Timmis A.,NIHR Cardiovascular Biomedical Research Unit |
Roobottom C.A.,Derriford Hospital
Heart | Year: 2017
In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it-like other international guidelines-had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be 'non-anginal' and CT coronary angiography (CTCA) in patients with 'typical' or 'atypical' chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical-A s opposed to functional-testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina. © 2017 Article author(s).
Ayling R.M.,Derriford Hospital
Annals of Clinical Biochemistry | Year: 2012
Most abdominal disorders present with a limited number of overlapping symptoms. Blood tests are not routinely available for use in diagnosis and so investigation tends to require complex imaging procedures or endoscopy and biopsy. These are invasive for the patient, may be associated with morbidity and mortality and have considerable resource implications. Biochemical tests on a single sample of faeces are therefore a valuable alternative. Measurement of faecal calprotectin has been shown to have a role in the diagnosis of inammatory bowel disease and in its monitoring. Lactoferrin is also of benefit used in this way. Faecal elastase has been demonstrated to be of use in the diagnosis of pancreatic insufficiency. A number of faecal markers have been explored in colorectal cancer. Faecal occult blood testing is used for population screening, but the metabolomic marker tumour, M2-pyruvate kinase, has potential for use in both diagnosis and screening. DNA testing has advantages in colorectal cancer but the exact applications of such tests require further evaluation.
Smith J.E.,Royal Center for Defence Medicine |
Smith J.E.,Derriford Hospital
Philosophical Transactions of the Royal Society B: Biological Sciences | Year: 2011
Blast injuries are becoming increasingly common in military conflicts as the nature of combat changes from conventional to asymmetrical warfare and counter-insurgency. This article describes a retrospective database review of cases from the UK joint theatre trauma registry from 2003 to 2009, containing details of over 3000 patients, mainly injured in Iraq and Afghanistan. During this period, 1678 patients were injured by explosion of whom 113 had evidence of blast lung injury. Of the 50 patients who survived to reach a medical facility, 80 per cent required ventilatory support. Injuries caused by explosion are increasing when compared with those caused by other mechanisms, and blast lung represents a significant clinical problem in a deployed military setting. Management of these patients should be optimized from point of wounding to definitive care. © 2011 The Royal Society.
Hilton D.A.,Derriford Hospital |
Hanemann C.O.,University of Plymouth
Brain Pathology | Year: 2014
Schwannomas may occur spontaneously, or in the context of a familial tumor syndrome such as neurofibromatosis type 2 (NF2), schwannomatosis and Carney's complex. Schwannomas have a variety of morphological appearances, but they behave as World Health Organization (WHO) grade I tumors, and only very rarely undergo malignant transformation. Central to the pathogenesis of these tumors is loss of function of merlin, either by direct genetic change involving the NF2 gene on chromosome 22 or secondarily to merlin inactivation the genetic pathways and morphological features of schwannomas associated with different genetic syndromes will be discussed. Merlin has multiple functions, including within the nucleus and at the cell membrane, and this review summarizes our current understanding of the mechanisms by which merlin loss is involved in schwannoma pathogenesis, highlighting potential areas for therapeutic intervention. © 2014 International Society of Neuropathology.
Potter D.,Derriford Hospital
Journal of the Royal Naval Medical Service | Year: 2013
The identification of major trauma patients before arrival in hospital allows the activation of an appropriate trauma response. The Wessex triage tool (WTT) uses a combination of anatomical injury assessment and physiological criteria to identify patients with major trauma suitable for triage direct to a major trauma centre (MTC), and has been adopted by the South-West Peninsula Trauma Network (PTN). A retrospective database review, using the Trauma Audit Research Network (TARN) database, was undertaken to identify a population of patients presenting to Derriford Hospital with an injury severity score (ISS) >15. The WTT was then applied to this population to identify the sensitivity of the tool. The sensitivity of the WTT at identifying patients with an ISS> 15 was 53%. One of the reasons for this finding was that elderly patients who are defined as having major trauma due to the nature of their injuries, but who did not have a mechanism to suggest they had sustained major trauma (such as a fall from standing height), were not identified by these triage tools. The implications of this are discussed.
Guly H.,Derriford Hospital
Resuscitation | Year: 2011
Death from exposure to cold has been recognised for thousands of years but hypothermia as a clinical condition was not generally recognised until the mid-20th century and then only in extreme conditions such as immersion in cold water or snow. In the UK, hypothermia in less extreme conditions was not generally recognised until the 1960s. Recognition of hypothermia required the temperature to be measured and this did not become a clinical tool until the late 1800s and it was not used routinely until the early 1900s. Although John Hunter and James Curry did some physiological experiments in the 1700s, detailed physiological experiments were not done until the early 20th century and the use of therapeutic hypothermia for malignancy and in anaesthesia in the 1930s and 1940s provided more impetus for investigating the physiology of hypothermia in humans and familiarising the medical profession with measuring core temperatures. © 2010 Elsevier Ireland Ltd.
