Apostolos Fakis

Markers of arterial stiffness are risk factors for progression to end-stage renal disease among patients with chronic kidney disease stages 4 and 5.

Background: Factors associated with chronic kidney disease (CKD) contribute to an increased risk of cardiovascular disease and death. The impact of vascular disease on CKD progression is, however, less well studied. Methods: We examined the effect of markers of vascular disease on the risk of progression to end-stage renal disease (ESRD) in 35 patients with CKD stages 4–5. Superficial femoral artery calcification was assessed by CT scan. Augmentation index (AI) and pulse wave velocity (PWV) were measured by applanation tonometry. Results: After 12.4 (5.5–28.4) months, 22/35 patients (63%) had commenced dialysis. Cox regression analysis identified baseline estimated glomerular filtration rate (hazard ratio, HR, 0.54; 95% CI 0.41–0.70; p < 0.0001), urinary protein (HR 1.84; 95% CI 1.32–2.58; p = 0.0005), PWV (HR 1.30; 95% CI 1.07–1.60; p = 0.01), AI (HR 1.08; 95% CI 1.04–1.14; p = 0.0001) and pack years of smoking (HR 1.01; 95% CI 1.00–1.03; p = 0.02) as independent risk factors for time to ESRD (–2 log likelihood = 86.7; χ2 = 30.9; p < 0.0001). Repeat analysis using AI as a categorical variable revealed an HR of 17.5 (95% CI 4.43–68.9; p < 0.0001) for time to ESRD in those with AI above versus below the median. Conclusions: We have identified two markers of arterial stiffness as independent risk factors for progression to ESRD suggesting that vascular disease may contribute to CKD progression.

Risk factors in lateral epicondylitis (tennis elbow): a case-control study

Lateral epicondylitis is a common condition, but relatively little is known about its aetiology and associated risk factors. We have undertaken a large case-control study using The Health Improvement Network database to assess and quantify the relative contributions of some constitutional and environmental risk factors for lateral epicondylitis in the community. Our dataset included 4998 patients with lateral epicondylitis who were individually matched with a single control by age, sex, and general practice. The median age at diagnosis was 49 (interquartile range 42–56) years . Multivariate analysis showed that the risk factors associated with lateral epicondylitis were rotator cuff pathology (OR 4.95), De Quervain’s disease (OR 2.48), carpal tunnel syndrome (OR 1.50), oral corticosteroid therapy (OR 1.68), and previous smoking history (OR 1.20). Diabetes mellitus, current smoking, trigger finger, rheumatoid arthritis, alcohol intake, and obesity were not found to be associated with lateral epicondylitis.

An epidemiological study of rotator cuff pathology using The Health Improvement Network database

Little is known about the incidence of rotator cuff pathology or its demographic associations in the general population. We undertook a large epidemiological study of rotator cuff pathology in the United Kingdom using The Health Improvement Network (THIN) database. The incidence of rotator cuff pathology was 87 per 100,000 person-years. It was more common in women than in men (90 cases per 100,000 person-years in women and 83 per 100,000 person-years in men; p < 0.001). The highest incidence of 198 per 100,000 person-years was found in those aged between 55 and 59 years. The regional distribution of incidence demonstrated an even spread across 13 UK health authorities except Wales, where the incidence was significantly higher (122 per 100,000 person-years; p < 0.001). The lowest socioeconomic group had the highest incidence (98 per 100,000 person-years). The incidence has risen fourfold since 1987 and as of 2006 shows no signs of plateauing. This study represents the largest general population study of rotator cuff pathology reported to date. The results obtained provide an enhanced appreciation of the epidemiology of rotator cuff pathology and may help to direct future upper limb orthopaedic services.

Determinants of Arterial Stiffness in Chronic Kidney Disease Stage 3

Background Early chronic kidney disease (CKD) is associated with increased cardiovascular (CV) risk but underlying mechanisms remain uncertain. Arterial stiffness (AS) is associated with increased CV risk in advanced CKD, but it is unclear whether AS is relevant to CV disease (CVD) in early CKD. Study Design Cross-sectional. Setting and participants 1717 patients with previous estimated glomerular filtration rate (eGFR) 59–30 mL/min/1.73 m2; mean age 73±9y, were recruited from 32 general practices in primary care. Outcomes Increased arterial stiffness. Measurements Medical history was obtained and participants underwent clinical assessment, urine and serum biochemistry testing. Carotid to femoral pulse wave velocity (PWV) was determined as a measure of AS, using a Vicorder™ device. Results Univariate analysis revealed significant correlations between PWV and risk factors for CVD including age (r = 0.456; p<0.001), mean arterial pressure (MAP) (r = 0.228; p<0.001), body mass index (r = −0.122; p<0.001), log urinary albumin to creatinine ratio (r = 0.124; p<0.001), Waist to Hip ratio (r = 0.124, p<0.001), eGFR (r = −0.074; p = 0.002), log high sensitivity c-reactive protein (r = 0.066; p = 0.006), HDL (r = −0.062; p = 0.01) and total cholesterol (r = −0.057; p = 0.02). PWV was higher in males (9.6 m/sec vs.10.3 m/sec; p<0.001), diabetics (9.8 m/sec vs. 10.3 m/sec; p<0.001), and those with previous CV events (CVE) (9.8 m/s vs. 10.3 m/sec; p<0.001). Multivariable analysis identified age, MAP and diabetes as strongest independent determinants of higher PWV (adjusted R2 = 0.29). An interactive term indicated that PWV increased to a greater extent with age in males versus females. Albuminuria was a weaker determinant of PWV and eGFR did not enter the model. Limitations Data derived from one study visit, with absence of normal controls. Conclusion In this cohort, age and traditional CV risk factors were the strongest determinants of AS. Albuminuria was a relatively weak determinant of AS and eGFR was not an independent determinant. Long-term follow-up will investigate AS as an independent risk factor for CVE in this cohort.

