London Teaching Hospital Research Articles

PMM.48 Mother to child transmission (MTCT) of HIV: Almost a thing of the past?

IntroductionInterventions, including commencement of antiretroviral therapy (ARV), have decreased the rate of MTCT to less than 1%. This study looks at women who commenced ARV therapy during pregnancy as this...

The Interaction of Vasopressin and Corticosteroids in Septic Shock

Vasopressin and corticosteroids are both commonly used adjunctive therapies in septic shock. Retrospective analyses have suggested that there may be an interaction between these drugs, with higher circulating vasopressin levels and improved outcomes in patients treated with both vasopressin and corticosteroids. We aimed to test for an interaction between vasopressin and corticosteroids in septic shock. Prospective open-label randomized controlled pilot trial. Four adult ICUs in London teaching hospitals. Sixty-one adult patients who had septic shock. Initial vasopressin IV infusion titrated up to 0.06 U/min and then IV hydrocortisone (50 mg 6 hourly) or placebo. Plasma vasopressin levels were measured at 6-12 and 24-36 hours after hydrocortisone/placebo administration. Thirty-one patients were allocated to vasopressin + hydrocortisone and 30 patients to vasopressin + placebo. The hydrocortisone group required a shorter duration of vasopressin therapy (3.1 d; 95% CI, 1.1-5.1; shorter in hydrocortisone group) and required a lower total dose of vasopressin (ratio, 0.47; 95% CI, 0.32-0.71) compared with the placebo group. Plasma vasopressin levels were not higher in the hydrocortisone group compared with the placebo group (64 pmol/L difference at 6- to 12-hour time point; 95% CI, -32 to 160 pmol/L). Early vasopressin use was well tolerated with only one serious adverse event possibly related to study drug administration reported. There were no differences in mortality rates (23% 28-day mortality in both groups) or organ failure assessments between the two treatment groups. Hydrocortisone spared vasopressin requirements, reduced duration, and reduced dose, when used together in the treatment of septic shock, but it did not alter plasma vasopressin levels. Further trials are needed to assess the clinical effectiveness of vasopressin as the initial vasopressor therapy with or without corticosteroids.

Detailed evaluation of One Step Nucleic Acid (OSNA) molecular assay for intra-operative diagnosis of sentinel lymph node metastasis and prediction of non-sentinel nodal involvement: Experience from a London Teaching Hospital

Detailed evaluation of One Step Nucleic Acid (OSNA) molecular assay for intra-operative diagnosis of sentinel lymph node metastasis and prediction of non-sentinel nodal involvement: Experience from a London Teaching Hospital

G165 Female genital mutilation in London and the UNICEF report; a local perspective on worldwide statistics

BackgroundIn July 2013 the UNICEF report stated that 125 million women worldwide are affected by female genital mutilation (FGM). Despite an estimated 20,000 children at risk in the UK there...

Detection of antibiotic resistances of Mycobacterium tuberculosis on DNA microarrays

