Hospitals Birmingham NHS Foundation Trust Research Articles

Diabetes Self-Management Behaviours among Adult Persons with Disabilities – A Systematic Review

International Journal of Medicine and Public Health,2023,13,1,31-36.DOI:10.5530/ijmedph.2023.1.5Published:June 2023Type:Original Article Diabetes Self-Management Behaviours among Adult Persons with Disabilities – A Systematic ReviewRajeswaran Thiagesan, Vijayaprasad Gopichandran, Sudharshini Subramaniam, Sanjai Subha, Kalpana Kosalram, and Hilaria Soundari Rajeswaran Thiagesan1,*, Vijayaprasad Gopichandran2, Sudharshini Subramaniam3, Sanjai Subha4, Kalpana Kosalram5, Hilaria Soundari1 1Centre for Applied Research, The Gandhigram Rural Institute – (Deemed to be University), Gandhigram, Dindigul, Tamil Nadu, INDIA. 2Department of Community Medicine, ESIC Medical College and PGIMSR, Ashok Pillar Main Road, KK Nagar, Chennai, Tamil Nadu, INDIA. 3Institute of Community Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, INDIA. 4Department of Neurology, Junior Specialist Doctor (Standard), Queen Elizabeth Hospital, University Hospital Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UNITED KINGDOM. 5School of Public Health, SRM Medical College and Hospital, SRM Institute of Science and Technology, SRM Nagar, Potheri, Chengalpattu, Tamil Nadu, INDIA. Abstract:Background: Self-management of diabetes is essential for proper control of blood sugars and prevention of complications. Persons with disabilities face challenges in adopting self-management behaviours. Objectives: To assess diabetes self-management behaviours among persons with disabilities. Materials and Methods: We searched PubMed with a comprehensive search strategy to retrieve epidemiological studies that reported the diabetes self-management behaviours among persons with disabilities in English language journals between 1990 – 2022. We did a step-wise screening of the retrieved articles and synthesized the findings of the selected papers. Results: Of the 992 papers that were obtained, 981 did not meet our inclusion criteria and were excluded at the stage of title and abstract screening. Eleven papers were retrieved and read in detail, and 8 of them were excluded at this stage. Finally, three papers two from China and one from Iran were included in the review. The studies revealed poor diabetes self-management behaviours among persons with disabilities, especially in the domains of diet and physical activity. Conclusion: There is a dearth of studies exploring diabetes self-management behaviours among persons with disabilities. Even the few reported studies show low levels of self-management behaviours. Keywords:Diabetes self-management, diet, Disabilities, Exercise, Glycemic control, Medication adherence., MonitoringView:PDF (149.67 KB)

A service evaluation of the newly introduced sciatic nerve local anaesthetic infusion catheters for acute pain management of major lower limb amputations

