Lipid-lowering optimisation for secondary prevention vascular and diabetic foot patients in a pharmacist-led clinic.

Patients attending vascular or diabetic foot clinics commonly have atherosclerotic disease, are at increased risk of cardiovascular disease (CVD), merit high-intensity lipid-modifying therapy to maintain secondary prevention targets and are often sub optimally treated in primary care. We set out to assess the impact of a pharmacist led lipid optimisation clinic in these patients in an area with high levels of social deprivation. METHODS: We performed a clinical cohort study to assess the effectiveness of a pharmacist led clinic to optimise lipid lowering therapy by optimising of statin therapy and commencing additional lipid lowering therapy if applicable with monitoring of blood lipid profiles. RESULTS: Of the 216 patients (166 (77%) on statins) triaged by the pharmacist, 175 (81%) had non-HDL cholesterol levels above the target value of 97 mg/dL (2.5 mmol/L) with a mean non-HDL cholesterol level of 135.73 mg/dL (3.51 mmol/L). Pre optimisation by the prescribing clinical pharmacist 41/216 (19%) patients were at target with a mean non-HDL cholesterol of 135.5 mg/dL improving to 92/137 (67%) patients achieving the target non-HDL cholesterol level with a mean post optimisation non-HDL cholesterol of 94.35 mg/dL (2.44 mmol/L), odds ratio for being at target 8.67 [95% CI 5.30-14.20]. The calculated LDL cholesterol levels (Friedewald) demonstrated a mean reduction of 35.19 [95% CI 29.23-41.38] mg/dL (0.91 [95% CI 0.76-1.07] mmol/l). Proportion on high intensity statin increased from 65 out of 166 (39%) to 129 of 170 (76%) at follow up O.R. 4.89 [3.06-7.82], equivalent to an NNT = 3. CONCLUSIONS: A pharmacist led service in undertreated and clinically challenging vascular and diabetic foot patients in an area of high social deprivation produced significant improvements in utilization of high intensity statin and other lipid lowering therapies and attainment of lipid goals.

Durability of CNS disease control in NSCLC patients with brain metastases treated with immune checkpoint inhibitors plus cranial radiotherapy.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have excellent systemic activity and are standard first line treatment in EGFR/ALK wild type metastatic non-small cell lung cancer (NSCLC). However, their role in patients with brain metastases, which affects over 20% of patients and cause significant morbidity, is less clear. METHODS: We reviewed patients with EGFR/ALK wild-type mNSCLC with CNS metastases. Serial MRIs were reviewed to determine the time to intracranial progression (iPFS). Multivariate regression was performed to adjust for the disease-specific graded prognostic score (ds-GPA). RESULTS: We identified 36 ICI- and 33 chemotherapy-treated patients with baseline CNS metastases and available serial MRIs (average frequency:3.5 months). Baseline radiation was given except for 2 chemotherapy-treated patients with asymptomatic solitary metastasis. The CNS burden of disease was higher in the ICI-treated group (ICI:22% vs. chemotherapy:0% had >10 lesions; p = 0.02), but the utilization of WBRT was not (ICI:31% vs. chemotherapy:45%; p = 0.09). At the time of progression, CNS involvement was identified in 30 % of ICI-treated patients compared to 64 % of chemotherapy controls (p = 0.02). ICI-treated patients had superior iPFS (13.5 vs 8.4 months) that remained significant in multivariate analysis (HR 1.9; 95%CI 1.1--3.4). Superior CNS outcomes in ICI-treated patients were driven by the PD-L1 high subgroup where the 12-month cumulative incidence rate of CNS progression was 19% in ICI-treated PD-L1 ≥ 50%, 50% in ICI-treated PD-L1 < 50% and 58% in chemotherapy-treated patients (p = 0.03). CONCLUSIONS: Remarkable CNS disease control is seen with baseline RT plus ICIs in patients with PD-L1 ≥ 50%. Strategies for delaying WBRT should be investigated in this subgroup of patients.

