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Smith G.B.,Queen Alexandra Hospital
Resuscitation | Year: 2010

The 'chain of survival' has been a useful tool for improving the understanding of, and the quality of the response to, cardiac arrest for many years. In the 2005 European Resuscitation Council Guidelines the importance of recognising critical illness and preventing cardiac arrest was highlighted by their inclusion as the first link in a new four-ring 'chain of survival'. However, recognising critical illness and preventing cardiac arrest are complex tasks, each requiring the presence of several essential steps to ensure clinical success. This article proposes the adoption of an additional chain for in-hospital settings - a 'chain of prevention' - to assist hospitals in structuring their care processes to prevent and detect patient deterioration and cardiac arrest. The five rings of the chain represent 'staff education', 'monitoring', 'recognition', the 'call for help' and the 'response'. It is believed that a 'chain of prevention' has the potential to be understood well by hospital clinical staff of all grades, disciplines and specialties, patients, and their families and friends. The chain provides a structure for research to identify the importance of each of the various components of rapid response systems. © 2010 Elsevier Ireland Ltd.


Lewis R.,Queen Alexandra Hospital
Annals of Clinical Biochemistry | Year: 2012

Chronic kidney disease (CKD) is now recognized as a major public health issue. One consequence of this condition is disturbance of mineral and bone homeostasis. Bone disease (renal osteodystrophy) as a consequence of CKD has long been recognized. However, it is now appreciated that the mineral and bone disturbances of CKD (and perhaps treatment of them) lead to vascular calcification, which is a cause of significant morbidity. In recognition of the widespread nature of the condition, the term CKD-mineral bone disorder (CKD-MBD) is now in general use to describe the biochemical, skeletal and vascular changes that occur in CKD. The pathogenesis of CKD-MBD is incompletely understood but has recently been redefined with the emergence of fibroblast growth factor 23 (FGF-23) as a major influence on control of vitamin D and parathyroid hormone. This review describes the classification of CKD and current understanding of the mechanisms underlying CKD-MBD (incorporating FGF-23). It describes and evaluates the means of identifying CKD-MBD in the clinical setting and the interventions available for treatment. It then reviews current clinical guidelines for the use of biochemical markers in clinical decision-making. In acknowledgement of the paucity of evidence upon which these guidelines are based, areas where clinical research might be directed in the future will be identified.


Grewal P.,Queen Alexandra Hospital
Hernia | Year: 2014

Introduction: The annual cost of employee absences from work to UK business is estimated to be £32 billion, with routine post-operative recovery time being the second commonest reason for employee absence. We surveyed what post-operative instructions are currently being given to patients by surgeons after inguinal hernia repair in England. Methods: Acute trusts were emailed in England asking for leaflets and patients information regarding inguinal hernia repair under the Freedom of Information Act (2000). Results: A total of 128 (89.5 %) trusts replied. Leaflets were returned by 93 (65 %) trusts. After inguinal hernia repair, the time to return to work varied widely according to office work (range 1-6 weeks) and manual labour work (range 2-12 weeks). The time advised to return to driving ranged from 24 h to 6 weeks. The time advised before allowing sexual activities ranged from 1 to 4 weeks and return to sports ranged from 2 to 12 weeks after hernia repair. Conclusion: Surgeons and trusts should be able to provide patients with printed consistent and accurate information regarding their post-operative recovery time, including return to driving and return to work. © 2013 Springer-Verlag France.


Introduction: While fine needle aspiration cytology (FNAC) is the mainstay of diagnosis in thyroid nodules, molecular markers of thyroid cancer have recently been shown to be of value in improving the diagnosis and reducing the rates of unnecessary surgery. Method: A technical method is presented for the assessment of the BRAF V600 gene mutation in thyroid cancer using a simple adaptation of a commercially available kit. After standard preparation and reporting of conventionally stained alcohol-fixed Papanicolaou or air-dried Giemsa-stained slides the coverslip is removed from one slide, the DNA is extracted and submitted for PCR analysis. Results: Assessment of the BRAF V600 mutational status is feasible in very small quantities of DNA, requiring just greater than 5 ng per case from a single pre-stained FNA slide using this method. From the 14 cases examined thus far, one Thy4/Bethesda Class V case (suspicious of malignancy) has been identified with a BRAF V600 mutation and this patient, after multidisciplinary discussion, received a total thyroidectomy. Conclusion: Based on this methodology and other published results for the BRAF mutation, we believe that it is now feasible and cost effective for the UK NHS to BRAF co-test all Thy4/Bethesda Class V thyroid FNAs, as the additional cost of BRAF testing will still be much less than the cost of submitting all Thy4 (Bethesda Class V) patients to a partial and then a later completion thyroidectomy. © 2013 John Wiley & Sons Ltd.


