NHS Greater Glasgow Research Articles

Fundoscopy screening for intraocular candida in patients with positive blood cultures-is it justified?

Although the worldwide prevalence of disseminated candidaemia is rising, reported intraocular candidiasis rates are variable, even as low as 1%. The Infectious Diseases Society of America recommends fundoscopy screening for all fungal blood culture positive patients. We wished to evaluate the impact of this recommendation on our department. A retrospective observational study was performed in NHS Greater Glasgow and Clyde (population = 1.15 million) for all patients with candida positive blood culture results over a 2-year period. From January 2015 to December 2016, 258 candida positive cultures were obtained from 168 adults (mean age = 62 years, range: 17-94 years; 85 females, 83 males). Candida species were isolated in 161/168 (95.8%) cases (43.5% Candida albicans, 35.7% Candida glabrata). All 168 cases were treated with intravenous antifungals. 84 patients (50%) were formally referred to ophthalmology. Of those not referred, 21 were deceased prior to culture result (12.5%) and 14 patients subsequently deteriorated (8.3%). Six patients reported visual symptoms. In total, 65% had no ocular findings and 32.5% had unrelated ocular signs. Only one patient had signs consistent with Candida chorioretinitis, making the prevalence of intraocular candida in our population 1.3% (1/80). The prevalence of ocular candidiasis is low, presumably due to potent systemic antifungal agents and good intraocular penetration. Our findings support the view that routine fundoscopy screening may not be indicated in every culture positive patient. This paper provides an evidence base for the Royal College's Eyecare in intensive care unit recommendations regarding targeted screening of non-verbal, symptomatic or high-risk patients.

Tackling health inequalities in access to Child and Adolescent Mental Health Services (CAMHS) using neighbourhood profiling of administrative data

BackgroundReducing health inequalities includes addressing access to and use of services, including considering how deprivation may affect service engagement and referrals. NHS Greater Glasgow and Clyde (NHSGGC) are close to the national average for most CAMHS benchmarking indicators, including waiting times, and referrals received and accepted. When comparing UK rates of Did Not Attends (DNA), however, NHSGGC were fourth highest in 2016. More detailed analysis of service use was thus of interest. While some service and patient risk factors are known, this study used data from NHSGGC’s electronic children’s health record system to develop neighbourhood profiles of access and use.
 Objectives
 
 To analyse activity within communities so health resourcescan be best targeted.
 To help clinical teams plan services and develop newmodels matched to local need.
 
 MethodsPatient-level administrative data was linked to geographic and population data to identify outlying areas of demand. Data on referrals, open cases, appointments and DNAs were extracted and population-based analyses undertaken with 120,000 data points, linked to 273 neighbourhoods across NHSGGC.
 FindingsGeomaps were used to highlight variation in activity, demand and population at neighbourhood and NHSGGC levels. Unexpectedly low levels of population reach (open cases/population under 18s) were found in some areas (Govanhill, 0.5%, relative to NHSGGC, 1.94%). Yet, the high level of DNAs in some East Glasgow areas is as one would predict given deprivation levels.
 ConclusionsFindings have been used to identify potential improvements and to target communities who could benefit most. For example, West Dunbartonshire teams noticed high DNA rates in two neighbourhoods, both geographically distant from clinics. Satellite clinics have been introduced to improve attendance by reducing travel time and costs for families.
 Neighbourhood profiles have proved valuable in highlighting population based trends and supporting comparisons locally and relative to NHSGGC wide benchmarks.

Embedding routine health checks for adults with intellectual disabilities in primary care: practice nurse perceptions.

