One lithium level >1.0 mmol/L causes an acute decline in eGFR: findings from a retrospective analysis of a monitoring database

Objectives Lithium is a mainstay of bipolar disorder treatment, however, there are still differences in opinion on the effects of lithium use on renal function. The aim of this analysis was to determine if there is an association between short-term exposure to various elevated lithium levels and estimated-glomerular filtration rate (eGFR) at ≤3 months, 6 months (±3 months) and 1 year (±3 months) follow-up. Setting Norfolk-wide (UK) lithium register and database. Participants 699 patients from the Norfolk database. Primary outcome measures eGFR change from baseline at ≤3 months, 6 months (±3 months) and 1 year (±3 months) after exposure to a lithium level within these ranges: 0.81–1.0 mmol/L (group 2), 1.01–1.2 mmol/L (group 3) and 1.21–2.0 mmol/L (group 4). The reference group was patients whose lithium levels never exceeded 0.8 mmol/L. Results Compared to the reference group, groups 3 and 4 showed a significant decrease in eGFR in the first 3 months after exposure (p=0.047 and p=0.040). At 6 months (±3 months) postexposure group 4 still showed a decline in eGFR, however, this result was not significant (p=0.298). Conclusions These results show for the first time that a single incident of a lithium level >1.0 mmol/L is associated with a significant decrease in eGFR in the following 3 months when compared to patients whose lithium levels never exceeded 0.8 mmol/L. It is still not known whether the kidneys can recover this lost function and the impact that more than a single exposure to a level within these ranges can have on renal function. These results suggest that lithium level monitoring should be undertaken at least every 3 months, in line with current UK guidelines and not be reduced further until the impact of more than one exposure to these lithium levels has been fully established

Exploring what patients think when answering the Interpersonal Skills Questionnaire (ISQ): A ‘think aloud’ study

Background: The Interpersonal Skills Questionnaire (ISQ) was developed to collect patient feedback on consultation skills of practitioners. However, it has not yet been evaluated with pharmacists. Objective: To explore the thinking process of patients as they completed the ISQ following a consultation with a pharmacist. Methods: A qualitative think aloud (TA) methodology was used to explore patients' thinking while completing the ISQ following a consultation with a pharmacist. The study was conducted in secondary care with outpatients ≥18 years old. Interviews were carried out in rounds and were informally analysed (i.e., by writing notes while listening to recordings) to identify any associated major problem(s). Discussions were held between researchers to determine whether changes were needed based on patients' comments. Results: Eight patients in total (50% females) participated in this study (mean age: 48 years). Three rounds of TA were conducted. Most items of the ISQ were interpreted similarly by all participants with no major problems necessitating refining the ISQ. Conclusions: Modification of the ISQ was unnecessary as interviews demonstrated no major problems with its use. The ISQ is thus a potentially suitable tool to collect patient feedback on pharmacists' consultations

Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline

Lumbar puncture (LP) is an important and frequently performed invasive procedure for the diagnosis and management of neurological conditions. There is little in the neurological literature on the topic of periprocedural management of antithrombotics in patients undergoing LP. Current practice is therefore largely extrapolated from guidelines produced by anaesthetic bodies on neuraxial anaesthesia, haematology groups advising on periprocedural management of antiplatelet agents and anticoagulants, and by neuroradiology on imaging-guided spinal procedures. This paper summarises the existing literature on the topic and offers recommendations to guide periprocedural antithrombotic management for LP, based on the consolidation of the best available evidence. ​. [Abstract copyright: © Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.

Elevated plasminogen activators are associated with hematoma progression in spontaneous intracerebral hemorrhage

Endogenous fibrinolysis might lead to hematoma progression in spontaneous intracerebral hemorrhage (ICH). We studied plasma biomarkers of fibrinolysis and hemostasis in twenty-two patients with ICH and nine healthy controls (HC) in a single-center study. Patients with ICH had significantly higher D-dimer and plasmin-alpha-2-antiplasmin complexes compared to HC. At baseline, patients with hematoma progression had higher urokinase-type plasminogen activator (uPA) and tissue-type plasminogen activator (tPA) and lower plasminogen levels, compared to those with no progression. 24-hour and day-7 matrix metalloproteinase-9 (MMP-9) was significantly increased in patients with hematoma progression

Patient feedback questionnaires to enhance consultation skills of healthcare professionals: a systematic review

Objective: To identify patient feedback questionnaires that assess the development of consultation skills (CSs) of practitioners. Methods: We conducted a systematic search using seven databases from inception to January 2017 to identify self-completed patient feedback questionnaires assessing and enhancing the development of CSs of individual practitioners. Results were checked for eligibility by three authors, and disagreements were resolved by discussion. Reference lists of relevant studies and open grey were searched for additional studies. Results: Of 16,312 studies retrieved, sixteen were included, describing twelve patient feedback questionnaires that were mostly designed for physicians in primary care settings. Most questionnaires had limited data regarding their psychometric properties, except for the Doctor Interpersonal Skills Questionnaire (DISQ). Most studies conducted follow-up, capturing positive views of practitioners regarding the process (n = 14). Feedback was repeated by only three studies, demonstrating different levels of improvement in practitioners’ performance. Conclusion: Identified questionnaires were mainly focused on physicians, however, to support using patient feedback, questionnaires need to be validated with other practitioners. Practice implications: Several patient feedback questionnaires are available, showing potential for supporting practitioners’ development. Valid questionnaires should be used with appropriate practitioners in developing more evidence for the impact they may have on actual consultations

Transfusion Camp: The UK experience and its value in improving knowledge of transfusion medicine among postgraduate trainees

