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Shander A, Van Aken H, Colomina MJ, Gombotz H, Hofmann A, Krauspe R, Lasocki S, Richards T, Slappendel R, Spahn DR. Patient blood management in Europe. Br J Anaesth 2012; 109:55-68. [PMID: 22628393 PMCID: PMC3374574 DOI: 10.1093/bja/aes139] [Citation(s) in RCA: 193] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Preoperative anaemia is common in patients undergoing orthopaedic and other major surgery. Anaemia is associated with increased risks of postoperative mortality and morbidity, infectious complications, prolonged hospitalization, and a greater likelihood of allogeneic red blood cell (RBC) transfusion. Evidence of the clinical and economic disadvantages of RBC transfusion in treating perioperative anaemia has prompted recommendations for its restriction and a growing interest in approaches that rely on patients' own (rather than donor) blood. These approaches are collectively termed ‘patient blood management’ (PBM). PBM involves the use of multidisciplinary, multimodal, individualized strategies to minimize RBC transfusion with the ultimate goal of improving patient outcomes. PBM relies on approaches (pillars) that detect and treat perioperative anaemia and reduce surgical blood loss and perioperative coagulopathy to harness and optimize physiological tolerance of anaemia. After the recent resolution 63.12 of the World Health Assembly, the implementation of PBM is encouraged in all WHO member states. This new standard of care is now established in some centres in the USA and Austria, in Western Australia, and nationally in the Netherlands. However, there is a pressing need for European healthcare providers to integrate PBM strategies into routine care for patients undergoing orthopaedic and other types of surgery in order to reduce the use of unnecessary transfusions and improve the quality of care. After reviewing current PBM practices in Europe, this article offers recommendations supporting its wider implementation, focusing on anaemia management, the first of the three pillars of PBM.
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Cross J, Raine R, Harris P, Richards T. Indications for fenestrated endovascular aneurysm repair. Br J Surg 2012; 99:217-24. [DOI: 10.1002/bjs.7811] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Endovascular technology has advanced rapidly in the development of fenestrated endovascular aneurysm repair (FEVAR). Current evidence for endovascular aneurysm repair is limited to infra-renal aortic aneurysms. With increased costs and complexity of FEVAR, its current role is unclear. A national multicentre, cross-disciplinary consensus model was developed to propose indications for FEVAR.
Methods
All UK FEVAR centres and a wide selection of high-volume aneurysm treatment centres were invited to participate. The RAND appropriateness methodology was used. Five key steps were undertaken: meta-analysis of current literature; survey of current UK practice; nominal group establishment and definition of key clinical attributes; round 1—online survey of case vignettes; and round 2—nominal group consensus meeting.
Results
More than 90 per cent of UK FEVAR centres participated. Literature review showed heterogeneous case series with no clear indications for use of FEVAR. Survey of current practice showed wide variations in aneurysm management. Consensus agreement on the role of FEVAR was achieved in 68·8 per cent of cases. Consensus for FEVAR was agreed in areas of moderate risk from open repair and need for suprarenal clamping, but it was less likely to be indicated in patients aged 85 years or more with 5·5–6-cm aneurysms, or short-necked infrarenal aortic aneurysms.
Conclusion
These data record areas of agreement and define the grey area of equipoise. Consequently, guidelines and recommendations can be developed on the indications for FEVAR to inform clinicians, commissioners and health economists.
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Cross J, Gurusamy K, Gadhvi V, Simring D, Harris P, Ivancev K, Richards T. Fenestrated endovascular aneurysm repair. Br J Surg 2011; 99:152-9. [PMID: 22183704 DOI: 10.1002/bjs.7804] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2011] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Fenestrated endovascular aneurysm repair (FEVAR) is a technically challenging operation. The duration, blood loss, and risk of limb ischaemia, contrast-induced nephropathy and reperfusion injury are likely to be higher than after standard endovascular aneurysm repair (EVAR). Benefits of FEVAR over open repair may be less than those seen with standard infrarenal EVAR. This paper is a meta-analysis of observational studies of all published data for FEVAR, with the aim to highlight current issues around the evidence for the potential benefit of FEVAR.
Methods
A search was performed for studies describing FEVAR for juxtarenal abdominal aortic aneurysms. Small series of fewer than ten procedures and studies describing predominantly branched endografts or FEVAR for aortic dissection were excluded. Authors of included papers were contacted to eliminate patient duplication.
Results
Eleven studies were identified describing a total of 660 procedures. Definitions of aneurysm morphology were variable, and clear inclusion and exclusion criteria were not always documented. Double fenestrations were more common than triple or quadruple fenestrations. Target vessel perfusion rates ranged from 90·5 to 100 per cent. Eleven deaths occurred within 30 days, giving a 30-day proportional mortality rate of 2·0 per cent. Morbidity was poorly reported.
