Oxford University Hospitals Research Articles

Mortality risks associated with empirical antibiotic activity in Escherichia coli bacteraemia: an analysis of electronic health records.

BackgroundReported bacteraemia outcomes following inactive empirical antibiotics (based on in vitro testing) are conflicting, potentially reflecting heterogeneity in causative species, MIC breakpoints defining resistance/susceptibility, and times to rescue therapy.MethodsWe investigated adult inpatients with Escherichia coli bacteraemia at Oxford University Hospitals, UK, from 4 February 2014 to 30 June 2021 who were receiving empirical amoxicillin/clavulanate with/without other antibiotics. We used Cox regression to analyse 30 day all-cause mortality by in vitro amoxicillin/clavulanate susceptibility (activity) using the EUCAST resistance breakpoint (>8/2 mg/L), categorical MIC, and a higher resistance breakpoint (>32/2 mg/L), adjusting for other antibiotic activity and confounders including comorbidities, vital signs and blood tests.ResultsA total of 1720 E. coli bacteraemias (1626 patients) were treated with empirical amoxicillin/clavulanate. Thirty-day mortality was 193/1400 (14%) for any active baseline therapy and 52/320 (16%) for inactive baseline therapy (P = 0.17). With EUCAST breakpoints, there was no evidence that mortality differed for inactive versus active amoxicillin/clavulanate [adjusted HR (aHR) = 1.27 (95% CI 0.83–1.93); P = 0.28], nor of an association with active aminoglycoside (P = 0.93) or other active antibiotics (P = 0.18). Considering categorical amoxicillin/clavulanate MIC, MICs > 32/2 mg/L were associated with mortality [aHR = 1.85 versus MIC = 2/2 mg/L (95% CI 0.99–3.73); P = 0.054]. A higher resistance breakpoint (>32/2 mg/L) was independently associated with higher mortality [aHR = 1.82 (95% CI 1.07–3.10); P = 0.027], as were MICs > 32/2 mg/L with active empirical aminoglycosides [aHR = 2.34 (95% CI 1.40–3.89); P = 0.001], but not MICs > 32/2 mg/L with active non-aminoglycoside antibiotic(s) [aHR = 0.87 (95% CI 0.40–1.89); P = 0.72].ConclusionsWe found no evidence that EUCAST-defined amoxicillin/clavulanate resistance was associated with increased mortality, but a higher resistance breakpoint (MIC > 32/2 mg/L) was. Additional active baseline non-aminoglycoside antibiotics attenuated amoxicillin/clavulanate resistance-associated mortality, but aminoglycosides did not. Granular phenotyping and comparison with clinical outcomes may improve AMR breakpoints.

It's never easy to leave our comfort zone.

Sam Foster, Chief Nurse, Oxford University Hospitals, suggests that putting the focus on both the patient and the staff experience can help leaders to overcome resistance to proposed workplace transformations.

Promoting professionalism

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on professional pride and discussions of what 'professionalism' in nursing and midwifery looks like-and how to enable it.

Sub-stratification of type-2 high airway disease for therapeutic decision-making: A 'bomb' (blood eosinophils) meets 'magnet' (FeNO) framework.

Sub-stratification of type-2 high airway disease for therapeutic decision-making: A 'bomb' (blood eosinophils) meets 'magnet' (FeNO) framework.

A vision for nursing research.

Sam Foster, Chief Nurse, Oxford University Hospitals, considers the challenges for institutions in picking up the Chief Nursing Officer's strategy for nursing involvement in research.

