK.
A retrospective before and after study.
The Peninsula Cancer Network in the South West of England, UK.
For the period July 2010–July 2011, data were collected on the number of 2-week referrals, number of endoscopic procedures performed and number of new cancers diagnosed. The average for the 6 months before the campaign was compared with the immediate 3 months and then the fourth to sixth months following the campaign. Student's t test was used to compare the means of the three groups.
There was a statistically significant increase in the number of 2-week referrals from GPs to hospital in the 3 months following the campaign but this effect disappeared after that. There was no statistical increase in the number of endoscopic procedures or new cancers diagnosed following the awareness campaign.
The pilot ‘Be Clear on Cancer’ awareness campaign had a significant effect on the number of patients being referred from GPs to hospital; however, the effect was short lived and had returned to baseline by 3 months. The campaign had no effect on the number of new cancers diagnosed, which was the stated underlying aim of the pilot.
Birth-related perineal trauma has a major impact on women's health. Appropriate management of perineal injuries requires clinical knowledge and skill. At present, there is no agreement as to what constitutes an effective clinical training programme, despite the presence of sufficient evidence to support standardised perineal repair techniques. To address this deficiency, we developed and validated an interactive distance learning multi-professional training package called MaternityPEARLS.
MaternityPEARLS was developed as a comprehensive e-learning package in 2010. The main aim of the MaternityPEARLS project was to develop, refine and validate this multi-professional e-learning tool. The effect of MaternityPEARLS in improving clinical skills and knowledge was compared with two other training models; traditional training (lectures + model-based hands on training) and offline computer lab-based training. Midwives and obstetricians were recruited for each training modality from three maternity units. An analysis of covariance was done to assess the effects of clinical profession and years of experience on scoring within each group. Feedback on MaternityPEARLS was also collected from participants. The project started in January 2010 and was completed in December 2010.
Thirty-eight participants were included in the study. Pretraining and post-training scores in each group showed considerable improvement in skill scores (p<0.001 in all groups). Mean changes were similar across all three groups for knowledge (3.24 (SD 5.38), 3.00 (SD 3.74), 3.30 (SD 3.73)) and skill (25.34 (SD 8.96), 22.82 (SD 9.24), 20.7 (SD 9.76)) in the traditional, offline computer lab-based and e-learning groups, respectively. There was no evidence of any effect of clinical experience and baseline knowledge on outcomes.
MaternityPEARLS is the first validated perineal trauma management e-learning package. It provides a level of improvement in skill and knowledge comparable to traditional methods of training. However, as an e-learning system, it has the advantage of ensuring the delivery of a standardised, continuously updated curriculum that has global accessibility.
Primary percutaneous coronary intervention (PPCI) programmes vary in admission criteria from open referral to acceptance of electrocardiogram (ECG) protocol positive patients only. Rigid criteria may result in some patients with acutely occluded coronary arteries not receiving timely reperfusion therapy.
To compare the prevalence of acute coronary occlusion and, in these cases, single time point biomarker estimates of myocardial infarct size between patients presenting with protocol positive ECG changes and those presenting with less diagnostic changes in the primary angioplasty cohort of an open access PPCI programme.
We retrospectively performed a single centre cross sectional analysis of consecutive patients receiving PPCI between January and August 2008. Cases were categorised according to presenting ECG—group A: protocol positive (ST segment elevation/left bundle branch block/posterior ST elevation myocardial infarction), group B: ST segment depression or T-wave inversion, or group C: minor ECG changes. Clinical characteristics, coronary flow grades and 12 h postprocedure troponin-I levels were reviewed.
During the study period there were 513 activations of the PPCI service, of which 390 underwent immediate angiography and 308 underwent PPCI. Of those undergoing PPCI, 221 (72%) were in group A, 41 (13%) in group B and 46 (15%) in group C. Prevalence of coronary occlusion was 75% in group A compared with 73% in group B and 63% in group C. Median 12 h postintervention troponin-I (25th–75th percentile) for those with coronary occlusion was significantly higher in group A patients; 28.9 μg/l (13.2–58.5) versus 18.1 μg/l (6.7–32.4) for group B (p=0.03); and 15.5 μg/l (3.8–22.0) for group C (p<0.001), suggesting greater infarct size in group A.
A number of patients referred to an open access PPCI programme have protocol negative ECGs but myocardial infarction and acute coronary artery occlusion amenable to angioplasty.