Background: Patients who undergo lower limb amputations experience severe acute postoperative pain. Despite having no strong evidence for the efficacy of peripheral nerve blocks in reducing phantom limb pain, the reduction in acute postoperative pain and opioid-sparing effect1 make these techniques important to consider. Acute pain management has been identified as a key priority in the management of patients undergoing amputation.2 An initial audit, in October 2021, found that postoperative pain scores and opiate use were high. In April 2022, postoperative local anaesthetic nerve catheters for major lower limb amputations were introduced at our institution. The aim of this service evaluation was to ascertain the postoperative pain scores and analgesic consumption for patients having undergone a lower limb amputation and who subsequently received a continuous postoperative local anaesthetic infusion (levobupivacaine 0.125%, at 6–10 ml h−1 for up to 5 days) via a sciatic nerve catheter. Methods: A retrospective audit was undertaken between July and September 2022 at Birmingham Heartlands Hospital. We included patients having undergone a lower limb amputation with a sciatic nerve catheter placed intraoperatively by surgeons under direct vision and left along the nerve in the cut nerve sheath. Data collected included patient characteristics, postoperative pain scores days 1–5, postoperative opioid use including opioid side-effects, postoperative neuropathic pain, and block related complications. Results: We collected data for 24 patients. Compared with the period before the introduction of sciatic nerve catheters, we observed that the mean pain scores on the numeric rating scale (NRS) decreased. This was particularly evident on day 1 postoperatively when the mean pain scores decreased from the moderate to mild range. On days 1–5 of the postoperative period, the mean immediate-release opioid consumption was 16.1 mg day−1 and mean prolonged-release opioid consumption was 11.6 mg day−1. This was in comparison to the audit in October 2021 that found mean opioid use of 24.1 mg day−1 and 21 mg day−1, respectively. Opioid side-effects reported were sedation (18%), constipation (13%), and nausea or vomiting (8%). Fifty percent of patients reported neuropathic pain. Conclusion: The postoperative pain scores improved and the postoperative opioid consumption reduced slightly with the addition of a sciatic nerve catheter. Opioid side-effects and acute neuropathic pain remain an issue for this group of patients postoperatively. Overall, the introduction of a continuous local anaesthetic infusion via a sciatic nerve catheter after major lower limb amputations in our hospital has been a success and the technique is likely to play a significant future role as part of our multi-modal analgesia regimen for these patients. The Acute Pain Team at University Hospitals Birmingham NHS Foundation Trust. 1.Ilfeld BM. Anesth Analg 2011; 113: 904–252.Gough MJ, Juniper M, Freeth H, Butt A, Mason M. Lower limb amputation: Working together. A report by the National Confidential Enquiry into Patient Outcome and Death, 2014. https://www.hqip.org.uk/wp-content/uploads/2018/02/lower-limb-amputation-report.pdf (accessed 20/03/23)

Letter to the Editor: Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management.

1Liver Unit, University Hospitals Birmingham, Birmingham, UK 2Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK 3Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria 4Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria Correspondence Tripathi, Dhiraj University Hospitals Birmingham NHS Foundation Trust, Liver Unit; University of Birmingham Institute of Immunology and Immunotherapy. Email: [email protected]

Privacy-Aware Early Detection of COVID-19 Through Adversarial Training.

Early detection of COVID-19 is an ongoing area of research that can help with triage, monitoring and general health assessment of potential patients and may reduce operational strain on hospitals that cope with the coronavirus pandemic. Different machine learning techniques have been used in the literature to detect potential cases of coronavirus using routine clinical data (blood tests, and vital signs measurements). Data breaches and information leakage when using these models can bring reputational damage and cause legal issues for hospitals. In spite of this, protecting healthcare models against leakage of potentially sensitive information is an understudied research area. In this study, two machine learning techniques that aim to predict a patient's COVID-19 status are examined. Using adversarial training, robust deep learning architectures are explored with the aim to protect attributes related to demographic information about the patients. The two models examined in this work are intended to preserve sensitive information against adversarial attacks and information leakage. In a series of experiments using datasets from the Oxford University Hospitals (OUH), Bedfordshire Hospitals NHS Foundation Trust (BH), University Hospitals Birmingham NHS Foundation Trust (UHB), and Portsmouth Hospitals University NHS Trust (PUH), two neural networks are trained and evaluated. These networks predict PCR test results using information from basic laboratory blood tests, and vital signs collected from a patient upon arrival to the hospital. The level of privacy each one of the models can provide is assessed and the efficacy and robustness of the proposed architectures are compared with a relevant baseline. One of the main contributions in this work is the particular focus on the development of effective COVID-19 detection models with built-in mechanisms in order to selectively protect sensitive attributes against adversarial attacks. The results on hold-out test set and external validation confirmed that there was no impact on the generalisibility of the model using adversarial learning.

Rowan Hillson Inpatient Safety Award 2022

Introduction: The annual National Diabetes Inpatient Audit (NaDIA and NaDIA-Harms) in the UK continues to show significant problems with patient care. During the COVID pandemic patient care has been even more difficult. New initiatives are urgently required to improve inpatient safety for people with diabetes. Method: The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) organised the seventh national Rowan Hillson Inpatient Safety Award on the theme of “the best interventions: redesigning, rebuilding and maintaining safe inpatient diabetes care during COVID”. Result: The winner was the DEKODE team, led by Dr Punith Kempegowda from University Hospitals Birmingham NHS Foundation Trust, for their innovative quality improvement project across hospitals during COVID to improve diabetes-related ketoacidosis (DKA) management and study DKA in people with COVID. Adherence to national guidance improved in some hospitals, with falls in hypoglycaemia, and overall there was a significant improvement in awareness about DKA amongst junior doctors. The King’s College NHS Foundation Trust team, led by Adrian Li and colleagues, received the highly commended award for their innovative project of remote blood glucose (BG) monitoring across healthcare boundaries. This improved diabetes control and tackled health inequalities. Summary and conclusion: These and similar schemes need to be developed, promoted and shared to improve safety for people with diabetes admitted in hospital during COVID times.

