Chris Allen

Improving the management of spontaneous bacterial peritonitis in cirrhotic patients: assessment of an intervention in trainee doctors.

Spontaneous bacterial peritonitis (SBP) in cirrhotic patients is a serious complication associated with a high mortality rate. A baseline audit of the acute medical take (AMT) at Northwick Park suggested a lack of awareness regarding management. A questionnaire based on contemporary SBP guidelines was circulated to all trainee doctors (FY1 to SpR). Ascitic fluid testing requests were analysed over a six-month period. The electronic requesting system was updated to include prompts and direct links to Trust SBP guidelines, and a one-hour lecture to all members of the AMT, supported by an educational booklet on SBP, was performed. Re-audit was carried out six months post-intervention, the AMT completed a second questionnaire and ascitic fluid testing requests were re-audited. In comparable pre- and post-intervention AMT cohorts, a clinical and educational intervention led to a significant improvement in understanding of when to investigate (p≤0.001), samples (p = 0.002) and containers (p≤0.001) required, urgency of obtaining results (p≤0.001), and initiation of treatment for suspected SBP (p = 0.007). Significantly more ascitic samples were sent, with specific suspicion of SBP more readily documented, crucial to expediting laboratory processing. Targeted education and production of a clinical algorithm has significantly improved the management of patients with SBP.

Ivabradine: A Current Overview

Ivabradine, acting on the funny channel (If) in the sino-atrial node, reduces myocardial oxygen demand without inducing hypotension. It was developed as a specific bradycardic agent in the 1980s, avoiding the adverse effects of more traditional antianginal agents (beta-blockers and calcium channel antagonists). This has seen significant interest in this first-in-class treatment, and is perceived as a promising drug in the management of ischaemic heart disease and heart failure. There has been much clinical research conducted exploring its role in these fields, to try to elucidate potential benefits and target patient group. The side effect profile of ivabradine ensures it is well tolerated, and consistently leads to a reduction in heart rate. This review discusses the drug development and trial data in ischaemic heart disease and chronic left ventricular systolic dysfunction. Key clinical trials and observational studies are discussed in depth to examine potential explanations of unexpected or diverging results. The emerging role of ivabradine in acute decompensated heart failure is explored with recent trial data, providing a potential novel treatment avenue in this difficult to manage patient cohort. The role of intravenous ivabradine, as a beneficial tool in the acute hospital setting, when oral medication is not ideal, or where fast onset of action is required, in cardiac computerised tomography for example, is also discussed. Future directions for research are highlighted, including options for further elucidating unexplained results from previous studies.

Improving the management of iron deficiency in ambulatory heart failure patients

Based on clinical trial data patients with heart failure (HF) and evidence of iron deficiency should be offered intravenous (iv) iron with the aim of improving exercise capacity and symptoms. Baseline measurement in outpatient HF clinics demonstrated that only 50% of patients who may be eligible for iv iron were investigated with iron studies. Our aim was to make sure that 90% of the patients attending our heart failure clinics who were symptomatic and had an ejection fraction (EF) ≤45% should have their iron studies checked within the last six months. In an effort to increase the proportion of suitable patients in whom iron studies are requested, we carried out three plan-do-study-act (PDSA) cycles each with a different intervention. These interventions included a presentation of the clinical trial evidence at a HF multidisciplinary meeting, email reminders prior to clinic and stickers in the patient notes (repeated twice). The effect of each intervention was measured with the outcome being the proportion of eligible patients in whom iron studies were documented within the previous 6 months. The interventions increased the number of suitable patients who had iron studies checked, to as high as 100%, however this effect was not sustained. Root cause analysis revealed that clinicians were unenthusiastic to continue performing iron studies due to inefficiency in the process of admitting patients and giving them iv iron. For example median in-hospital stay of seven hours for an infusion that is given over 15 minutes. In an attempt to improve patient and physician satisfaction we piloted an ambulatory outpatient service to deliver iv iron. We demonstrated that this service was feasible and more efficient as less time was required waiting for a bed or spent in hospital and was less costly. In summary we have demonstrated interventions which can increase the identification of patients who would benefit from iv iron and piloted a new time and cost efficient system of administration of iv iron.

Experience from two decades of the Cambridge Rapid Access Neurology Clinic.

We report on the evolution of the rapid access neurology clinic (established in 1995) at Addenbrookes Hospital, Cambridge. Annualised attendance data demonstrate an ever increasing demand, with primary headache disorders now accounting for more than 40% of referrals. Secondary causes of headache (including intracranial tumours, idiopathic intracranial hypertension, carotid or vertebral artery dissection and subdural haematomas) remain infrequent. In all such cases, there were additional diagnostic clues. The number of patients referred with problems related to chronic neurological diseases has fallen considerably, reflecting the roles of specialist nurses and clinics. Imaging investigation of choice shifted from computerised tomography scan (45 to 16%) towards magnetic resonance imaging (17 to 47%). Management is increasingly on an outpatient basis, often without the need for a follow-up appointment. The experience presented here should inform further development of rapid access neurology clinics across the UK and suggests the need for acute headache services, in line with those for transient ischaemic attack and first seizure.

THE CHANGING FACE OF URGENT NEUROLOGY OUTPATIENT REFERRALS

Introduction A recent report published jointly by the RCP and ABN found that neurological presentations accounted for a significant proportion of GP and emergency room time, but access to acute neurological services was lacking. A study of urgent neurology outpatient referrals from primary health care physicians in Cambridge was first carried out in 1995 with the purpose of identifying which patients genuinely required urgent assessment, and the type of pathology seen. We thought it would be interesting to repeat this study a decade later to see whether there has been any change in the nature of neurological presentation, especially given recent changes in (for example) government health targets, waiting list initiatives, availability of imaging, and changes to local neurological services. Method Patients are referred to the neurology registrar on call, and they are booked in to the next available (weekday) emergency clinic slot. 458 patients were seen during 2008 and 2009, of which we had information for 415. Data was collected retrospectively from the original emergency clinic letter, follow up clinic letters, and investigation results. Results Seventy–five per cent of referrals were from general practitioners, most of which were within a 30 mile radius of Cambridge. Demand for an emergency clinic service has remained just as high, but there has been a clear change in presenting symptom and pathology seen, with more headaches (48%, compared to 27% in 1995), sensory limb disturbance (35% vs. 10%), and dizziness (19% vs. 5%). Conversely, fewer patients were seen with loss of consciousness (6% vs. 13%). 19% of patients were previously known to neurology, and of these 13% were patients with MS, compared to 42% in 1995. There were positive neurological examination findings in 60% of patients, the majority of which were focal cerebral. Only 7% of patients were admitted (compared to 19% in 1995), 52% were followed up in a neurology clinic, 12% were referred to a different specialty, and 32% were discharged. Following investigation, a definite ‘neurological’ diagnosis was made in 75% of patients, although this included headaches of all aetiologies (43% if excluded). Discussion There is still a clear need for an acute neurology clinic service given the high percentage of neurological diagnoses made. However, there is a clear change in pattern of presentation and diagnosis over the period 1995–2008. Far fewer patients were seen with loss of consciousness and MS relapses, a fact likely to be explained by the growth of other ‘rapid access’ services, such as a daily first seizure clinic and a nurse led community MS team. Just as many patients are being seen, and this may suggest that demand has grown to fill supply; referrals with more benign pathology have increased, in particular those for headache and dizziness. Emergency admission from the clinic is less common, and this may be due to improved availability of outpatient MRI and lumbar punctures in our programmed investigation unit, and also more structured outpatient pathways such as that for CNS tumours.