A prospective study of adverse drug reactions to antiepileptic drugs in children

Objectives To prospectively determine the nature and rate of adverse drug reactions (ADRs) in children on antiepileptic drugs (AEDs) and to prospectively evaluate the effect of AEDs on behaviour. Setting A single centre prospective observational study. Participants Children (<18 years old) receiving one or more AEDs for epilepsy, at each clinically determined follow-up visit. Primary and secondary outcomes Primary outcome was adverse reactions of AEDs. Behavioural and cognitive functions were secondary outcomes. Results 180 children were recruited. Sodium valproate and carbamazepine were the most frequently used AEDs. A total of 114 ADRs were recorded in 56 of these children (31%). 135 children (75%) were on monotherapy. 27 of the 45 children (60%) on polytherapy had ADRs; while 29 (21%) of those on monotherapy had ADRs. The risk of ADRs was significantly lower in patients receiving monotherapy than polytherapy (RR: 0.61, 95% CI 0.47 to 0.79, p<0.0001). Behavioural problems and somnolence were the most common ADRs. 23 children had to discontinue their AED due to an ADR. Conclusions Behavioural problems and somnolence were the most common ADRs. Polytherapy significantly increases the likelihood of ADRs in children. Trail registration number EudraCT (2007-000565-37).

Quantitative Analysis of Qualitative Information From Interviews A Systematic Literature Review

Background: A systematic literature review was conducted on mixed methods area. Objectives: The overall aim was to explore how qualitative information from interviews has been analyzed using quantitative methods. Methods: A contemporary review was undertaken and based on a predefined protocol. The references were identified using inclusion and exclusion criteria and specific key terms in 11 search databases. Results: Evidence was synthesized from 14 references that included the methods used for quantifying qualitative information, analyzing it statistically and the rationale behind this. Gaps in the existing literature and recommendations for future research were identified. Conclusions: This review highlights the need for a new mixed method based on advanced statistical modeling method that will explore complex relationships arising from qualitative information.

Rationale and design of a multi-centre randomised controlled trial of individualised cooled dialysate to prevent left ventricular systolic dysfunction in haemodialysis patients

BackgroundThe main hypothesis of this study is that patients having regular conventional haemodialysis (HD) will have a smaller decline in cardiac systolic function by using cooler dialysate. Cooler dialysate may also be beneficial for brain function.Methods/DesignThe trial is a multicentre, prospective, randomised, un-blinded, controlled trial. Patients will be randomised 1:1 to use a dialysate temperature of 37°C for 12 months or an individualised cooled dialysate. The latter will be set at 0.5°C less than the patient’s own temperature, determined from the mean of 6 prior treatment sessions with a tympanic thermometer, up to a maximum of 36°C. Protocol adherence will be regularly checked. Inclusion criteria are incident adult HD patients within 180 days of commencing in-centre treatment 3 times per week with capacity to consent for the trial and without contra-indications for magnetic resonance imaging. Exclusion criteria include not meeting inclusion criteria, inability to tolerate magnetic resonance imaging and New York Heart Association Grade IV heart failure. During the study period, resting cardiac and cerebral magnetic resonance imaging will be performed at baseline and 12 months on an inter-dialytic day. Cardiovascular performance during HD will also be assessed by continuous cardiac output monitors, intra-dialytic echocardiography and biomarkers at baseline and 12 months. The primary outcome measure is a 5% between-group difference in left ventricular ejection fraction measured by cardiac magnetic resonance imaging at 12 months compared to baseline. Analysis will be by intention-to-treat. Secondary outcome measures will include changes in cerebral microstructure and changes in cardiovascular performance during HD. A total of 73 patients have been recruited into the trial from four UK centres. The trial is funded by a Research for Patient Benefit Grant from the National Institute of Healthcare Research. AO is funded by a British Heart Foundation Clinical Research Training Fellowship Grant. The funders had no role in the design of the study.DiscussionThis investigator-initiated study has been designed to provide evidence to help nephrologists determine the optimal dialysate temperature for preserving cardiac and cerebral function in HD patients.Trial registrationISRCTN00206012 and UKCRN ID 7422

