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Appleton N.D.,Royal Glamorgan Hospital | Bailey D.M.,University of South Wales | Morris-Stiff G.,Royal Glamorgan Hospital | Lewis M.H.,Royal Glamorgan Hospital
Vascular and Endovascular Surgery | Year: 2014

Objectives: This study assesses the predictive value of neutrophil to lymphocyte ratio (NLR) in relation to 30-day and overall mortality following open abdominal aortic aneurysm (AAA) repairs. In addition, it assess assesses any correlation between NLR and age, size of the AAA and gender. Methods: Patients undergoing elective or urgent open repair of their AAA by a single surgeon during a 10-year period were included. A pre-operative NLR of >5 was regarded as abnormal. Results: 350 consecutive patients underwent AAA repair. 52 had an NLR>5. 30-day mortality rate was 12/52 (23%) in the NLR>5 group and 20/298 (6.7%) in the NLR<5 group (p = 0.0007). All deaths in the NLR>5 group were due to myocardial infarction. The median NLR was higher in those that died within 30 days at 4.2 [IQR: 2.6-7.5] versus 2.8 [IQR: 2.1-3.8] (p = 0.0001). Overall mortality at 10 years, in the NLR>5 group - 26/52 (50%) was significantly greater than that of the NLR<5 group - 102/298 (34.2%) (p = 0.043). Median NLR of those dying during follow-up was significantly higher in those with a baseline NLR>5 at 3.2 (IQR 2.5-4.6) versus 2.6 (IQR: 2.0-3.6) in those surviving (p = 0.00004). No difference was found between NLR and age, aneurysm size or gender. Conclusion: Preoperative NLR>5 appears to be a significant predictor of both 30-day mortality and long-term outcome in elective and urgent open AAA surgery. It is plausible the NLR is identifying a group with sub-clinical cardiovascular disease at risk of peri-operative myocardial infarction. © The Author(s) 2014.


Christofides S.,City and Hackney Child and Adolescent Mental Health Service | Johnstone L.,Royal Glamorgan Hospital | Musa M.,Fromeside Unit
Psychology and Psychotherapy: Theory, Research and Practice | Year: 2012

Objectives. To investigate clinical psychologists' accounts of their use of psychological case formulation in multidisciplinary teamwork. Design. A qualitative study using inductive thematic analysis. Methods. Ten clinical psychologists working in community and inpatient adult mental health services who identified themselves as using formulation in their multidisciplinary team work participated in semi-structured interviews. Results. Psychological hypotheses were described as shared mostly through informal means such as chipping in ideas during a team discussion rather than through explicit means such as staff training or case presentations that usually only took place once participants had spent time developing their role within the team. Service context and staff's prior experience were also factors in how explicitly formulation was discussed. Participants reported that they believed that this way of working, although often not formally recognized, was valuable and improved the quality of clinical services provided. Conclusions. More investigation into this under-researched but important area of clinical practice is needed, in order to share ideas and support good practice. ©2011 The British Psychological Society.


Sheikh A.S.,Royal Glamorgan Hospital | Ranjan K.,University of London
Clinical Medicine, Journal of the Royal College of Physicians of London | Year: 2014

Brugada syndrome is an example of a channelopathy caused by an alteration in the transmembrane ion currents that together constitute the cardiac action potential. Approximately 20% of the cases of Brugada syndrome have been shown to be associated with mutations in the gene coding for the sodium ion channel in the cell membranes of the muscle cells of the heart. Patients with Brugada syndrome are prone to develop ventricular tachyarrhythmias that may lead to syncope, cardiac arrest or sudden cardiac death. Many clinical situations have been reported to unmask or exacerbate the electrocardiography (ECG) pattern of Brugada syndrome. Genetic testing for Brugada syndrome is clinically available. Here we report two cases of Brugada syndrome followed by a comprehensive review of the literature. © Royal College of Physicians 2014. All rights reserved.


