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Stefanova I, Kyle E, Wilson I, Tobbal M, Veeramootoo D, De'Ath HD. Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis. Am Surg 2024:31348241248564. [PMID: 38636538 DOI: 10.1177/00031348241248564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND Gallstone pancreatitis (GSP) is common in elderly patients and carries worse outcomes. Laparoscopic cholecystectomy (LC) is recommended for prevention of recurrent GSP. In frail populations, an endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-s) is an alternative. Management guidelines of GSP in the elderly are lacking. This study aimed to investigate and compare management strategies for GSP in the elderly. MATERIALS AND METHODS A retrospective comparison of outcome of patients aged ≥65 years with first presentation of GSP treated either with (1) LC only, (2) ERCP-s, (3) ERCP-S followed by LC, or (4) no intervention. RESULTS 216 patients were included. Median age was 76 years (interquartile range 70-83). Most (80%, n = 172) had mild pancreatitis, whilst 12% (n = 26) had severe disease. 24% (n = 55) were treated with ERCP-s; 40% (n = 87) underwent LC alone; 11% (n = 23) had ERCP-s followed by LC; and 25% (n = 55) received no intervention. Patients without intervention were older (P < .001) and frailer (P < .001). The LC-only group had lower post-procedure re-admission rates of 6% (n = 5) compared to 27% (n = 14) for ERCP-s, 33% (n = 7) for ERCP-S + LC, and 31% (n = 17) for the no intervention group (P = .0001). Biliary cause mortality was highest in the no intervention group (n = 11, 20%). CONCLUSION Laparoscopic cholecystectomy represents the gold standard for elderly patients with GSP.
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Affiliation(s)
- Irena Stefanova
- Department of Upper Gastrointestinal Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, UK
| | - Ewan Kyle
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Iain Wilson
- Department of Upper Gastrointestinal Surgery, Wexham Park Hospital, Wexham St, Slough, UK
| | - Mohammed Tobbal
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Darmarajah Veeramootoo
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Henry D De'Ath
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
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Evans T, Binns H, Mandal AK, De'Ath HD, Missouris CG. The impact of anticholinergic burden on clinical outcomes in older hospitalised surgical patients. Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38300682 DOI: 10.12968/hmed.2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Polypharmacotherapy is an ever-increasing issue with an ageing patient population. Anticholinergic medications make up a large proportion of patient medication but cause significant side effects, contributing to well-documented issues within the older population and in hospital medicine. This review explores the documented impact of anticholinergic burden in older surgical patients on postoperative delirium, infection, length of stay and readmission, urinary retention, ileus and mortality. It also highlights the need for further high-quality research into anticholinergic burden management among older surgical patients to further impact practice and policy in the area.
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Affiliation(s)
- Thomas Evans
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Hannah Binns
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Amit Kj Mandal
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Henry D De'Ath
- Department of General Surgery, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Frimley, Surrey UK
| | - Constantinos G Missouris
- Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- University of Nicosia Medical School, Cyprus, UK
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Durrands TH, Murphy M, Wohlgemut JM, De'Ath HD, Perkins ZB. Diagnostic accuracy of clinical examination for identification of life-threatening torsos injuries: a meta-analysis. Br J Surg 2023; 110:1885-1886. [PMID: 37847819 DOI: 10.1093/bjs/znad285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Thomas Harry Durrands
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- The Central London School of Anaesthesia, London, UK
| | - Mark Murphy
- Department of Anaesthesia, Frimley Health NHS Foundation Trust, UK
| | - Jared M Wohlgemut
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Henry D De'Ath
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Zane B Perkins
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- London's Air Ambulance, Royal London Hospital, Barts Health NHS Trust, London, UK
