Is a randomised controlled trial of take home naloxone distributed in emergency settings likely to be feasible and acceptable? Findings from a UK qualitative study exploring perspectives of people who use opioids and emergency services staff.

OBJECTIVE: Distribution of take-home naloxone (THN) by emergency services may increase access to THN and reduce deaths and morbidity from opioid overdose. As part of a feasibility study for a randomised controlled trial (RCT) of distribution of THN kits and education within ambulance services and Emergency Departments (EDs), we used qualitative methods to explore key stakeholders' perceptions of feasibility and acceptability of delivering the trial. METHODS: We undertook semi-structured interviews and focus groups with 26 people who use opioids and with 20 paramedics and ED staff from two intervention sites between 2019 and 2021. Interviews and focus groups were recorded, transcribed verbatim and analysed using Framework Analysis. RESULTS: People using opioids reported high awareness of overdose management, including personal experience of THN use. Staff perceived emergency service provision of THN as a low-cost, low-risk intervention with potential to reduce mortality, morbidity and health service use. Staff understood the trial aims and considered it compatible with their work. All participants supported widening access to THN but reported limited trial recruitment opportunities partly due to difficulties in consenting patients during overdose. Procedural problems, restrictive recruitment protocols, limited staff buy-in and patients already owning THN limited trial recruitment. Determining trial effectiveness was challenging due to high levels of alternative community provision of THN. CONCLUSIONS: Distribution of THN in emergency settings was considered feasible and acceptable for stakeholders but an RCT to establish the effectiveness of THN delivery is unlikely to generate further useful evidence due to difficulties in recruiting patients and assessing benefits.

Interventions to improve the management of pain in emergency departments: systematic review and narrative synthesis.

INTRODUCTION: Pain management in emergency departments (ED) is often inadequate despite the availability of effective analgesia, with many patients receiving insufficient and untimely analgesia. We conducted a systematic literature review to identify interventions that could improve pain management in the ED. METHODS: We systematically searched seven databases for studies reporting pain management outcomes after intervention to change professional practice to improve pain management in the ED, compared with pain management before or without intervention. Data was synthesised using principles of narrative synthesis. RESULTS: We identified 43 relevant studies, including 40 uncontrolled before-and-after studies. Interventions included implementation of guidelines and protocols, educational interventions, pain scoring tools and changes in nursing roles, with many multifaceted interventions incorporating two or more of these elements. Interventions aimed to improve assessment and documentation of pain, knowledge and awareness of pain management and reduce time to analgesia. Due to the high probability of bias in study design and significant variation between studies, it was not possible to estimate the overall effectiveness of interventions, or identify which had the greatest impact. Intervention to improve pain management was reported to have some positive impact in most studies, but these findings may be explained by limitations in study design. CONCLUSIONS: Many interventions reported improvements in pain management, but current evidence is insufficient to recommend any for widespread adoption. In order to improve pain management we need to understand more about the theory underlying interventions, the context in which interventions work, and develop interventions based on this stronger theoretical understanding.

Diagnostic value of CT for deep vein thrombosis: results of a systematic review and meta-analysis.

AIM: To estimate the sensitivity and specificity of computed tomography (CT) for the diagnosis of deep vein thrombosis (DVT) in patients with suspected DVT and pulmonary embolus (PE). MATERIALS AND METHODS: A search of the medical literature and citation lists was undertaken, and selected studies comparing CT to a reference standard in patients with suspected DVT or PE were retrieved. Data were analysed by random effects meta-analysis. RESULTS: Thirteen articles were included in the meta-analysis. Most compared CT to ultrasound in patients with clinically suspected PE. The sensitivity ranged from 71-100%, while specificity ranged from 93-100%. The pooled estimate of sensitivity was 95.9% (95% CI 93 to 97.8%) and the pooled estimate of specificity was 95.2% (93.6 to 96.5%). However, pooled estimates should be interpreted with caution as these were subject to significant heterogeneity (p=0.025 and p<0.001, respectively). Most studies only appeared to report proximal DVT. Too few data were available to estimate sensitivity for distal DVT. CONCLUSIONS: CT has a similar sensitivity and specificity to ultrasound in patients with suspected PE where investigation of suspected DVT is required. There is insufficient research to determine the diagnostic accuracy of CT in patients with suspected DVT alone.