Adults with intellectual disabilities (IDs) have consistently poorer health outcomes than the general population. There is evidence that routine health checks in primary care may improve outcomes. We conducted a randomised controlled trial of practice nurse led health checks. Here, we report findings from the nested qualitative study. To explore practice nurse perceptions and experience of delivering an anticipatory health check for adults with IDs. Qualitative study in General Practices located in NHS Greater Glasgow and Clyde, Scotland, UK. Eleven practice nurses from 11 intervention practices participated in a semi-structured interview. Analysis was guided by a framework approach. Practice nurses reported initially feeling 'swamped' and 'baffled' by the prospect of the intervention, but early misgivings were not realised. Health checks were incorporated into daily routines with relative ease, but this was largely contingent on existing patient engagement. The intervention was thought most successful with patients already well known to the practice. Chronic disease management models are commonly used by practice nurses and participants tailored health checks to existing practice. It emerged that few of the nurses utilised the breadth of the check instead modifying the check to respond to individual patients' needs. As such, already recognised 'problems' or issues dominated the health check process. Engaging with the health checks in this way appeared to increase the acceptability and feasibility of the check for nurses. There was universal support for the health check ethos, although some questioned whether all adults with IDs would access the health checks, and as a consequence, the long-term benefits of checks. While the trial found the intervention to be dominant over standard health care, the adjustments nurses made may not have maximised potential benefits to patients. Increasing training could further improve the benefits that health checks provide for people with IDs.

6 Prognostic value of the glasgow admission prediction score: hospital length of stay, mortality and hospital readmission

IntroductionAs patient numbers presenting to emergency departments (ED) increase, with their myriad of comorbidities, early hospital admission prediction and demand modelling are crucial both in the ED and beyond. The...

Abstract P140: Serum Chloride Predicts Mortality Risk in Type 2 Diabetes - Analysis of 91,159 Patients From the West of Scotland

Objective: Low serum chloride (Cl - ) is associated with increased risk of death in those with heart failure, hypertension or chronic kidney disease. We sought to investigate the association of serum Cl - with risk of cause-specific death in adults with type 2 diabetes mellitus (T2DM). Methods: Data was available for 91,159 adults from the West of Scotland with T2DM from NHS Greater Glasgow and Clyde Safe Haven with 10 years follow up. Two groups were created: serum Cl - <100 and Cl - ≥100 mmol/L. Cox-PH models, adjusted for age, sex and serum sodium (Na + ), were used to assess the association between serum Cl - and risk of death (all-cause mortality, vascular death, death from myocardial infarction (MI), death from heart failure, death from stroke, death from cancer). Results: There were 13,459 patients with serum Cl - <100 mmol/L; 53% were male with median age 62.5 (IQR 50.9-73.1) years and median Na+ 136 (133-138) mmol/L. There were 77,757 patients with serum Cl - ≥100 mmol/L; 53% were male with median age 61.2 (IQR 50.2-71.4) years and median Na + 139 (IQR 138-141) mmol/L. Serum Cl - <100 mmol/L was associated with an 44% increased risk of all-cause mortality (N=20,304, HR 1.44[95% CI 1.38-1.49]; p <0.0001), independent of serum Na + (Figure). The increased mortality risk of serum Cl - <100 mmol/L was observed for cardiovascular mortality (N=6,323, 1.41[1.31-1.51]; p <0.0001); death from MI (N=1,986, 1.42[1.25-1.60]; p <0.0001); stroke (N=1,590, 1.24[1.08-1.42]; p 0.003); heart failure (N=200, 1.38[0.95-2.0]; p 0.09) and cancer (N=5,577, 1.12[1.04-1.21]; p 0.003). Conclusions: Serum chloride <100 mmol/L was associated with increased risk of death in adults with type 2 diabetes mellitus.

Factors associated with the efficacy of polyp detection during routine flexible sigmoidoscopy

ObjectiveFlexible sigmoidoscopy reduces the incidence of colonic cancer through the detection and removal of premalignant adenomas. However, the efficacy of the procedure is variable. The aim of the present study...

Clinical associations of the positive anti Ro52 without Ro60 autoantibodies: undifferentiated connective tissue diseases

AimsAutoantibodies targeting Ro52 and Ro60 antigens are historically reported as anti SSA/Ro. In general anti SSA/Ro results are either anti Ro52+Ro60+ or anti Ro52−Ro60+ antibodies. Anti Ro52 without anti Ro60...

OCTOPUS: A randomised, multi-centre phase II umbrella trial of weekly paclitaxel+/- novel agents in platinum-resistant ovarian cancer—Vistusertib (AZD2014).