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Ramaraj P, Al-Buluchi T, Al-Shaqsi S, Al-Kashmiri A, Perkins ZB, De'Ath HD. Epidemiology of traumatically injured Yemeni civilians treated at the Omani National Trauma Centre over a 2-year period: a retrospective cohort study. BMJ Mil Health 2023:e002509. [PMID: 37699734 DOI: 10.1136/military-2023-002509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 08/25/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Armed conflict is a growing global cause of death, posing a significant threat to the resilience of global health systems. However, the burden of disease resulting from the Yemeni Civil War remains poorly understood. Approximately half of healthcare facilities in Yemen are non-operational, and around 15% of the population has been displaced. Consequently, neighbouring countries' trauma systems have been providing care to the injured. The objective of this study was to investigate the epidemiology and management of Yemeni civilian victims injured during the war who were subsequently extracted and treated at the study centre in Oman. METHODS We conducted a retrospective cohort study, including all Yemeni civilians treated for traumatic injuries at the study centre from January 2015 to June 2017. We extracted data on age, sex, date of attendance, mechanism of injury, injuries sustained and treatment. RESULTS A total of 254 injured patients were identified. Their median age was 25 (range 3-65) years and 244 (96.1%) were male. Explosions (160 patients, 63.0%) were the most common mechanism of injury, and fractures (n=232 fractures, 42.3% of all injuries; in 149 patients, 58.7% of all patients) the most common injury. Eighty-four of the 150 patients (56%) who received operative management at the study centre were receiving a second procedure after an index procedure outside of Oman.One hundred and twenty-eight (50.4%) patients experienced permanent loss of function in at least one body part and/or limb loss. CONCLUSIONS This study demonstrates the downstream needs of Yemeni civilians who were evacuated to the study centre, revealing a considerable burden of morbidity associated with this population. The findings emphasise key areas that receiving hospitals should prioritise in resource allocation when managing conflict-wounded evacuees. Additionally, the study underscores the need for holistic rehabilitation for civilian casualties displaced by conflict.
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Affiliation(s)
- Prashanth Ramaraj
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - T Al-Buluchi
- Department of Plastic Surgery, Khoula Hospital, Mina Al Fahal, Oman
| | - S Al-Shaqsi
- Department of Plastic Surgery, Khoula Hospital, Mina Al Fahal, Oman
| | - A Al-Kashmiri
- Department of Plastic Surgery, Khoula Hospital, Mina Al Fahal, Oman
| | - Z B Perkins
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - H D De'Ath
- Centre for Trauma Sciences, Queen Mary University of London, London, UK
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De'Ath HD, Nagendram S, Smith E, Ramadan M, Veeramootoo D, Singh S. A high-volume ERCP service led by surgeons is associated with good outcomes and meets national key performance indicators: results from a British district general hospital. Surg Endosc 2022; 36:6016-6023. [PMID: 35020059 DOI: 10.1007/s00464-021-08978-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 12/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a common, but technically challenging procedure used in the management of hepatopancreaticobiliary (HPB) disease. It is traditionally performed by medical gastroenterologists. In 2014, the British Society of Gastroenterology (BSG) proposed key performance indicators to evaluate and set standards of ERCP practice. This study aimed to compare our ERCP outcomes against these targets, in a centre where ERCP is exclusively performed by surgeons. METHODS A retrospective analysis of all ERCPs undertaken over a 38 months in a District General Hospital in the United Kingdom (UK), by three Upper Gastrointestinal Surgeons. Study outcomes were based upon, and compared against, BSG key performance indicators, including number of ERCPs per annum, proportion of successful cannulations of bile duct and stone clearance, ERCP-specific complications and mortality. RESULTS The unit's caseload over this period was 1324, equating to approximately 418 per annum (BSG minimum 200 per unit). Management of bile duct stones was the commonest indication for ERCP. Overall, 95% (1253/1324) of bile ducts were cannulated and 92% (645/698) for those undergoing their first ERCP. Bile duct clearance was achieved in 80% of patients (BSG recommend > 75%) and the successful stenting of extra-hepatic strictures in 94% (BSG recommend > 80%). The overall complication rate was 4.3% (BSG standard < 6%). Procedure-specific mortality was 0.3% (4/1324) where death was either caused by pancreatitis or sepsis. CONCLUSION A high-volume ERCP service led and performed exclusively by surgeons meets all BSG performance indicators, with good procedural and patient outcomes. Formal training pathways should be developed to encourage more surgical centres to provide an ERCP service and deal with what are common surgical pathologies.
