86 results found
Hellyer TP, McAuley DF, Walsh TS, et al., 2020, Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation., Lancet Respir Med, Vol: 8, Pages: 182-191
BACKGROUND: Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia. METHODS: VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveola
Milinkovic A, Singh S, Simmons B, et al., 2019, Sleep and functional characteristics of Central London Outpatient HIV Cohort, Publisher: WILEY, Pages: 274-274, ISSN: 1464-2662
Vutipongsatorn K, Fujitake E, Singh S, 2019, Extracorporeal membrane oxygenation in life-threatening asthma unresponsive to mechanical ventilation: a comparison of patient demographics and outcomes between a large London-based intensive care unit and an international registry., Clin Med (Lond), Vol: 19
Vutipongsatorn K, Fujitake E, Singh S, 2019, Tracheobronchopathia osteochondroplastica in a patient requiring extracorporeal membrane oxygenation: a case report., Clin Med (Lond), Vol: 19, Pages: 33-34
Garner JL, Garner SD, Hardie RJ, et al., 2019, Evaluation of a re-useable bronchoscopy biosimulator with ventilated lungs, ERJ Open Research, Vol: 5, ISSN: 2312-0541
Background: Restrictions on respiratory trainee time and access to procedures reduce the opportunities toacquire necessary skills in bronchoscopy. Simulation, not subject to such impediments, is a usefulsupplementary aid to teaching bronchoscopic techniques in a safe environment but there is a limitedchoice of simulators that are sufficiently realistic and not prohibitively expensive. This study evaluated alow-cost device that simulates an intubated and ventilated patient, employing re-useable, inflatable,BioFlex-preserved, porcine lungs.Methods: 26 bronchoscopists, trainee and experienced, after using the bronchoscopy biosimulator,completed a questionnaire using a five-point Likert scale comparing its performance with that of thecomputerised CAE AccuTouch.Results: Participants were largely positive about their experience (mean score of 4.76). The bronchoscopybiosimulator was found to be realistic (mean score 4.64), easy to use (mean score 4.88), and helpful inlearning to perform a variety of diagnostic and therapeutic procedures (mean score 4.85). Importantly, thebronchoscopy biosimulator compared favourably to the computer simulator (mean score 4.84).Conclusions: These data support the concept of the bronchoscopy biosimulator as an acceptable modelwith which to supplement the experience of bronchoscopic procedures.
Ark R, Mandalia S, Moore L, et al., Evaluating the long-term impact of an antimicrobial stewardship programme in a central London mixed medical and surgical intensive care unit, European Congress of Clinical Microbiology & Infectious Diseases
Elliot ER, Wang X, Singh S, et al., 2019, Increased dolutegravir peak concentrations in people living with HIV aged 60 and over and analysis of sleep quality and cognition, Clinical Infectious Diseases, Vol: 68, Pages: 87-95, ISSN: 1058-4838
Background: Demographic data show an increasingly aging HIV population worldwide. Recent concerns over dolutegravir-related neuropsychiatric toxicity have emerged, particularly amongst older HIV patients. We describe the pharmacokinetics (PK) of dolutegravir (DTG) 50mg once daily in people living with HIV (PLWH) aged 60 and older. Additionally, to address the call for prospective neuropsychiatric toxicodynamic data, we evaluate changes in sleep quality and cognitive function after switching to abacavir (ABC)/lamivudine (3TC)/DTG, over 6 months in this population. Methods: PLWH aged≥60years with HIV-RNA<50copies/mL on any non-DTG based antiretroviral combination were switched to ABC/3TC/DTG. On day 28, 24-hour PK sampling was undertaken. Steady-state PK parameters were compared to a published historical control population aged≤50years. Six validated sleep questionnaires and neurocognitive (Cogstate®) testing were administered pre-switch and over 180 days (NCT02509195). Results: Forty-three participants were enrolled; 40 completed the PK phase. Overall, five discontinued (two due adverse events, both sleep related, 4.6%). DTG maximum concentration (Cmax) was significantly higher in patients≥60 versus controls (GM 4246ng/mL versus 3402ng/mL, p=0.005). In those who completed day 180 (n=38), sleep impairment was higher at day 28 (PSQI median global score 5.0 versus 6.0 p=0.02) but not at day 90 or 180. Insomnia, daytime function, fatigue test scores did not change statistically over time. Conclusion: DTG Cmax was significantly higher in older PLWH. Our data provides clinicians with key information on the safety of prescribing DTG in older PLWH.
