Rhyl, United Kingdom
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Price R.,Royal Alexandra Hospital | MacLennan G.,University of Aberdeen | Glen J.,Glan Clwyd Hospital
BMJ (Online) | Year: 2014

Objectives: To determine the effect on mortality of selective digestive decontamination, selective oropharyngeal decontamination, and topical oropharyngeal chlorhexidine in adult patients in general intensive care units and to compare these interventions with each other in a network meta-analysis. Design: Systematic review, conventional meta-analysis, and network meta-analysis. Medline, Embase, and CENTRAL were searched to December 2012. Previous meta-analyses, conference abstracts, and key journals were also searched. We used pairwise meta-analyses to estimate direct evidence from intervention-control trials and a network meta-analysis within a Bayesian framework to combine direct and indirect evidence. Inclusion criteria: Prospective randomised controlled trials that recruited adult patients in general intensive care units and studied selective digestive decontamination, selective oropharyngeal decontamination, or oropharyngeal chlorhexidine compared with standard care or placebo. Results: Selective digestive decontamination had a favourable effect on mortality, with a direct evidence odds ratio of 0.73 (95% confidence interval 0.64 to 0.84). The direct evidence odds ratio for selective oropharyngeal decontamination was 0.85 (0.74 to 0.97). Chlorhexidine was associated with increased mortality (odds ratio 1.25, 1.05 to 1.50). When each intervention was compared with the other, both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine. The difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain. Conclusion: Selective digestive decontamination has a favourable effect on mortality in adult patients in general intensive care units. In these patients, the effect of selective oropharyngeal decontamination is less certain. Both selective digestive decontamination and selective oropharyngeal decontamination are superior to chlorhexidine, and there is a possibility that chlorhexidine is associated with increased mortality.


Farboud A.,Glan Clwyd Hospital | Crunkhorn R.,Queen Elizabeth Hospital | Trinidade A.,James Paget Hospital
Journal of Laryngology and Otology | Year: 2013

Objective: Symptoms, including tinnitus, ear pain and vertigo, have been reported following exposure to wind turbine noise. This review addresses the effects of infrasound and low frequency noise and questions the existence of 'wind turbine syndrome'. Design: This review is based on a search for articles published within the last 10 years, conducted using the PubMed database and Google Scholar search engine, which included in their title or abstract the terms 'wind turbine', 'infrasound' or 'low frequency noise'. Results: There is evidence that infrasound has a physiological effect on the ear. Until this effect is fully understood, it is impossible to conclude that wind turbine noise does not cause any of the symptoms described. However, many believe that these symptoms are related largely to the stress caused by unwanted noise exposure. Conclusion: There is some evidence of symptoms in patients exposed to wind turbine noise. The effects of infrasound require further investigation. Copyright © JLO (1984) Limited 2013.


Lewis S.A.,Glan Clwyd Hospital | Noyes J.,Bangor University | Mackereth S.,Royal Alexandra Hospital
BMC Pediatrics | Year: 2010

Background: Young people with neurological impairments such as epilepsy are known to receive less adequate services compared to young people with other long-term conditions. The time (age 13-19 years) around transition to adult services is particularly important in facilitating young people's self-care and ongoing management. There are epilepsy specific, biological and psycho-social factors that act as barriers and enablers to information exchange and nurturing of self-care practices. Review objectives were to identify what is known to be effective in delivering information to young people age 13-19 years with epilepsy and their parents, to describe their experiences of information exchange in healthcare contexts, and to identify factors influencing positive and negative healthcare communication.Methods: The Evidence for Policy and Practice Information Coordinating Centre systematic mixed-method approach was adapted to locate, appraise, extract and synthesise evidence. We used Ley's cognitive hypothetical model of communication and subsequently developed a theoretical framework explaining information exchange in healthcare contexts.Results: Young people and parents believed that healthcare professionals were only interested in medical management. Young people felt that discussions about their epilepsy primarily occurred between professionals and parents. Epilepsy information that young people obtained from parents or from their own efforts increased the risk of epilepsy misconceptions. Accurate epilepsy knowledge aided psychosocial adjustment. There is some evidence that interventions, when delivered in a structured psycho-educational, age appropriate way, increased young people's epilepsy knowledge, with positive trend to improving quality of life. We used mainly qualitative and mixed-method evidence to develop a theoretical framework explaining information exchange in clinical encounters.Conclusions: There is a paucity of evidence reporting effective interventions, and the most effective ways of delivering information/education in healthcare contexts. No studies indicated if improvement was sustained over time and whether increased knowledge was effective in improving in self-care. Current models of facilitating information exchange and self-care around transition are not working well. There is an urgent need for further studies to develop and evaluate interventions to facilitate successful information exchange, and follow young people over time to see if interventions showing early promise are effective in the medium to long-term. © 2010 Lewis et al; licensee BioMed Central Ltd.