How is deep vein thrombosis diagnosed and managed in UK and Australian emergency departments?

BACKGROUND: Recent research has identified technologies that may be of value in the diagnosis and management of deep vein thrombosis (DVT). We aimed to survey current practice in the United Kingdom (UK) and Australia to determine the extent to which these technologies have been implemented in these two healthcare systems. METHODS: We undertook a postal survey of 255 hospitals in the UK and 89 hospitals in Australia, requesting details of individual diagnostic tests, use of diagnostic algorithms, and management of DVT. RESULTS: We received replies from 186/255 UK hospitals (73%) and 84/89 of Australian hospitals (94%). Ultrasonography and laboratory based D-dimer were the most commonly available tests. We received 43 different algorithms from 51 hospitals. With only a very few exceptions, DVT diagnosis was ruled in by positive venography or positive ultrasound without venographic confirmation. By contrast a variety of different criteria were used to rule out DVT. Most algorithms used a combination of low clinical risk and negative D-dimer to rule out DVT, but some required all patients to receive ultrasound or venography. Few ruled out on the basis of low clinical risk or negative D-dimer alone. Low molecular weight heparins were overwhelmingly the treatment of choice for established DVT. Most departments (214/264; 81%) offered outpatient treatment. CONCLUSION: Recently developed technologies for the diagnosis and treatment of DVT have been widely implemented in the UK and Australia. Variation in practice, and thus presumably uncertainty, seems to be greatest in relation with the criteria used to rule out DVT.

Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis.

BACKGROUND: Numerous studies have evaluated the accuracy of D-dimer in diagnosing suspected deep vein thrombosis (DVT), but results are conflicting. AIM: To overview estimates of the diagnostic accuracy of D-dimer and identify causes of variation. DESIGN: Systematic review, meta-analysis and meta-regression. METHODS: We searched Medline, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Reviews of Effectiveness, the ACP Journal Club, citation lists, and contacted manufacturers. We selected studies that compared D-dimer to a reference standard in patients with suspected DVT. Data were analysed by random effects meta-analysis and meta-regression. RESULTS: We included 97 studies reporting 198 assays in 99 different patient groups. Overall estimated sensitivity and specificity of D-dimer were 90.5% and 54.7%, but both estimates were subject to significant heterogeneity (p < 0.001). Meta-regression identified that some heterogeneity was explained by study setting, exclusion criteria, whether recruitment was consecutive or the study prospective, whether D-dimer and the reference standard were measured blind, and whether the D-dimer threshold was determined a priori. Sensitivity and specificity also varied between ELISA (94% and 45% respectively), latex (89% and 55%) and whole blood agglutination assays (87% and 68%). Sensitivity was higher for proximal than distal DVT. Specificity was dependent upon whether clinical probability of DVT was high (specificity 51%), intermediate (67%) or low (78%). DISCUSSION: D-dimer has good sensitivity, but poor specificity, for DVT. Estimates are subject to substantial heterogeneity from various sources. D-dimer specificity appears to be strongly dependent upon the pre-test clinical probability of DVT.

Cost-effectiveness of high-dose chemotherapy in first-line treatment of advanced multiple myeloma.

The cost-effectiveness of high-dose chemotherapy in multiple myeloma was considered as part of a UK National Health Service Executive regional evidence-based appraisal process. The use of high-dose chemotherapy supported by autologous stem cell transplantation in patients under 65 years of age was shown to provide a marginal benefit of 0.7 life-years over conventional chemotherapy. This corresponded to an incremental cost 'per life-year gained' figure of approximately pound15 000, based upon initial treatment costs and trial-period data only. The use of high-dose chemotherapy in the first-line treatment of advanced multiple myeloma improves event-free and overall survival and appears to be a cost-effective treatment option.

The cost-effectiveness of high dose chemotherapy in the treatment of relapsed Hodgkin's disease and non-Hodgkin's lymphoma.

As part of an NHS Executive Trent regional initiative we considered the role and cost-effectiveness of high dose chemotherapy in the treatment of relapsed Hodgkin's disease and non-Hodgkin's lymphoma. The key trials and case series show an additional patient benefit of 0.8-1.1 life years over standard chemotherapy. We estimate incremental cost per life year gained of 12 800 pound silver-17 600 pound silver, which reduces further if long-term benefits are considered. High dose chemotherapy in these conditions is both life-saving and cost-effective.