Leeds Teaching Hospitals NHS Trust Research Articles

Factors predicting 30-day mortality after ERCP in patients with inoperable malignant hilar biliary obstruction: a single tertiary referral centre experience and systematic review

ObjectiveThere is a paucity of studies in the literature body evaluating short term outcomes following endoscopic retrograde cholangiopancreatography (ERCP) in patients with inoperable malignant hilar biliary obstruction (MHBO). We aimed...

P25 An opportunity for antimicrobial stewardship? Assessing the diagnosis and treatment of lower urinary tract infections among inpatients aged 65 and older in a large English teaching hospital

BackgroundBetween 2015 and 2019 the rate of bacteraemias reported in the UK increased by 16.9% along with an increase of 32.5% of resistant organisms associated with bloodstream infections. This increase appears to be driven by a high number of Gram-negative bloodstream infections (GNBSI). There were 312 GNBSI within Leeds Teaching Hospital NHS Trust (LTHT) for the financial year (FY) of 2019–20 and 275 in FY 2020–21. Escherichia coli has been identified as the most common Gram-negative organism associated with bacteraemias. Urinary tract infections (UTIs) have been consistently highlighted as a primary source of E. coli infections, alongside other Gram-negative infections, therefore justifying a review of practice within LTHT regarding diagnosis and treatment of UTI in patients over the age of 65. This quality improvement work aimed to build on the foundations laid by NHS England's Commissioning for Quality and Innovations (CQUIN) scheme 2019–20, which had a focus on the treatment of UTIs in patients over the age of 65. This interventional prospective project was carried out to assess the impact of an antimicrobial stewardship (AMS) pharmacist-led review of patients prescribed antimicrobial treatment for UTIS.ObjectivesTo assess the impact of a pharmacist led clinical review of the diagnosis and treatment of UTIs in patients over the age of 65.StandardsEighty percent compliance was expected in the following standards: (i) patients having symptoms of a UTI documented in their clinical notes; (ii) a urine dipstick is not used as part pf the diagnosis pathway; (iii) have a had a midstream urine sample sent; and (iv) if appropriate, an antibiotic prescribed that complies with NICE/Trust guidelines.MethodsA prospective study of 87 inpatients prescribed antimicrobials for lower UTI (LUTI) was conducted from September 2020 to November 2020. The study aimed to evaluate if LUTI was diagnosed in accordance with PHE guidance, treated as per Trust guidelines and the impact an AMS pharmacist interventions had on treatment. Patients were identified using a daily antimicrobial list; searching and filtering based on indication for antimicrobial prescribed. Online medical notes were reviewed for information relating to the standards, where no information could be found wards were contacted with recommendations or further questions. If a patient was identified as requiring an intervention, for example a change of treatment, this was communicated with the ward team by an appropriate route as well as documenting in the medical notes. Inclusion criteria: >65 years old, prescribed an antibiotic for the treatment of LUTI or catheter associated UTI. Exclusion criteria: <65 years old, complicated UTI, upper UTI, urosepsis.ResultsEighty-seven patients were audited against the criteria: documentation of UTI symptoms = 74%; urine dipstick was not used to diagnose UTI = 69%; urine sample requested = 82%; appropriate antimicrobial was prescribed = 76% (Figures 1 and 2). As a treatment pathway 32% (28 patients) met all four criteria required to accomplish compliance to the diagnosis and treatment of LUTI. Of the 24% of antimicrobial prescriptions deemed inappropriate common themes included: not prescribing appropriate first line antibiotic; no clear indication for antibiotics; resistant to antibiotic prescribed; and inappropriate IV antibiotic prescribing (Figure 3). After an AMS pharmacist contacted the clinical teams to discuss the 24% of inappropriate antimicrobials it resulted in 92% of the antimicrobials being amended to appropriate antimicrobial choices. Increasing appropriate antimicrobials prescribed from 76% to 99%.Figure 1.Graph showing the percentage of datasets meeting the standard.Figure 2.Pie chart showing the percentage of inappropriate versus appropriate antimicrobial prescriptions.Figure 3.Bar chart showing the number of inappropriate antimicrobials and the reasons associated with them being inappropriate.ConclusionsThe results show that whilst most patients met some of the criteria expected to diagnose a LUTI, most did not meet all four. This warrants further quality improvement work to improve the recognition and adherence of the diagnosis and treatment of LUTIs with the aim to embed the processes across all age groups. The interventions of an AMS pharmacist positively impacted the prescribing of antimicrobials in LUTI and appears to be significant, particularly with regards to stopping inappropriate antimicrobials and recommending better treatment choices. These decisions included: promoting oral antibiotics instead of IV; recommending effective treatment based on renal impairment; acting on urine culture sensitivities; and choosing more narrow spectrum antibiotics. This provides a new potential tool for targeted AMS in relation to the treatment of LUTI within a large scale teaching hospital.

