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Lucas D.N.,Northwick Park Hospital | Robinson P.N.,Northwick Park Hospital | Nel M.R.,Hillingdon Hospital
International Journal of Obstetric Anesthesia | Year: 2012

Sepsis in pregnancy and the puerperium remains a significant cause of maternal mortality and morbidity worldwide. Major morbidity arising as a result of obstetric sepsis includes fetal demise, organ failure, chronic pelvic inflammatory disease, chronic pelvic pain, bilateral tubal occlusion and infertility. Early recognition and timely response are key to ensuring good outcome. This review examines the clinical problem of sepsis in obstetrics and the role of the anaesthetist in the management of this condition. © 2011 Elsevier Ltd. All rights reserved.

Dubrey S.W.,Hillingdon Hospital
Postgraduate Medical Journal | Year: 2012

Heart involvement by amyloid deposition remains the most challenging of all organ sytems that may become involved, in what is generally a systemic disease. The correct diagnosis of amyloid type is critical to selection of the appropriate and wide range of therapies. The treatment of amyloid heart disease comprises two strategies: conventional management of a restrictive cardiomyopathy, and varied therapies aimed at the underlying amyloidogenic process. In light chain (AL) amyloidosis, many of the most efficacious therapies involve chemotherapeutic agents with their own inherent toxicities to the heart and bone marrow. In the case of the hereditary amyloidosis, major surgery in the form of liver transplantation is usually required. Moreover, consideration should be given to screening of family members for a potentially hereditary disease. Several types of amyloidosis may require one or more, of heart, liver and/or kidney transplantation, sometimes in addition to high-dose chemotherapy. The objective is to provide a schematic overview of available therapies in the management of AL, hereditary, senile systemic, isolated atrial and secondary forms of amyloidosis.

Godfrey G.,Hillingdon Hospital | Hilton A.,Austin Hospital | Bellomo R.,Australian and New Zealand Intensive Care Research Center
Current Opinion in Critical Care | Year: 2013

PURPOSE OF REVIEW: Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. RECENT FINDINGS: DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. SUMMARY: There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Selby J.,Foundation School | Prabhudesai A.,Hillingdon Hospital
International Journal of Colorectal Disease | Year: 2014

Aims: To explore if post-operative day 3 C-reactive protein (CRP), the ratio of pre-operative to day 3 white cell count (WCC) and platelet count can be used to predict the risk of post-operative complication and stratify the severity of complications as defined by the Clavien-Dindo classification. Methods: Data was obtained retrospectively on 127 patients who had elective bowel resection for malignancy between 2011 and 2013. Baseline demographics and clinical details were obtained including pre-operative and day 3 WCC and platelets and day 3 CRP. Ratio of pre-operative to day 3 WCC and platelets was calculated. Outcome measures were if a complication occurred (death included) and complication as defined by the Clavien-Dindo clasification. Mann-Whitney U test and Kruskal-Wallis were used to test for significance. Results: Of 127 patients, 57 % (n = 73) were male with a total median age of 72 and the commonest histology result T3N0 (40.6 %, n = 52). CRP was found to predict a complication (p < 0.0005) and the severity of complication as per the Clavien-Dindo classification (p < 0.0005). Day 3 CRP over 285 suggested a life-threatening complication (Clavien-Dindo score 4). There was no statistical significance between the ratio of WCC and platelets to any of the outcome measures. Conclusions: WCC, platelets and CRP are routinely performed in the post-operative period. Previous research has shown CRP to be a good predictor of a complication. This paper has shown that day 3 CRP can not only predict but can also stratify the severity of post-operative complications. © 2014, Springer-Verlag Berlin Heidelberg.

Dubrey S.W.,Hillingdon Hospital | Comenzo R.L.,Tufts Medical Center
QJM | Year: 2012

Amyloid diseases in man are caused by as many as 23 different pre-cursor proteins already described. Cardiologists predominantly encounter three main types of amyloidosis that affect the heart: light chain (AL) amyloidosis, senile systemic amyloidosis (SSA) and hereditary amyloidosis, most commonly caused by a mutant form of transthyretin. In the third world, secondary amyloid (AA) is more prevalent, due to chronic infections and inadequately treated inflammatory conditions. Much less common, are the non-transthyretin variants, including mutations of fibrinogen, the apolipoproteins apoA1 and apoA2 and gelsolin. These rarer types do not usually cause significant cardiac compromise. Occurring worldwide, later in life and of less clinical significance, isolated atrial amyloid (IAA) also involves the heart. Heart involvement by amyloid often has devastating consequences. Clinical outcome depends on amyloid type, the extent of systemic involvement and the treatment options available. An exact determination of amyloid type is critical to appropriate therapy. In this review we describe the different approaches required to treat this spectrum of amyloid cardiomyopathies. © The Author 2012. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved.

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