Evaluating Actions to Improve Air Quality at University Hospitals Birmingham NHS Foundation Trust

Air pollution is the single largest environmental risk to human health in the UK, exerting a major healthcare sector burden and exacerbating health and social inequalities. The NHS Long Term Plan commits the healthcare sector to reducing emissions from all sources, however, to date few Acute NHS Trusts have implemented air quality focused sustainability plans. In this case study, we assess potential air quality improvement actions at University Hospitals Birmingham NHS Foundation Trust’s, Queen Elizabeth Hospital in Birmingham, UK as a test case for NHS sustainability actions. We generate an evidenced based, prioritized shortlist of actions to mitigate emissions and protect patients, staff, and local communities from air pollution exposure. The project supports adoption of an evidence-based, contextually relevant, approach to air quality management within healthcare provision. The methodology used could be employed by organizations with similar goals to address environmental concerns.

Electronic prescribing systems as tools to improve patient care: a learning health systems approach to increase guideline concordant prescribing for venous thromboembolism prevention

BackgroundVenous thromboembolism (VTE) causes significant mortality and morbidity in hospitalised patients. Risk factors for VTE are well known and there are validated risk assessment tools to support the use of prophylactic therapies. In England, reporting the percentage of patients with a completed VTE risk assessment is mandated, but this does not include whether that risk assessment resulted in appropriate prescribing. Full guideline compliance, defined as an assessment which led to an appropriate action—here prescribing prophylactic low molecular weight heparin where indicated, is rarely reported. Education, audit and feedback enhance guideline compliance but electronic prescribing systems (EPS) can mandate guideline-compliant actions. We hypothesised that a systems-based EPS intervention (prescribing rules which mandate approval or rejection of a proposed prescription of prophylactic low molecular weight heparin based on the mandated VTE assessment) would increase full VTE guideline compliance more than interventions which focused on targeting individual prescribers.MethodsAll admitted patients within University Hospitals Birmingham NHS Foundation Trust were included for analysis between 2011 and 2020. The proportion of patients who received a fully compliant risk assessment and action was assessed over time. Interventions included teaching sessions and face-to-face feedback based on measured performance (an approach targeting individual prescribers) and mandatory risk assessment and prescribing rules into an EPS (a systems approach).ResultsData from all 235,005 admissions and all 5503 prescribers were included in the analysis. Risk assessments were completed in > 90–95% of all patients at all times, but full guideline compliance was lower (70% at the start of this study). Face-to-face feedback improved full VTE guideline compliance from 70 to 77% (p ≤ 0.001). Changes to the EPS to mandate assessment with prescribing rules increased full VTE compliance to 95% (p ≤ 0.001). Further amendments to the EPS system to reduce erroneous VTE assessments slightly reduced full compliance to 92% (p < 0.001), but this was then maintained including during changes to the low molecular weight heparin used for VTE prophylaxis.DiscussionAn EPS-systems approach was more effective in improving sustained guideline-compliant VTE prevention over time. Non-compliance remained at 8–5% despite this mandated system. Further research is needed to assess the potential reasons for this.