Background: This study describes the development of an automated surveillance system using antimicrobial consumption data for the prediction of potential emergence of carbapenem-resistant organisms. It was derived from a retrospective analysis of an intervention to contain a prolonged OXA-48 producing K. pneumoniae outbreak. Methods & Materials: A time series analysis (May 2005-April 2013) was conducted around an intervention to contain an outbreak (Jan2008-April 2010)of anOXA-48-producingK. pneumoniae in the renal unit of a West London teaching hospital. The intervention focused on reinforcement of the renal antimicrobial policy and the decrease of carbapenem usage, as part of the overall stewardship strategy. Three mechanisms were promoted: awareness, education and feedback. A multivariate ARIMA model was developed utilising meropenem consumption data (defined daily dose per 100 occupied bed-days; DDD/100OBD) as a predictor of the incidence of OXA-48-producing organisms. Results: Meropenem usage was increasing by 7.13DDD/100OBD/year (95%CI 3.46-10.80; p<0.001) from 6.30DDD/100OBD/year prior to the intervention but decreased steadily for 4 years thereafter. The changes in slope of the time series were -10.18DDD/100OBD/year (95% CI, -16.63-3.73). Analysis of consumption of other gram negative antimicrobials was also undertaken and showed a significant increase in amikacin usage post-intervention from 0.56 to 4.07DDD/100OBD/year (slope= +0.83; 95%CI, 0.13-1.53). The incidence of OXA-48producing organisms was significantly increasing by 2.2 cases per year pre-intervention, and decreased thereafter. Meropenem usage at lag-1 year was highly correlated to the incidence of OXA-48-producing organisms (r =0.74, pvalue =0.04) and was included as a predictor within the ARIMA model for forecasting the incidence of resistant isolates. Conclusion: Our findings support an association between reinforcement of a specific antimicrobial policy and both meropenem usage, and a decreasing incidence of OXA-48-producing K. pneumoniae. Meropenem usage at lag-1 year was found to be a good predictor of the incidence of OXA-48-producing K. pneumoniae in the ARIMA model, although we need to remain cautious about the causality. This prediction model requires further development but shows early signs of how close surveillance of antimicrobial consumption can act as a warning indicator to anticipate potential outbreaks of drug resistance organisms and should be considered as part of healthcare organisations’ antimicrobial stewardship programmes.

Surveillance of antimicrobial consumption data: Development of an early warning system for carbapenem resistance derived from a retrospective analysis of an OXA-48 producing K. pneumoniae outbreak

Background: This study describes the development of an automated surveillance system using antimicrobial consumption data for the prediction of potential emergence of carbapenem-resistant organisms. It was derived from a retrospective analysis of an intervention to contain a prolonged OXA-48 producing K. pneumoniae outbreak. Methods & Materials: A time series analysis (May 2005-April 2013) was conducted around an intervention to contain an outbreak (Jan2008-April 2010)of anOXA-48-producingK. pneumoniae in the renal unit of a West London teaching hospital. The intervention focused on reinforcement of the renal antimicrobial policy and the decrease of carbapenem usage, as part of the overall stewardship strategy. Three mechanisms were promoted: awareness, education and feedback. A multivariate ARIMA model was developed utilising meropenem consumption data (defined daily dose per 100 occupied bed-days; DDD/100OBD) as a predictor of the incidence of OXA-48-producing organisms. Results: Meropenem usage was increasing by 7.13DDD/100OBD/year (95%CI 3.46-10.80; p<0.001) from 6.30DDD/100OBD/year prior to the intervention but decreased steadily for 4 years thereafter. The changes in slope of the time series were -10.18DDD/100OBD/year (95% CI, -16.63-3.73). Analysis of consumption of other gram negative antimicrobials was also undertaken and showed a significant increase in amikacin usage post-intervention from 0.56 to 4.07DDD/100OBD/year (slope= +0.83; 95%CI, 0.13-1.53). The incidence of OXA-48producing organisms was significantly increasing by 2.2 cases per year pre-intervention, and decreased thereafter. Meropenem usage at lag-1 year was highly correlated to the incidence of OXA-48-producing organisms (r =0.74, pvalue =0.04) and was included as a predictor within the ARIMA model for forecasting the incidence of resistant isolates. Conclusion: Our findings support an association between reinforcement of a specific antimicrobial policy and both meropenem usage, and a decreasing incidence of OXA-48-producing K. pneumoniae. Meropenem usage at lag-1 year was found to be a good predictor of the incidence of OXA-48-producing K. pneumoniae in the ARIMA model, although we need to remain cautious about the causality. This prediction model requires further development but shows early signs of how close surveillance of antimicrobial consumption can act as a warning indicator to anticipate potential outbreaks of drug resistance organisms and should be considered as part of healthcare organisations’ antimicrobial stewardship programmes.