TPS5609 Background: There is an urgent need to improve outcomes for patients with platinum-resistant and refractory ovarian cancer (PROC). OCTOPUS is an umbrella phase II framework for testing whether the addition of novel targeted agents to weekly paclitaxel (wPxl) improves efficacy in PROC. The first agent to be evaluated is the dual mTORC1/mTORC2 inhibitor, vistusertib (AZD2014), as preclinical studies support targeting the PI3kinase/Akt/mTOR pathway in PROC and the combination of vistusertib and wPxl has shown promising preliminary activity in high grade serous ovarian cancer (HGS) patients in a phase I trial (Banerji et al poster discussion ESMO 2016). This is the first randomised trial of wPxl and a dual mTORC1/2 inhibitor in ovarian cancer. Methods: OCTOPUS is an investigator-initiated, randomised, double-blind, placebo-controlled, multicentre, phase II trial. 140 patients with PROC (histologically confirmed HGS) are randomised 1:1 to receive wPxl (80mg/m2 D1, D8, D15 of 28 day cycle) plus oral vistusertib (50mg BD) or placebo (D1-3, D8-10, D15-17). The primary endpoint is progression-free survival (PFS) based on combined RECIST v1.1/GCIG CA125 criteria. The study is designed to detect a 50% improvement in median PFS from 3.7 months on placebo to 5.55 months on the experimental arm with 90% power, at the 20% 1-sided level of statistical significance (or equivalently with 80% power at the 10% level of statistical significance) using a 3-outcome design. Secondary endpoints include response (based on RECIST 1.1 and GCIG CA125 criteria), overall survival, toxicity and quality of life. Patients whom received prior wPxl for PROC are not eligible. A mandatory pre-treatment biopsy (if technically feasible), archival tissue, and serial blood samples will be collected for translational research studies. 49 patients have been recruited. The study is part of the NIHR CRN Cancer/Astrazeneca Alliance, sponsored by NHS Greater Glasgow and Clyde/University of Glasgow and endorsed by Cancer Research UK (CRUKE/14/052). Clinical trial information: ISRCTN16426935.

A phase I trial of the oral hedgehog inhibitor taladegib (LY2940680) in combination with weekly paclitaxel in patients with advanced, solid tumours.

2594 Background: Aberrant Hedgehog (Hh) signaling is implicated in carcinogenesis and is associated with poor prognosis in multiple tumours types. Hh inhibitors increase sensitivity to paclitaxel in taxane-resistant cell lines. Taladegib is an orally bioavailable, potent inhibitor of Smoothened, a key Hh pathway component, with activity in basal cell carcinoma. The single agent recommended dose is 400mg od. We present the dose escalation phase of a phase I study of weekly paclitaxel with oral taladegib. Methods: Primary objective: determine the dose limiting toxicity (DLT) and maximum tolerated dose (MTD) of taladegib on a continuous oral daily dosing regimen in combination with paclitaxel (80mg/m2, iv, day 1, 8 and 15 q 28) in patients with advanced solid cancers. Secondary objectives: assess the safety and tolerability, determine the recommended phase II dose (RP2D), and evaluate the pharmacokinetics of taladegib and paclitaxel. Exploratory objective: assess preliminary efficacy. A standard 3 + 3 dose escalation design was used. All patients received up to 6 cycles of paclitaxel. In addition, successive cohorts received continuous oral taladegib continued until progression or unacceptable toxicity as follows: dose level 1: 100mg od; 2: 200mg od; 3: 400mg od. Results: No DLTs were seen at dose level 1 or in the first 3 patients at dose level 2. 3 DLTs of grade 2 neuropathy were seen at dose level 3 (400mg taladegib); therefore, dose level 2 was expanded to 6 patients. No DLT was seen in the fourth patient and 2 additional patients have started treatment. After the DLT period 2 patients developed G2 and 4 developed G1 neuropathy. Other non DLT, drug-related G3 toxicities: uncomplicated neutropenia x2, muscle cramp x1 and fatigue x1. To date, 3 patients have had partial responses. Conclusions: The combination of daily oral taladegib and weekly paclitaxel is feasible. DLT of G2 neuropathy was seen at 400mg. Promising activity has been seen in solid tumours. A dose expansion cohort is due to commence in high grade ovarian carcinoma. ISRCTN No:ISRCTN15903698 Eudract Ref:2014-004695-37 Funded by Cancer Research UK C8361/A18775 and Ignyta. Sponsored by NHS Greater Glasgow and Clyde. Clinical trial information: ISRCTN15903698.