Rahimi S.,Queen Alexandra Hospital
Clinica Terapeutica | Year: 2013

Cutaneous squamous cell carcinoma (SCC) is the second most common skin cancer in Caucasians, most frequently occurring on sun-exposed areas of the body. Most SCCs are treated surgically, either by excision or Mohs micrographic surgery. Despite the large amount of English literature with regard to cutaneous SCC in many instances the surgical treatment is not appropriate resulting in recurrences and/ or metastasis. The following brief review highlights the histology, molecular biology and surgical treatment of skin SCC. © Società Editrice Universo.


Boos C.J.,Queen Alexandra Hospital
Journal of the Royal Army Medical Corps | Year: 2010

We describe the case of a 32-year-old soldier who presented with acute organic psychosis during an operational tour to Iraq. This was precipitated by excessive consumption of caffeine coupled with additional use of oral nutritional stimulants. Her biochemical profile was compounded by the additional use of exogenous creatine. We present a brief overview of the issue of exercise supplementation and highlight some of the potential problems and clinical issues surrounding their use. This has important implications for both serving soldiers and the wider medical community.


Porter R.J.,Queen Alexandra Hospital | Fogg C.,University of Portsmouth
Clinical Microbiology and Infection | Year: 2015

Faecal microbiota transplantation (FMT) has been shown to be highly effective in treating recurrent Clostridium difficile infection, but to date there have been no data from the United Kingdom. An electronic survey was developed at Portsmouth Hospitals' National Health Service (NHS) Trust and sent out to UK hospital specialists utilizing the contact databases of the British Infection Association and the Royal College of Gastroenterologists. A total of 162 responses were received, representing nearly one in every seven of the United Kingdom's infection specialists and a response from one in every two UK NHS acute trusts or boards. Ninety-six per cent believe that the evidence base supports the use of FMT, and 94% reported consulting on at least one patient a year in whom they would recommend FMT. However, only 22% reported FMT use in their institution in the last 10 years, and 6% reported performing more than ten FMTs in the last 10 years. Concerns with patient acceptance, donor selection, availability of screened faecal solution, feasibility of procedure and availability of local expertise were reported as inhibiting the use of FMT. More than 90% of respondents would like access to regional guidelines, prescreened faecal solution and expert advice to facilitate implementation, and more than two thirds of respondents would support a regional FMT referral centre. A large gap exists in the United Kingdom between physicians desire to use FMT and the ability and facilities to provide it as a therapy at the bedside. © 2015.


Senapati A.,Queen Alexandra Hospital
Digestive Diseases | Year: 2012

Diverticular disease affects up to 50% of people by the time they reach the age of 80. The major complications of diverticular disease (abscess, perforation, fistula, obstruction and bleeding) have their own management pathways, but the treatment of uncomplicated diverticulitis is controversial. On initial presentation, diverticulitis is always treated conservatively. Whether this should be followed by resectional surgery has been the subject of speculation for many decades. The American Society of Colon and Rectal Surgeons recommended in 2000 that an elective resection should follow two attacks of acute diverticulitis. Much of the work underpinning their policy was based on seminal studies by Parks in the 1960s and 1970s who followed cohorts of patients with diverticular disease and examined their outcomes. However, many of these studies were based on inaccurate diagnostic data where the diagnosis was made primarily on clinical grounds. Investigations such as barium enema or colonoscopy are not reliable in confirming the presence of inflammation. Since CT scanning has become routine, the diagnosis of acute diverticulitis can now be made accurately. In recent years much work has been done, such as by Ambrosetti, who has produced evidence predicting the outcome of diverticulitis based on CT findings. More recent papers, in which the diagnosis of acute diverticulitis is likely to have been made more accurately, confirm that although recurrent attacks of diverticulitis are fairly common, there is a very low incidence of serious complications after long-term follow-up. It has also become apparent that the majority of patients who present with the major complications of diverticulitis, specifically abscess, perforation and fistula, do so as their first presentation of the disease, without previous episodes of diverticulitis. The corollary of this is that patients having had acute diverticulitis do not run the risk of developing life-threatening complications without elective surgery. The complications of left-sided colonic resection are not inconsiderable with anastomotic leaks, the formation of a stoma, either temporary or permanent, as well as mortality. When these data are put alongside the very low risk of serious harm to the patient after diverticulitis, the balance of opinion has now swung heavily in favour of a more conservative approach. In addition to this there are modern and innovative medical therapeutic approaches to the treatment of diverticulitis such as 5ASAs, poorly absorbed antibiotics and probiotics. Copyright © 2012 S. Karger AG, Basel.