Conclusion
FEVAR for repair of suprarenal and juxtarenal aneurysms is a viable alternative to open repair. However, there is no level 1 evidence for FEVAR, and current evidence is weak with many unanswered questions.
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O'Sullivan F, Wolsztynski E, O'Sullivan J, Richards T, Conrad EU, Eary JF. A statistical modeling approach to the analysis of spatial patterns of FDG-PET uptake in human sarcoma. IEEE TRANSACTIONS ON MEDICAL IMAGING 2011; 30:2059-2071. [PMID: 21724502 PMCID: PMC4753574 DOI: 10.1109/tmi.2011.2160984] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Clinical experience with positron emission tomography (PET) scanning of sarcoma, using fluorodeoxyglucose (FDG), has established spatial heterogeneity in the standardized uptake values within the tumor mass as a key prognostic indicator of patient survival. But it may be that a more detailed quantitation of the tumor FDG uptake pattern could provide additional insights into risk. The present work develops a statistical model for this purpose. The approach is based on a tubular representation of the tumor mass with a simplified radial analysis of uptake, transverse to the tubular axis. The technique provides novel ways of characterizing the overall profile of the tumor, including the introduction of an approach for the measurement of its phase of development. The phase measure can distinguish between early phase tumors, in which the uptake is highest at the core, and later stage masses, in which there can often be central voids in FDG uptake. Biologically, these voids arise from necrosis and fluid, fat or cartilage accumulations. The tumor profiling technique is implemented using open-source software tools and illustrations are provided with clinically representative scans. A series of FDG-PET studies from 185 patients is used to formally evaluate the prognostic benefit. Significant improvements in the prediction of patient survival and progression are obtained from the tumor profiling analysis. After adjustment for other factors including heterogeneity, a typical one standard deviation increase in phase (as determined by the analysis) is associated with close to 20% more risk of progression or death. The work confirms that more detailed quantitative assessments of the spatial pattern of PET imaging data of tumor masses, beyond the maximum FDG uptake (SUV(max)) and previously considered measures of heterogeneity, provide improved prognostic information for potential input to treatment decisions for future patients.
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Morgan-Rowe L, Simring D, Raja J, Agu O, Richards T, Ivancev K. The Use of an Endovascular Stent Graft with ‘Home-made’ Fenestrations to Treat an Infected Aortic Endograft in an Emergency Setting: A Short Report. Eur J Vasc Endovasc Surg 2011. [DOI: 10.1016/j.ejvs.2011.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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81
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Conroy DM, Altaf N, Goode SD, Braithwaite BD, MacSweeney ST, Richards T. Use of the Hardman Index in Predicting Mortality in Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. ACTA ACUST UNITED AC 2011; 23:274-9. [DOI: 10.1177/1531003511408737] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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83
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Aung N, Ling HZ, Aggarwal S, Flint J, Weissert S, Cheng A, Richards T, Francis DP, Mayet J, Thomas M, Okonko DO. 107 Expansion of the red cell distribution width and evolving iron deficiency as predictors of poor outcome in chronic heart failure. BRITISH HEART JOURNAL 2011. [DOI: 10.1136/heartjnl-2011-300198.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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84
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Calmet D, Ameon R, Beck T, Bombard A, Bourquin MN, Brun S, De Jong P, Forte M, Fournier M, Herranz M, Jerome S, Klett A, Kwakman P, Llaurado M, Loyen J, Michel R, Nardoux P, Richards T, Schuler C, Tokonami S, Woods M. International standardisation work on the measurement of radon in air and water. RADIATION PROTECTION DOSIMETRY 2011; 145:267-272. [PMID: 21498866 DOI: 10.1093/rpd/ncr077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Radon is considered to be the main source of human exposure to natural radiation. As stated by the World Health Organization, the exposure due to the inhalation of indoor radon is much greater than the one via the ingestion of water as radon degasses from water during handling. In response to these concerns about the universal presence of radon, environmental assessment studies are regularly commissioned to assess the radon exposure of public and workers. The credibility of such studies relies on the quality and reliability of radon analysis as well as on the sample representativeness of the radiological situation. The standard-setting approach, based on consensus, seemed to lend itself to a settlement of technical aspects of potential comparison. At present, two Working Groups of the International Standardization Organization are focussing on drafting standards on radon and its decay products measurement in air and water. These standards, which aim for a set of rigorous metrology practices, will be useful for persons in charge of the initial characterisation of a site with respect to natural radioactivity as well as to those performing the routine surveillance of specific sites.
