Benzodiazepine maintenance in opiate substitution treatment: Good or bad? A retrospective primary care case-note review

2016 ◽  
Vol 31 (1) ◽  
pp. 62-66 ◽  
Author(s):  
Adam Bakker ◽  
Emmanuel Streel
Keyword(s):  
High Risk Group ◽  
Case Note ◽  
Treatment Retention ◽  
Patient Treatment ◽  
Substitution Treatment ◽  
National Guidelines ◽  
Opiate Substitution Treatment ◽  
The Uk ◽  
Treatment Mortality ◽  
Case Note Review

Background: Co-prescribing benzodiazepines to patients in opiate substitution treatment is controversial and often alleged to increase mortality. In an inner-London general practice, patients with problematic benzodiazepine co-dependence were allowed benzodiazepine maintenance treatment (BMT) since 1994, providing an opportunity for analysis. Method: 1) Case-note review of all 278 opiate substitution treatment patients, accruing 1289 patient treatment years; 46% had concurrent BMT. 2) National Health Service database search for patients who died after leaving accrued a further 883 years of information; only patients who left the UK were unaccounted for (4%). Three groups were studied: 1) never obtained benzodiazepine prescription (NOB): n=80); 2) briefly/occasionally prescribed benzodiazepines (BOP): n=71; 3) BMT: n=127. Outcomes measured: Treatment retention (months); deaths/100 patient treatment years; deaths after leaving the service/100 years of information. Results: Treatment retention: NOB: 34 months; BOP: 51 months; BMT: 72 months. In-treatment mortality: NOB: 1.79/100 patient treatment years; BOP: 0.33/100 patient treatment years; BMT: 1.31/100 patient treatment years. Deaths after leaving service: NOB: 2.24/100 years of information, BOP: 0.63/100 years of information. However, mortality for previously BMT-patients increased by 450% to 5.90/100 years of information. Discussion: BMT patients had longer treatment retention than NOB or BOP and lower mortality than NOB patients. It is unlikely that patients had access to prescribed benzodiazepines on leaving the service because of restrictions in the national guidelines but co-dependent patients are a high-risk group who may stand to gain most benefit from opiate substitution treatment if combined with benzodiazepine-maintenance.

scholarly journals A retrospective case note review of laparoscopic versus open reversal of Hartmann’s procedure

2014 ◽  
Vol 96 (7) ◽  
pp. 539-542 ◽  
Author(s):  
CL Walklett ◽  
NP Yeomans
Keyword(s):  
Case Note ◽  
Hartmann’S Procedure ◽  
Reversal Rate ◽  
Teaching Hospitals ◽  
Laparoscopic Technique ◽  
Complication Rates ◽  
Retrospective Case ◽  
Hartmann's Procedure ◽  
The Uk ◽  
Case Note Review

Introduction First described in 1921, Hartmann’s procedure is the gold standard treatment for complicated sigmoid diverticular disease. It is also used commonly for other causes of perforation of the large bowel. However, the reversal rate in the UK is much lower than in comparable countries, at only 18–22%. Furthermore, laparoscopic reversal (LRH) is used far less frequently than open reversal (ORH) despite evidence that a laparoscopic technique reduces patient morbidity and decreases patient recovery time. Methods This retrospective case note review undertook an analysis of all the patients who had undergone Hartmann’s procedure at two centres in Leeds Teaching Hospitals NHS Trust between February 2007 and February 2012. Out of 305 patients, 235 were identified and included in the analysis. Comparisons were then drawn between LRH and ORH groups. Results The reversal rate was 21%. Three-quarters (76%) were performed using an open technique, 20% were laparoscopic and 5% were converted to an open procedure. The mean hospital stay was longer for the ORH group (9.82 days, standard deviation [SD]: 5.85 days, 95% confidence interval [CI]: 2.99 days) than for the LRH group (7.29 days, SD: 4.65 days, 95% CI: 11.58 days) p=0.006). Seven ORH patients (21%) were reoperated but only one LRH patient (13%) had a reoperation at six months. Five factors were found to have a significant effect on the likelihood of reversal of Hartmann’s procedure. Conclusions The overall reversal rate for Hartmann’s procedure remains low. Shorter hospital stays, lower 6-month reoperation rates and reduced 30-day complication rates are associated with LRH when compared with ORH.