Data linkage of Psychiatric and Maternity data to investigate the pregnancy outcomes of women with Non-affective Psychosis in Scotland

ABSTRACTObjectiveWomen with a diagnosis of non-affective psychosis have a lower fertility rate than the general population. However, perinatal outcomes in mothers with non-affective psychosis are under-researched. What is the general fertility rate (GFR) of women with a lifetime diagnosis of non-affective psychosis in Scotland? Does such a diagnosis affect the outcome of pregnancy?
 ApproachAn ‘exposed’ cohort with non-affective psychosis and at least one pregnancy was established using a combined dataset derived via data linkage in local safe havens of routine psychiatric and maternity data from two Scottish regions:•NHS Grampian (NHSGr): Aberdeen Maternity and Neonatal Databank (AMND); psychiatric casenotes•NHS Greater Glasgow and Clyde (NHSGG&C): SMR02; PsyCIS bespoke psychiatric databaseExposed women were matched to women without a diagnosis of non-affective psychosis, by maternal age (NHSGG&C only), year of first birth, parity and deprivation, sourced from AMND/SMR02 in a 3:1 unexposed:exposed ratio.
 Demographics and pregnancy outcomes of exposed versus unexposed women were analysed to describe effect of psychosis on pregnancy.
 ResultsMany challenges were encountered in terms of having legal agreements in place between institutions and safe havens, constructing cohorts and datasets within each study site and joining the data to analyse the overall cohort. Challenges with the data itself included discrepancies between the variables measured in datasets in different sites and missing information within patient records, particularly in earlier years. Preliminary results for the NHSGG&C region show that the average GFR for exposed women aged 15-44 from 2005 to 2014 was 14.38 compared to the general population rate of 55.26. The number of women ever having a miscarriage was significantly higher in the exposed group (23.4% vs 9.9%; p-value <0.001). However during the study period (1996 to 2014), more unexposed women had miscarriages (0.5% vs 4.7%; p-value = 0.002). There were no significant differences in pregnancy complications for the study period. The mean birthweight of babies was lower (3.23kg vs 3.35kg; p-value = 0.029) and more babies were admitted to neonatal units (17.5% vs 9.8%; p-value = 0.004) in the exposed group. Results for the NHSGr region and the combined dataset will also be reported.
 ConclusionThis work highlights that there remain hurdles to linking data across sites, despite availability of rich datasets within Scotland. Women with non-affective psychosis within NHSGG&C region had a lower fertility rate on average than the general population and some poorer outcomes, such as birthweight and rate of admission to neonatal units.

Evaluation of a complex intervention to improve primary care prescribing: a phase IV segmented regression interrupted time series analysis.

It is uncertain whether improvements in primary care high-risk prescribing seen in research trials can be realised in the real-world setting. To evaluate the impact of a 1-year system-wide phase IV prescribing safety improvement initiative, which included education, feedback, support to identify patients to review, and small financial incentives. An interrupted time series analysis of targeted high-risk prescribing in all 56 general practices in NHS Forth Valley, Scotland, was performed. In 2013-2014, this focused on high-risk non-steroidal anti-inflammatory drugs (NSAIDs) in older people and NSAIDs with oral anticoagulants; in 2014-2015, it focused on antipsychotics in older people. The primary analysis used segmented regression analysis to estimate impact at the end of the intervention, and 12 months later. The secondary analysis used difference-in-difference methods to compare Forth Valley changes with those in NHS Greater Glasgow and Clyde (GGC). In the primary analysis, downward trends for all three NSAID measures that were existent before the intervention statistically significantly steepened following implementation of the intervention. At the end of the intervention period, 1221 fewer patients than expected were prescribed a high-risk NSAID. In contrast, antipsychotic prescribing in older people increased slowly over time, with no intervention-associated change. In the secondary analysis, reductions at the end of the intervention period in all three NSAID measures were statistically significantly greater in NHS Forth Valley than in NHS GGC, but only significantly greater for two of these measures 12 months after the intervention finished. There were substantial and sustained reductions in the high-risk prescribing of NSAIDs, although with some waning of effect 12 months after the intervention ceased. The same intervention had no effect on antipsychotic prescribing in older people.