Subtypes of EGFR- and HER2-Mutant Metastatic NSCLC Influence Response to Immune Checkpoint Inhibitors.

INTRODUCTION: The efficacy of immune checkpoint inhibitors (ICIs) is low among EGFR-mutated non-small-cell lung cancer (NSCLC), although prolonged responses have occasionally been reported. We investigated the association between mutation subtypes and ICI outcomes among HER2- and EGFR-mutated NSCLC. PATIENTS AND METHODS: This retrospective single-center study analyzed patients with EGFR- and HER2-mutated advanced NSCLC who received at least 1 cycle of ICI between 2013 and 2019. Patient characteristics, mutation subtype, and ICI outcomes. RESULTS: Among 48 patients with advanced NSCLC, 14 (29%) had HER2 mutations and 34 (71%) had EGFR mutations. EGFR mutations included 16 (47%) exon 19 deletion, 7 (21%) L858R, 5 (15%) uncommon, and 6 (18%) exon 20 insertion. Compared to EGFR-sensitizing mutations (ESMs), HER2 and EGFR exon 20 mutations were associated with a trend toward better response (respectively, ESM, HER2, and EGFR exon 20: 11%, 29%, and 50%; P = .07) and significantly better disease control rates (respectively, 18%, 57%, and 67%; P = .008). Compared to ESM, HER2 mutations (adjusted hazard ratio, 0.35; P = .02) and EGFR exon 20 mutations (adjusted hazard ratio, 0.37; P = .10 trend) were also associated with improved PFS. Programmed death ligand 1 (PD-L1) expression remained an independent predictor of PFS (adjusted hazard ratio, 0.42; 95% confidence interval, 0.23-0.76; P = .004). The 6-month PFS rates were 29% (HER2), 33% (EGFR exon 20), and 4% (ESM). ICIs were generally well tolerated in this population. Importantly, no immune-related toxicity was observed in 10 patients who received a tyrosine kinase inhibitor (TKI) as the immediate next line treatment after ICI. CONCLUSION: HER2 and EGFR exon 20 mutations derive greater benefit from ICIs with comparable PFS to wild-type historical second/third-line unselected cohorts. ICIs remain a treatment option for this genomic subgroup, given the absence of approved targeted therapies for these rare mutations.

Not just little adults: preparing a children's emergency department for COVID-19.

COVID-19 presented unique challenges in preparing our stand-alone children's emergency department for the pandemic and has demonstrated well the paediatric adage, 'children aren't little adults'.

Empowering podiatrists to perform pulse checks for opportunistic atrial fibrillation detection during annual diabetes foot checks.

Objective: To determine whether training podiatrists to provide opportunistic screening for atrial fibrillation (AF) during the local diabetes foot check was feasible and whether it detects previously unknown AF. Method: During the initiative, 45 podiatrists from across North Durham, Darlington and Durham Dales Easington and Sedgefield Clinical Commissioning Groups were trained to recognise heart irregularities when taking pulse readings of feet of patients with diabetes during their annual foot screening reviews. Results: Over the course of the 3-month pilot, 5000 patients with diabetes had their feet pulse-tested. The project uncovered that for every 500 patients who had their feet checked, one new case of AF could be identified. Conclusion: A report following the Podiatry and Atrial Fibrillation Case Finding scheme revealed that the National Health Service in the United Kingdom North East and North Cumbria area could benefit from potential cost savings in excess of £500 000. In 2013, the National Diabetes Information Service, Yorkshire and Humber Public Health Observatory estimated 231 777 people in the North East, North Cumbria, Hambleton and Richmondshire area with diabetes. Therefore 463 patients could be found with AF, preventing 23 strokes and saving £539 742 or in excess of £0.5 M.

Simulation in undergraduate paediatrics: a cluster-randomised trial.

