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Javanmard-Emamghissi H, Doleman B, Lund JN, Lockwood S, Hare S, Pearce L, Moug S, Tierney GM. Beyond high-risk: analysis of the outcomes of extreme-risk patients in the National Emergency Laparotomy Audit. Anaesthesia 2023; 78:1376-1385. [PMID: 37772642 DOI: 10.1111/anae.16130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 09/30/2023]
Abstract
Patients who require emergency laparotomy are defined as high risk if their 30-day predicted risk of mortality is ≥ 5%. Despite a large difference in the characteristics of patients with a mortality risk score of between 5% and 50%, these outcomes are aggregated by the National Emergency Laparotomy Audit (NELA). Our aim was to describe the outcomes of the cohort of patients at extreme risk of death, which we defined as having a NELA-predicted 30-day mortality of ≥ 50%. All patients enrolled in the NELA database between December 2012 and 2020 were included. We compared patient characteristics; length of hospital stay; rates of unplanned return to the operating theatre; and 90-day survival in extreme-risk groups (predicted ≥ 50%) and high-risk patients (predicted 5-49%). Of 161,337 patients, 5193 (3.2%) had a predicted mortality of ≥ 50%. When patients were further subdivided, 2437 (47%) had predicted mortality of 50-59% (group 50-59); 1484 (29%) predicted mortality of 60-69% (group 60-69); 840 (16%) predicted mortality of 70-79% (group 70-79); and 423 (8%) predicted mortality of ≥ 80% (group 80+). Extreme-risk patients were significantly more likely to have been admitted electively than high-risk patients (p < 0.001). Length of stay increased from a median (IQR [range]) of 26 (16-43 [0-271]) days in group 50-59 to 35 (21-56 [0-368]) days in group 80+, compared with 17 (10-30 [0-1136]) days for high-risk patients. Rates of unplanned return to the operating theatre were higher in extreme-risk groups compared with high-risk patients (11% vs. 8%). The 90-day survival was 43% in group 50-59, 34% in group 60-69, 27% in group 70-79 and 17% in group 80+. These data underscore the need for a differentiated approach when discussing risk with patients at extreme risk of mortality following an emergency laparotomy. Clinicians should focus on patient priorities on quantity and quality of life during informed consent discussions before surgery. Future work should extend beyond the immediate postoperative period to encompass the longer-term outcomes (survival and function) of patients who have emergency laparotomies.
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Affiliation(s)
- H Javanmard-Emamghissi
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - B Doleman
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Department of Medicine and Health Sciences, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - S Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - S Hare
- Department of Anaesthesia, William Harvey Hospital, East Kent University Hospitals, Ashford, UK
| | - L Pearce
- Department of Colorectal Surgery, Salford Royal Hospital, Salford, UK
| | - S Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
| | - G M Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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2
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Eugene N, Kuryba A, Martin P, Oliver CM, Berry M, Moppett IK, Johnston C, Hare S, Lockwood S, Murray D, Walker K, Cromwell DA. Development and validation of a prognostic model for death 30 days after adult emergency laparotomy. Anaesthesia 2023; 78:1262-1271. [PMID: 37450350 DOI: 10.1111/anae.16096] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
The probability of death after emergency laparotomy varies greatly between patients. Accurate pre-operative risk prediction is fundamental to planning care and improving outcomes. We aimed to develop a model limited to a few pre-operative factors that performed well irrespective of surgical indication: obstruction; sepsis; ischaemia; bleeding; and other. We derived a model with data from the National Emergency Laparotomy Audit for patients who had emergency laparotomy between December 2016 and November 2018. We tested the model on patients who underwent emergency laparotomy between December 2018 and November 2019. There were 4077/40,816 (10%) deaths 30 days after surgery in the derivation cohort. The final model had 13 pre-operative variables: surgical indication; age; blood pressure; heart rate; respiratory history; urgency; biochemical markers; anticipated malignancy; anticipated peritoneal soiling; and ASA physical status. The predicted mortality probability deciles ranged from 0.1% to 47%. There were 1888/11,187 deaths in the test cohort. The scaled Brier score, integrated calibration index and concordance for the model were 20%, 0.006 and 0.86, respectively. Model metrics were similar for the five surgical indications. In conclusion, we think that this prognostic model is suitable to support decision-making before emergency laparotomy as well as for risk adjustment for comparing organisations.