Randomised controlled trial of video clips and interactive games to improve vision in children with amblyopia using the I-BiT system

Background Traditional treatment of amblyopia involves either wearing a patch or atropine penalisation of the better eye. A new treatment is being developed on the basis of virtual reality technology allowing either DVD footage or computer games which present a common background to both eyes and the foreground, containing the imagery of interest, only to the amblyopic eye. Methods A randomised control trial was performed on patients with amblyopia aged 4–8 years with three arms. All three arms had dichoptic stimulation using shutter glass technology. One arm had DVD footage shown to the amblyopic eye and common background to both, the second used a modified shooter game, Nux, with sprite and targets presented to the amblyopic eye (and background to both) while the third arm had both background and foreground presented to both eyes (non-interactive binocular treatment (non-I-BiT) games). Results Seventy-five patients were randomised; 67 were residual amblyopes and 70 had an associated strabismus. The visual acuity improved in all three arms by approximately 0.07 logMAR in the amblyopic eye at 6 weeks. There was no difference between I-BiT DVD and non-I-BiT games compared with I-BiT games (stated primary outcome) in terms of gain in vision. Conclusions There was a modest vision improvement in all three arms. Treatment was well tolerated and safe. There was no difference between the three treatments in terms of primary stated outcomes but treatment duration was short and the high proportion of previously treated amblyopia and strabismic amblyopia disadvantaged dichoptic stimulation treatment. Trial registration number NCT01702727, results.

A prospective study to assess the palatability of analgesic medicines in children

AIM This study examined childrens opinions on the taste of three analgesic medicines: paracetamol, ibuprofen and codeine. BACKGROUND Many medicines for children are unpleasant and unacceptable. Research has shown that childrens taste preferences differ to adults, in whom palatability is often tested. Little British research exists on childrens opinions on the palatability of medicines. This study aimed to address this gap in knowledge. DESIGN Prospective observational study. METHODS Between May-September 2008, hospital inpatients aged 5-16 years rated the taste of required analgesics on a 100-mm visual analogue scale. This incorporated a 5-point facial hedonic scale. They were also asked their favourite flavour and colour for a medicine. RESULTS A total of 159 children took part. Eighty-five males (53·5%) and 74 females (46·5%). The median age was 8 years (Inter-quartile range 6-11). The taste of ibuprofen was significantly preferred to paracetamol or codeine. Significant differences were observed depending if the medicine rated was taken first or second (for example pre-medication with paracetamol and ibuprofen). Younger children (5-8 years) were more likely to choose the extremes of the scale when grading than older children were. Preferred flavours on questioning were strawberry 44% and banana 17%. Favourite colours were pink 25·8% and red 20·8%, with girls more likely to choose pink and boys blue. CONCLUSION Ibuprofen was the most palatable analgesic medicine tested. Children reported they preferred fruit flavours and colour was sex dependent. Nurses when administering two medicines together should consider giving the least palatable first, for example paracetamol before ibuprofen for pre-medication.

Levine-Katz (Boston) Questionnaire analysis: means, medians or grouped totals?

were prescribed oral antibiotics on discharge. Those patients who were admitted (n1⁄4 12) were admitted to the plastic surgery or orthopaedic surgery units, with a majority being received in plastic surgery (50 from 51 patients). This is mainly attributable to the proportion of days on call for hand trauma (6:1). Of those patients who were admitted, two were transferred to the children’s hospital due to their age. Surgical exploration was performed exclusively in the emergency theatres, under general anaesthesia and tourniquet. Specialist registrars performed 100% of cases. Structural damage was revealed in 83% of cases. The injuries were flexor tendon laceration (n1⁄4 6), digital nerve damage (n1⁄4 4) or both tendon and nerve damage (n1⁄4 2). The majority of admissions were for injuries to zones II and III (5 and 6 admissions respectively). One patient presented with a laceration to the skin overlying the mandible. Oral antibiotics were prescribed on discharge to 10 patients; all were admitted patients who underwent surgery during their admission, with amoxicillin clavulanic acid (Augmentin Duo ) the antimicrobial of choice (n1⁄4 9). Fourteen patients were reviewed at least once postoperatively. Mean follow up was 8.4 weeks (range 1 to 36 weeks). Five of these patients dropped out of follow up and the remaining nine were discharged by the reviewing doctor. Six individuals, all with flexor tendon injury, were referred for physiotherapy. Longterm subjective complaints were seen in two individuals. One patient complained of stiffness and one patient complained of numbness associated with severed superficial digital nerve branch. Two flexor tendon repairs were lost to follow up. Longer follow up will be required for any meaningful conclusion to be drawn. To our knowledge, this is the first large study to clinically document the epidemiology and pathology of hand injuries caused by corrugated iron fences. The results indicate that the majority of the injuries are of a superficial nature, not particularly different from those caused by knives, glass and saws. Such injuries require similar treatment, consisting in repair of damaged structures. The majority of cases can be managed on an outpatient basis.