Large scale implementation of a medicines reconciliation care bundle in NHS GGC GP practices

Medicines reconciliation (MR) is an essential process for patient safety, promoting safer use of medicines with effective communication at the interface, particularly when patients are admitted and discharged from hospital....

Economic impact of recurrent respiratory papillomas in a UK adult population

To calculate the financial burden of recurrent respiratory papilloma. This study is UK-based, where up until now no financial estimates have been calculated for this group of patients. Recurrent respiratory papilloma is caused by the human papilloma virus (subtypes 6 and 11). The burden for the patient and the healthcare system is significant given the recurrent nature of the disease. Data were collected, using a questionnaire completed during routine clinical follow up, from a single centre managing recurrent respiratory papilloma in Glasgow, Scotland. Cost information was sourced from the Scottish Government's Information Services Division. Fourteen patients with active recurrent respiratory papilloma between 2013 and 2014 were identified. The direct measurable cost to NHS Greater Glasgow and Clyde amounted to £107 478. Recurrent respiratory papilloma is a benign condition, but the financial implications of diagnosis are significant. Recurrent respiratory papilloma has a natural history of relapse and remission, and patients may require healthcare input over a period of several years.

Community pharmacy-based opiate substitution treatment and related health services: a study of 508 patients and 111 pharmacies

Community pharmacies have a central role in the provision of opiate substitution therapy (OST) for drug misusers, offering accessible, additional health services within recovery-oriented systems of care. However, little is known about the patients receiving OST, availability and uptake of related services and associated pharmacy characteristics. We aimed to describe OST in terms of patients, pharmacies and services within the UK’s largest health authority, NHS Greater Glasgow and Clyde, Scotland. Patients completed semi-structured questionnaires and pharmacists provided summary statistics relating to OST provision. Responses from 508 patients receiving OST from 111 participating pharmacies revealed an established patient population, with 89 % (449/507) aged 30 years or above and 80 % (387/484) attending the same pharmacy for 1 year or more. Methadone was the main form of OST (96 % (487/508), with 97 % (491/504) receiving supervision. Within pharmacies, OST consumption was supervised in one of four main areas: consultation room, dispensing hatch, quiet/private area or over the counter. Location of supervision was considered suitably private by 96 % of patients. Positive staff attitudes, privacy and the provision of additional health services were key factors influencing choice of pharmacy. Additional health services were offered to 75 % of patients and included information provision (43 %), signposting to other health care providers (72 %) and a Scottish service offering free advice and medicines for minor ailments (74 %). Patients and pharmacists have developed working relationships, enabling access to multiple services associated with health gain and harm reduction. Further development of enhanced services in community pharmacies is merited.

The prevalence of multimorbidity in an older acute general surgical population

The prevalence of multimorbidity in an older acute general surgical population

Anatomical variations of the temporal bone on high-resolution computed tomography imaging: how common are they?

This study aimed to evaluate the prevalence of normal variations of temporal bone anatomy on high-resolution computed tomography imaging and report their clinical importance. A retrospective review was conducted of high-resolution temporal bone computed tomography imaging performed at NHS Greater Glasgow and Clyde over an eight-year period. The presence of five variants was determined. These variants were: a high dehiscent jugular bulb, an anteriorly located sigmoid sinus, a deep sinus tympani, an enlarged cochlear aqueduct and a large internal auditory meatus. A total of 339 temporal bones were examined. The incidences of a high dehiscent jugular bulb, anteriorly located sigmoid sinus, deep sinus tympani, enlarged cochlear aqueduct and an enlarged internal auditory meatus were 2.76 per cent, 2.94 per cent, 5.01 per cent, 0.58 per cent and 1.76 per cent respectively. Anatomical variations of the temporal bone are not uncommon and it is important for the investigating otologist to be aware of such variations prior to undertaking surgery.