Clinical validation and evaluation of a novel six-lead handheld electrocardiogram recorder compared to the 12-lead electrocardiogram in unselected cardiology patients (EVALECG Cardio).

Handheld electrocardiogram (ECG) monitors are increasingly used by both healthcare workers and patients to diagnose cardiac arrhythmias. There is a lack of studies validating the use of handheld devices against the standard 12-lead ECG. The Kardia 6L is a novel handheld ECG monitor which can produce a 6-lead ECG. In this study, we compare the 6L ECG against the 12-lead ECG. A prospective study consisting of unselected cardiac inpatients and outpatients at Leeds Teaching Hospital NHS Trust. All participants had a 12- and 6-lead ECGs. All ECG parameters were analysed by using a standard method template for consistency between independent observers. Electrocardiograms from the recorders were compared by the following statistical methods: linear regression, Bland-Altman, receiver operator curve, and kappa analysis. There were 1015 patients recruited. The mean differences between recorders were small for PR, QRS, cardiac axis, with receiver operator analysis area under the curve (AUC) of >80%. Mean differences for QT and QTc (between recorders) were also small, with AUCs for QT leads of >75% and AUCs for QTc leads of >60%. Key findings from Bland-Altman analysis demonstrate overall an acceptable agreement with few outliers instances (<6%, Bland-Altman analysis). Several parameters recorded by the Kardia 6L (QT interval in all six leads, rhythm detection, PR interval, QRS duration, and cardiac axis) perform closely to the gold standard 12-lead ECG. However, that consistency weakens for left ventricular hypertrophy, QRS amplitudes (Lead I and AVL), and ischaemic changes.

Treatment patterns and survival outcomes for patients with non-small cell lung cancer in the UK in the preimmunology era: a REAL-Oncology database analysis from the I-O Optimise initiative

ObjectivesTo report characteristics, treatment and overall survival (OS) trends, by stage and pathology, of patients diagnosed with non-small cell lung cancer (NSCLC) at Leeds Teaching Hospital NHS Trust in 2007–2018.DesignRetrospective...

Whose Right Is It Anyway? The Duties Owed to a Deceased and to Surviving Family Members When Dealing with a Corpse: Brennan v City of Bradford Metropolitan District Council and Leeds Teaching Hospitals NHS Trust [2021] 1 WLUK 429.

This commentary considers the case of Brennan, in which surviving family members successfully brought a Human Rights Act 1998 (HRA) claim against a hospital and a council for the way in which they both treated a body post-mortem. Their failure to freeze it led to such a state of decomposition that it was unfit for viewing. The family argued this constituted an unjustified interference with their rights to family and private life. After a review of Strasbourg case law, the Leeds County Court found for them and awarded them damages under section 8 of the HRA. This commentary evaluates both the Strasbourg law and the way it was utilised and interpreted domestically. While agreeing with the outcome, the authors conclude that the Strasbourg case law does not line up four square-and instead they suggest that a different approach, accepting the legitimacy of a claim based on 'memory-securing', is warranted on the facts. The commentary also questions whether the court was correct in seeing the rights reposed in the surviving family, and offers the view that greater coherence to the law might be achieved if we conceive of the survivors as the vehicle for the exercise of rights by the deceased.

Editorial introductions.

Editorial introductions.

Chest X-ray sensitivity and lung cancer outcomes: a retrospective observational study.

BackgroundChest X-ray (CXR) is the first-line investigation for lung cancer in many healthcare systems. An understanding of the consequences of false-negative CXRs on time to diagnosis, stage, and survival is limited.AimTo determine the sensitivity of CXR for lung cancer and to compare stage at diagnosis, time to diagnosis, and survival between those with CXR that detected, or did not detect, lung cancer.Design and settingRetrospective observational study using routinely collected healthcare data.MethodAll patients diagnosed with lung cancer in Leeds Teaching Hospitals NHS Trust during 2008–2015 who had a GP-requested CXR in the year before diagnosis were categorised based on the result of the earliest CXR performed in that period. The sensitivity of CXR was calculated and analyses were performed with respect to time to diagnosis, survival, and stage at diagnosis.ResultsCXR was negative for 17.7% of patients (n = 376/2129). Median time from initial CXR to diagnosis was 43 days for those with a positive CXR and 204 days for those with a negative CXR. Of those with a positive CXR, 29.8% (95% confidence interval [CI] = 27.9% to 31.8%) were diagnosed at stage I or II, compared with 33.5% (95% CI = 28.8% to 38.6%) with a negative CXR.ConclusionGPs should consider lung cancer in patients with persistent symptoms even when CXR is negative. Despite longer duration to diagnosis for those with false-negative CXRs, there was no evidence of an adverse impact on stage at diagnosis or survival; however, this comparison is likely to be affected by confounding variables.