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Affiliation(s)
- Henry D De'Ath
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK.
| | - Sathyan Nagendram
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Eleanor Smith
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Mohamed Ramadan
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Darmarajah Veeramootoo
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Sukhpal Singh
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
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De'Ath HD, Kelly JJ. Overeating and a Wandering Spleen: What Is the Link? Gastroenterology 2019; 157:e11-e12. [PMID: 31319072 DOI: 10.1053/j.gastro.2019.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/12/2019] [Indexed: 12/02/2022]
Affiliation(s)
- Henry D De'Ath
- Department of Upper Gastrointestinal Surgery, Southampton General Hospital, Southampton, UK
| | - Jamie J Kelly
- Department of Upper Gastrointestinal Surgery, Southampton General Hospital, Southampton, UK
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Lee SL, Lai J, Dudding T, De'Ath HD. Emergency presentation of a dermoid cyst of the groin: a diagnostic confounder on the acute surgical take. ANZ J Surg 2019; 90:E50-E51. [PMID: 31060101 DOI: 10.1111/ans.15216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 03/09/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Sheah Lin Lee
- Department of General Surgery, Southampton General Hospital, Southampton, UK
| | - Jacqueline Lai
- Department of Pathology, Southampton General Hospital, Southampton, UK
| | - Thomas Dudding
- Department of General Surgery, Southampton General Hospital, Southampton, UK
| | - Henry D De'Ath
- Department of General Surgery, Southampton General Hospital, Southampton, UK
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De'Ath HD, Wong S, Szentpali K, Somers S, Peck T, Wakefield CH. The Laparoscopic Management of Median Arcuate Ligament Syndrome and Its Long-Term Outcomes. J Laparoendosc Adv Surg Tech A 2018; 28:1359-1363. [PMID: 29781769 DOI: 10.1089/lap.2018.0204] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Case reports and small series of the surgical and radiological management of median arcuate ligament syndrome (MALS) have been described, however, long-term outcome data are lacking. The purpose of this study was to review our experience of the laparoscopic management of MALS, and describe the long-term outcomes after surgical intervention. METHODS Data were collected between 2005 and 2016 in a single U.K. institution. All patients with MALS who underwent laparoscopic decompression of the celiac artery were included. Surgical outcomes were recorded from a prospectively collected database. Long-term outcomes were determined by outpatient review and the Gastrointestinal Quality of Life Index (GIQLI). RESULTS Six patients were included. Five were female with a median age of 30 years (22.3-48.3). All six presented with abdominal pain and a bruit. Length of symptoms on presentation was 41 months (19-69). Duplex ultrasonography indicated celiac trunk stenosis in each case, with an elevated peak velocity flow in the celiac trunk of 230 cm/s (210-287.5). All six underwent successful laparoscopic decompression of the celiac artery with no conversions to open. Operating time was 137.3 minutes (95.6-166.3) and intraoperative blood loss was 110 mL (65-225). Length of stay was one day (1-2.3), with no postoperative complications or mortality. Median follow-up was 109.5 months (78-113.5). At this point, all patients remained symptom free with an overall GIQLI score of 129/144 (123.8-134.5). CONCLUSIONS MALS is a rare condition. Laparoscopic decompression of the median arcuate ligament is safe and offers long-term resolution of symptoms, and improvement in patient quality of life.
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Affiliation(s)
- Henry D De'Ath
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Simon Wong
- 2 Queen Alexandra Hospital , Cosham, Portsmouth, United Kingdom
| | - Karoly Szentpali
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Shaw Somers
- 2 Queen Alexandra Hospital , Cosham, Portsmouth, United Kingdom
| | - Tom Peck
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
| | - Christian H Wakefield
- 1 Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital , Winchester, United Kingdom
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De'Ath HD, Oakland K, Brohi K. CT screened arterial calcification as a risk factor for mortality after trauma. Scand J Trauma Resusc Emerg Med 2016; 24:120. [PMID: 27724913 PMCID: PMC5057451 DOI: 10.1186/s13049-016-0317-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 10/04/2016] [Indexed: 01/06/2023] Open
Abstract