‘Case of the Month’ from Oxford University Hospitals, Oxford, UK: ketamine uropathy with metallic stents and obstructing calculus

‘Case of the Month’ from Oxford University Hospitals, Oxford, UK: ketamine uropathy with metallic stents and obstructing calculus

P135 Lower limb muscle strength and balance in older adults with distal radius fracture: a systematic review

Abstract Background/Aims Distal radius fractures (DRF) are common fall-related fragility fractures disproportionately affecting older females. After a DRF, there is an increased risk of future fragility fractures and functional decline. Systematic review evidence shows balance and muscle strengthening exercises reduce falls in older adults. Despite this, existing DRF rehabilitation trials have mainly focused on upper limb impairments. To inform rehabilitation requirements, we aimed to 1.) compare lower limb muscle strength and balance between older adults with a DRF with age- and sex-matched controls, and 2.) synthesise lower limb muscle strength and balance outcomes in older adults with a DRF. Methods We searched Embase, MEDLINE and CINAHL (1990 to August 2021). We included randomised and non-randomised controlled trials, and observational studies, that assessed lower limb strength and/or balance in adults aged ≥50 years enrolled within one year after a DRF. Strength and balance had to be assessed using validated instrumented or physical performance measures. Two reviewers independently screened titles and abstracts, and full-text reports of potentially eligible studies. One reviewer extracted data, then checked by another. Two reviewers independently appraised studies using the Cochrane risk-of-bias tool or Newcastle-Ottawa scale. We synthesised results narratively due to heterogeneity. PROSPERO registration: CRD42020196274. Results Seventeen studies (10 case-control studies, three RCTs and four case-series) including 1112 participants (95% women) with a DRF were included. Participants’ mean age ranged from 56 to 73 years; median sample size was 80 (IQR 54-106). Eleven (65%) studies assessed lower limb muscle strength using 10 different methods. Knee extensor strength assessment was most common (5/11 studies) followed by the 30-second and five times sit-to-stand tests (3/11 studies). All studies assessed balance, using 14 different methods. Single leg balance assessment was most common (6/17 studies) followed by functional reach and postural sway (3/17 studies). 5/10 case-control studies assessed lower limb muscle strength. Two studies found cases performed worse than controls during sit-to-stand tests; three studies assessed knee extensor strength with conflicting findings. All case-control studies assessed balance, with cases demonstrating impaired balance compared to controls on some measures. 4/17 studies assessed strength and 6/17 studies assessed balance at multiple timepoints. Over time, strength progressively improved in 3/4 studies but changes in balance were inconsistent across studies. Conclusion There is some evidence that older adults with a DRF have impaired lower limb muscle strength and balance compared to age- and sex-matched controls, but findings are inconsistent. Synthesis of results was limited by heterogeneity in the design, quality, and assessment methods used in included studies. Large-scale robust case-control and/or prospective observational studies are needed to better establish the rehabilitation requirements for this population. Disclosure C. Forde: Grants/research support; CF is supported by the NIHR Biomedical Research Centre, based at Oxford University Hospitals Trust, Oxford. P.J.A. Nicolson: Grants/research support; PN is supported by a Versus Arthritis Foundation Fellowship (ref. 22428). C. Vye: None. J.C.H. Pun: Grants/research support; JP received financial support from the NMAHPs Internship Versus Arthritis (Grant reference 22082). W. Sheehan: None. M. Costa: Grants/research support; MC receives grants from NIHR and related health charities. S.E. Lamb: Grants/research support; SL receives grants from NIHR and related health charities. D.J. Keene: Grants/research support; DK is supported by a National Institute of Health Research (NIHR) Postdoctoral Fellowship (ref. PDF-2016-09-056) and by the NIHR Biomedical Research Centre, based at Oxford University Hospitals Trust.

Working on the roadmap to ACP.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on the issues still facing institutions and individuals in developing and supporting ACP roles, and areas to explore for improvement.

Reflecting on retention: reasons why nurses choose to stay.

Sam Foster, Chief Nurse, Oxford University Hospitals, considers retention as one cornerstone of government targets for increasing the number of nurses in England by 2024.

An alternative way to conceptualise aspects of modern nursing.

Sam Foster, Chief Nurse, Oxford University Hospitals, describes a different approach to considering the many components of work undertaken by nurses that could help to reduce workforce pressures.