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Affiliation(s)
- N Eugene
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - A Kuryba
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - P Martin
- Department of Applied Health Research, University College London, London, UK
| | - C M Oliver
- UCL Division of Surgery and Interventional Science, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Berry
- Critical Care, King's College Hospital NHS Foundation Trust, London, UK
| | - I K Moppett
- Anaesthesia and Critical Care Section, Academic Unit of Injury, Inflammation and Repair, University of Nottingham, Nottingham, UK
| | - C Johnston
- Department of Anaesthesia, St George's Hospital, London, UK
| | - S Hare
- Department of Anaesthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | - S Lockwood
- Colorectal Surgery Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - D Murray
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - K Walker
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D A Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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3
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Javanmard-Emamghissi H, Doleman B, Lund JN, Frisby J, Lockwood S, Hare S, Moug S, Tierney G. Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit. Tech Coloproctol 2023; 27:729-738. [PMID: 36609892 PMCID: PMC10404199 DOI: 10.1007/s10151-022-02747-1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/13/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Quantitative futility is an appraisal of the risk of failure of a treatment. For those who do not survive, a laparotomy has provided negligible therapeutic benefit and may represent a missed opportunity for palliation. The aim of this study was to define a timeframe for quantitative futility in emergency laparotomy and investigate predictors of futility using the National Emergency Laparotomy Audit (NELA) database. METHODS A two-stage methodology was used; stage one defined a timeframe for futility using an online survey and steering group discussion; stage two applied this definition to patients enrolled in NELA December 2013-December 2020 for analysis. Futility was defined as all-cause mortality within 3 days of emergency laparotomy. Baseline characteristics of this group were compared to all others. Multilevel logistic regression was carried out with potentially clinically important predictors defined a priori. RESULTS Quantitative futility occurred in 4% of patients (7442/180,987). Median age was 74 years (range 65-81 years). Median NELA risk score was 32.4% vs. 3.8% in the surviving cohort (p < 0.001). Early mortality patients more frequently presented with sepsis (p < 0.001). Significant predictors of futility included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality (95% CI 1.22-1.55). Surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery (OR 2.67; 95% CI 2.50-2.85). CONCLUSIONS Quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively. These findings should be incorporated qualitatively by the multidisciplinary team into shared decision-making discussions with extremely high-risk patients.
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Affiliation(s)
- H Javanmard-Emamghissi
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK.
| | - B Doleman
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J N Lund
- Department of Medicine and Health Science, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - J Frisby
- Department of Palliative Care Medicine, Royal Derby Hospital, Derby, UK
| | - S Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - S Hare
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - S Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
| | - G Tierney
- Department of Colorectal Surgery, Royal Derby Hospital, Derby, UK
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Partridge JSL, Ryan J, Dhesi JK, Barker C, Bates L, Bell R, Bryden D, Carter S, Clegg A, Conroy S, Cowley A, Curtis A, Diedo B, Eardley W, Evley R, Hare S, Hopper A, Humphry N, Kanga K, Kilvington B, Lees NP, McDonald D, McGarrity L, McNally S, Meilak C, Mudford L, Nolan C, Pearce L, Price A, Proffitt A, Romano V, Rose S, Selwyn D, Shackles D, Syddall E, Taylor D, Tinsley S, Vardy E, Youde J. New guidelines for the perioperative care of people living with frailty undergoing elective and emergency surgery-a commentary. Age Ageing 2022; 51:6847803. [PMID: 36436009 DOI: 10.1093/ageing/afac237] [Citation(s) in RCA: 5] [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] [Received: 07/07/2022] [Revised: 08/02/2022] [Indexed: 11/28/2022] Open
Abstract
Frailty is common in the older population and is a predictor of adverse outcomes following emergency and elective surgery. Identification of frailty is key to enable targeted intervention throughout the perioperative pathway from contemplation of surgery to recovery. Despite evidence on how to identify and modify frailty, such interventions are not yet routine perioperative care. To address this implementation gap, a guideline was published in 2021 by the Centre for Perioperative Care and the British Geriatrics Society, working with patient representatives and all stakeholders involved in the perioperative care of patients with frailty undergoing surgery. The guideline covers all aspects of perioperative care relevant to adults living with frailty undergoing elective and emergency surgery. It is written for healthcare professionals, as well as for patients and their carers, managers and commissioners. Implementation of the guideline will require collaboration between all stakeholders, underpinned by an implementation strategy, workforce development with supporting education and training resources, and evaluation through national audit and research. The guideline is an important step in improving perioperative outcomes for people living with frailty and quality of healthcare services. This commentary provides a summary and discussion of the evidence informing the standards and recommendations in the published guideline.