Background Arterial calcification on Computerised Tomography (CT) is a marker of cardiovascular disease. It is predictive of future adverse cardiac events and mortality in many disease states. The incidence of arterial disease and its impact on outcomes of the injured is not known. The objectives of this study were to describe the incidence of arterial calcification in trauma patients, and establish its impact on mortality. Methods A retrospective cohort study of all injured patients aged over 45 years presenting to a major trauma centre over a 34-month period. The presence and quantity of coronary, aortic and abdominal arterial calcification on admission CT scans of the chest, abdomen and pelvis was established, and the association between cardiovascular disease and in-hospital mortality following trauma was determined. Results Five hundred ninety-one patients were included in the study. Cardiac calcium was visible on 432 (73 %) scans, and abdominal arterial calcification on 472 (79.9 %). Fifty (8.5 %) patients died. Patients with Superior Mesenteric (SMA) and Common Iliac Artery calcification had a significantly higher mortality than those without (p < 0.01). In multivariarate analysis, only SMA calcification was independently associated with mortality (OR 2.462, 95 % CI 1.08–5.60, p = 0.032). Coronary calcium demonstrated no independent statistical relationship with death (Left Anterior Descending Artery OR 1.189, 95 % CI 0.51–2.78, Circumflex OR 1.290, 95 % CI 0.56–2.98, Right Coronary Artery OR 0.483, 95 % CI 0.21–1.10). Discussion This study has demonstrated that the identification of arterial calcification on admission CT scans of trauma patients is possible. Calcification was common, and present in around three-quarters of injured individuals over the age of 45 years. SMA calcium was an independent predictor of mortality. However, whilst the presence of arterial calcium demonstrated a tendency towards lower survival, this association was not significant in other territories, including the coronary arteries. Future studies should investigate further the association and pathophysiology linking SMA disease and mortality in trauma, in addition to the relationship between longer tem survival, adverse cardiac events and arterial calcification in injured patients. Conclusions Arterial calcification can be reliably identified on trauma CT scans, and is common in injured patients. Abdominal vascular calcification appears to be a better predictor of mortality than coronary artery disease. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0317-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henry D De'Ath
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, Newark Street, London, E1 2AT, UK.
| | - Kathryn Oakland
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, Newark Street, London, E1 2AT, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, Newark Street, London, E1 2AT, UK
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Manson J, Cole E, De'Ath HD, Vulliamy P, Meier U, Pennington D, Brohi K. Early changes within the lymphocyte population are associated with the development of multiple organ dysfunction syndrome in trauma patients. Crit Care 2016; 20:176. [PMID: 27268230 PMCID: PMC4895987 DOI: 10.1186/s13054-016-1341-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/12/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early survival following severe injury has been improved with refined resuscitation strategies. Multiple organ dysfunction syndrome (MODS) is common among this fragile group of patients leading to prolonged hospital stay and late mortality. MODS after trauma is widely attributed to dysregulated inflammation but the precise mechanics of this response and its influence on organ injury are incompletely understood. This study was conducted to investigate the relationship between early lymphocyte responses and the development of MODS during admission. METHODS During a 24-month period, trauma patients were recruited from an urban major trauma centre to an ongoing, observational cohort study. Admission blood samples were obtained within 2 h of injury and before in-hospital intervention, including blood transfusion. The study population was predominantly male with a blunt mechanism of injury. Lymphocyte subset populations including T helper, cytotoxic T cells, NK cells and γδ T cells were identified using flow cytometry. Early cytokine release and lymphocyte count during the first 7 days of admission were also examined. RESULTS This study demonstrated that trauma patients who developed MODS had an increased population of NK dim cells (MODS vs no MODS: 22 % vs 13 %, p < 0.01) and reduced γδ-low T cells (MODS vs no MODS: 0.02 (0.01-0.03) vs 0.09 (0.06-0.12) × 10^9/L, p < 0.01) at admission. Critically injured patients who developed MODS (n = 27) had higher interferon gamma (IFN-γ) concentrations at admission, compared with patients of matched injury severity and shock (n = 60) who did not develop MODS (MODS vs no MODS: 4.1 (1.8-9.0) vs 1.0 (0.6-1.8) pg/ml, p = 0.01). Lymphopenia was observed within 24 h of injury and was persistent in those who developed MODS. Patients with a lymphocyte count of 0.5 × 10(9)/L or less at 48 h, had a 45 % mortality rate. CONCLUSIONS This study provides evidence of lymphocyte activation within 2 h of injury, as demonstrated by increased NK dim cells, reduced γδ-low T lymphocytes and high blood IFN-γ concentration. These changes are associated with the development of MODS and lymphopenia. The study reveals new opportunities for investigation to characterise the cellular response to trauma and examine its influence on recovery.