Combining faecal immunochemical testing with blood test results for colorectal cancer risk stratification: a consecutive cohort of 16,604 patients presenting to primary care

BackgroundFaecal immunochemical tests (FITs) are used to triage primary care patients with symptoms that could be caused by colorectal cancer for referral to colonoscopy. The aim of this study was to determine whether combining FIT with routine blood test results could improve the performance of FIT in the primary care setting.MethodsResults of all consecutive FITs requested by primary care providers between March 2017 and December 2020 were retrieved from the Oxford University Hospitals NHS Foundation Trust. Demographic factors (age, sex), reason for referral, and results of blood tests within 90 days were also retrieved. Patients were followed up for incident colorectal cancer in linked hospital records. The sensitivity, specificity, positive and negative predictive values of FIT alone, FIT paired with blood test results, and several multivariable FIT models, were compared.ResultsOne hundred thirty-nine colorectal cancers were diagnosed (0.8%). Sensitivity and specificity of FIT alone at a threshold of 10 μg Hb/g were 92.1 and 91.5% respectively. Compared to FIT alone, blood test results did not improve the performance of FIT. Pairing blood test results with FIT increased specificity but decreased sensitivity. Multivariable models including blood tests performed similarly to FIT alone.ConclusionsFIT is a highly sensitive tool for identifying higher risk individuals presenting to primary care with lower risk symptoms. Combining blood test results with FIT does not appear to lead to better discrimination for colorectal cancer than using FIT alone.

Start spreading the word ….

Sam Foster, Chief Nurse, Oxford University Hospitals, considers how best to start a movement to benefit the patient experience, such as the #CallMe movement, which encourages staff to use patients' preferred names.

Real-world evaluation of rapid and laboratory-free COVID-19 triage for emergency care: external validation and pilot deployment of artificial intelligence driven screening