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Affiliation(s)
- Judith S L Partridge
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
| | - Jack Ryan
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jugdeep K Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Life Course and Population Sciences, King's College London London, UK
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Javanmard-Emamghissi H, Doleman B, Hare S, Lund JN, Tierney GM, Moug SJ. WE5.10 Death in the early post-operative period: recognising the concept of non-beneficiality in emergency laparotomy and modelling its predictors. Br J Surg 2022. [DOI: 10.1093/bjs/znac248.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
The publication of data from the National Emergency Laparotomy Audit (NELA) has resulted in overall improvement in post-operative mortality rates. However, little is known about the characteristics of patients that die in the immediate post-operative period. These patients may represent a missed opportunity for the consideration of palliation. We describe this specific group of patients where death occurred within three days of emergency laparotomy, and investigate predictors of early mortality.
Methods
All patients enrolled in the NELA database from December 2013–2020 were included. Early post-operative death was defined as all-cause mortality within three days of emergency laparotomy. Multi-level logistic regression was carried out with potentially clinically important predictors defined a priori. Frailty was modelled separately due to missing data.
Results
Four per cent of patients (7,442/180,987) died in the early post-operative period and 85% were admitted to critical care post-operatively. Median NELA risk score was 32.4% compared to 3.8% in the rest of the cohort (p<0.001). One in four patients were commenced on an end-of-life pathway following laparotomy. Significant predictors on multivariate analysis included female sex, increasing age, higher ASA, surgery for intestinal ischaemia or perforation, hypotension, reduced GCS, urgency of surgery, cardiac and respiratory signs (n=178,442). The addition of frailty (n=52,766) was also predictive (OR 1.37; 95% CI 1.22–1.55) when added to the model.
Conclusion
Early post-operative mortality is associated with quantifiable predictable factors in addition to the NELA risk score. This finding has significant implications for the multi-disciplinary team having shared decision-making discussions with extremely high-risk patients.
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Robinson GRE, Edey A, Hare S, Holloway B, Jacob J, Johnstone A, McStay R, Nair A, Rodrigues J. Re: Indiscriminate use of CT chest imaging during the COVID-19 pandemic. A reply. Clin Radiol 2022; 77:317-318. [PMID: 35177226 PMCID: PMC8801900 DOI: 10.1016/j.crad.2022.01.042] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/23/2022]
Affiliation(s)
| | - A Edey
- North Bristol NHS Trust, Bristol, United Kingdom
| | - S Hare
- Royal Free Hospital, London, United Kingdom
| | - B Holloway
- University of Birmingham, Birmingham, United Kingdom
| | - J Jacob
- University College London, London, United Kingdom
| | - A Johnstone
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - R McStay
- Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, United Kingdom
| | - A Nair
- University College London, London, United Kingdom
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7
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Javanmard-Emamghissi H, Lockwood S, Hare S, Lund JN, Tierney GM, Moug SJ. The false dichotomy of surgical futility in the emergency laparotomy setting: scoping review. BJS Open 2022; 6:zrac023. [PMID: 35389427 PMCID: PMC8988868 DOI: 10.1093/bjsopen/zrac023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Futile is defined as 'the fact of having no effect or of achieving nothing'. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This scoping review aimed to identify key concepts around surgical futility as it relates to emergency laparotomy. METHODS Using the Arksey and O'Malley framework, a scoping review was conducted. A search of the Cochrane Library, Google Scholar, MEDLINE, and Embase was performed up until 1 November 2021 to identify literature relevant to the topic of futility in emergency laparotomy. RESULTS Three cohort studies were included in the analysis. A total of 105 157 patients were included, with 1114 patients reported as futile. All studies were recent (2019 to 2020) and focused on the principle of quantitative futility (assessment of the probability of death after surgery) within a timeline after surgery: two defining futility as death within 48 hours of surgery and one as death within 72 hours. In all cases this was derived from a survival histogram. Predictors of defined futile procedures included age, level of independence prior to admission, surgical pathology, serum creatinine, arterial lactate, and pH. CONCLUSION There remains a paucity of research defining, exploring, and analysing futile surgery in patients undergoing emergency laparotomy. With limited published work focusing on quantitative futility and the binary outcome of death, research is urgently needed to explore all principles of futility, including the wishes of patients and their families.