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Affiliation(s)
- Joanna Manson
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK.
| | - Elaine Cole
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Henry D De'Ath
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Paul Vulliamy
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Ute Meier
- Centre for Neuroscience, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Dan Pennington
- Centre for Immunobiology, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Karim Brohi
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
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Khan S, Davenport R, Raza I, Glasgow S, De'Ath HD, Johansson PI, Curry N, Stanworth S, Gaarder C, Brohi K. Damage control resuscitation using blood component therapy in standard doses has a limited effect on coagulopathy during trauma hemorrhage. Intensive Care Med 2014; 41:239-47. [PMID: 25447807 DOI: 10.1007/s00134-014-3584-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 11/25/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To determine the effectiveness of blood component therapy in the correction of trauma-induced coagulopathy during hemorrhage. BACKGROUND Severe hemorrhage remains a leading cause of mortality in trauma. Damage control resuscitation strategies target trauma-induced coagulopathy (TIC) with the early delivery of high-dose blood components such as fresh frozen plasma (FFP) and platelet transfusions. However, the ability of these products to correct TIC during hemorrhage and resuscitation is unknown. METHODS This was an international prospective cohort study of bleeding trauma patients at three major trauma centers. A blood sample was drawn immediately on arrival and after 4, 8 and 12 packed red blood cell (PRBC) transfusions. FFP, platelet and cryoprecipitate use was recorded during these intervals. Samples were analyzed for functional coagulation and procoagulant factor levels. RESULTS One hundred six patients who received at least four PRBC units were included. Thirty-four patients (32 %) required a massive transfusion. On admission 40 % of patients were coagulopathic (ROTEM CA5 ≤ 35 mm). This increased to 58 % after four PRBCs and 81 % after eight PRBCs. On average all functional coagulation parameters and procoagulant factor concentrations deteriorated during hemorrhage. There was no clear benefit to high-dose FFP therapy in any parameter. Only combined high-dose FFP, cryoprecipitate and platelet therapy with a high total fibrinogen load appeared to produce a consistent improvement in coagulation. CONCLUSIONS Damage control resuscitation with standard doses of blood components did not consistently correct trauma-induced coagulopathy during hemorrhage. There is an important opportunity to improve TIC management during damage control resuscitation.
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Affiliation(s)
- Sirat Khan
- Centre for Trauma Sciences, Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK,
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Raza I, Davenport R, Rourke C, Platton S, Manson J, Spoors C, Khan S, De'Ath HD, Allard S, Hart DP, Pasi KJ, Hunt BJ, Stanworth S, MacCallum PK, Brohi K. The incidence and magnitude of fibrinolytic activation in trauma patients. J Thromb Haemost 2013; 11:307-14. [PMID: 23176206 DOI: 10.1111/jth.12078] [Citation(s) in RCA: 340] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma is a global disease, with over 2.5 million deaths annually from hemorrhage and coagulopathy. Overt hyperfibrinolysis is rare in trauma, and is associated with massive fatal injuries. Paradoxically, clinical trials suggest a much broader indication for antifibrinolytics. OBJECTIVE To determine the incidence and magnitude of fibrinolytic activation in trauma patients and its relationship to clot lysis as measured by thromboelastometry. METHODS A prospective cohort study of 303 consecutive trauma patients admitted between January 2007 and June 2009 was performed. Blood was drawn on arrival for thromboelastometry (TEM) and coagulation assays. Follow-up was until hospital discharge or death. TEM hyperfibrinolysis was defined as maximum clot lysis of > 15%. Fibrinolytic activation (FA) was determined according to plasmin-antiplasmin (PAP) complex and D-dimer levels. Data were collected on demographics, mechanism, severity of injury, and baseline vital signs. The primary outcome measure was 28-day mortality. The secondary outcome measures were 28-day ventilator-free days and 24-h transfusion requirement. RESULTS Only 5% of patients had severe fibrinolysis on TEM, but 57% of patients had evidence of 'moderate' fibrinolysis, with PAP complex levels elevated to over twice normal (> 1500 μg L(-1)) without lysis on TEM. TEM detected clot lysis only when PAP complex levels were increased to 30 times normal (P < 0.001) and antiplasmin levels were < 75% of normal. Patients with FA had increased 28-day mortality as compared with those with no FA (12% vs. 1%, P < 0.001), fewer ventilator-free days, and longer hospital stay. CONCLUSIONS FA occurs in the majority of trauma patients, and the magnitude of FA correlates with poor clinical outcome. This was not detected by conventional TEM, which is an insensitive measure of endogenous fibrinolytic activity.