SummaryBackgroundUncertainty in patients' COVID-19 status contributes to treatment delays, nosocomial transmission, and operational pressures in hospitals. However, the typical turnaround time for laboratory PCR remains 12–24 h and lateral flow devices (LFDs) have limited sensitivity. Previously, we have shown that artificial intelligence-driven triage (CURIAL-1.0) can provide rapid COVID-19 screening using clinical data routinely available within 1 h of arrival to hospital. Here, we aimed to improve the time from arrival to the emergency department to the availability of a result, do external and prospective validation, and deploy a novel laboratory-free screening tool in a UK emergency department.MethodsWe optimised our previous model, removing less informative predictors to improve generalisability and speed, developing the CURIAL-Lab model with vital signs and readily available blood tests (full blood count [FBC]; urea, creatinine, and electrolytes; liver function tests; and C-reactive protein) and the CURIAL-Rapide model with vital signs and FBC alone. Models were validated externally for emergency admissions to University Hospitals Birmingham, Bedfordshire Hospitals, and Portsmouth Hospitals University National Health Service (NHS) trusts, and prospectively at Oxford University Hospitals, by comparison with PCR testing. Next, we compared model performance directly against LFDs and evaluated a combined pathway that triaged patients who had either a positive CURIAL model result or a positive LFD to a COVID-19-suspected clinical area. Lastly, we deployed CURIAL-Rapide alongside an approved point-of-care FBC analyser to provide laboratory-free COVID-19 screening at the John Radcliffe Hospital (Oxford, UK). Our primary improvement outcome was time-to-result, and our performance measures were sensitivity, specificity, positive and negative predictive values, and area under receiver operating characteristic curve (AUROC).Findings72 223 patients met eligibility criteria across the four validating hospital groups, in a total validation period spanning Dec 1, 2019, to March 31, 2021. CURIAL-Lab and CURIAL-Rapide performed consistently across trusts (AUROC range 0·858–0·881, 95% CI 0·838–0·912, for CURIAL-Lab and 0·836–0·854, 0·814–0·889, for CURIAL-Rapide), achieving highest sensitivity at Portsmouth Hospitals (84·1%, Wilson's 95% CI 82·5–85·7, for CURIAL-Lab and 83·5%, 81·8–85·1, for CURIAL-Rapide) at specificities of 71·3% (70·9–71·8) for CURIAL-Lab and 63·6% (63·1–64·1) for CURIAL-Rapide. When combined with LFDs, model predictions improved triage sensitivity from 56·9% (51·7–62·0) for LFDs alone to 85·6% with CURIAL-Lab (81·6–88·9; AUROC 0·925) and 88·2% with CURIAL-Rapide (84·4–91·1; AUROC 0·919), thereby reducing missed COVID-19 cases by 65% with CURIAL-Lab and 72% with CURIAL-Rapide. For the prospective deployment of CURIAL-Rapide, 520 patients were enrolled for point-of-care FBC analysis between Feb 18 and May 10, 2021, of whom 436 received confirmatory PCR testing and ten (2·3%) tested positive. Median time from arrival to a CURIAL-Rapide result was 45 min (IQR 32–64), 16 min (26·3%) sooner than with LFDs (61 min, 37–99; log-rank p<0·0001), and 6 h 52 min (90·2%) sooner than with PCR (7 h 37 min, 6 h 5 min to 15 h 39 min; p<0·0001). Classification performance was high, with sensitivity of 87·5% (95% CI 52·9–97·8), specificity of 85·4% (81·3–88·7), and negative predictive value of 99·7% (98·2–99·9). CURIAL-Rapide correctly excluded infection for 31 (58·5%) of 53 patients who were triaged by a physician to a COVID-19-suspected area but went on to test negative by PCR.InterpretationOur findings show the generalisability, performance, and real-world operational benefits of artificial intelligence-driven screening for COVID-19 over standard-of-care in emergency departments. CURIAL-Rapide provided rapid, laboratory-free screening when used with near-patient FBC analysis, and was able to reduce the number of patients who tested negative for COVID-19 but were triaged to COVID-19-suspected areas.FundingThe Wellcome Trust, University of Oxford Medical and Life Sciences Translational Fund.

The use of smartphone-application based medical photography for open fractures: A national survey of orthoplastic affiliated Major Trauma Centres in England

IntroductionBAPRAS/BOAST 4 guidelines recommend the use of medical photography for peri-operative management of open fractures. Smartphones are a common commodity for the modern day plastic surgeon and there is evidence their utilization improves guideline compliance at Major Trauma Centres (MTCs). AimTo capture national data assessing the prevalence and intricacies of smartphone app-based photography systems used for open fractures in plastic surgery units at MTCs in England. MethodA structured questionnaire survey was used to collate and analyze the responses of plastic surgeons and trainees at all MTCs in England. The survey included participant demographics, type and use of medical photography systems, and opinions on the usefulness of integrating a dedicated app in practice. We later explore the background, costs, download process, functionality and NHS governance applicability of each application. ResultsThe most popular clinical imaging modalities included professional photographers (65%) and departmental cameras (60%). Only 6 (26%) of MTCs use the following four smartphone app-based photography systems: Oxford University Hospital FotoApp, Medical Data Solutions and Services, Haiku and Secure Clinical Image Transfer. All systems are GDPR compliant and three systems auto upload images onto hospital databases. Five units report using messaging apps (Forward, Siilo, Whatsapp) with photography functionality. All participants agreed that a dedicated imaging smartphone app would be useful in open fracture management. ConclusionPlastic surgery is a highly visual specialty and clinical photography complements patient care. In the era of COVID-19 where resources are finite and professional photography not always available, this national survey highlights a demand for integrating smartphone app-based photography to improve guideline compliance, inter- and intra-disciplinary team communication and patient care.