TikTok™ and dermatology: lessons for medical education

We read with interest the article by Roche et al. inClinical and Experimental Dermatology. The authors acknowledge increasing popularity and usage of TikTok for dermatology and the dangers of harmful dissemination of health-related content.1 We offer further reflections on opportunities and risks with such platforms, specifically related to dermatology medical education.

Chest pain mimicking pulmonary embolism may be a common presentation of COVID‐19 in ambulant patients without other typical features of infection

BackgroundRadiological and pathological studies in severe COVID‐19 pneumonia (SARS‐CoV‐2) have demonstrated extensive pulmonary immunovascular thrombosis and infarction. This study investigated whether these focal changes may present with chest pain mimicking pulmonary emoblism (PE) in ambulant patients.MethodsCTPAs from outpatients presenting with chest pain to Leeds Teaching Hospital NHS Trust 1st March to 31 May 2020 (n = 146) and 2019 (n = 85) were compared. Regions of focal ground glass opacity (GGO), consolidation and/or atelectasis (parenchymal changes) were determined, and all scans were scored using British Society for Thoracic Imaging (BSTI) criteria for COVID‐19, and the 2020 cohort was offered SARS‐CoV‐2 antibody testing.ResultsBaseline demographic and clinical data were similar between groups with absence of fever, normal lymphocytes and marginally elevated CRP and D‐Dimer values. Evidence of COVID‐19 or parenchymal changes was observed in 32.9% (48/146) of cases in 2020 compared to 16.5% (14/85) in 2019 (P = 0.007). 11/146 (7.5%) patients met BSTI criteria for COVID‐19 in 2020 compared with 0/14 in 2019 (P = 0.008). 3/39 patients tested had detectable COVID‐19 antibodies (2 with parenchymal changes and 1 with normal parenchyma) however 0/6 patients whose CTPA met BSTI criteria “likely/suspicious for COVID‐19” and attended antibody testing were SARS‐CoV‐2 antibody positive.Conclusions32.8% ambulatory patients with suspected PE in 2020 had parenchymal changes with 7.5% diagnosed as COVID‐19 infection by imaging criteria, despite the absence of other COVID‐19 symptoms. These findings suggest that localized COVID‐19 pneumonitis with immunothrombosis occurs distal to the bronchiolar arteriolar circulation, causing pleural irritation and chest pain without viraemia, accounting for the lack of fever and systemic symptoms.

Recognising the elephant in the room: Foundation doctors and anticipatory care planning

Anticipatory/advance care planning (ACP) conversations are often known to be challenging and should be undertaken sensitively. A qualitative service evaluation was undertaken with the elderly care department at The Leeds Teaching Hospitals NHS Trust by medical students to explore the thoughts and experiences of foundation doctors. ACP discussions include consideration of future treatment options and preferences; however, foundation doctors were not confident to discuss issues beyond resuscitation status. The key themes identified include understanding of and confidence in ACP, variation across specialty and medical educational needs. The analysis highlights a further need for qualitative research into prevalent attitudes towards ACP discussions across the range of specialties.

A Multidisciplinary NHS COVID-19 Service to Manage Post-COVID-19 Syndrome in the Community

The National Institute for Health and Care Excellence (NICE) describe “post COVID-19 syndrome” or “Long COVID” as a set of persistent physical, cognitive and/or psychological symptoms that continue for more than 12 weeks after illness and which are not explained by an alternative diagnosis. These symptoms are experienced not only by patients discharged from hospital but also those in the community who did not require inpatient care. To support the recovery of this group of people, a unique integrated rehabilitation pathway was developed following extensive service evaluations by Leeds Primary Care Services, Leeds Community Healthcare NHS Trust and Leeds Teaching Hospital NHS Trust. The pathway aligns itself to the NHS England “Five-point plan” to embed post-COVID-19 syndrome assessment clinics across England, supporting the comprehensive medical assessment and rehabilitation intervention for patients in the community. The pathway was first of its kind to be set up in the UK and comprises of a three-tier service model (level 1: specialist MDT service, level 2: community therapy teams and level 3: self-management). The MDT service brings together various disciplines with specialist skill sets to provide targeted individualized interventions using a specific core set of outcome measures including C19-YRS (Yorkshire Rehabilitation Scale). Community and primary care teams worldwide need such an integrated multidisciplinary comprehensive model of care to deal with the growing number of cases of post-COVID-19 syndrome effectively and in a timely manner.