757 ASSESSING THE READMISSION RATES OF THE OLDER PERSON’S ASSESSMENT AND LIAISON ACUTE FRAILTY TEAM AT GOOD HOPE HOSPITAL

IntroductionThe Older Person’s Assessment and Liaison (OPAL) team at Good Hope Hospital (GHH), part of the University Hospitals Birmingham NHS Foundation Trust, provides multidisciplinary, patient-centred comprehensive assessment to patients presenting to the hospital front door. The team takes a ‘home first’ approach and where possible aims to discharge patients home with support by community teams. The service is part of the Birmingham wide Early Intervention programme. A front door OPAL service therefore enables early discharge for frail patients who would otherwise be likely to have a prolonged hospital admission. This has to be balanced against ensuring readmission rates do not exceed that of a comparable hospital inpatient population.MethodWe measured the 7 and 28-day readmission rate of all patients who received OPAL input and were discharged from A&E, the Medical Admissions Unit or the Acute Medical unit from July 2020—January 2021. This was compared with an inpatient short stay frailty unit however data was not available beyond November 2020 due to changes in response to the Covid-19 pandemic.Results2096 patients were discharged by OPAL with a 7-day readmission rate of 9.2% (95% CI 4.6–13.7%) and a 28-day readmission rate of 20.2% (95% CI 14.0–26.4%). From July—October 2020 the short stay frailty unit at GHH had a 7-day readmission rate of 9.7% (95% CI 3.1–16.3%) and a 28-day readmission rate of 25.2% (95% CI 8.2–42.2%). In the same period OPAL had a 7-day readmission rate of 8.7% (95% CI 3.2–14.2%) and a 28-day readmission rate of 19.9% (95% CI 13.3–26.5%).ConclusionThe OPAL service enabled the early discharge of patients without compromising readmission rates. The readmission rates for patients discharged by the OPAL team were better than the inpatient frailty unit with over 20% fewer 28 day readmissions.

Arterial and Venous Thromboembolism in Critically Ill, COVID-19 Positive Patients Admitted to Intensive Care Unit

Arterial and Venous Thromboembolism in Critically Ill, COVID-19 Positive Patients Admitted to Intensive Care Unit

75 - Evaluation of the use of next generation sequencing for directing treatment for patients with advanced non-small cell lung cancer (NSCLC): a single centre experience from University Hospitals Birmingham NHS Foundation Trust (UHB)

75 - Evaluation of the use of next generation sequencing for directing treatment for patients with advanced non-small cell lung cancer (NSCLC): a single centre experience from University Hospitals Birmingham NHS Foundation Trust (UHB)

Introduction of Systematized Nomenclature of Medicine–Clinical Terms Coding Into an Electronic Health Record and Evaluation of its Impact: Qualitative and Quantitative Study

BackgroundThis study describes the conversion within an existing electronic health record (EHR) from the International Classification of Diseases, Tenth Revision coding system to the SNOMED-CT (Systematized Nomenclature of Medicine–Clinical Terms) for the collection of patient histories and diagnoses. The setting is a large acute hospital that is designing and building its own EHR. Well-designed EHRs create opportunities for continuous data collection, which can be used in clinical decision support rules to drive patient safety. Collected data can be exchanged across health care systems to support patients in all health care settings. Data can be used for research to prevent diseases and protect future populations.ObjectiveThe aim of this study was to migrate a current EHR, with all relevant patient data, to the SNOMED-CT coding system to optimize clinical use and clinical decision support, facilitate data sharing across organizational boundaries for national programs, and enable remodeling of medical pathways.MethodsThe study used qualitative and quantitative data to understand the successes and gaps in the project, clinician attitudes toward the new tool, and the future use of the tool.ResultsThe new coding system (tool) was well received and immediately widely used in all specialties. This resulted in increased, accurate, and clinically relevant data collection. Clinicians appreciated the increased depth and detail of the new coding, welcomed the potential for both data sharing and research, and provided extensive feedback for further development.ConclusionsSuccessful implementation of the new system aligned the University Hospitals Birmingham NHS Foundation Trust with national strategy and can be used as a blueprint for similar projects in other health care settings.