Szakmany T.,University of Cardiff | Szakmany T.,Royal Glamorgan Hospital | Russell P.,University of Cardiff | Wilkes A.R.,University of Cardiff | Hall J.E.,University of Cardiff
British Journal of Anaesthesia | Year: 2015

Background. Early tracheostomy may decrease the duration of mechanical ventilation sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes but the evidence is conflicting. Methods. Systematic review and meta-analysis of randomized trials in patients allocated to tracheostomy within 10 days of start of mechanical ventilation was compared with placement of tracheostomy after 10 days if still required. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register, and Google Scholar were searched for eligible trials. The co-primary outcomes were mortality within 60 days, and duration of mechanical ventilation, sedation and intensive care unit stay. Secondary outcomes were the number of tracheostomy procedures performed, and incidence of ventilator-associated pneumonia (VAP). Outcomes are described as relative risk or weighted mean difference with 95%confidence intervals. Results. Of note, 4482 publications were identified and 14 trials enrolling 2406 patients were included. Tracheostomy within 10 days was not associated with any difference in mortality [risk ratio (RR): 0.93 (0.83-1.05)]. There were no differences in duration of mechanical ventilation [-0.19 days (-1.13-0.75)], intensive care stay [-0.83 days (-2.05-0.40)], or incidence of VAP. However, duration of sedation was reduced in the early tracheostomy groups [-2.78 days (-3.68 to -1.88)]. More tracheostomies were performed in patients randomly assigned to receive early tracheostomy [RR: 2.53 (1.18-5.40)]. Conclusion.We found no evidence that early (within 10 days) tracheostomy reducedmortality duration of mechanical ventilation, intensive care stay, or VAP. Early tracheostomy leads to more procedures and a shorter duration of sedation. © The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.


Szakmany T.,University of Cardiff | Szakmany T.,Royal Glamorgan Hospital | Woodhouse T.,University of Cardiff
Minerva Anestesiologica | Year: 2015

Cisatracurium is currently one of the most commonly used neuromuscular blocking agent (NMBA) in intensive care units. Cisatracurium was developed primarily for anaesthetic purposes in order to attempt to resolve some of the problems associated with earlier NMBAs, such as histamine release and laudanosine accumulation. Cisatracurium, the the R-cis-R-cis isomer of atracurium, is up to 5 times more potent than atracurium and so is administered in smaller quantities and produces a lesser degree of laudanosine accumulation in the plasma. In both adult and paediatric settings cisatracurium has favourable pharmacological characteristics compared to vecuronium, a steroid based NMBA often used in critical care. Recent randomised clinical trials suggested that the use of cisatracurium is associated with better outcome in acute respiratory distress syndrome (ARDS). Its use has been associated with better outcomes in therapeutic hypothermia and in traumatic brain injury. Although it has many favorable pharmacological properties, it is more expensive than comparable agents and some safety concerns persist regarding adverse events associated with the drug. The aim of the present study was to perform the first comprehensive review to date of all literature relating to the use of cisatracurium in critically ill patients. COPYRIGHT© 2015 EDIZIONI MINERVA MEDICA.


Ingram T.E.,University of Cardiff | Fraser A.G.,University of Cardiff | Bleasdale R.A.,Royal Glamorgan Hospital | Ellins E.A.,University of Cardiff | And 3 more authors.
Journal of the American College of Cardiology | Year: 2013