Implementation of podiatry telephone appointments for people with rheumatic and musculoskeletal diseases

BackgroundFoot health problems are common in the general population, and particularly so in people with rheumatic and musculoskeletal disorders (RMD). Several clinical guidelines state that people with RMDs should have access to foot health services, although service capacity is often limited. The current COVID-19 pandemic has increased the need for alternative ways to provide patient care. The aim of this clinical audit was to review a newly implemented telephone follow-up appointment service conducted within the Rheumatology Podiatry Department in Leeds, UK.MethodsFifty-eight patients attending the Rheumatology Podiatry Department at Leeds Teaching Hospitals NHS Trust were contacted by telephone approximately 6–8 weeks following initial intervention. During the telephone consultation, all patients were asked pre-defined questions relating to their symptoms, intervention efficacy, the need for further appointments and their preference for the type of consultation. To assess the cost of the telephone consultation the number of attempts needed in order to make successful contact, the duration of the call and the number of telephone follow-up appointments completed in a working day were also recorded.ResultsTwenty-five patients (43%) were successfully contacted within the 6–8 weeks stipulated time frame and were included in the analysis. Of the 25 contacted, twelve (48%) patients were successfully contacted on the first attempt. Ten (40%) were successfully contacted on the second attempt. The remaining three patients (12%) required 3 or more attempts to make successful contact. Telephone consultations were estimated not to last longer than 10 min, including notes screening and documentation. Eleven patients (44%) reported an improvement in their symptoms, thirteen (52%) reported no change and one patient (4%) reported their symptoms to be worse.ConclusionTelephone follow-up consultations may be a potentially cost-effective alternative to face-to-face appointments when implemented in a Rheumatology Podiatry Department, and provide an alternative way of providing care, especially when capacity for face-to-face contact is limited. The potential cost saving and efficiency benefits of this service are likely to be enhanced when telephone consultations are pre-arranged with patients.

Diagnosis and risk stratification in hypertrophic cardiomyopathy using machine learning wall thickness measurement: a comparison with human test-retest performance

Left ventricular maximum wall thickness (MWT) is central to diagnosis and risk stratification of hypertrophic cardiomyopathy, but human measurement is prone to variability. We developed an automated machine learning algorithm for MWT measurement and compared precision (reproducibility) with that of 11 international experts, using a dataset of patients with hypertrophic cardiomyopathy. 60 adult patients with hypertrophic cardiomyopathy, including those carrying hypertrophic cardiomyopathy gene mutations, were recruited at three institutes in the UK from August, 2018, to September, 2019: Barts Heart Centre, University College London Hospital (The Heart Hospital), and Leeds Teaching Hospitals NHS Trust. Participants had two cardiovascular magnetic resonance scans (test and retest) on the same day, ensuring no biological variability, using four cardiac MRI scanner models represented across two manufacturers and two field strengths. End-diastolic short-axis MWT was measured in test and retest by 11 international experts (from nine centres in six countries) and an automated machine learning method, which was trained to segment endocardial and epicardial contours on an independent, multicentre, multidisease dataset of 1923 patients. Machine learning MWT measurement was done with a method based on solving Laplace's equation. To assess test-retest reproducibility, we estimated the absolute test-retest MWT difference (precision), the coefficient of variation (CoV) for duplicate measurements, and the number of patients reclassified between test and retest according to different thresholds (MWT >15 mm and >30 mm). We calculated the sample size required to detect a prespecified MWT change between pairs of scans for machine learning and each expert. 1440 MWT measurements were analysed, corresponding to two scans from 60 participants by 12 observers (11 experts and machine learning). Experts differed in the MWT they measured, ranging from 14·9 mm (SD 4·2) to 19·0 mm (4·7; p<0·0001 for trend). Machine learning-measured mean MWT was 16·8 mm (4·1). Machine learning precision was superior, with a test-retest difference of 0·7 mm (0·6) compared with experts, who ranged from 1·1 mm (0·9) to 3·7 mm (2·0; p values for machine learning vs expert comparison ranging from <0·0001 to 0·0073) and a significantly lower CoV than for all experts (4·3% [95% CI 3·3-5·1] vs 5·7-12·1% across experts). On average, 38 (64%) patients were designated as having MWT greater than 15 mm by machine learning compared with 27 (45%) to 50 (83%) patients by experts; five (8%) patients were reclassified in test-retest by machine learning compared with four (7%) to 12 (20%) by experts. With a cutoff point of more than 30 mm for implantable cardioverter-defibrillator, three experts would have changed recommendations between tests a total of four times, but machine learning was consistent. Using machine learning, a clinical trial to detect a 2 mm MWT change would need 2·3 times (range 1·6-4·6) fewer patients. In this preliminary study, machine learning MWT measurement in hypertrophic cardiomyopathy is superior to human experts with potential implications for diagnosis, risk stratification, and clinical trials. European Regional Development Fund and Barts Charity.