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Affiliation(s)
- I Raza
- Centre for Trauma Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of, London, UK
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Abstract
BACKGROUND Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation. METHODS A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included. RESULTS Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction. CONCLUSION Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Z B Perkins
- Trauma Clinical Academic Unit, The Royal London Hospital, Whitechapel, London, UK.
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14
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Chana MS, Manson J, Davenport R, De'Ath HD, Spoors C, Raza I, Khan S, Coates A, Rourke C, Brohi K. Time course of lactate clearance in trauma and its relevance to outcomes. Scand J Trauma Resusc Emerg Med 2012; 20. [PMCID: PMC3311005 DOI: 10.1186/1757-7241-20-s1-o9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- MS Chana
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - J Manson
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - R Davenport
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - HD De'Ath
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - C Spoors
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - I Raza
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - S Khan
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - A Coates
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - C Rourke
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
| | - K Brohi
- The Blizard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, UK
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15
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De'Ath HD, Rourke C, Davenport R, Manson J, Renfrew I, Uppal R, Davies LC, Brohi K. Clinical and biomarker profile of trauma-induced secondary cardiac injury. Br J Surg 2012; 99:789-97. [PMID: 22437496 DOI: 10.1002/bjs.8728] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Secondary cardiac injury has been demonstrated in critical illness and is associated with worse outcomes. The aim of this study was to establish the existence of trauma-induced secondary cardiac injury, and investigate its impact on outcomes in injured patients. METHODS Injured adult patients eligible for enrolment in the Activation of Coagulation and Inflammation in Trauma 2 study, and admitted to the intensive care unit between January 2008 and January 2010, were selected retrospectively for the study. Markers of cardiac injury (brain natriuretic peptide (BNP), heart-type fatty acid binding protein (H-FABP) and troponin I) were measured on admission, and after 24 and 72 h in blood samples from injured patients. Individual records were reviewed for adverse cardiac events and death. RESULTS During the study period, 135 patients were enrolled (106 male, 78·5 per cent) with a median age of 40 (range 16-89) years. Eighteen patients (13·3 per cent) had an adverse cardiac event during admission and these events were not associated with direct thoracic injury. The in-hospital mortality rate was higher among the adverse cardiac event cohort: 44 per cent (8 of 18) versus 17·1 per cent (20 of 117) (P = 0·008). Raised levels of H-FABP and BNP at 0, 24 and 72 h, and troponin I at 24 and 72 h, were associated with increased adverse cardiac events. BNP levels were higher in non-survivors on admission (median 550 versus 403 fmol/ml; P = 0·022), after 24 h (794 versus 567 fmol/ml; P = 0·033) and after 72 h (1043 versus 753 fmol/ml; P = 0·036), as were admission troponin I levels. CONCLUSION Clinical and cardiac biomarker characteristics support the existence of trauma-induced secondary cardiac injury, which is associated with death, and unrelated to direct thoracic injury.
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Affiliation(s)
- H D De'Ath
- Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK.
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16
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Kambal AA, De'Ath HD, Albon H, Watson A, Shandall A, Greenstein D. Endovenous laser ablation for persistent and recurrent venous ulcers after varicose vein surgery. Phlebology 2008; 23:193-5. [DOI: 10.1258/phleb.2008.006044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A 75-year-old woman presented with painful recurrent venous ulcers (VU) continuously for the past 33 months on a background of frequent intermittent problems for the last 16 years. She had previously been treated with varicose vein surgery and trials of compression bandaging. Subsequently, she underwent endovenous laser ablation (EVLA) targeting the distal incompetent remnant of her great and small saphenous veins. This resulted in complete healing of her ulcers within four weeks. The dramatic response demonstrated in this case suggests that EVLA may represent an effective intervention in the management of postsurgery refractory VU.
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Affiliation(s)
- A A Kambal
- Department of Surgery, Royal Gwent Hospital, Newport
| | | | - H Albon
- Department of Surgery, Northwick Park Hospital, Harrow, UK
| | - A Watson
- Department of Surgery, Northwick Park Hospital, Harrow, UK
| | - A Shandall
- Department of Surgery, Royal Gwent Hospital, Newport
| | - D Greenstein
- Department of Surgery, Northwick Park Hospital, Harrow, UK
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