Neurofilament heavy chain as a marker of neuroaxonal pathology and prognosis in acute encephalitis

The neurological outcome of acute encephalitis can be devastating and early prognosis remains difficult. Biomarkers that quantify the extent of early brain injury are needed to improve the prognostic accuracy and aid patient management. Our objective was to assess whether cerebrospinal fluid (CSF) protein biomarkers of neuroaxonal and glial cell injury are elevated in distinct forms of acute encephalitis and predictive of poor outcome. This was a prospective study of patients presenting with acute encephalitis to three teaching hospitals in London, UK. Levels of neurofilament heavy chain (NfH, SMI35) and S100B were quantified in CSF using enzyme-linked immunosorbent assay. The outcome was assessed by the Glasgow Outcome Scale (GOS). Fifty-six patients with acute encephalitis were recruited and classified into the following diagnostic categories: infectious (n=20), inflammatory (n=14) and unknown etiology (n=22). Pathological levels of NfH and S100B were observed in 24/56 (43%) and 54/56 (96%), respectively. Patients with infectious encephalitis had significantly higher NfH levels compared with the other two groups (P<0.05). A poor outcome (GOS <5) was associated with significantly higher CSF NfH levels within samples taken 2weeks after symptom onset. This study suggests that longitudinal CSF NfH levels are of superior prognostic value compared with CSF S100B levels. Prolonged release of NfH, a marker of neuroaxonal damage, was associated with poor outcome. Potentially there is a window of opportunity for future neuroprotective treatment strategies in encephalitis.

Internationally recruited neonatal nurses' experiences in the National Health Service in London

The aim of this study was to explore internationally recruited neonatal nurses' (IRNNs) perceptions of their experiences of working in the National Health Service (NHS) in London. This was an exploratory study. A purposive sample of 13 nurses (all females) from two teaching hospitals in London participated in this study. Semi-structured face-to-face interviews were used to capture IRNNs views of working in the NHS in London. Five themes emerged, namely: motivation to migrate, lack of preparation for neonatal nurses, environmental conditions impacting on care delivery, neonatal nurses deskilling, and role restrictions as well as professional development. The findings of this study provide first-hand insights from the subjective perspectives of IRNN experiences. IRNNs experienced some challenges to their working lives; however, good preparation is important when recruiting them to work in the NHS.

Detailed evaluation of one step nucleic acid (OSNA) molecular assay for intra-operative diagnosis of sentinel lymph node metastasis and prediction of non-sentinel nodal involvement: Experience from a London Teaching Hospital

One step nucleic acid (OSNA) is a molecular diagnostic assay for intra-operative detection of sentinel node metastases. This study compared OSNA with standard histopathology in 283 nodes from 170 patients to evaluate sensitivity, specificity and concordance of the two methods. Additional analysis was done to investigate how cytokeratin 19 mRNA copy number affects prediction of non-sentinel node positivity. OSNA sensitivity was 93.2% and specificity 95.8%. Concordance between OSNA and histology was 95.6%. In the patients who had axillary clearance, the OSNA mRNA copy number on the sentinel node had 100% negative predictive value for histologically proven metastasis. mRNA copy numbers <1400 were not associated with histologically proven metastasis in subsequent nodes at axillary clearance. OSNA is a reliable method for the intra-operative evaluation of axillary lymph node metastasis even when half of the lymph node is used. Identification of mRNA copy number threshold predicting the positivity of non-sentinel axillary nodes seems to be feasible and would be clinically important.

The Headache Patients Journey through the Emergency Department: A Service Evaluation

The objective of this study was to evaluate the assessment, management, and re-attendance rates for patients presenting with headache to the Emergency Department (ED) at a large London Teaching Hospital.

Teenage Pregnancy: Risk Factors, Outcomes, and Possible Targets for Prevention: A Retrospective Cohort Study

Aim : To identify the important risk factors as well as observe some short and long term maternal and perinatal outcomes associated with teenage pregnancy. Methods: A retrospective cohort study of 142 teen age adolescent mothers was carried out over a 2 year period in an inner city teaching hospital and tertiary referral centre in South East London. Results were compared with a control group of 4004 22-29 year old pregnant women over the same period. Results: Our study demonstrates associations between teenage pregnancy and some adverse outcomes, namely low birth weight, low Apgar scores and lower incidence of artificial first feed. But contrary to the published literature, no correlation was found with pre-eclampsia, fetal growth restriction, preterm labour, operative vaginal delivery and caesarean section.