To determine the prevalence of dermatological manifestations in intensive care unit (ICU) patients and assess its impact on outcomes.
This was a prospective cohort study of 1013 ICU patients admitted between December 2009 and April 2011. Patients were categorised following an initial screening (within 48 h) and subsequent daily review as those with dermatological manifestations in association with multisystem disorder (category 1), occurring due to treatment or critical illness (category 2), coincidental lesions (category 3) or primary dermatological conditions needing intensive care (category 4). Outcomes included mortality, duration of ventilation and hospitalisation. Factors associated with mortality were explored using univariate and multivariate analyses.
Dermatological manifestations were observed in 427 (42.2%) patients, predominantly of categories 1 (n=159) and 2 (n=160). Common aetiologies were infections (39.3%) and mechanical, thermal or physical injuries (32.8%). Primary dermatological conditions (n=33) included 21 patients with cutaneous infections, 3 with angioedema, 2 each with pemphigus, toxic epidermal necrolysis and psoriasis, and 1 each with Stevens–Johnson syndrome, drug hypersensitivity syndrome and crusted scabies. The presence of cutaneous lesions increased mortality risk (OR 1.56, 95% CI 1.20 to 2.03) and significantly (p<0.001) prolonged ventilation and hospitalisation. Mortality was higher (p<0.001) in patients in categories 4 (65.6%) and 2 (57.5%) compared to those without manifestations (35.5%). After adjusting for age, Acute Physiology And Chronic Health Evaluation II (APACHE-II) score, ventilation and dialysis, the association between dermatological manifestations and mortality was insignificant (OR 1.37, 95% CI 0.97 to 1.95).
Dermatological manifestations are common in ICU patients. Their presence may impact mortality and duration of ventilation and hospitalisation.
The transition from medical student to junior doctor is a critical stage in career progression. We report junior doctors’ views 1 year after graduation on whether their medical school prepared them well for clinical work.
Questionnaire surveys of the medical graduates of 2008 and 2009, from all UK medical schools, 1 year after graduation. Responses were compared with those of UK medical graduates of 1999, 2000, 2002 and 2005. The main outcome measure was the doctors’ level of agreement that medical school had prepared them well for work.
53% of 2008 graduates and 49% of 2009 graduates agreed that their medical school had prepared them well. The percentage who felt unprepared has fallen from 31% of the 1999–2005 graduates, combined, to 19% of the 2008 and 2009 graduates (the remainder gave neutral responses). Combining 2008 and 2009 graduates’ responses, percentages who agreed that they had been well prepared ranged from 83% (95% CI 78 to 89) at the medical school with the highest level of agreement to 27% (95% CI 20 to 34) at the lowest. 25% of doctors specified that feeling unprepared had been a serious or medium-sized problem for them (only 2.7% regarded it as serious).
Medical schools need feedback from their graduates about elements of medical school training that could improve preparedness for medical work. It also seems likely that there are some reasonably straightforward lessons that medical schools could learn from each other.
Street-based sex workers (SSWs) in Lausanne, Switzerland, are poorly characterised. We set out to quantify potential vulnerability factors in this population and to examine SSW healthcare use and unmet healthcare requirements.
We conducted a cross-sectional questionnaire-based survey among SSWs working in Lausanne's red light district between 1 February and 31 July 2010, examining SSW socio-demographic characteristics and factors related to their healthcare.
We interviewed 50 SSWs (76% of those approached). A fifth conducted their interviews in French, the official language in Lausanne. 48 participants (96%) were migrants, of whom 33/48 (69%) held no residence permit. 22/50 (44%) had been educated beyond obligatory schooling. 28/50 (56%) had no health insurance. 18/50 (36%) had been victims of physical violence. While 36/50 (72%) had seen a doctor during the preceding 12 months, only 15/50 (30%) were aware of a free clinic for individuals without health insurance. Those unaware of free services consulted emergency departments or doctors outside Switzerland. Gynaecology, primary healthcare and dental services were most often listed as needed. Two individuals (of 50, 4%) disclosed positive HIV status; of the others, 24/48 (50%) had never had an HIV test.
This vulnerable population comprises SSWs who, whether through mobility, insufficient education or language barriers, are unaware of services they are entitled to. With half the participants reporting no HIV testing, there is a need to enhance awareness of available facilities as well as to increase provision and uptake of HIV testing.