Garner J, Soni S, O'Dea K, et al., 2018, Late Breaking Abstract - Intra-alveolar neutrophil-derived microvesicles: a biomarker of COPD severity, 28th International Congress of the European-Respiratory-Society (ERS), Publisher: EUROPEAN RESPIRATORY SOC JOURNALS LTD, ISSN: 0903-1936
Vandenbriele C, Bhudia N, Dhillon E, et al., 2018, Heparin anti-Xa assay versus Activated Partial Thromboplastin Time to monitor unfractionated heparin during Extra-Corporeal-Membrane-Oxygenation, European-Society-of-Cardiology Congress, Publisher: OXFORD UNIV PRESS, Pages: 358-358, ISSN: 0195-668X
Singh S, 2018, Respiratory assessment for Driving, Essentials of Clinical Pulmonology, Editors: Shah, Publisher: CRC Press, ISBN: 9781498715799
Set at the level between the definitive reference work and the clinical manual, Essentials of Clinical Pulmonology is an invaluable cornerstone for all pulmonologists whether trainees or experienced clinicians.
Singh S, 2018, Preassessment for anaesthesia, Essentials of Clinical Pulmonology, Editors: Shah, Publisher: CRC Press, ISBN: 9781498715799
Set at the level between the definitive reference work and the clinical manual, Essentials of Clinical Pulmonology is an invaluable cornerstone for all pulmonologists whether trainees or experienced clinicians.
Morris AC, Gadsby N, McKenna JP, et al., 2017, 16S pan-bacterial PCR can accurately identify patients with ventilator-associated pneumonia, Thorax, Vol: 72, Pages: 1046-1048, ISSN: 1468-3296
Ventilator-associated pneumonia (VAP) remains a challenge to intensive care units, with secure diagnosis relying on microbiological cultures that take up to 72 hours to provide a result. We sought to derive and validate a novel, real-time 16S rRNA gene PCR for rapid exclusion of VAP. Bronchoalveolar lavage (BAL) was obtained from two independent cohorts of patients with suspected VAP. Patients were recruited in a 2-centre derivation cohort and a 12-centre confirmation cohort. Confirmed VAP was defined as growth of >104 colony forming units/ml on semiquantitative culture and compared with a 16S PCR assay. Samples were tested from 67 patients in the derivation cohort, 10 (15%) of whom had confirmed VAP. Using cycles to cross threshold (Ct) values as the result of the 16S PCR test, the area under the receiver operating characteristic (ROC) curve (AUROC) was 0.94 (95% CI 0.86 to 1.0, p<0.0001). Samples from 92 patients were available from the confirmation cohort, 26 (28%) of whom had confirmed VAP. The AUROC for Ct in this cohort was 0.89 (95% CI 0.83 to 0.95, p<0.0001). This study has derived and assessed the diagnostic accuracy of a novel application for 16S PCR. This suggests that 16S PCR in BAL could be used as a rapid test in suspected VAP and may allow better stewardship of antibiotics.Trial registration number VAPRAPID trial ref NCT01972425.
Xu H, Halacli B, Banya W, et al., 2017, Can we predict Veno-Venous extra-corporeal membrane oxygenation duration?, European Journal of Heart Failure, Vol: 19, Pages: 48-48, ISSN: 1388-9842
Halacli B, Xu H, Banya W, et al., 2017, Are Risk Scores Applicable in Tertiary Veno-Venous Extra-Corporeal Membrane Oxygenation Centers?, EuroELSO 2017, Publisher: Wiley, Pages: 36-49, ISSN: 1567-4215
Singh S, Hetzel J, Shah PL, 2017, Controlled Pressure: The Solution for a High-Pressure Situation - Aetiology and Techniques for Control of Airway Haemorrhage, RESPIRATION, Vol: 93, Pages: 398-400, ISSN: 0025-7931
Bhatti A, Ash J, Gokani S, et al., 2017, Hydration stickers - improving oral hydration in vulnerable patients, BMJ Quality Improvement Reports, Vol: 6, ISSN: 2050-1315
Dehydration is a growing problem among elderly patients in hospital wards. Incidents such as those raised in the Francis Report highlight a problem that may not have been sufficiently addressed by current schemes. This improvement project aimed to identify the barriers faced by staff in improving oral hydration and to design and implement an effective solution. A 33 patient pilot study carried out at Chelsea & Westminster Hospital NHS Trust, United Kingdom, revealed that a significant proportion of patients were reported to be dehydrated on admission, with few having their hydration needs addressed. Staff cited time pressures and unclear task responsibility as the major barriers. The intervention was a Hydration Sticker education scheme. These stickers were placed on patient cups, notes and beside areas as a visual prompt for staff and family members to encourage the patient to drink. The intervention was implemented on the Acute Assessment Unit and Stroke ward through a poster campaign. The Hydration Stickers scheme resulted in a 6.5-fold increase in patients' hydration needs being assessed and addressed. Coupled with the low implementation cost and ease of use, Hydration Stickers may be a simple, effective, transferable and sustainable solution to the problem of dehydration among elderly inpatients.