Balloon sinuplasty: our first year

2010 ◽  
Vol 125 (1) ◽  
pp. 43-52 ◽  
Author(s):  
C Hopkins ◽  
E Noon ◽  
D Bray ◽  
D Roberts
Keyword(s):  
New Technology ◽  
Case Note ◽  
First Year ◽  
Subjective Improvement ◽  
Retrospective Case ◽  
Balloon Sinuplasty ◽  
Additional Costs ◽  
The Uk ◽  
Snot 22 ◽  
Case Note Review

AbstractIntroduction:Balloon sinuplasty is a new technology which has only recently been introduced in the UK. We review the current literature, and we present our first year's results for the technique together with a description of indications, outcomes and problems.Methods:Retrospective case note review of 27 consecutive patients undergoing sinuplasty alone in the first year in which this procedure was performed. The main outcome measures used were subjective improvement and Sino-Nasal Outcome Test (SNOT-22) score.Results:Dilatation was successful in 98 per cent of sinuses in which it was attempted; however, subjective improvement was noted in only 62 per cent of patients thus treated.Conclusion:We believe that balloon sinuplasty has a place in routine rhinology practice but that its applications are limited, and that its additional costs must be considered. We present advantages and possible limitations of the technique.

Can we predict Acute Medical readmissions using the BOOST tool? A retrospective case note review

2016 ◽  
Vol 15 (3) ◽  
pp. 119-123
Author(s):  
Geraldine A Lee ◽  
◽  
D Freedman ◽  
Penelope Beddoes ◽  
Emily Lyness ◽  
...  
Keyword(s):  
Risk Factors ◽  
Older Adults ◽  
Risk Assessment ◽  
Risk Factor ◽  
Hospital Discharge ◽  
Assessment Tool ◽  
Case Note ◽  
Retrospective Case ◽  
The Uk ◽  
Case Note Review

Background: Readmissions within 30-days of hospital discharge are a problem. The aim was to determine if the Better Outcomes for Older Adults through Safe Transitions (BOOST) risk assessment tool was applicable within the UK. Methods: Patients over 65 readmitted were identified retrospectively via a casenote review. BOOST assessment was applied with 1 point for each risk factor. Results: 324 patients were readmitted (mean age 77 years) with a median of 7 days between discharge and readmission. The median BOOST score was 3 (IQR 2-4) with polypharmacy evident in 88% and prior hospitalisation in 70%. The tool correctly predicted 90% of readmissions using two or more risk factors and 99.1% if one risk factor was included. Conclusion: The BOOST assessment tool appears appropriate in predicting readmissions however further analysis is required to determine its precision.

Loss of consciousness, collapse and associated driving restrictions: a retrospective case note review – an important reminder regarding driving restrictions

2017 ◽  
Vol 62 (2) ◽  
pp. 43-47
Author(s):  
Adam Williamson ◽  
Scott Muir
Keyword(s):  
Media Coverage ◽  
Case Note ◽  
Loss Of Consciousness ◽  
Fitness To Drive ◽  
National Guidelines ◽  
Retrospective Case ◽  
High Profile ◽  
Driving Restrictions ◽  
Medical Standards ◽  
Case Note Review