Evaluating trainee experience of surgical skills teaching

Introduction: Operating theatres are a crucial learning environment for trainee surgeons developing surgical skills. There is no structured framework for teaching during surgery or its evaluation. Objective assessment of the learning experience can assess quality and highlight areas for improvement, maximizing benefit. Methods: A 5-point Likert rating scale was devised to assess surgical teaching experience. Positive and negative teaching attributes were established with a literature review and interviews of trainees and teachers. Sixty surgical trainees at a major London teaching hospital, operating under consultant supervision, evaluated the supervisor teaching using the tool. Significance of test results from the assessment tool was analysed using repeated measures analysis of variance for Likert scoring. A P value 50.05 was considered statistically significant. Results: There was consensus between trainees on the relevance of tool themes, with most ranked important or absolutely essential and no difference across grades (P5 0.05). There was no difference in the overall supervisor scores between trainees with different levels of experience (P5 0.05) or between procedures with different levels of complexity (P5 0.05). Junior supervisors scored more highly overall than senior supervisors (P = 0.024). Discussion: The study demonstrated that the assessment tool is feasible, practical and applicable, with face and content validity. Discrimination between supervisors with different levels of experience shows discriminative validity. The tool facilitates objective assessment of the teaching experience in surgery. We hope this will aid improvements in teaching quality, an area for further study.

An analysis of medicine costs of adult patients on a critical care unit

PurposeTo evaluate the costs of medicines used to treat critically ill patients in an intensive care environment and to correlate this with severity of illness and mortality. Materials and MethodsThe study was conducted at a London Teaching Hospital Critical Care Unit. Data were collected for patients who were either discharged or died during September 2011 and stayed longer than 48 hours. The drug cost was related to 150 drugs that were then related to patient's acuity and outcome. ResultsThe median daily drug cost of the 85 patients was £26. The highest cost patients in the 85th percentile had significantly higher daily drug costs (median, £403) and higher scores for patient acuity. Patients with hematologic malignancy had a median daily drug cost (£561) more than 20 times higher than those without. A regression analysis based on patient's diversity explained 93% of the variance in the daily drug cost. ConclusionsAlthough the median daily drug cost for an adult critically ill patient was low, this cost significantly escalated with patient acuity and hematologic malignancy. A reference method has been designed for an in-depth evaluation of daily drug cost that could be used to compare expenditure in other units.

P64 The impact of simple interventions on oxygen prescribing and monitoring: Audit of oxygen management in Central London Teaching Hospital

IntroductionOxygen is one of the most commonly used drugs, but one of the most poorly prescribed. National BTS audits show many patients receive oxygen without prescription1. Local historical data showed...

Joint replacement recipients' views about health information privacy

Researchers are concerned about the possibility of restricted access to data as a result of specific consent requirements in privacy legislation, potentially resulting in smaller samples and a lack of representativeness which could bias results. In addition, there is uncertainty about what influences individuals to give consent for the use of their personal health information. To measure joint replacement recipients' health information privacy views and to assess potential predictors of these views. Cross-sectional survey. Potential joint replacement recipients from two teaching hospitals in London, Ontario, Canada. Age, gender, education, employment status, anticipated joint replacement, and expectations for surgery. Privacy concerns as measured by the Concern Scale. The response rate was 182/253 or 72%. The mean Concern score was 143.9/235.0 for the total sample (range = 82-216). Women had higher levels of privacy concerns than men on slightly over half of the individual questionnaire items. In women, surgical joint, age and employment explained 15% of the variance in concerns about personal health information privacy (P = 0.001). The model explained 6% of the variance in concerns in men (P = 0.138) and was not statistically significant. This study indicates that demographic characteristics and health-care experiences play a role in the variability of health information privacy concerns. A greater understanding of patients' privacy views about health information could lead to a greater harmonization among privacy rules, research and data access, and the preferences of health-care consumers.