Objectives The aim of this study was to assess the potential benefits of inorganic nitrite in 2 clinical models: stress-induced myocardial ischemia and whole-arm ischemia-reperfusion. Background Inorganic nitrite, traditionally considered a relatively inert metabolite of nitric oxide, may exert vasomodulatory and vasoprotective effects. Despite promising results from animal models, few have shown effectiveness in human model systems, and none have fully translated to the clinical setting. Methods In 10 patients with inducible myocardial ischemia, saline and low-dose sodium nitrite (NaNO2) (1.5 μmol/min for 20 min) were administered in a double-blind fashion during dobutamine stress echocardiography, at separate visits and in a random order; long-axis myocardial function was quantified by peak systolic velocity (Vs) and strain rate (SR) responses. In 19 healthy subjects, flow-mediated dilation was assessed before and after whole-arm ischemia-reperfusion; nitrite was given before ischemia or during reperfusion. Results Comparing saline and nitrite infusions, Vs and SR at peak dobutamine increased in regions exhibiting ischemia (Vs from 9.5 ± 0.5 cm/s to 12.4 ± 0.6 cm/s, SR from -2.0 ± 0.2 s-1 to -2.8 ± 0.3 s-1), whereas they did not change in normally functioning regions (Vs from 12.6 ± 0.4 cm/s to 12.6 ± 0.6 cm/s, SR from -2.6 ± 0.3 s-1 to -2.3 ± 0.1 s-1) (p < 0.001, analysis of variance). With NaNO2, the increment of Vs (normalized for increase in heart rate) increased only in poorly functioning myocardial regions (+122%, p < 0.001). Peak flow-mediated dilation decreased by 43% after ischemia-reperfusion when subjects received only saline (6.8 ± 0.7% vs. 3.9 ± 0.7%, p < 0.01); administration of NaNO2 before ischemia prevented this decrease in flow-mediated dilation (5.9 ± 0.7% vs. 5.2 ± 0.5%, p = NS), whereas administration during reperfusion did not. Conclusions Low-dose NaNO2 improves functional responses in ischemic myocardium but has no effect on normal regions. Low-dose NaNO2 protects against vascular ischemia-reperfusion injury only when it is given before the onset of ischemia.© 2013 by the American College of Cardiology Foundation Published by Elsevier Inc.


Hodcroft C.J.,Royal Glamorgan Hospital | Rossiter M.C.,University of Wales | Buch A.N.,East Carolina University
Journal of Emergency Medicine | Year: 2014

Background The use of cannabis is not usually regarded as a risk factor for acute coronary syndrome. However, several cases of myocardial infarction (MI) associated with cannabis use have been reported in the scientific literature. The etiology of this phenomenon is not known. Objectives To present a case of cannabis-associated MI in which atherosclerotic coronary disease was excluded as a potential etiology by intravascular ultrasound examination, and briefly review the other possible mechanisms by which this effect may be mediated. Case Report We present the case of a previously healthy 21-year-old man who regularly smoked cannabis and presented to the Emergency Department with ST-elevation myocardial infarction after participating in a sport. He was also a cigarette smoker, but had no other conventional cardiovascular risk factors. At coronary angiography, a large amount of thrombus was found in the left anterior descending coronary artery. He recovered with medical treatment, and subsequent intravascular ultrasound examination showed no evidence of atherosclerosis at the site of the thrombus. Conclusion Cannabis-associated MI is increasingly recognized. The etiology is unclear, but we believe this is the first report of the phenomenon where atherosclerotic plaque rupture has been excluded as the cause with a high degree of confidence. © 2014 Elsevier Inc.


Szakmany T.,Royal Glamorgan Hospital
Cochrane database of systematic reviews (Online) | Year: 2012