EP.TH.449Routine G&amp;S in elective laparoscopic cholecystectomy and the impact on NHS resources

Abstract Aim Current guidelines for routine pre-operative tests for elective surgery, don’t mention routine Group &amp; Save (G&amp;S). At present the need for G&amp;S sample is dependent on the operative severity and the likelihood of blood loss. However, despite consistently low major bleeding rates in elective laparoscopic cholecystectomy (ELC) (0.1 – 0.46%) many hospitals, including ours, still hold local policies to have routine G&amp;S pre-operatively and/or on the day of surgery. Our aim is to audit our hospitals local policy regarding G&amp;S samples in ELC and establish its necessity and financial impact. Methods Retrospective study looking at adult patients undergoing ELC at University Hospitals Birmingham NHS Foundation Trust in 2020. Results 344 ELC procedures were carried out in 2020. Of those 82 had no G&amp;S, 137 had pre-op sample taken with no following samples, with a total of 182 samples sent on the day of surgery. Antibodies were identified in 5 patients (1,45%) however none were cross-matched before surgery. Only 1 patient needed transfusion in the peri-operative period and was cross-matched from sample sent after surgery. Conclusion Based on our results the likelihood of having peri-operative bleeding in ELC requiring blood transfusion is minimal (0.29%), therefore the need for routine G&amp;S in this context is questionable. Arguably, diagnosing antibodies in itself would justify one G&amp;S sample. In agreement with this our results show that in 2020 our Trust spent unnecessarily more that 2’431£, additionally adding workload to already stretched staff and delaying theatres.

There is still time to save the NHS, but time is running out

The NHS is falling over. Not everywhere, but in some places and in some services the signs of extreme stress are manifest. These signs are the result of the irresistible...

‘Fast-track’ pathway for resectable pancreatic cancer: barriers and facilitators to implementation across a regional network

The National Institute for Health and Care Excellence guidelines recommend a 'fast-track' approach to avoid preoperative biliary drainage (PBD) when treating resectable pancreatic cancer. For reasons not yet known, there is variable uptake of this approach across the UK. A 'fast-track' pathway which avoids PBD was introduced in University Hospitals Birmingham NHS Foundation Trust (UHB) and referring centres in 2015. Eleven semi-structured interviews were conducted with members of the hepatobiliary multidisciplinary team (MDT) in UHB and referring centres. Barriers and facilitators to pathway implementation were assessed. Facilitators underpinning implementation were collaboration between stakeholders, clinical leadership and careful coordination of referrals. Barriers to implementation included clinician opposition and increased workload. Barriers were mitigated through phased implementation and the appointment of dedicated staff. Future work may focus on exploring contextual factors in other tertiary centres and evaluating the emotional impact of 'fast-tracked' versus delayed surgery in patients with resectable pancreatic cancer.

Spatiotemporal analysis of the first wave of COVID-19 hospitalisations in Birmingham, UK

ObjectivesTo evaluate the spatiotemporal distribution of the incidence of COVID-19 hospitalisations in Birmingham, UK during the first wave of the pandemic to support the design of public health disease control...

Serological responses to SARS-CoV-2 following non-hospitalised infection: clinical and ethnodemographic features associated with the magnitude of the antibody response

ObjectiveTo determine clinical and ethnodemographic correlates of serological responses against the SARS-CoV-2 spike glycoprotein following mild-to-moderate COVID-19.DesignA retrospective cohort study of healthcare workers who had self-isolated due to COVID-19.SettingUniversity Hospitals...

COVID-19 rapid antigen testing strategies require careful evaluation

COVID-19 rapid antigen testing strategies require careful evaluation

Antinociceptive and Discriminative Stimulus Effects of Six Novel Psychoactive Opioid Substances in Male Rats.

