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Gershlick A.H.,University of Leicester | Banning A.P.,Oxford Radcliffe Hospitals | Myat A.,Kings College London | Verheugt F.W.A.,Radboud University Nijmegen | Gersh B.J.,Mayo Medical School
The Lancet | Year: 2013

In the past ten years, primary percutaneous coronary intervention (PCI) has replaced thrombolysis as the revascularisation strategy for many patients presenting with ST-segment elevation myocardial infarction (STEMI). However, delivery of primary PCI within evidence-based timeframes is challenging, and health-care provision varies substantially worldwide. Consequently, even with the ideal circumstances of rapid initial diagnosis, long transfer delays to the catheter laboratory can occur. These delays are detrimental to outcomes for patients and can be exaggerated by variations in timing of patients' presentation and diagnosis. In this Series paper we summarise the value of immediate out-of-hospital thrombolysis for STEMI, and reconsider the potential therapeutic interface with a contemporary service for primary PCI. We review recent trial data, and explore opportunities for optimisation of STEMI outcomes with a pharmacoinvasive approach.

Cahill R.A.,Beaumont Hospital | Ris F.,University of Geneva | Mortensen N.J.,Oxford Radcliffe Hospitals
Colorectal Disease | Year: 2011

Multimodal laparoscopic imaging systems possessing the capability for extended spectrum irradiation and visualization within a unified camera system are now available to provide enhanced intracorporeal operative anatomic and dynamic perfusion assessment and potentially augmented patient outcome. While ultraviolet-range energies have limited penetration and hence are probably more useful for endoscopic mucosal interrogation, the near-infrared (NIR) spectrum is of greater potential utility for the purposes of examining inducible fluorescence in abdominopelvic tissue that can be achieved by administration of specific tracer agents, either directly into the circulation (e.g. for anastomotic perfusion assessment at the time of stapling) or into the lymphatic system (e.g. for lymph basin road-mapping and/or focussed target nodal assessment). This technology is also capable of supplementing anatomic recognition of the biliary system while implantable fibres can also be inserted intraoperatively for the purpose of safeguarding vital structures such as the oesphagus and ureters especially in difficult reoperations. It is likely that this technological capability will find a clear and common indication in colorectal specialist and general surgical departments worldwide in the near future. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

Kennedy R.H.,St. Marks Hospital | Cahill R.A.,Oxford Radcliffe Hospitals | Sibbons P.,Northwick Park Biomedical Institute | Fraser C.,St. Marks Hospital
Endoscopy | Year: 2011

Background and study aims: Colonic lesions unsuitable for endoscopic resection and some early cancers that have been incompletely excised endoscopically, are generally treated by segmental colectomy, even though local excision might be adequate. The aim of this study was to develop a laparo-endoscopic procedure for full-thickness local excision of the colon. Methods: After detailed planning using story-boarding to discuss each step of the procedure, both nonsurvival and survival experiments were performed in seven 50-kg pigs. The technique used was as follows: a simulated colonic polyp was created by endoscopic ink injection; this was inverted using laparo-endoscopically placed BraceBars passing from the outside to the inside of the colon; after laparoscopic over-sewing of the inversion in two layers, endoscopic full-thickness excision was performed. Pigs were sacrificed immediately (n = 3) or between 7 and 9 days after surgery (n = 4). Results: The procedure was performed without operative perforation or hemorrhage in a median of 233 min (range 201 - 245 min), and achieved full-thickness excision in all procedures. Specimen diameter was a median of 2.5 cm (range 2 - 3 cm). All survival pigs convalesced without complication and, at autopsy, normal luminal diameter was confirmed without any peritoneal reaction, hernia or sepsis. Bursting pressures were a median of 245 mmHg (range 240 - 260 mmHg), with the site of bursting being in normal colon in all but one pig. Conclusions: This is a novel technique that permits full-thickness laparo-endoscopic excision (FLEX) of a colonic lesion as an alternative to segmental colectomy. © Georg Thieme Verlag KG Stuttgart - New York.

Lim M.W.,Llandough Hospital | Benham S.W.,Oxford Radcliffe Hospitals
British Journal of Anaesthesia | Year: 2010

BackgroundNarrow-bore cricothyrotomy retains a clinical role, due to the availability of its component equipment in acute clinical environments, ease of assembly, and operator preference. However, due to infrequent use, there is a need to model this for research and teaching. We present mathematical and laboratory models.MethodsUsing electrical analogy, we mathematically modelled a generic cannula cricothyrotomy circuit, relating inspiratory and expiratory times to the upper airway resistance (Ru). We constructed a laboratory model to support our mathematical model. The simulated lung is a smooth-bore tube on a tilting table. The upper airway is simulated by 20 G cannulae. Inspiratory and expiratory times for the water meniscus to travel a preset distance (corresponding to tidal volume) were measured and plotted against the number of cannula.ResultsFrom the mathematical model, inspiratory time increases hyperbolically with decreasing Ru, such that there is a minimum Ru beyond which most of the fresh gas flow leaks out without inflating the chest. Conversely, as Ru increases, inspiratory time decreases to a plateau. Expiratory time is limited by respiratory factors at low Ru and by the resistance of the transtracheal expiratory pathway at high Ru, producing a sigmoid-shaped expiratory curve. The experimental results seem consistent with these predictions, although direct theory-experiment mapping is problematic because of the difficulty in assigning a single value to the dynamically changing upper airway resistance.ConclusionsWe can exploit the contrasting changes in inspiratory and expiratory times with the upper airway resistance to optimize conditions for emergent cannula cricothyrotomy ventilation.

Cook T.M.,Royal United Bath Hospital | Scott S.,Oxford Radcliffe Hospitals | Mihai R.,Oxford Radcliffe Hospitals
Anaesthesia | Year: 2010

Claims notified to the NHS Litigation Authority in England between 1995 and 2007 and filed under anaesthesia were analysed to explore patterns of injury and cost related to airway or respiratory events. Of 841 interpretable claims the final dataset contained 96 claims of dental damage, 67 airway-related claims and 24 respiratory claims. Claims of dental damage contributed a numerically important (11%), but financially modest (0.5%) proportion of claims. These claims predominantly described injury during tracheal intubation or extubation; a minority associated with electroconvulsive therapy led to substantial cost per claim. The total cost of (non-dental) airway claims was £4.9 million (84% closed, median cost £30 000) and that of respiratory claims was £3.3 million (81% closed, median £27 000). Airway and respiratory claims account for 12% of anaesthesia-related claims, 53% of deaths, 27% of cost and ten of the 50 most expensive claims in the dataset. Airway claims most frequently described events at induction of anaesthesia, involved airway management with a tracheal tube and typically led to hypoxia and patient death or brain injury. Airway trauma accounted for one third of airway claims and these included deaths from mediastinal injury at intubation. Pulmonary aspiration and tube misplacement, including oesophageal intubation, led to several claims. Among respiratory claims, ventilation problems, combined with hypoxia, were an important source of claims. Although limited clinical details hamper analysis, the data suggest that most airway and respiratory-related claims arise from sentinel events. The absence of clinical detail and denominators limit opportunities to learn from such events; much more could be learnt from a closed claim or sentinel event analysis scheme. © 2010 The Association of Anaesthetists of Great Britain and Ireland.

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