22 Retrospective Regional Audit of In-Patient Assessment of Left Ventricular Systolic Function and Guideline-Recommended Prescription of Eplerenone following St-elevation Myocardial Infarction

Introduction The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) trial demonstrated that eplerenone reduces all-cause mortality and death or hospitalisation for cardiovascular events in patients with symptomatic left ventricular (LV) systolic dysfunction (ejection fraction ≤40%) or diabetes following ST-elevation myocardial infarction (STEMI). Current national and international guidelines recommend initiation of eplerenone in this patient group. We conducted a retrospective audit of assessment of LV systolic function and subsequent prescribing of eplerenone in eligible patients presenting with acute STEMI over a 4-month period. Aims and objectives 1. Establish what proportion of patients presenting with STEMI had in-patient assessment of LV systolic function 2. Identify whether LV systolic function assessment was performed qualitatively or quantitatively 3. Determine what proportion of eligible patients were prescribed eplerenone on hospital discharge Methods Patients from NHS Greater Glasgow and Clyde (GG&C) who underwent primary percutaneous coronary intervention (PPCI) for STEMI were retrospectively (01/08/13–30/11/13) identified using the coronary intervention patient-database at the West of Scotland Regional Heart and Lung Centre (Golden Jubilee National Hospital). Data were collected using electronic patient records and national radiology archive. Qualitative assessment was defined as a subjective description of LV systolic function (normal, mild, moderate or severe impairment). Quantitative assessment was defined as a documented ejection fraction (EF). Patients were considered eligible for eplerenone if they had a qualitative assessment of LV systolic function documented as moderately or severely impaired, or EF ≤ 40% on quantitative assessment, and symptomatic LV systolic dysfunction or diabetes. Results 172 patients were identified. 90% of the total population had in-patient assessment of LV systolic function ([Table 1][1]). All of these patients had qualitative assessment ([Table 1][1]). LV systolic function was quantitatively assessed in 27% (10% modified Simpson’s Biplane method, 11% estimated EF, 5% unspecified) ([Table 1][1]). 8% of patients were considered eligible for eplerenone ([Table 2][2]). Of those eligible, eplerenone was appropriately prescribed on discharge in 21% ([Table 2][2]). View this table: Abstract 22 Table 1 Assessment of LV systolic function View this table: Abstract 22 Table 2 Prescribing of eplerenone in eligible patients Conclusions This audit indicates that national and international guidelines for the assessment and management of LV systolic function post-STEMI are not being adhered to within this region. Identifying those with LV systolic dysfunction post-STEMI is not only of importance for the optimisation of drug therapy, but also for patient selection for implantable defibrillators. The wider implications of LV systolic dysfunction include DVLA-imposed restrictions on driving and critical illness policies. Potential barriers to compliance with guidelines include time-constraints, training and shorter inpatient stay since the adoption of PPCI. These factors may explain the low prescribing rate of eplerenone in eligible patients. [1]: #T1 [2]: #T2

P120 Injecting, obesity and antibiotic resistance: an exploration of nursing practice in relation to the administration of intramuscular injection in the treatment of gonorrhoea

Background/introduction Traditionally, conventional green needles (1.5 inch) are used to reach the dorsogluteal muscle. However, in the face of increasing obesity, there may be difficulty in reaching the target muscle due to subcutaneous fat. This can lead to potential ineffective delivery of medication resulting in non-treatment of infection, and possibly contributing to antibiotic resistance. Aim(s)/objectives To explore existing practice of sexual health practitioners in relation to site and technique when administering intramuscular gonorrhoea treatment, in NHS Greater Glasgow and Clyde. Methods Focus group interviews with 22 sexual health participants with a variety of experiences. Interviews were analysed using a framework approach. Results The dorsogluteal muscle was used for all injections excluding vaccines. Only two participants had heard of the recommended ventrogluteal site. Mentors were key influences in role modelling within clinical situations. No updates were reported since learning this basic skill as a student. Despite awareness of the obesity epidemic, using a longer needle or changing target muscle site had not been contemplated until the focus group. Discussion/conclusion Obesity constitutes health challenges to basic nursing care, and commands a practical skilled workforce in anticipation of these complexities. This study reveals a theory-practice gap in the essential assessment of appropriate target muscle, which has potential to compound resistance issues. As rapid emergence of resistant strains pose a threat to untreatable gonorrhoea, we recommend that adoption of best practice guidance is essential alongside further study to ensure efficacy of treatment.

Gram-negative bacteraemia in haemodialysis.