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Affiliation(s)
- Hannah Javanmard-Emamghissi
- Faculty of Medicine, Division of Health Sciences and Graduate Entry Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | - Sonia Lockwood
- Department of Colorectal Surgery, Bradford Royal Infirmary, Bradford, UK
| | - Sarah Hare
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - Jon N. Lund
- Faculty of Medicine, Division of Health Sciences and Graduate Entry Medicine, University of Nottingham at Derby, Royal Derby Hospital, Derby, UK
| | | | - Susan J. Moug
- Department of Colorectal Surgery, Royal Alexandra Hospital, Paisley, UK
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Abstract
More than 1.53 million adults undergo inpatient surgery in the UK NHS. Patients undergoing emergency abdominal surgery have a much greater risk of death than patients admitted for elective surgery. Widespread variations in key standards of care between hospitals exist and are associated with differences in mortality rates.Recently there have been three large-scale initiatives to improve quality of care for emergency laparotomy patients: the National Emergency Laparotomy Audit, the enhanced perioperative care for high-risk patients trial and the Emergency Laparotomy Collaborative. Here we provide a critical review of what we currently know about the use of structured methods for improving the quality of healthcare services, with reference to the three initiatives. We find that using structured methods to improve care is the hallmark of quality improvement but attention must too be paid to the context in which these methods are used.
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Affiliation(s)
- Tim Stephens
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Carolyn Johnston
- St Georges University Hospital NHS Trust, London, UK and quality improvement lead, National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
| | - Sarah Hare
- Medway Maritime Hospital, Kent, UK and clinical lead, National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
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9
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Pervez A, Saqib A, Hare S. Development and implementation of a structured leadership programme for junior doctors. leader 2020. [DOI: 10.1136/leader-2020-000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
IntroductionHealthcare performance and quality of care have been shown to improve when clinicians actively participate in leadership roles. However, the training for junior doctors in leadership and management is either not formally provided or requires out of programme training. In this article, we discuss how we devised a leadership training programme for junior doctors at our district general hospital and reflections on how it can be implemented elsewhere.MethodsA junior doctors leadership programme was developed involving workshops and guidance through delivery of quality improvement projects. A precourse and postcourse questionnaire assessing preparedness to lead was given to trainees to assess the effectiveness of the course.ResultsUsing a Likert Scale, trainees provided quantitative self-assessment for precourse and postcourse changes in their leadership skills. There was an overall increase in confidence across key areas such as communication, preparing business cases and understating hierarchies of management teams.DiscussionThe structure of this leadership programme has provided the opportunity to address gaps in leadership skills that trainees encounter, without the need to extend training. This programme is easily reproducible and offers other trusts a guide on how to do so.