Slessor D.,North Hampshire Hospital | Hunter S.,Queen Alexandra Hospital
Annals of Emergency Medicine | Year: 2015

Study objective The role of emergency department (ED) thoracotomy after blunt trauma is controversial. The objective of this review is to determine whether patients treated with an ED thoracotomy after blunt trauma survive and whether survivors have a good neurologic outcome. Methods A structured search was performed with MEDLINE, EMBASE, CINAHL, and PubMed. Inclusion criteria were ED thoracotomy or out-of-hospital thoracotomy, cardiac arrest or periarrest, and blunt trauma. Outcomes assessed were mortality and neurologic result. The articles were appraised with the system designed by the Institute of Health Economics of Canada. A fixed-effects model was used to meta-analyze the data. Heterogeneity was assessed with the I2 statistic. Results Twenty-seven articles were included in the review. All were case series. Of 1,369 patients who underwent an ED thoracotomy, 21 (1.5%) survived with a good neurologic outcome. All 21 patients had vital signs present on scene or in the ED and a maximum duration of cardiopulmonary resuscitation of 11 to 15 minutes. Thirteen studies were included in the meta-analysis. If there were either vital signs or signs of life present in the ED, the probability of a poor outcome was 99.2% (95% confidence interval 96.4% to 99.7%). Conclusion There may be a role for ED thoracotomy after blunt trauma, but only in a limited group of patients. Good outcomes have been achieved for patients who had vital signs on admission and for patients who received an ED thoracotomy within 15 minutes of cardiac arrest. The proposed guideline should be used to determine which patients should be considered for an ED thoracotomy, according to level 4 evidence. © 2014 American College of Emergency Physicians.


Grewal P.,Queen Alexandra Hospital | Alagaratnam S.,Royal Free London NHS Foundation Trust
International Journal of Surgery | Year: 2013

Introduction: Patients can rapidly access the internet and more young people are using their mobile to access health-related information. The aim of this study is to assess the readability and quality of colorectal disease websites for colorectal cancer. Methods: We searched the Google, Yahoo and Bing for colorectal cancer. Readability was assessed using Flesch Reading Ease Score (FRES), Flesch-Kincaid Grade (FKG) and Gunning Fog Index (GFI). The LIDA tool and DISCERN instrument were used to measure the design and content of health information on the Internet. A sub-group analysis was performed on websites certified by HONcode and Information Standard against non-certified websites. Results: The mean FRES were 56.3, mean FKG of 6.9, mean GFI of 9.5, equivalent to TIME magazine. The mean LIDA Tool overall score was 85.6% and mean DISCERN instrument was 52.2 (95% CI 45-59.4). Conclusion: This study shows that colorectal cancer websites were readable but potentially unreliable. Government certified sites were superior to non-certified sites.Improvements are required to provide patients with reliable information to make informed decisions on medical treatments.We propose that national cancer services develop reliable and easily readable information regarding the diagnosis and investigation of colorectal cancer. The site should provide adequate information regarding the treatment options and importantly how each treatment option would affect the patient's quality of life. Clinicians can then provide these websites to the patients before and after their consultations to allow the patient to be fully informed. © 2013 Surgical Associates Ltd.

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