Compounds with novel or fentanyl-like structures continue to appear on the illicit drug market and have been responsible for fatalities, yet there are limited preclinical pharmacological data available to evaluate the risk of these compounds to public health. The purpose of the present study was to examine acetyl fentanyl, butyryl fentanyl, 3,4-dichloro-N-[[1-(dimethylamino)cyclohexyl]methyl]benzamide (AH-7921), 1-cyclohexyl-4-(1,2-diphenylethyl)piperazine (MT-45), 4-chloro-N-[1-(2-phenylethyl)-2-piperidinylidene]-benzenesulfonamide (W-15), and 4-chloro-N-[1-[2-(4-nitrophenyl)ethyl]-2-piperidinylidene]-benzenesulfonamide (W-18) for their relative potency to reference opioids and their susceptibility to naltrexone antagonism using the 55oC warm-water, tail-withdrawal assay of antinociception and a morphine drug discrimination assay in male, Sprague-Dawley rats. In the antinociception assay, groups of 8 rats per drug were placed into restraining tubes, their tails were immersed into 40o or 55oC water, and the latency for tail withdrawal was measured with a cutoff time of 15 seconds. In the drug discrimination assay, rats (n = 11) were trained to discriminate between 3.2 mg/kg morphine and saline, subcutaneously, in a two-choice, drug discrimination procedure under a fixed ratio-5 schedule of sucrose pellet delivery. Morphine, fentanyl, and four of the synthetic opioids dose dependently produced antinociception and fully substituted for morphine in the drug discrimination assay with the following rank order of potency: fentanyl > butyryl fentanyl > acetyl fentanyl > AH-7921 > MT45 > morphine. All drugs that produced antinociception or morphine-like discriminative stimulus effects were blocked by naltrexone. W-15 and W-18 did not show antinociceptive or morphine-like discriminative stimulus effects at the doses tested supporting a lack of opioid activity for these two compounds. These findings suggest that butyryl fentanyl, acetyl fentanyl, AH-7941, and MT-45 have abuse liability like other opioid agonists. SIGNIFICANCE STATEMENT: As novel psychoactive substances appear on the illicit drug market, preclinical pharmacological testing is required to assist law enforcement, medical professionals, and legal regulators with decisions about potential public health risks. In this study, four synthetic opioids, acetyl fentanyl, butyryl fentanyl, AH-7921, and MT-45 produced effects similar to fentanyl and morphine and were blocked by naltrexone. These data suggest the four synthetic opioids possess similar abuse liability risks as typical opioid agonists.

Is it safe to perform elective orthopaedic surgery with high community rates of COVID-19? An observational cohort study.

During the first wave of the COVID-19 pandemic, University Hospitals Birmingham NHS Foundation trust was able to recommence elective orthopaedic surgery using private hospitals procured by the NHS as COVID-19 free 'green' sites. We report on the safety of elective orthopaedic surgery with high rates of community transmission. We conducted an observational cohort study on consecutive NHS patients attending three private hospitals between 4 May 2020 and 16 June 2020. Patients attended preoperative assessment, including coronavirus disease (COVID-19) symptom screening, were instructed to self-isolate for 14 days and had a negative COVID-19 swab within 72 hours of surgery. Patient age, American Society of Anesthesiologists (ASA) grade, body mass index, surgery performed, type of anaesthetic and length of stay were collected. Our primary outcome was a positive COVID-19 swab, secondary outcomes were COVID-19 symptoms, readmission, surgical complications and mortality. Between 4 May 2020 and 16 June 2020, 191 patients were admitted to three private hospitals for elective surgery; 121 (67%) patients underwent general or regional anaesthetic, 179 patients were ASA grades 1 or 2 (94%) and 12 (6%) were ASA 3. In total, 187 (98%) patients were successfully contacted at 30 days postoperative and no COVID-19 symptoms, positive COVID-19 swabs or mortality or were recorded. One patient was readmitted following a pulmonary embolism and two patients were treated as outpatients for a deep vein thrombosis and a superficial infection. With 'green pathways' elective orthopaedic surgery can safely be performed while rates of COVID-19 in the community are high.

The changing characteristics of COVID-19 presentations. A regional comparison of SARS-CoV-2 hospitalised patients during the first and second wave

Background: This study assesses COVID-19 hospitalised patient demography and outcomes during wave 1 and wave 2, prior to new variants of the virus. Methods: All patients with a positive SARS-CoV-2 swab between 10th March 2020 and 5th July 2020 (wave 1) and 1st September 2020 and 16th November 2020 (wave 2) admitted to University Hospitals Birmingham NHS Foundation Trust were included (n=4856), followed for 28 days. Results: Wave 2 patients were younger, more ethnically diverse, had less co-morbidities and disease presentation was milder on presentation. After matching for these factors, mortality was reduced, but without differences in intensive care admissions. Conclusion: Prior to new SARS-CoV-2 variants, outcomes for hospitalised patients with COVID-19 were improving but with similar intensive care needs.