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10
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Hare S, Hayden P. Role of critical care in improving outcomes for high-risk surgical patients. Br J Surg 2020; 107:e15-e16. [PMID: 31903590 DOI: 10.1002/bjs.11423] [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: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 11/11/2022]
Affiliation(s)
- S Hare
- Department of Anaesthesia, Critical Care and Perioperative Medicine, Medway Maritime Hospital, Gillingham, ME7 5NY, UK.,National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
| | - P Hayden
- Department of Anaesthesia, Critical Care and Perioperative Medicine, Medway Maritime Hospital, Gillingham, ME7 5NY, UK
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11
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Aitken RM, Partridge JSL, Oliver CM, Murray D, Hare S, Lockwood S, Beckley-Hoelscher N, Dhesi JK. Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1-4. Age Ageing 2020; 49:656-663. [PMID: 32484859 DOI: 10.1093/ageing/afaa075] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [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: 11/15/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND older patients aged ≥65 years constitute the majority of the National Emergency Laparotomy Audit (NELA) population. To better understand this group and inform future service changes, this paper aims to describe patient characteristics, outcomes and process measures across age cohorts and temporally in the 4-year period (2014-2017) since NELA was established. METHODS patient-level data were populated from the NELA data set years 1-4 and linked with Office of National Statistics mortality data. Descriptive data were compared between groups delineated by age, NELA year and geriatrician review. Primary outcomes were 30- and 90-day mortality, length of stay (LOS) and discharge to care-home accommodation. RESULTS in total, 93,415 NELA patients were included in the analysis. The median age was 67 years. Patients aged ≥65 years had higher 30-day (15.3 versus 4.9%, P < 0.001) and 90-day mortality (20.4 versus 7.2%, P < 0.001) rates, longer LOS (median 15.2 versus 11.3 days, P < 0.001) and greater likelihood of discharge to care-home accommodation compared with younger patients (6.7 versus 1.9%, P < 0.001). Mortality rate reduction over time was greater in older compared with younger patients. The proportion of older NELA patients seen by a geriatrician post-operatively increased over years 1-4 (8.5 to 16.5%, P < 0.001). Post-operative geriatrician review was associated with reduced mortality (30-day odds ratio [OR] 0.38, confidence interval [CI] 0.35-0.42, P < 0.001; 90-day OR 0.6, CI 0.56-0.65, P < 0.001). CONCLUSIONS older NELA patients have poorer post-operative outcomes. The greatest reduction in mortality rates over time were observed in the oldest cohorts. This may be due to several interventions including increased perioperative geriatrician input.
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Affiliation(s)
- Rachel M Aitken
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
| | - Judith S L Partridge
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Charles Matthew Oliver
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Health Systems Research, UCL Division of Targeted Intervention, London, UK
| | - Dave Murray
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - Sarah Hare
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- Department of Anaesthesia, Medway Maritime Hospital, Kent, UK
| | - Sonia Lockwood
- National Emergency Laparotomy Audit, Royal College of Anaesthetists, London, UK
- General Surgery Unit, Bradford Royal Infirmary, Bradford Teaching Hospitals, Bradford, UK
| | | | - Jugdeep K Dhesi
- Perioperative Care of Older People undergoing Surgery (POPS), Department of Ageing and Health, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Division of Primary Care and Public Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
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Nair A, Rodrigues JCL, Hare S, Edey A, Devaraj A, Jacob J, Johnstone A, McStay R, Denton E, Robinson G. A British Society of Thoracic Imaging statement: considerations in designing local imaging diagnostic algorithms for the COVID-19 pandemic. Clin Radiol 2020; 75:329-334. [PMID: 32265036 PMCID: PMC7128118 DOI: 10.1016/j.crad.2020.03.008] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 01/08/2023]
Affiliation(s)
- A Nair
- Department of Radiology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - J C L Rodrigues
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK
| | - S Hare
- Department of Radiology, Royal Free London NHS Trust, Pond Street, London, NW3 2QJ, UK
| | - A Edey
- Department of Radiology, Southmead Hospital, North Bristol NHS Trust, Southmead Road, Bristol, BS10 5NB, UK
| | - A Devaraj
- Department of Radiology, The Royal Brompton & Harefield NHS Foundation Trust London, SW3 6NP, UK
| | - J Jacob
- Department of Respiratory Medicine, University College London, London, NW1 2BU, UK; Centre for Medical Image Computing, University College London, London, NW1 2BU, UK
| | - A Johnstone
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Great George Street, Leeds, LS1 3EX, UK
| | - R McStay
- Department of Radiology, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Freeman Road, Newcastle Upon Tyne, NE7 7DN, UK
| | - Erika Denton
- Department of Radiology, Norfolk and Norwick University Hospital, Colney Lane, Norwich, NR4 7UY, UK
| | - G Robinson
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, BA1 3NG, UK.