Background and aims National guidelines outlining medical standards for fitness to drive are provided by The Driver and Vehicle Licensing Agency. We aimed to establish whether patients presenting with collapse or loss of consciousness received documented advice regarding driving restrictions, if appropriate for their working diagnosis. Methods and results A retrospective case note review was undertaken over a four-month period for emergency patients clinically coded as seizure/convulsion (R568) and collapse/syncope (R55X); 163 patients had a primary or working diagnosis on discharge that suggested driving status and restrictions could have been reviewed. Six groupings of diagnoses were noted, and variation was seen amongst documentation for each. Current driving status was documented for 32 patients, and 34 had restriction advice documented; 73% (119 patients) had further investigations or clinic review planned. Conclusion Documentation of driving status and restrictions is poor. This audit serves to remind clinicians of the importance of considering driving status when discharging patients who have presented with collapse or loss of consciousness. Recent high-profile media coverage regarding medical driving restrictions, both locally and nationally, have emphasised the need for knowledge of The Driver and Vehicle Licensing Agency guidance.

scholarly journals FRI0649-HPR HYDROXYCHLOROQUINE PRESCRIBING AND OPHTHALMOLOGY SCREENING WITHIN RHEUMATOLOGY DEPARTMENTS IN THE NORTH-WEST OF THE UNITED KINGDOM: A PROSPECTIVE REGIONAL AUDIT

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 928.2-929
Author(s):  
S. Juman ◽  
T. David ◽  
L. Gray ◽  
R. Hamad ◽  
S. Horton ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Group ◽  
Service Level ◽  
High Risk Group ◽  
North West ◽  
The North ◽  
The United Kingdom ◽  
The Uk ◽  
Treatment Dosage ◽  
Sd Oct

Background:Hydroxychloroquine (HCQ) is widely used in the management of rheumatoid arthritis and connective tissue disease. The prevalence of retinopathy in patients taking long-term HCQ is approximately 7.5%, increasing to 20-50% after 20 years of therapy. Hydroxychloroquine prescribed at ≤5 mg/kg poses a toxicity risk of <1% up to five years and <2% up to ten years, but increases sharply to almost 20% after 20 years. Risk factors for retinopathy include doses >5mg/kg/day, concomitant tamoxifen or chloroquine use and renal impairment. The UK Royal College of Ophthalmologists (RCOphth) 2018 guidelines for HCQ screening recommend optimal treatment dosage and timing for both baseline and follow-up ophthalmology review for patients on HCQ, with the aim of preventing iatrogenic visual loss. This is similar to recommendations made by the American Academy of Ophthalmology (2016).Objectives:To determine adherence to the RCOphth guidelines for HCQ screening within the Rheumatology departments in the North-West of the UK.Methods:Data for patients established on HCQ and those initiated on HCQ therapy were collected over a 7 week period from 9 Rheumatology departments.Results:473 patients were included of which 56 (12%) were new starters and 417 (88%) were already established on HCQ. 79% of the patients were female, with median ages of 60.5 and 57 years for new and established patients respectively. The median (IQR) weight for new starters was 71 (27.9) kg and for established patients, 74 (24.7) kg.20% of new starters exceeded 5mg/kg daily HCQ dose. 16% were identified as high risk (9% had previously taken chloroquine, 5% had an eGFR <60ml/min/m2and 2% had retinal co-pathology). Of the high-risk group, 44% were taking <5mg/kg. In total, 36% of new starters were referred for a formal baseline Ophthalmology review.In the established patients, 74% were taking ≤5mg/kg/day HCQ dose and 16% were categorized as high risk (10% had an eGFR less than 60ml/min/m2, 3% had previous chloroquine or tamoxifen use and 2% had retinal co-pathology). In the high-risk group, 75% were not referred for spectral domain optical coherence tomography (SD-OCT). 41% of patients established on HCQ for <5 years, and 33% of patients on HCQ for >5 years were not referred for SD-OCT. Reasons for not referring included; awaiting 5 year review, previous screening already performed and optician review advised.Since the introduction of the RCOphth guidelines, 29% patients already established on HCQ had an alteration in the dosage of HCQ in accordance with the guidelines. In the high-risk group, 16% were not on the recommended HCQ dose.Conclusion:This audit demonstrates inconsistencies in adherence to the RCOphth guidelines for HCQ prescribing and ophthalmology screening within Rheumatology departments in the North-West of the UK for both new starters and established patients. Plans to improve this include wider dissemination of the guidelines to Rheumatology departments and strict service level agreements with ophthalmology teams to help optimize HCQ prescribing and screening for retinopathy.Acknowledgments:Drs. S Jones, E MacPhie, A Madan, L Coates & Prof L Teh. Co-1st author, T David.Disclosure of Interests:None declared

scholarly journals Evaluating Programs to Counter Violent Extremism: The Example of Case-Managed Interventions