O'Dea KP, Porter J, TIrlapur N, et al., 2016, Circulating microvesicles are elevated acutely following major burns injury and associated with clinical severity, PLOS One, Vol: 11, ISSN: 1932-6203
Microvesicles are cell-derived signaling particles emerging as important mediators and biomarkers of systemic inflammation, but their production in severe burn injury patients has not been described. In this pilot investigation, we measured circulating microvesicle levels following severe burns, with severe sepsis patients as a comparator group.We hypothesized that levels of circulating vascular cell-derived microvesicles are elevated acutely following burns injury, mirroring clinical severity due to the early onset and prevalence of systemic inflammatory response syndrome (SIRS) in these patients. Blood samples were obtained from patients with moderate to severe thermal injury burns, with severe sepsis, and from healthy volunteers. Circulating microvesicles derived from total leukocytes, granulocytes, monocytes, and endothelial cells were quantified in plasma by flow cytometry.All circulating microvesicle subpopulations were elevated in burns patients on day of admission (day 0) compared to healthy volunteers (leukocyte-microvesicles: 3.5-fold, p=0.005; granulocyte-microvesicles: 12.8-fold, p<0.0001; monocyte-microvesicles: 20.4-fold, p<0.0001; endothelial- microvesicles: 9.6-fold, p=0.01), but decreased significantly by day 2. Microvesicle levels were increased with severe sepsis, but less consistently between patients. Leukocyte- and granulocyte-derived microvesicles on day 0 correlated with clinical assessment scores and were higher in burns ICU non-survivors compared to survivors (leukocyte MVs 4.6 fold, p=0.002; granulocyte MVs 4.8 fold, p=0.003). Mortality prediction analysis of area under receiver operating characteristic curve was 0.92 (p=0.01) for total leukocyte microvesicles and 0.85 (p=0.04) for granulocyte microvesicles. These findings demonstrate, for the first t
Hellyer TP, Anderson NH, Parker J, et al., 2016, Erratum to: 'Effectiveness of biomarker-based exclusion of ventilator-acquired pneumonia to reduce antibiotic use (VAPrapid-2): study protocol for a randomised controlled trial'., Trials, Vol: 17, ISSN: 1745-6215
Hellyer TP, Anderson NH, Parker J, et al., 2016, Effectiveness of biomarker-based exclusion of ventilator-acquired pneumonia to reduce antibiotic use (VAPrapid-2): study protocol for a randomised controlled trial., Trials, Vol: 17, ISSN: 1745-6215
BACKGROUND: Ventilator-acquired pneumonia (VAP) is a common reason for antimicrobial therapy in the intensive care unit (ICU). Biomarker-based diagnostics could improve antimicrobial stewardship through rapid exclusion of VAP. Bronchoalveloar lavage (BAL) fluid biomarkers have previously been shown to allow the exclusion of VAP with high confidence. METHODS/DESIGN: This is a prospective, multi-centre, randomised, controlled trial to determine whether a rapid biomarker-based exclusion of VAP results in fewer antibiotics and improved antimicrobial management. Patients with clinically suspected VAP undergo BAL, and VAP is confirmed by growth of a potential pathogen at > 10(4) colony-forming units per millilitre (CFU/ml). Patients are randomised 1:1, to either a 'biomarker-guided recommendation on antibiotics' in which BAL fluid is tested for IL-1β and IL-8 in addition to routine microbiology testing, or to 'routine use of antibiotics' in which BAL undergoes routine microbiology testing only. Clinical teams are blinded to intervention until 6 hours after randomisation, when biomarker results are reported to the clinician. The primary outcome is a change in the frequency distribution of antibiotic-free days (AFD) in the 7 days following BAL. Secondary outcome measures include antibiotic use at 14 and 28 days; ventilator-free days; 28-day mortality and ICU mortality; sequential organ failure assessment (SOFA) at days 3, 7 and 14; duration of stay in critical care and the hospital; antibiotic-associated infections; and antibiotic-resistant pathogen cultures up to hospital discharge, death or 56 days. A healthcare-resource-utilisation analysis will be calculated from the duration of critical care and hospital stay. In addition, safety data will be collected with respect to performing BAL. A sample size of 210 will be required to detect a clinically significant shift in the distribution of AFD towards more patients having fewer antib
Sciurba FC, Criner GJ, Strange C, et al., 2016, Effect of endobronchial coils vs usual care on exercise tolerance in patients with severe emphysema the RENEW randomized clinical trial, Journal of the American Medical Association, Vol: 315, Pages: 2178-2189, ISSN: 0002-9955