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13
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Hare S, Frye JM, Samuelson BL. Open Pedagogy as an Approach to Introducing Doctoral Students to Open Educational Resources and Information Literacy Concepts. Library Trends 2020. [DOI: 10.1353/lib.2020.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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14
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Hare S, Sullivan M. A Qualitative Study on the Digital Preservation of OER. portal 2020. [DOI: 10.1353/pla.2020.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Stephens TJ, Peden CJ, Haines R, Grocott MPW, Murray D, Cromwell D, Johnston C, Hare S, Lourtie J, Drake S, Martin GP, Pearse RM. Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data. BMJ Qual Saf 2019; 29:623-635. [PMID: 31515437 DOI: 10.1136/bmjqs-2019-009537] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 03/08/2019] [Revised: 08/07/2019] [Accepted: 08/23/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES A clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies. METHODS We performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of >80% median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal. RESULTS Of 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2-5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. CONCLUSION Only a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.
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Affiliation(s)
- Timothy J Stephens
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Carol J Peden
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Ryan Haines
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Dave Murray
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK
| | - David Cromwell
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Carolyn Johnston
- Department of Anaesthesia, St Georges University Hospital NHS Foundation Trust, London, UK
| | - Sarah Hare
- Department of Aneasthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | | | | | | | - Rupert M Pearse
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Hare S. Library Publishers as Educators: Crafting Curriculum for Undergraduate Research Journals. Journal of Librarianship and Scholarly Communication 2019. [DOI: 10.7710/2162-3309.2296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Library publishing programs continue to play an increasingly important role in educating their constituents. In particular, library publishers that support undergraduate student journals often provide guidance to students on both mechanical and conceptual issues related to publishing. This article presents a case study for developing a one-credit-hour course to support an undergraduate student journal publication, the Indiana University Journal of Undergraduate Research (IUJUR), at Indiana University Bloomington. DESCRIPTION OF COURSE The course is offered every fall as a mechanism for onboarding about thirty new undergraduate editors. The course was developed and taught by a librarian and an undergraduate student in consultation with IU’s Office of the Vice Provost for Undergraduate Education. Course curriculum touches on topics that scholarly communication and information literacy librarians alike can adapt for a variety of educational contexts, including authentic activities for understanding peer review models and applying publishing innovations. ASSESSMENT The article details both the formative and summative assessment strategies the instructor utilized to gauge student understanding of key publishing concepts. The summative assessment utilizes pre- and post-tests and extends previous library literature to evaluate students’ actual understanding of publishing concepts in addition to their perceived understanding and confidence. LIMITATIONS AND NEXT STEPS The course curriculum will continue to grow and change in order to accommodate students’ misconceptions and interests.
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Boyd-Carson H, Doleman B, Herrod PJJ, Anderson ID, Williams JP, Lund JN, Tierney GM, Murray D, Hare S, Lockwood S, Oliver CM, Spurling LJ, Poulton T, Johnston C, Cromwell D, Kuryba A, Martin P, Lourtie J, Goodwin J, Mooesinghe R, Eugene N, Catrin-Cook S, Anderson I. Association between surgeon special interest and mortality after emergency laparotomy. Br J Surg 2019; 106:940-948. [DOI: 10.1002/bjs.11146] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/07/2019] [Accepted: 01/31/2019] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Approximately 30 000 emergency laparotomies are performed each year in England and Wales. Patients with pathology of the gastrointestinal tract requiring emergency laparotomy are managed by general surgeons with an elective special interest focused on either the upper or lower gastrointestinal tract. This study investigated the impact of special interest on mortality after emergency laparotomy.
Methods
Adult patients having emergency laparotomy with either colorectal or gastroduodenal pathology were identified from the National Emergency Laparotomy Audit database and grouped according to operative procedure. Outcomes included all-cause 30-day mortality, length of hospital stay and return to theatre. Logistic and Poisson regression were used to analyse the association between consultant special interest and the three outcomes.
Results
A total of 33 819 patients (28 546 colorectal, 5273 upper gastrointestinal (UGI)) were included. Patients who had colorectal procedures performed by a consultant without a special interest in colorectal surgery had an increased adjusted 30-day mortality risk (odds ratio (OR) 1·23, 95 per cent c.i. 1·13 to 1·33). Return to theatre also increased in this group (OR 1·13, 1·05 to 1·20). UGI procedures performed by non-UGI special interest surgeons carried an increased adjusted risk of 30-day mortality (OR 1·24, 1·02 to 1·53). The risk of return to theatre was not increased (OR 0·89, 0·70 to 1·12).