Fisher M.,Royal North Shore Hospital | Fisher M.,University of Sydney | Ridley S.,Glan Clwyd Hospital
Critical Care and Resuscitation | Year: 2012

Assessing the appropriateness of continuing life support is a difficult task for intensive care unit staff. Part of this difficulty relates to prognostic uncertainty and the varying reliability of clinical decisions. Uncertainty about prognosis is quickly recognised by patients and families, and can be a source of mistrust and potential conflict. We discuss the reasons for uncertainty and outline key measures to reduce and manage such uncertainty. Practical certainty, where the clinicians are as certain as they can be, with both prognostication and knowledge of patient wishes, may be an appropriate concept for physicians engaged in end-oflife decisions. It involves accurate prognostication, informed surrogates, advance care planning, time to assess response, and the collective wisdom of experienced clinicians. The family conference should develop an agreed plan through shared decision making. The collective wisdom of experienced health care workers with good communication skills and informed patient advocates increases the likelihood of achieving practical certainty and the best decisions. However, greater time and effort seems to be required to improve end-of-life care in the ICU.


Lefemine V.,Glan Clwyd Hospital | Morgan R.J.,Glan Clwyd Hospital
Hepatobiliary and Pancreatic Diseases International | Year: 2011

BACKGROUND: Common bile duct (CBD) stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones. The patients were managed surgically, allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones. METHOD: Retrospective analysis of patients presenting with jaundice due to CBD stones, and managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram with or without CBD exploration. RESULTS: The jaundice settled pre-operatively in 76/108 patients, and in 60/108 the CBD stones had passed spontaneously by the time of surgery. These 60 patients avoided any intervention to their CBD. CONCLUSIONS: CBD stones pass spontaneously in more than half of jaundiced patients. Surgical management (laparoscopic cholecystectomy and intra-operative cholangiogram, with willingness to perform CBD exploration if positive) allows the avoidance of CBD intervention in these patients. © 2011, Hepatobiliary Pancreat Dis Int.


Objective: There is currently no system in widespread use that accurately prioritizes colorectal referrals in symptomatic patients with an acceptable degree of sensitivity and specificity. We have validated a weighted numerical scoring system for the prioritization of such colorectal referrals in an attempt to rectify this, with detection of colorectal cancer (CRC) the primary outcome. Method: We conducted a prospective study of symptomatic patients referred by primary care to the colorectal service in a district general hospital. A computer-generated weighted numerical score (WNS) was derived from the primary symptoms and symptom combinations. Patients underwent colorectal investigations and a final diagnosis was established. Sensitivity, specificity and accuracy of CRC detection as determined by the WNS, Department of Health (DOH) and National Institute for Health and Clinical Excellence guidelines was determined. Primary Care compliance with guidelines was analysed. Results: A definitive diagnosis was established in 3457 patients. One hundred and eighty-six (5.4%) had CRC. The mean score for the cancer patients (76.9, 95%CI 72-81) was significantly higher than that of non-cancer patients (52, 95%CI 52-53) . P < 0.001. Receiver Operator Curve analysis demonstrates a high discriminatory power for the Patient Consultation Questionnaire (PCQ) with an area under curve of 0.76. Compliance by primary care with the nationally recommended referral guidelines was poor with only 55% and 58% compliance with DOH and National Institute for Clinical Excellence referral guidelines for suspected cancer respectively. Conclusion: The PCQ and the WNS is an efficient, objective system that allows the accurate prioritization of colorectal referrals with a high sensitivity for cancer and other serious colorectal pathologies. © 2010 The Authors. Journal Compilation © 2010 The Association of Coloproctology of Great Britain and Ireland.


The military hospital at camp bastion Afghanistan is reputed to be the world's busiest trauma centre. Much has been learnt there in the field of managing massive haemorrhage, the protocols used by the military show a significantly higher survival rate than might be expected of such injuries. This article aims to explain the use of rotational thromboelastometry (ROTEM) monitoring and its role in reducing mortality in battle injured trauma patients.