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Schick U, Richards T, Miah A, Nutting C. Stereotactic Body Radiotherapy: Overview of the 2010 Royal College of Radiologists’ Annual Scientific Meeting. Clin Oncol (R Coll Radiol) 2011; 23:165-7. [DOI: 10.1016/j.clon.2011.01.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
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Cross J, Amiri N, Fung C, Simring D, Ivancev K, Harris P, Richards T. Endovascular repair of abdominal aortic aneurysms (AAA) outside manufacturers instructions for use: Infra-renal sealing is not a safe option. Int J Surg 2011. [DOI: 10.1016/j.ijsu.2011.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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87
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Richards T. Flexible retirement age is needed to tackle Europe's ageing population. West J Med 2010. [DOI: 10.1136/bmj.c5668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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88
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Richards T, Groves T. BMJ extends its European reach. West J Med 2010. [DOI: 10.1136/bmj.c4681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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89
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Goode S, Chowdhury A, Crockett M, Beech A, Simpson R, Richards T, Braithwaite B. Laser and Radiofrequency Ablation Study (LARA study): A Randomised Study Comparing Radiofrequency Ablation and Endovenous Laser Ablation (810nm). J Vasc Surg 2010. [DOI: 10.1016/j.jvs.2010.06.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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90
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Richards T, Neretnieks I. Filtering of Clay Colloids in Bentonite Detritus Material. Chem Eng Technol 2010. [DOI: 10.1002/ceat.201000108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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91
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Richards T. Novel partnerships help poor countries extend access to health services. West J Med 2010. [DOI: 10.1136/bmj.c2897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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92
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Shah M, Martin A, Myers B, MacSweeney S, Richards T. Recognising anaemia and malnutrition in vascular patients with critical limb ischaemia. Ann R Coll Surg Engl 2010; 92:495-8. [PMID: 20513273 DOI: 10.1308/003588410x12664192075738] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Anaemia is a common problem in surgical patients. Patients with critical limb ischaemia (CLI) suffer chronic inflammation, repeated infection, require intervention, and can have a protracted hospital stay. The aims of this study were to assess anaemia and nutritional status in patients presenting with CLI. PATIENTS AND METHODS Two observational studies were undertaken, initially a retrospective series of 27 patients with CLI. Patient demographics, clinical details, transfusion status and in-patient laboratory haemoglobin values (Hb) were recorded. In a prospective series of 32 patients, laboratory markers to identify the cause for anaemia were assessed. Further nutritional status was assessed by records of height, weight, body mass index and a validated scoring system. RESULTS In the retrospective series, 15 patients (56%) were anaemic. Ten (37%) were transfused a median of 2 units (range, 2-13), a total of 35 units. Patients who were transfused had lower Hb on admission (P = 0.0019), most were anaemic on admission (90%). At discharge, most patients were anaemic (n = 23; 83%). In the prospective series of 32 patients, 20 (63%) were anaemic. Nutritional assessment was performed on 18, only seven patients were scored undernourished. This was increased to 23 by an independent assessor. Anaemia was associated with malnutrition (n = 17; P = 0.049) and an increased hospital stay (mean 25 days [SD 16] vs mean 12 days [SD 8], P = 0.0125; total 513 vs 144 bed days). CONCLUSIONS Anaemia and poor nutrition are common and not recognised in vascular patients presenting with critical limb ischaemia. Anaemia is associated with and increased length of hospital stay.
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Richards T. EU reshuffle has health potential. West J Med 2010. [DOI: 10.1136/bmj.c382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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94
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Richards T. EU seeks to define its role in global health strategies. West J Med 2009. [DOI: 10.1136/bmj.b5370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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95
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Richards T. New centre seeks to promote global health security. West J Med 2009. [DOI: 10.1136/bmj.b4869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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96
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Richards T. Brave new world. West J Med 2009. [DOI: 10.1136/bmj.b4537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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97
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Richards T. Governments must act now to prevent slide into poverty and ill health after recession. BMJ : BRITISH MEDICAL JOURNAL 2009. [DOI: 10.1136/bmj.b4087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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98
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Richards T, Goode S, Hinchliffe R, Altaf N, MacSweeney S, Braithwaite B. The Importance of Anatomical Suitability and Fitness for the Outcome of Endovascular Repair of Ruptured Abdominal Aortic Aneurysm. J Vasc Surg 2009. [DOI: 10.1016/j.jvs.2009.07.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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99
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Richards T. Views from Venice. West J Med 2009. [DOI: 10.1136/bmj.b3362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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100
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Kleinhans NM, Johnson LC, Richards T, Greenson J, Dawson G, Aylward EH. Abnormal Functional Connectivity during Emotional Face Processing is Associated with Neural Abnormalities in the Amygdala in Autism Spectrum Disorders. Neuroimage 2009. [DOI: 10.1016/s1053-8119(09)70059-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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