Importance Preliminary clinical trials have demonstrated that endobronchial coils compress emphysematous lung tissue and may improve lung function, exercise tolerance, and symptoms in patients with emphysema and severe lung hyperinflation.Objective To determine the effectiveness and safety of endobronchial coil treatment.Design, Setting, and Participants Randomized clinical trial conducted among 315 patients with emphysema and severe air trapping recruited from 21 North American and 5 European sites from December 2012 through November 2015.Interventions Participants were randomly assigned to continue usual care alone (guideline based, including pulmonary rehabilitation and bronchodilators; n = 157) vs usual care plus bilateral coil treatment (n = 158) involving 2 sequential procedures 4 months apart in which 10 to 14 coils were bronchoscopically placed in a single lobe of each lung.Main Outcomes and Measures The primary effectiveness outcome was difference in absolute change in 6-minute-walk distance between baseline and 12 months (minimal clinically important difference [MCID], 25 m). Secondary end points included the difference between groups in 6-minute walk distance responder rate, absolute change in quality of life using the St George’s Respiratory Questionnaire (MCID, 4) and change in forced expiratory volume in the first second (FEV1; MCID, 10%). The primary safety analysis compared the proportion of participants experiencing at least 1 of 7 prespecified major complications.Results Among 315 participants (mean age, 64 years; 52% women), 90% completed the 12-month follow-up. Median change in 6-minute walk distance at 12 months was 10.3 m with coil treatment vs −7.6 m with usual care, with a between-group difference of 14.6 m (Hodges-Lehmann 97.5% CI, 0.4 m to ∞; 1-sided P = .02). Improvement of at least 25 m occurred in 40.0% of patients in the coil group vs 26.9% with usual care (odds ratio, 1.
Singh S, 2016, Respiratory symptoms and signs, Medicine (United Kingdom), Vol: 44, Pages: 205-212, ISSN: 1357-3039
© 2016 Published by Elsevier Ltd. The year 2016 marks the 200th anniversary of Laënnec's invention of the stethoscope, with the subsequent publication of auscultatory sounds for clinical diagnosis in 1819. Today, history and examination remain pivotal to accurate diagnosis. The hypotheticodeductive method of diagnosis based on Bayes' theorem requires a detailed history and examination skills to elicit symptoms and signs. The key symptoms of respiratory disease are breathlessness, chest pain, wheeze, cough and associated sputum production. Non-respiratory conditions may also produce such symptoms. A systematic approach to history-taking should include all primary symptoms, their time-course, characteristics, severity and trajectory. A review of non-respiratory associations, pharmaceutical and historical aspects of respiratory symptoms should precede a thorough review of clinical signs. Further questioning or examination will lead to assimilation of information, synthesis with clinicopathophysiological knowledge of respiratory diseases, and formulation of a differential diagnosis. On examination, based on the model of inspection, palpation, percussion and auscultation, there are a few classical patterns of the most important focal abnormalities, although there may be an absence of clinical signs. This article reviews the key features of respiratory symptoms and signs, outlines tips on how best to elicit these, and discusses patterns of clinical features suggesting certain diagnoses.
Spiritoso R, Padley S, Singh S, 2015, Chest X-ray interpretation in UK intensive care units: A survey 2014., J Intensive Care Soc, Vol: 16, Pages: 339-344, ISSN: 1751-1437
PURPOSE: This survey investigated current practice in intensive care unit radiology reporting using a survey tool. We ascertained physician attitudes regarding best practice. METHODS: A national survey was sent by email to a sample of intensive care units throughout UK between March and October 2014. The questionnaire determined current practice in reporting chest X-ray in intensive care units. It also identified differences between 'routine' and emergency and out-of-hours service. Further, it investigated how reports were documented and physician preferences for perceived best practice. RESULTS: Of 146 intensive care units contacted, 55% completed the survey. Of the sample, radiologists were solely responsible for chest X-ray reporting in 43.7%, intensive care unit clinicians in 33.7% and joint reporting in 25% of intensive care units. The reporting clinician on intensive care unit was a consultant in 67% of the centres. Written reports by radiologists were provided in 71.7% of cases. This was only 54.5% when intensive care unit clinicians reported chest X-rays. For all routine and emergency films, written reports by radiologists occurred in 63.1% of responders. Out-of-hours, 54.9% of clinicians described different reporting practice to normal hours. Regarding perceived best practice, 64.8% of clinicians preferred joint daily reporting, whilst 27% preferred a radiologist's formal report. For emergencies, 55.2% of the survey recipients preferred a joint report. CONCLUSION: Based on this cohort of UK intensive care units, at present, there appears to be a lack of a standardised system for image reporting. There are discrepancies in who reports chest X-rays, written documentation and the timing of reports, more so out-of-hours. Clinicians suggest that joint reporting should be the standard.