Disenfranchised grief following a non-fatal road traffic incident: A case study exploring a mother’s experience

This case study explores a scenario that was observed by a final year nursing student on placement in a paediatric emergency department, in a busy London teaching hospital. A mother appeared distressed following the news that her son who had survived a road traffic incident with minimal impact to his cognitive and physical abilities, was stable enough to be transferred to the children’s medical ward. Whilst this appeared to be positive for supporting figures in her life and the emergency practitioners involved, observation and discussion with the mother revealed that her distress was related to her experience of losses that were undetected by those around her. This included losses related to her son’s future and the loss of her previous world. Amongst the plethora of theories about how we as humans react to loss and change, one theory which could explain the mother’s grief suggests that it was disenfranchised, i.e. it was not acknowledged or validated by society. There are consequences of disenfranchised grief, such as a lack of social support leading to a higher risk of adverse psychological outcomes. Nurses in the emergency department can help resolve negative outcomes for patients and families experiencing disenfranchised grief. The key steps are to have knowledge of disenfranchised grief to be able to detect it, and then to validate it as a form of grief.

Errors made with 24 hour plain film reporting – a single centre’s 2 year experience

Background: Pressure for rapid turnaround of Xray reports has led to 24hr reporting in a central London teaching hospital. This audit aimed to assess whether time of day had an impact on reporting errors when working a shift pattern.

Editorial introductions

Editorial introductions

Patient characteristics and severity of human rhinovirus infections in children

BackgroundIt is increasingly recognized that human rhinoviruses (HRV) can be associated with severe infections. However, conflicting results have been reported on the relative prevalence and severity of the three HRV species. ObjectivesThe relative prevalence and clinical characteristics of HRV-A, B and C, in children attending a South London teaching hospital were investigated retrospectively. Study designChildren aged <16 years with episodes of respiratory tract infections and detectable entero/rhinovirus RNA in respiratory samples between November 2009 and December 2010 were investigated. Retrospective case review was performed and patients’ characteristics recorded. ResultsEntero/rhinoviruses were the commonest viral pathogens (498/2316; 21.5%). Amongst 204 infection episodes associated with entero/rhinovirus, 167 were typed HRV, HRV-C was the most prevalent (99/167, 59.3%) followed by HRV-A (60/167; 35.9%) and HRV-B (8/167, 4.8%). The severity spectrum of HRV-A and HRV-C infections were similar and affected all parts of the respiratory tract. Co-pathogens were observed in 54 (26.5%) episodes. Severity was increased in patients with non-viral co-pathogens and those with an underlying respiratory condition. Univariate and multiple regression analyses of potential prognostic variables including age, co-pathogens and underlying respiratory illnesses showed that mono-infection with HRV-C, as compared with other HRV species, was associated with more severe disease in young children <3 years. ConclusionsHRV-C was the most prevalent species and on its own was associated with severe disease in children <3 years. The association between infection with HRV species and clinical presentation is complex and affected by many confounding factors.

Emergency department multiprofessional handover

Emergency department (ED) handovers are arguably more complex than handovers in the ward environment. This is because of an unpredictable patient load, fluctuations in acuity, compressed time frames and the undifferentiated or undiagnosed nature of clinical problems. In order to ensure safe, relevant and accurate handovers, we have implemented a novel multiprofessional model. The model ensures that staff groups communicate, interact and learn together. In this study we investigated the effectiveness and usefulness of this new morning handover structure at St Thomas' Hospital, a busy teaching hospital in London, UK. A questionnaire about the multiprofessional handover (MPH) was given to all 75 staff attending an MPH over a 1-week period, a year after it was introduced. The objective was to determine whether MPH is effective in the Emergency Department. All 75 staff attending MPH in the study period completed a questionnaire. All of the staff found it a useful update on departmental and trust-wide issues. The results demonstrated that staff mostly supported the new MPH structure. A majority agreed that it provided enough information about patient care (67 staff members). The results suggested that MPH is an effective way to deliver handover within the ED. Our unique morning handover structure ensures patient safety, as well as the appropriate transfer of information and responsibility to all involved with the care of patients in the ED. It offers the opportunity for multiprofessional learning, encourages teamwork and improves operational processes within the ED.