Patients on renal replacement therapy experience higher rates of morbidity and mortality, infection being the second commonest cause of death. In our haemodialysis population, we identify the pathogens, sensitivity patterns, sources of infection and outcomes of Gram-negative bacteraemia. Data from the NHS Greater Glasgow & Clyde and NHS Forth Valley haemodialysis population were collected July 2011 to April 2014 through an interrogation of the renal unit electronic patient record, and confirmed by an independent search of the Microbiology database. Over 544 377 haemodialysis days, 84 patients experienced 95 Gram-negative bacteraemia events, a rate of 0.175 events per 1000 haemodialysis days, which varied with dialysis modality: non-tunnelled central venous catheters 4.77, arteriovenous grafts 0.24, tunnelled central venous catheters 0.21, and arteriovenous fistulae 0.11 per 1000 haemodialysis days. The commonest sources of bacteraemia were central venous catheters (CVCs) (16.8%, n = 16), infected ulcers (14.7%, n = 14), urinary (10.5%, n = 10), biliary (9.5%, n = 9) and intra-abdominal (9.5%, n = 9).The principal organisms were Escherichia coli (49.5%, n = 47), Enterobacter spp. (13.1%, n = 13), Klebsiella spp. (11.1%, n = 11), Proteus mirabilis (6.1%, n = 6) and Pseudomonas aeruginosa (5.1%, n = 5). Of the Enterobacteriaceae (n = 84), 88% were sensitive to gentamicin, 81% to ciprofloxacin, 91% to piperacillin-tazobactam and 100% were sensitive to meropenem.Three-month case mortality was 25.3% (n = 24). Ten patients (11.9%) had more than one Gram-negative bacteraemia; of these, nine patients (90.0%) were the same causative organism, predominantly E. coli. CVCs and diabetic foot ulcers remain significant risk factors for Gram-negative bacteraemia, highlighting the importance of vascular access planning. Despite good levels of antibiotic sensitivity, the early mortality following Gram-negative bacteraemia remains high, supporting aggressive treatment of such pathogens.

Financial Incentives for Smoking Cessation in Pregnancy

Each year, 25,000 spontaneous miscarriages are associated with smoking during pregnancy. While there are many medical approaches to smoking cessation, they have not proven to be the particularly effective. A recent Cochrane systematic review suggests that financial incentives may be effective in helping pregnant smokers quit. The current study explored the efficacy and cost-effectiveness of financial incentives added to routine specialist pregnancy NHS “Stop Smoking Services” that provide assistance to pregnant women to quit smoking. The design of this study used a phase II therapeutic randomized controlled trial in a single center that covered a wide geographical location. Women eligible for the study were smokers who had a carbon monoxide measurement of 7 ppm, were 16 years or younger, at less than 24 weeks’ gestation, and resident in NHS Greater Glasgow and Clyde. All eligible women were allocated to a control group (306) or incentives (306). The routine specialist pregnancy care consisted of a face-to-face appointment followed by 4 weekly phone support calls and free nicotine replacement therapy for 10 weeks, with a confirmation of smoking status at 4 and 12 weeks of agreed quit date. Control groups were offered routine support; an intervention group received a £50 voucher for attending all appointments and to set a quit date. The incentive group was also offered £400 shopping vouchers if they engaged with stop smoking services or quit. Those who remained abstinent, confirmed by a carbon monoxide breath test (<10 ppm), in the intervention group were also given additional £50 vouchers at 2 weeks and £100 vouchers at 12 weeks. A final £200 voucher was given to the incentive group when confirmed smoking abstinence at quit date. In the primary outcome assessment, there was a significant difference between the 2 groups. More women had stopped smoking in the incentives group (22.5% vs 8.6 %; P < 0.001), and relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval, 1.73–4.01). Secondary outcome assessment revealed a higher rate of continued abstinence 4 weeks after quit date in the incentives group. This study suggests that financial incentives can aid women to quit smoking during pregnancy and are more effective than other approaches currently recommended. The cost of this incentive is also below the current UK National Health Service threshold and is a cost-effective option in the short term. Smoking during pregnancy may prevent both maternal and neonatal complications, and financial incentives should be considered as a more effective method to avoid these conditions than the current incentives provided.