Griffin J.,Derriford Hospital |
Nicholls B.,Derriford Hospital
Anaesthesia | Year: 2010
Ultrasound guidance is rapidly becoming the gold standard for regional anaesthesia. There is an ever growing weight of evidence, matched with improving technology, to show that the use of ultrasound has significant benefits over conventional techniques, such as nerve stimulation and loss of resistance. The improved safety and efficacy that ultrasound brings to regional anaesthesia will help promote its use and realise the benefits that regional anaesthesia has over general anaesthesia, such as decreased morbidity and mortality, superior postoperative analgesia, cost-effectiveness, decreased postoperative complications and an improved postoperative course. In this review we consider the evidence behind the improved safety and efficacy of ultrasound-guided regional anaesthesia, before discussing its use in pain medicine, paediatrics and in the facilitation of neuraxial blockade. The Achilles' heel of ultrasound-guided regional anaesthesia is that anaesthetists are far more familiar with providing general anaesthesia, which in most cases requires skills that are achieved faster and more reliably. To this ends we go on to provide practical advice on ultrasound-guided techniques and the introduction of ultrasound into a department.
Tillyard A.,Derriford Hospital
Intensive Care Medicine | Year: 2010
Purpose: To provide a revised definition, process and purpose of triage to maximise the number of patients receiving intensive care during a crisis. Methods: Based on the ethical principle of virtue ethics and the underlying goal of providing individual patients with treatment according to their best interests, the methodology of triage is reassessed and revised. Results: The decision making processes regarding treatment decisions during a pandemic are redefined and new methods of intensive care provision recommended as well as recommending the use of a 'ranking' system for patients excluded from intensive care, defining the role of non-intensive care specialists, and applying two types of triage as 'organisational triage' and 'treatment triage' based on the demand for intensive care. Conclusion: Using a different underlying ethical basis upon which to plan for a pandemic crisis could maximise the number of patients receiving intensive care based on individual patients' best interests. © The Author(s) 2010.
Ajala O.,Derriford Hospital |
English P.,Derriford Hospital |
Pinkney J.,Derriford Hospital
American Journal of Clinical Nutrition | Year: 2013
Background: There is evidence that reducing blood glucose concentrations, inducing weight loss, and improving the lipid profile reduces cardiovascular risk in people with type 2 diabetes. Objective: We assessed the effect of various diets on glycemic control, lipids, and weight loss. Design: We conducted searches of PubMed, Embase, and Google Scholar to August 2011. We included randomized controlled trials (RCTs) with interventions that lasted 6 mo that compared lowcarbohydrate, vegetarian, vegan, low-glycemic index (GI), highfiber, Mediterranean, and high-protein diets with control diets including low-fat, high-GI, American Diabetes Association, European Association for the Study of Diabetes, and low-protein diets. Results: A total of 20 RCTs were included (n = 3073 included in final analyses across 3460 randomly assigned individuals). The lowcarbohydrate, low-GI, Mediterranean, and high-protein diets all led to a greater improvement in glycemic control [glycated hemoglobin reductions of 20.12% (P = 0.04), 20.14% (P = 0.008), 20.47% (P < 0.00001), and 20.28% (P < 0.00001), respectively] compared with their respective control diets, with the largest effect size seen in the Mediterranean diet. Low-carbohydrate and Mediterranean diets led to greater weight loss [20.69 kg (P = 0.21) and 21.84 kg (P < 0.00001), respectively], with an increase in HDL seen in all diets except the high-protein diet. Conclusion: Low-carbohydrate, low-GI, Mediterranean, and highprotein diets are effective in improving various markers of cardiovascular risk in people with diabetes and should be considered in the overall strategy of diabetes management. © 2013 American Society for Nutrition.
Higginson I.,Derriford Hospital
Emergency Medicine Journal | Year: 2012
Background: Emergency department (ED) crowding is a significant international problem. There is increasing overseas research into this field. In the UK, the focus has been on waiting times in EDs, and on the government's 4 h standard, rather than on crowding itself. Aims: To examine the causes and effects of ED crowding, along with solutions. To consider whether the 4 h standard has had an effect on ED crowding in the UK. Methods: A structured literature review on ED crowding. Results: The evidence base largely consists of retrospective or descriptive studies (65% combined) from North America and Australasia (89% combined). Measurement of crowding is not well developed, and the lack of a gold standard additionally limits the quality of research. The main cause of crowding is access block, because of high levels of hospital occupancy. Crowding carries a number of adverse consequences for patients and staff. Many solutions are described, but with weak evidence behind them. Most of these focus on interventions in the ED, despite the fact that the main causes lie outside. Solutions aimed at achieving the 4 h standard may mitigate crowding. Conclusion: The extent of ED crowding in the UK is unknown. The problem is probably mitigated by process standards such as the 4 h standard. The causes and effects of crowding are likely to be the same as overseas, but there is little research to validate this. The best solutions are not known.