Survival Outcomes for Plasmablastic Lymphoma: An International, Multicentre Study By the Australasian Lymphoma Alliance

Survival Outcomes for Plasmablastic Lymphoma: An International, Multicentre Study By the Australasian Lymphoma Alliance

Acalabrutinib in Combination with Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone (R-CHOP) As First Line Therapy for Patients with Diffuse Large B-Cell Lymphoma (DLBCL): The Accept Phase Ib/II Single Arm Study

Acalabrutinib in Combination with Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone (R-CHOP) As First Line Therapy for Patients with Diffuse Large B-Cell Lymphoma (DLBCL): The Accept Phase Ib/II Single Arm Study

Enhanced Outcome Prediction in Early Stage Classical Hodgkin Lymphoma Using Pre-Treatment Biomarkers and Interim PET (BioPET); A Sub-Analysis of the UK NCRI RAPID Trial

Enhanced Outcome Prediction in Early Stage Classical Hodgkin Lymphoma Using Pre-Treatment Biomarkers and Interim PET (BioPET); A Sub-Analysis of the UK NCRI RAPID Trial

Tumour growth rate of carcinoma of the colon and rectum: retrospective cohort study.

BackgroundThe growth pattern of colorectal cancer is seldom investigated. This cohort study aimed to explore tumour growth rate in colorectal cancers managed non‐surgically or deemed not resectable, and to determine its implication for prognosis.MethodsConsecutive patients with colonic or rectal adenocarcinoma were identified through the colorectal multidisciplinary team database at Leeds Teaching Hospitals NHS Trust over a 2‐year interval. Patients who received no treatment (surgery, stenting, colonic defunctioning procedures, chemotherapy, radiotherapy) and who underwent CT twice more than 5 weeks apart were included. Multidetector CT/three‐dimensional image analysis was performed independently by three experienced radiologists.ResultsOf 804 patients reviewed, 43 colorectal cancers were included in the final analysis. Median age at first CT was 80 (73–85) years and the median interval between scans was 150 (i.q.r. 72–471) days. An increase in T category was demonstrated in 31 of 43 tumours, with a median doubling time of 211 (112–404) days. The median percentage increase in tumour volume was 34·1 (13·3–53·9) per cent per 62 days. The all‐cause 3‐year mortality rate was 81 per cent (35 of 43) with a median survival time of 1·1 (0·4–2·2) years after the initial diagnostic scan. In those obstructed, the relative risk of death from subsequent perforation was 1·26 (95 per cent c.i. 1·07 to 1·49; P = 0·005).ConclusionThis study documented a median doubling time of 211 days, with a concerning suggestion of tumour progression, which has implications for the current management standard.

Can survivors of COVID-19 later experience guilt?

Research nurses describe how some patients report anxiety and feelings of guilt after discharge from hospital Since the early days of the COVID-19 pandemic, the UK government has prioritised research into effective treatments. Studies were under way in record time. And as two research nurses – one normally working in oncology and the second a senior nurse manager with cardiology research experience – we have responded to the crisis by contributing to the set up and delivery of COVID-19 studies in our trust, Leeds Teaching Hospitals NHS Trust.

Editorial introductions

Editorial introductions

Supporting Students’ Practice Covid 2020: What Are the Fears for the Third-year Midwifery Student Cohort?

Lives were turned upside down and a harsh, new reality kicked in as the world entered the Covid-19 pandemic. Students filled with anxiety are worried about how this will affect their midwifery programmes. In this article, Tracy provides a working example of how Leeds Teaching Hospital NHS Trust (LTHT) has supported its students.