Objectives: To report the UK experience of rolling out Transfusion Camp. Background: Transfusion Camp is a structured education programme developed in Toronto, with the aim of reducing knowledge gaps in transfusion medicine in postgraduate trainees. It consists of didactic lectures viewed online by the participants, then interactive, locally delivered seminars. Since 2015, it has been rolled out in the United Kingdom, and is now available in four centres. Here, we report the UK experience of Transfusion Camp and outcomes. Methods: Trainees are recruited via the training programme directors in each region. Pre‐ and post‐course assessments are administered using the validated BEST (Biomedical Excellence for Safer Transfusion) test, with possible scores 0–20, and confidence measured on an A‐E Likert scale. Results: Since 2015, 130 trainees have participated in Transfusion Camp in the United Kingdom. Trainees from all specialties significantly improved their BEST‐test scores after attending the course (mean score 11.6/20 before the course, compared with 14.3/20 after the course), and confidence in managing transfusion‐related issues was also significantly improved. Conclusion: We recommend that all centres consider offering Transfusion Camp to trainees in haematology and other specialties that frequently use blood transfusions, such as anaesthesia/ICU, Internal Medicine and others

Severe platelet dysfunction in NHL patients receiving ibrutinib is absent in patients receiving acalabrutinib

The Bruton’s tyrosine kinase (Btk) inhibitor ibrutinib induces platelet dysfunction and causes increased risk of bleeding. Off-target inhibition of Tec is believed to contribute to platelet dysfunction and other side-effects of ibrutinib. The second generation Btk inhibitor acalabrutinib was developed with improved specificity for Btk over Tec. We investigated platelet function in patients with Non-Hodgkin Lymphoma (NHL) receiving ibrutinib or acalabrutinib by aggregometry and by measuring thrombus formation on collagen under arterial shear. Both patient groups had similarly dysfunctional aggregation responses to collagen and collagen-related peptide (CRP-XL) and comparison with mechanistic experiments in which platelets from healthy donors were treated with the Btk inhibitors suggested that both drugs inhibit platelet Btk and Tec at physiological concentrations. Only ibrutinib caused dysfunctional thrombus formation, while size and morphology of thrombi following acalabrutinib treatment were of normal size and morphology. We found that ibrutinib but not acalabrutinib inhibited SFKs and that SFKs have a critical role in platelet adhesion to collagen that is likely to underpin unstable thrombus formation observed in ibrutinib patients. We found that platelet function was enhanced by increasing levels of vWF and FVIII ex vivo by addition of intermediate purity FVIII (haemate P) to blood from patients, resulting in consistently larger thrombi. We conclude that acalabrutinib avoids major platelet dysfunction associated with ibrutinib therapy, and platelet function may be enhanced in patients with B-cell NHL by increasing plasma vWF and FVIII

Desmopressin for reversal of Antiplatelet drugs in Stroke due to Haemorrhage (DASH): protocol for a phase II double-blind randomised controlled feasibility trial

IntroductionIntracerebral haemorrhage can be devastating and is a common cause of death and disability worldwide. Pre-intracerebral haemorrhage antiplatelet drug use is associated with a 27% relative increase in one-month case fatality compared to patients not using antithrombotic drugs. We aim to assess the feasibility of conducting a randomised controlled testing the safety and efficacy of desmopressin for patients with antiplatelet-associated intracerebral haemorrhage.Methods and AnalysisWe aim to include 50 patients within 24 hours of spontaneous intracerebral haemorrhage onset, associated with oral antiplatelet drug(s) use in at least the preceding seven days. Patients will be randomised (1:1) to receive intravenous desmopressin 20μg in 50 mls sodium chloride 0.9% infused over 20 minutes or matching placebo. We will mask participants, relatives and outcome assessors to treatment allocation. Feasibility outcomes include proportion of patients approached being randomised, number of patients receiving allocated treatment, rate of recruitment, and adherence to treatment and follow up. Secondary outcomes include change in intracerebral haemorrhage volume at 24 hours; hyponatraemia at 24 hours, length of hospital stay, discharge destination, early death less than 28 days, death or dependency at day 90, death up to day 90, serious adverse events (including thromboembolic events) up to day 90; disability (Barthel index, day 90), quality of life (EuroQol 5D (EQ-5D], day 90), cognition (telephone mini-mental state examination day 90), and health economic assessment (EQ-5D).Ethics and disseminationThe DASH trial received ethical approval from the East Midlands - Nottingham 2 research ethics committee (18/EM/0184). The DASH trial is funded by NIHR RfPB grant: PB-PG-0816-20011. Trial results will be published in a peer reviewed academic journal and disseminated through academic conferences and through patient stroke support groups. Reporting will be in compliance with CONSORT recommendations

Desmopressin for prevention of bleeding for thrombocytopenic, critically ill patients undergoing invasive procedures: A randomised, double‐blind, placebo‐controlled feasibility trial

Thrombocytopenic patients have an increased risk of bleeding when undergoing invasive procedures. In a multicentre, phase II, blinded, randomised, controlled feasibility trial, critically ill patients with platelet count 100 × 109/L or less were randomised 1:1 to intravenous desmopressin (0.3 µg/kg) or placebo before an invasive procedure. Forty‐three participants (18.8% of those eligible) were recruited, with 41 eligible for analysis. Post‐procedure bleeding occurred in one of 22 (4.5%) in the placebo arm and zero of 19 in the desmopressin arm. Despite liberal inclusion criteria, there were significant feasibility challenges recruiting patients in the critical care setting prior to invasive procedures