BACKGROUND: Medical students lack confidence in recognising, assessing and managing unwell patients, particularly children. Our aim was to evaluate the impact of a 1-day novel paediatric simulation course on medical students' ability to recognise and assess sick children, and to evaluate medical students' views on the use of simulation in child health teaching. METHODS: We conducted a cluster-randomised trial with a mixed-methods design. Students were cluster randomised into the intervention (simulation) group or control group (standard paediatric attachment). Students in the intervention group attended a 1-day simulation course during the last week of their attachment. The primary outcome measure was students' self-reported ability and confidence in recognising, assessing and managing sick children. RESULTS: There were 61 students in the study: 32 in the intervention group and 29 in the control group. Self-assessed confidence in recognising, assessing and managing a sick child was higher after the simulation course, compared with controls (p < 0.001). Six key themes were identified, including: increased confidence in emergency situations; the value of learning through participation in 'real-life' realistic scenarios in a safe environment; and an appreciation of the importance of human factors. Students found the simulation useful and wanted it offered to all undergraduates during child health attachments. DISCUSSION: A 1-day simulation course improves medical students' confidence in assessing and managing unwell children, and is highly valued by students. It could be used to complement undergraduate teaching on the management of sick children. Further studies are needed to evaluate its impact on real-life clinical performance and confidence over time. Students lack confidence in managing unwell patients, particularly children.

Use of statistical process control to support improved care for patients with acute myocardial infarction eligible for thrombolytic treatment: experience from 2 hospitals in England during 2002-2003.

Efforts to reduce mortality from acute myocardial infarction (MI) through expediting thrombolytic and other reperfusion treatments have included the publication of clinical guidelines and standards of care for "door-to-needle" time in many countries. Across England, the National Service Framework, a national program of reform of cardiac care in the National Health Service, has resulted in, inter alia, significant reductions in treatment delay for thrombolysis-eligible patients. One component of the improvement program has been the use of service improvement methodologies, including statistical process control. We describe the early experience of 2 general hospitals in improving care of thrombolysis-eligible MI patients.

Extended nursing roles in intermediate care: a cost-benefit evaluation.

A study examined the effectiveness of extended nursing roles in a GP-admissions unit. Evaluation was through analysis of unit actively; semi-structured interviews and surveys of service providers and users; audits of treatment plans, discharge plans and leg-ulcer management; and comparisons weekly unit costs. All nurses felt they had extended their roles and were taking greater responsibility for clinical decisions as well as extending their prescribing responsibilities. Most patients had confidence in the ability of the unit's staff to manage their care; 96% were given detailed care plans covering discharge. The management of leg ulcers improved over the first year and the unit's costs were lower than those of local acute medical wards.

An evaluation of diabetic retinopathy screening models.

BACKGROUND: The aim of the study was to evaluate three models of diabetic retinopathy screening in a North London Health Authority so as to advise on setting up a comprehensive screening programme. The study evaluated the models against their own objectives and standards published by the British Diabetic Association (BDA) and the Royal Colleges for diabetic retinopathy screening, and assessed service user and provider satisfaction. METHODS: Methods used were: analysis of the patient database and a case note review on uptake and coverage; follow-up for abnormal findings; comparisons of positive predictive values; postal questionnaire survey of service user satisfaction; semi-structured interviews of service providers. RESULTS: A total of 2230 people with diabetes were screened between March 1998 and August 2000. The general practitioner (GP) led model achieved 63 per cent coverage and the two optometrist models 24 per cent. The detection rate for sight-threatening diabetic retinopathy was 6 per cent and 2.5 per cent for the optometrists and GP models, respectively. Positive predictive values of 94 per cent, 90 per cent and 60 per cent, respectively, were established for the GP-led model, the optometrists using the retinal camera and the optometrists using indirect ophthalmoscopy only. Twenty-eight (45 per cent) of the 62 people with sight-threatening diabetic retinopathy failed to attend for further investigation. Service user and service provider satisfaction were high for all three models. CONCLUSION: The evaluation confirmed that all three methods of screening provided an effective service. The implementation of a district-wide diabetic retinopathy screening programme requires the establishment of a systematic call and recall system to achieve attendance for screening. A formal follow-up of people referred for specialist assessment and treatment should be part of the service.