A guide to new anticoagulant medications for ENT surgeons.

OBJECTIVES: This study aimed to ascertain otolaryngologists' current knowledge of new (e.g. apixaban, rivaroxaban) and old (e.g. warfarin) anticoagulant medications, and to provide an educational overview of new anticoagulants for use by surgeons. METHODS: A questionnaire survey was distributed across the Wessex region, UK, to ascertain the levels of knowledge of and confidence in managing patients taking various anticoagulants. In total, 50 questionnaires were completed (41 by trainees and 9 by consultants). A literature review of new anticoagulant medications was then conducted. RESULTS: In general, there was poor clinical and pharmacokinetic knowledge of newly licensed anticoagulant medications. Respondents were more confident in the use of older vs newer forms of anticoagulants. This was true across all grades of doctors, but particularly at the senior level. All respondents stated that they would like to see an educational resource on anticoagulants. CONCLUSION: Knowledge of newly licensed anticoagulation medications is poor. This study has produced an educational resource for the management of anticoagulant agents. A thorough knowledge of these drugs is essential for the acute management of bleeding patients and in peri-operative surgical planning.

Guidance on the dental management of patients with haemophilia and congenital bleeding disorders.

Recommendations for dental preventive strategies and treatment planning were originally developed through consensus meetings by the Scottish Oral Health Group for Medically Compromised Patients and published in 2003 as a Guideline. The United Kingdom Haemophilia Centre Doctors' Organisation (UKHCDO) Dental Working Party has updated these recommendations following the AGREE II approach (www.agreetrust.org), involving a literature search, a review of national and international guidelines and after seeking the opinions of haemophilia treaters in the United Kingdom by an online survey. Where possible, evidence from the literature is graded according to the 'GRADE' system (www.bcshguidelines.com/bsch_process/evidence_levels_and_grades_of_recommendations/43_grade.html); however, overall there is a lack of robust data and most studies have methodological limitations. The objective of this guidance, which is largely consensus-based, is to assist dental practitioners in primary and secondary care to provide routine dental care for patients of all ages with congenital bleeding diatheses in order to improve overall access to dental care. The guidance may not be appropriate in all cases and individual patient circumstances may dictate an alternative approach. Date for guideline review: May 2016.

Treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients.

BACKGROUND AND OBJECTIVES: There is currently little published guidance on the management of anticoagulant and antiplatelet medication in patients admitted with epistaxis. The routine practice of withholding such medication in an attempt to control the epistaxis is common in the UK. However, this practice is not evidence-based, is often unnecessary, and can be associated with significant morbidity. This study introduces a treatment algorithm for oral anticoagulant and antiplatelet therapy in epistaxis patients, validated through a completed audit cycle. METHODS: One hundred patients admitted with epistaxis to the University Hospital Southampton NHS Foundation Trust were studied via a two-audit cycle covering the implementation of a new treatment algorithm formulated jointly by the otolaryngology and haematology departments. RESULTS: On admission, 58 per cent of patients were taking some form of anticoagulant or antiplatelet medication. The number of patients having such medication withheld decreased significantly between the two audits, for all drugs studied (i.e. aspirin, clopidogrel and warfarin). There was no significant increase in re-bleeding or re-admission rates between the audits. CONCLUSION: Implementation of this treatment algorithm would help standardise management for epistaxis patients taking anticoagulant or antiplatelet drugs, and should reduce morbidity associated with unnecessary routine discontinuation of such medication.

The bioethical experiences of student dietitians on their final clinical placement.

BACKGROUND: Dietetic students are exposed to bioethical dilemmas on clinical placements; however, the nature of these situations has not been investigated. The present study aimed to analyse students' reports of incidents and their associated personal development plans (PDP) to assess the type of ethical incidents faced and how they cope with them. METHODS: Final-year dietetic students were recruited via an announcement in class. The students' PDPs were analysed using thematic analysis to identify the type of ethical issues faced and how they felt about them. The 500-word PDPs were submitted after the final placement. RESULTS: Thirteen (13/26) students identified 'ethics' as a learning need and most of these incidents were related to enteral feeding (10/13). Ethical issues identified related to nonmaleficence; best interest; consent and capacity; truth telling and integrity; autonomy and substituted decision-making; futile treatment; beneficence and confidentially. The themes for how the students coped included being unsure; lack of confidence or knowledge with ethics and/or with communication; lack of experience; unease/concern about shared decision-making; and their own role in the situation. CONCLUSIONS: Student dietitians are exposed to a wide range of complex ethical clinical situations, with those related to enteral feeding being the most common. Students felt unsure of what to do and lacked confidence, which resulted in unease and concern; however, students appeared to have some ethical sensitivity. Communication problems with the multidisciplinary team or families were a common theme. Clinical educators need to support students in these situations and act as role models.

Needs-based cognitive-behavioural family intervention for carers of patients suffering from schizophrenia: 12-month follow-up.

OBJECTIVE: To examine longer-term effectiveness of a needs-based family intervention for carers and out-patients suffering from schizophrenia. METHOD: Seventy-nine unselected patient-carer pairs were recruited from a geographical area and allocated randomly to one of two conditions. One group received needs-based cognitive-behavioural family intervention in combination with general family support plus the standard care. The control group received the general family support and standard care only. RESULTS: Analysis was carried out on an intention-to-treat basis. There was a significant advantage for family intervention, in terms of relapse (37% relapsed compared to 72%, NNT=3) and on other clinical measures. Treatment group and medication compliance were significant and independent predictors of relapse. There was a significant reduction in carer needs in the intervention group. CONCLUSION: Family intervention directed at carers' needs within a standard mental health service can produce benefits for patients beyond the term of intervention.

Randomised controlled effectiveness trial of a needs-based psychosocial intervention service for carers of people with schizophrenia.

BACKGROUND: Family interventions are effective in reducing relapse in patients with schizophrenia, but there is little work demonstrating the effectiveness of the interventions in routine service settings. AIMS: To test the effectiveness of a needs-based family intervention service for patients recruited as out-patients and their carers, including those of low expressed emotion status. METHOD: Carers of out-patient schizophrenia sufferers selected only on illness history factors were randomly allocated to receive either family support alone or in combination with systematic psychosocial interventions based on an assessment of need. Delivery of family interventions attempted to involve the clinical team. RESULTS: Relapse outcomes were superior for family-treated patients at six-month follow-up, although most of the clinical and symptom patient variables assessed remained stable, as did measures of carer burden. CONCLUSIONS: The study demonstrated the effectiveness of family interventions in routine service settings. Problems with staff, patient and carer engagement and participation were identified.