Proceedings ◽  
2021 ◽  
Vol 77 (1) ◽  
pp. 20
Author(s):  
Adrian Cherney
Keyword(s):  
New South ◽  
New South Wales ◽  
Linear Process ◽  
Case Note ◽  
Control Group ◽  
Client Participation ◽  
South Wales ◽  
Client Change ◽  
Violent Extremism ◽  
The Uk

In recent years, there has been a proliferation of programs aimed at preventing radicalization and disengaging known violent extremists. Some programs have targeted individuals through the use of case management approaches and the development of individual intervention plans (e.g., the Desistance and Disengagement Program and the Channel program in the UK; the Australian New South Wales Corrections Proactive Integrated Support Model—PRISM—and state-based division initiatives in Australia). There is a broad consensus in the literature that the evaluation of such initiatives has been neglected. However, the evaluation of case-managed interventions to counter violent extremism (CVE) is challenging. They can have small caseloads which makes it difficult to have any comparison or control group. Client participation can vary over time, with no single intervention plan being alike. This can make it hard to untangle the relative influence of different components of the intervention on indicators of radicalization and disengagement. In this presentation, results from primary research that set out to evaluate case-managed CVE interventions in Australia and develop evaluation metrics are presented. This research involves the examination of interventions implemented by New South Wales corrections and state police. The effectiveness of these interventions was assessed against a five-point metric of client change. Client change overtime was analyzed using case note information collected by the various interventions on client participation. Results show that client change is not a linear process and that the longer an individual is engaged in a case-managed intervention, the more likely they are to demonstrate change relating to disengagement. Specific case studies are used to illustrate trajectories and turning points related to radicalization and to highlight the role of case-managed interventions in facilitating disengagement. Key elements of effective interventions include the provision of ongoing informal support. Investment in capturing case note information should be a priority of intervention providers. Different challenges confronted by case-managed CVE interventions are highlighted.

scholarly journals Orthogeriatrics and Hip Fracture Care in the UK: Factors Driving Change to More Integrated Models of Care

Geriatrics ◽  
2018 ◽  
Vol 3 (3) ◽  
pp. 55 ◽  
Author(s):  
Mark Middleton
Keyword(s):  
Hip Fracture ◽  
Financial Incentives ◽  
Models Of Care ◽  
Social Needs ◽  
Medical Rehabilitation ◽  
Integrated Models ◽  
National Guidelines ◽  
Fracture Care ◽  
The Uk ◽  
The Impact

In the United Kingdom (UK), approximately 80,000 hip fractures each year result in an estimated annual cost of two billion pounds in direct healthcare costs alone. Various models of care exist for collaboration between orthopaedic surgeons and geriatricians in response to the complex medical, rehabilitation, and social needs of this patient group. Mounting evidence suggests that more integrated models of orthogeriatric care result in superior quality of care indicators and clinical outcomes. Clinical governance through national guidelines, audit through the National Hip Fracture Database (NHFD), and financial incentives through the Best Practice Tariff (providing a £1335 bonus for each patient) have driven hip fracture care in the UK forward. The demanded improvement in quality indicators has increased the popularity of collaborative care models and particularly integrated orthogeriatric services. A significant fall in 30-day mortality has resulted nationally. Ongoing data collection by the NHFD will lead to greater understanding of the impact of all elements of hip fracture care including models of orthogeriatrics.

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