Death is common in systemic inflammatory response syndrome (SIRS) or sepsis-induced multisystem organ failure and it has been thought that antioxidants such as N-acetylcysteine could be beneficial. We assessed the clinical effectiveness of intravenous N-acetylcysteine for the treatment of patients with SIRS or sepsis. We searched the following databases: Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library 2011, Issue 12); MEDLINE (January 1950 to January 2012); EMBASE (January 1980 to January 2012); CINAHL (1982 to January 2012); the NHS Trusts Clinical Trials Register and Current Controlled Trials (www.controlled-trials.com); LILACS; KoreaMED; MEDCARIB; INDMED; PANTELEIMON; Ingenta; ISI Web of Knowledge and the National Trials Register to identify all relevant randomized controlled trials available for review. We included only randomized controlled trials (RCTs) in the meta-analysis. We independently performed study selection, quality assessment and data extraction. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We included 41 fully published studies (2768 patients). Mortality was similar in the N-acetylcysteine group and the placebo group (RR 1.06, 95% CI 0.79 to 1.42; I(2) = 0%). Neither did N-acetylcysteine show any significant effect on length of stay, duration of mechanical ventilation or incidence of new organ failure. Early application of N-acetylcysteine to prevent the development of an oxidato-inflammatory response did not affect the outcome, nor did late application that is after 24 hours of developing symptoms. Late application was associated with cardiovascular instability. Overall, this meta-analysis puts doubt on the safety and utility of intravenous N-acetylcysteine as an adjuvant therapy in SIRS and sepsis. At best, N-acetylcysteine is ineffective in reducing mortality and complications in this patient population. At worst, it can be harmful, especially when administered later than 24 hours after the onset of symptoms, by causing cardiovascular depression. Unless future RCTs provide evidence of treatment effect, clinicians should not routinely use intravenous N-acetylcysteine in SIRS or sepsis and academics should not promote its use.


Loughran D.,Royal Glamorgan Hospital
Journal of Medical Ethics | Year: 2015

As the law around surgical consent continues to evolve, surgeons and those in training risk being caught redfaced and defenceless. Despite repeated concerns regarding surgical consent being raised by the General Medical Council of the UK, how much is changing on the National Health Service shop floor? This report investigates the variation between consenting practices for six common general surgical operations in 123 individual operations. Results showed that only 20% of mentioned operative complications for each operation were being documented on >75% of consent forms. The vast majority of mentioned complications were mentioned inconsistently, leading to patients being given grossly varying information preoperatively. Reassuringly, only 4.1% of consent procedures were done by those not in core surgical training ( junior resident) or above, but nonetheless significant omissions were observed. When consenting a patient for an emergency exploratory laparotomy, an operation carrying a 14% chance of death, a risk of death was only documented in 28% of cases. Trainees failed to document the possibility of an orchidectomy in 30% of scrotal exploration cases. Data showed that complication incidences were only documented for 0.004% of the 721 complications mentioned in total, and a consent process was documented in the chronological notes in only 38% of cases. Seventy-seven per cent of surgical trainees surveyed across four UK deaneries stated that they would strongly support an online and mobile consenting resource detailing the recommended mentionable risks and incidences. Is it time for the traditional consenting approach to give way to an evidence-based gold standard?


Al-Hussaini A.,Royal Glamorgan Hospital | Latif E.H.,Royal Glamorgan Hospital | Singh V.,Royal Glamorgan Hospital
Clinical Otolaryngology | Year: 2013

Background: Dysphagia is frequently encountered by the otolaryngologist and due to its diverse aetiologies often poses a diagnostic challenge. Of particular importance in diagnosis is to distinguish between oropharyngeal and oesophageal dysphagia. This article aims to provide a systematic, concise and evidence-based method of managing the patient with dysphagia. Method: This review was based on a literature search last undertaken on 15 January 2013. The MEDLINE, EMBASE and Cochrane databases were searched using the subject heading dysphagia in combination with classification, diagnosis, investigations, management, treatment and surgery. Results were limited to English language articles including case series, clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed. Results: The majority of published literature for dysphagia is of level II/III evidence, with 16 relevant randomised controlled trials identified. The clinical history is of paramount importance in delineating the cause of dysphagia. There is no significant difference regarding the diagnostic efficacy of fibreoptic endoscopic evaluation of swallowing compared to videofluoroscopy, and where indicated and practicable, these investigations complement each other. In general, structural causes of dysphagia are managed surgically, whereas swallowing therapy is efficacious in managing dysphagia due to neuromyogenic disorders. Conclusions: A structured history of dysphagia and its associated symptoms, flexible laryngoscopy and endoscopic assessment of swallowing where relevant in addition to targeted investigations should lead to the correct diagnosis and appropriate management. © 2013 John Wiley & Sons Ltd.

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