Objective: To review the published evidence relating to the use of radiotherapy (RT), chemotherapy and biological therapy as adjuncts to surgery in the curative treatment of rectal cancer. Methods: Searches were carried out of the MEDLINE and CANCERLIT databases together with conference abstracts from key meetings including the American Society of Clinical Oncology Annual Meeting and Gastrointestinal Cancers Symposium and the ECCO/ESMO Multidisciplinary Congress. Results: RT reduces local pelvic recurrence when used as an adjunct to surgery, even when this is performed optimally by total mesorectal excision (TME). RT is usually given as short-course preoperative radiotherapy (SCPRT) followed by immediate surgery which produces no or very little downstaging or long-course concurrent chemoradiation (CRT) followed by a 6-8 week gap prior to surgery which produces significant downstaging. The prognostic importance of achieving a clear histological circumferential resection margin is now well recognised and pathological assessment of the quality of surgery can predict long-term outcomes. Internationally there is considerable heterogeneity in the staging modalities and criteria used in deciding which approach might be used, in the reporting of histological results and in RT parameters (time/dose/fractionation/volume). Attempts to increase the potency of CRT have included the addition of concurrent chemotherapeutic and biological agents to the standard fluoropyrimidine although there is little randomised data and none with regard to long-term survival outcomes. Neither SCPRT nor downstaging CRT have been shown to reduce the rate of subsequent distant metastatic relapse which remains a significant clinical problem. The potential additional benefit of neoadjuvant or adjuvant chemotherapy in addition to SCPRT or long-course CRT remains ill-defined. Late morbidity can include bowel and sexual dysfunction, pelvic fractures and second malignancies with considerably more being known in relation to SCPRT than long-course CRT. Conclusions: Improvements in imaging, pathology and surgical technique combined with multimodality treatment using RT and chemotherapy are leading to continuing improvements in the long term outcome for patients with rectal cancer although much remains to be learnt regarding the optimum strategy for use of these in different clinical contexts and their relationship to long-term morbidity. © 2010 The Author. Journal Compilation © 2010 Blackwell Publishing Ltd.


Ridley S.,Glan Clwyd Hospital | Fisher M.,Royal North Shore Hospital
Current Opinion in Critical Care | Year: 2013

PURPOSE OF REVIEW: Uncertainty surrounding medical decision-making is particularly important during end-of-life decision-making. Doubts about the patientÊs best interests and prognostic accuracy may lead to conflict. RECENT FINDINGS: Many authors have suggested recently that medical attitudes to uncertainty need review. It is inappropriate to avoid discussion of uncertainty during end-of-life care and American literature suggests that patients and families accept uncertainty in end-of-life discussions. Recently, authors have advocated the concept of 'Practical Certainty' accepting that absolute certainty is rarely possible in end-of-life decision-making and openly acknowledging that the physicians are as certain as they can be in the circumstances. Allowing time to provide acceptance of a palliative care pathway and using the collective wisdom of colleagues improves the accuracy of prediction and reduces conflict at the end of life. SUMMARY: The implications of this review are that doctors should not avoid discussing uncertainty in end-of-life conversations and the article provides some recommendations for minimizing conflict arising from end-of-life discussion. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Pugh R.J.,Glan Clwyd Hospital | Cooke R.P.D.,University of Liverpool | Dempsey G.,University of Liverpool
Journal of Hospital Infection | Year: 2010

Hospital-acquired pneumonia (HAP) is a common cause of morbidity and mortality in the critically ill, yet the optimal duration of antibiotic therapy is unknown. Too short a course may lead to treatment failure, whereas too long a course may lead to increased antibiotic resistance, antibiotic-related morbidity and increased costs. Standard duration of antibiotic therapy for Gram-negative (GN-)HAP at our institution is 5 days, significantly shorter than advocated in many current guidelines. We performed a retrospective review of all cases of GN-HAP on our critical care unit fulfilling clinical and microbiological criteria to investigate recurrence rate and mortality following short course antibiotic therapy. Seventy-nine eligible patients with GN-HAP were identified. Of these, 79% were receiving mechanical respiratory support at diagnosis; 42% had GN-HAP due to non-fermenting Gram-negative bacilli (NF-GNB) and 72% were treated with the recommended 5 day course of antibiotics. Two patients had clear evidence of non-resolution of pneumonia after 5 days of therapy. Overall recurrence rate was 14%, with relapse rates significantly higher among patients with NF-GNB when compared to patients with other Gram-negative organisms (17% vs 2%; P= 0.03). The overall recurrence rate was no higher than rates reported in earlier studies (17-41%). Critical care mortality (34.2%) was also not in excess of previously reported values (18-57%). In this limited study, use of a 5 day course of appropriate antibiotics for GN-HAP does not appear to increase risk of recurrence or mortality when pneumonia resolution has been achieved prior to the cessation of therapy. © 2009 The Hospital Infection Society.

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