Grover V, Kelleher P, Singh S, 2015, Temporal changes in monocytic and neutrophilic trem-1 and trem-2 surface receptors in blood and bronchoalveolar lavage fluid in the development and resolution of ventilator-associated pneumonia (vap), Intensive Care Medicine Experimental, Vol: 3, ISSN: 2197-425X
Singh S, Zhang YZ, Chalkley S, et al., 2015, A three-point time series study of antibiotic usage on an intensive care unit, following an antibiotic stewardship programme, after an outbreak of multi-resistant Acinetobacter baumannii, EUROPEAN JOURNAL OF CLINICAL MICROBIOLOGY & INFECTIOUS DISEASES, Vol: 34, Pages: 1893-1900, ISSN: 0934-9723
Sanders RD, Grover V, Goulding J, et al., 2015, Immune cell expression of GABA(A) receptors and the effects of diazepam on influenza infection, JOURNAL OF NEUROIMMUNOLOGY, Vol: 282, Pages: 97-103, ISSN: 0165-5728
Zoumot Z, Kemp SV, Singh S, et al., 2015, Endobronchial Coils for Severe Emphysema Are Effective Up to 12 Months following Treatment: Medium Term and Cross-Over Results from a Randomised Controlled Trial, PLOS One, Vol: 10, ISSN: 1932-6203
Shaw M, Singh S, 2015, Complex clinical reasoning in the critical care - unit difficulties, pitfalls and adaptive strategies, INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Vol: 69, Pages: 396-400, ISSN: 1368-5031
Zhang Y-Z, Singh S, 2015, Antibiotic stewardship programmes in intensive care units: Why, how, and where are they leading us., World J Crit Care Med, Vol: 4, Pages: 13-28, ISSN: 2220-3141
Antibiotic usage and increasing antimicrobial resistance (AMR) mount significant challenges to patient safety and management of the critically ill on intensive care units (ICU). Antibiotic stewardship programmes (ASPs) aim to optimise appropriate antibiotic treatment whilst minimising antibiotic resistance. Different models of ASP in intensive care setting, include "standard" control of antibiotic prescribing such as "de-escalation strategies"through to interventional approaches utilising biomarker-guided antibiotic prescribing. A systematic review of outcomes related studies for ASPs in an ICU setting was conducted. Forty three studies were identified from MEDLINE between 1996 and 2014. Of 34 non-protocolised studies, [1 randomised control trial (RCT), 22 observational and 11 case series], 29 (85%) were positive with respect to one or more outcome: These were the key outcome of reduced antibiotic use, or ICU length of stay, antibiotic resistance, or prescribing cost burden. Limitations of non-standard antibiotic initiation triggers, patient and antibiotic selection bias or baseline demographic variance were identified. All 9 protocolised studies were RCTs, of which 8 were procalcitonin (PCT) guided antibiotic stop/start interventions. Five studies addressed antibiotic escalation, 3 de-escalation and 1 addressed both. Six studies reported positive outcomes for reduced antibiotic use, ICU length of stay or antibiotic resistance. PCT based ASPs are effective as antibiotic-stop (de-escalation) triggers, but not as an escalation trigger alone. PCT has also been effective in reducing antibiotic usage without worsening morbidity or mortality in ventilator associated pulmonary infection. No study has demonstrated survival benefit of ASP. Ongoing challenges to infectious disease management, reported by the World Health Organisation global report 2014, are high AMR to newer antibiotics, and regional knowledge gaps in AMR surveillance. Improved AMR surveil
Williams N, Ioannou Y, Stewart C, et al., 2015, An innovative interactive medical student induction programme in paediatrics., Med Teach, Vol: 37, Pages: 200-201
Singh S, Grover V, Christie L, et al., 2015, A Comparative Study of Bronchoscopic Microsample Probe versus Bronchoalveolar Lavage in Patients with Burns-Related Inhalational Injury, Acute Lung Injury and Chronic Stable Lung Disease, RESPIRATION, Vol: 89, Pages: 19-26, ISSN: 0025-7931
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