CT angiogram field of view for suspected thoracic aortic dissection

Background: Computed tomography (CT) angiograms performed to look for acute thoracic aortic dissection routinely include the abdomen. Data collected over a two-year period (2018–2020) at Oxford University Hospitals found a 2.9% positive detection rate for thoracic aortic dissection and 1.7% of scans showed a thoracic aortic dissection extending below the diaphragm. Detecting potential abdominal extension is the primary reason for including the abdomen in the examination. The need to routinely scan the abdomen and pelvis for cases of suspected thoracic aortic dissection alone was therefore questioned.

Clinical associations with carriage of pulmonary Stenotrophomonas maltophilia.

Stenotrophomonas maltophilia causes opportunistic respiratory infections and is associated with declining lung function in patients with cystic fibrosis (CF). Risk factors for carrying S. maltophilia remain unclear. We conducted a retrospective study of patients yielding ⩾1 respiratory S. maltophilia isolate at the Oxford University Hospitals Trust between 2014 and 2019 and a cohort study of S. maltophilia carriage in CF patients attending annual review in 2018. Seven hundred and forty isolates were identified from 238 patients (median 1.0 isolate/patient). Predisposing conditions included invasive ventilation (29.8%), CF (25.6%) and non-CF bronchiectasis (24.4%). The rates of Stenotrophomonas isolates and co-trimoxazole resistance were stable over time. About 10.8% of isolates were co-trimoxazole-resistant, with resistance more common in CF than in other diagnoses (29.5% vs 5.8%, p < 0.001). No clinical features were significantly associated with S. maltophilia carriage in the CF population. We present new insight into the epidemiology of Stenotrophomonas colonisation/infection and identify increased co-trimoxazole resistance in CF isolates.

Audit of Neoadjuvant Chemoradiotherapy Outcomes for Locally Advanced Oesophageal Cancer at Oxford University Hospital Trust

Category: Gastro-oesophageal

Unpicking the reasons for missed care.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on the need to understand reasons for 'errrors of omission' and how they relate to the environment in which nurses provide care.

Germline variant testing in serrated polyposis syndrome.

Background and AimSerrated polyposis syndrome (SPS) is now known to be the commonest polyposis syndrome. Previous analyses for germline variants have shown no consistent positive findings. To exclude other polyposis syndromes, 2019 British Society of Gastroenterology (BSG) guidelines advise gene panel testing if the patient is under 50 years, there are multiple affected individuals within a family, or there is dysplasia within any of the polyps.MethodsA database of SPS patients was established at the Oxford University Hospitals NHS Foundation Trust. Patients were referred for genetic assessment based on personal and family history and patient preference. The majority were tested for a hereditary colorectal cancer panel including MUTYH, APC, PTEN, SMAD4, BMPR1A, STK11, NTLH1, POLD1, POLE, GREM1 (40‐kb duplication), PMS2, and Lynch syndrome mismatch repair genes.ResultsOne hundred and seventy‐three patients were diagnosed with SPS based on World Health Organization 2019 criteria between February 2010 and December 2020. The mean age of diagnosis was 54.2 ± 16.8 years. Seventy‐three patients underwent genetic testing and 15/73 (20.5%) were found to have germline variants, of which 7/73 (9.6%) had a pathogenic variant (MUTYH n = 2, SMAD4 n = 1, CHEK2 n = 2, POLD1 n = 1, and RNF43 n = 1). Only 60% (9/15) of these patients would have been recommended for gene panel testing according to current BSG guidelines.ConclusionsA total of 20.5% of SPS patients tested were affected by heterozygous germline variants, including previously unreported associations with CHEK2 and POLD1. This led to a change in management in seven patients (9.6%). Current recommendations may miss SPS associated with germline variants, which is more common than previously anticipated.

Understanding those 'future nurses'.

Sam Foster, Chief Nurse, Oxford University Hospitals, looks at the findings of a new report from UCAS and Health Education England into the mindset of the 2021 applicants to study nursing.