Conclusion
Emergency laparotomy performed by a surgeon whose special interest is not in the area of the pathology carries an increased risk of death at 30 days. This finding potentially has significant implications for emergency service configuration, training and workforce provision, and should stimulate discussion among all stakeholders.
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Affiliation(s)
- H Boyd-Carson
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - B Doleman
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - P J J Herrod
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - I D Anderson
- National Emergency Laparotomy Audit Project Team, Royal College of Anaesthetists, London, UK
| | - J P Williams
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - J N Lund
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
- Department of Surgery, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - G M Tierney
- Division of General Surgery, Royal Derby Hospital, Derby Hospitals NHS Trust, Derby, UK
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Decker E, Williams S, Leong M, Hare S, Grimes C. Use of patient focus groups to improve patient information in enhanced recovery in colorectal surgery. Int J Surg 2018. [DOI: 10.1016/j.ijsu.2018.05.201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Li Y, Lippincott SK, Hare S, Wittenberg J, Preate SM, Page A, Guiod SE. The Library-Press Partnership: An Overview and Two Case Studies. Library Trends 2018. [DOI: 10.1353/lib.2018.0039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ashour O, Rashid M, Shaaban G, Grimes C, Hare S, Kukreja N. Evaluating Patient Reported Outcomes After Elective Colorectal and Emergency Surgery at a Single Acute NHS Trust. A Pilot Study. Int J Surg 2017. [DOI: 10.1016/j.ijsu.2017.08.308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Brill SE, Sikka S, Miller CE, Ghali A, Hare S, Vancheeswaran R. P218 Prevalence of bronchiectasis in COPD patients in a general respiratory clinic. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Senaratne MP, Griffiths J, Mooney D, Kasza L, Macdonald K, Hare S. Effectiveness of a planned strategy using cardiac rehabilitation nurses for the management of dyslipidemia in patients with coronary artery disease. Am Heart J 2001; 142:975-81. [PMID: 11717600 DOI: 10.1067/mhj.2001.118739] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Firm evidence exists for reduction in mortality and morbidity by lipid-lowering therapy in patients with coronary artery disease (CAD), yet a significant proportion remain untreated. This prospective study determined the effectiveness of a planned strategy of management using a cardiac rehabilitation nurse in achieving (1) lower 6-month low-density lipoprotein (LDL) levels and (2) a higher proportion of patients on pharmacologic therapy. METHODS A cardiac rehabilitation nurse arranged for the lipid profiles and initiated pharmacologic therapy as soon as possible after the diagnosis of CAD. In phase 1, this planned-strategy intervention group (n = 80) was compared with the usual-care control group (n = 189), where the management was left at the discretion of the attending cardiologist with the assignment to the 2 groups based on the weekly on-call rotations of the attending cardiologists in a nonrandomized manner. In phase 2 of the study all patients (n = 366) were enrolled in the planned strategy of management. RESULTS There were no significant differences in the baseline lipid values between the control and intervention groups. The 6-month cholesterol and LDL values and the percentage of patients on lipid-lowering medications were significantly better in the intervention group (P =.01). In phase 2 the results obtained in the intervention group were duplicated in a much larger group of consecutive patients. The 6-month (millimoles per liter) results in the control, intervention, and phase 2 groups (respectively) were cholesterol 4.92 +/- 0.06, 4.60 +/- 0.07, 4.30 +/- 0.05; low-density lipoprotein 2.91 +/- 0.06, 2.68 +/- 0.07, 2.4 +/- 0.06; high-density lipoprotein 1.18 +/- 0.07, 1.12 +/- 0.09, 1.10 +/- 0.01; triglycerides 1.89 +/- 0.12, 1.78 +/- 0.09, 1.70 +/- 0.05; and on medications 49%, 83%, and 84%. CONCLUSION A planned strategy of management with use of early pharmacologic therapy with a cardiac rehabilitation nurse assigned to obtain and follow lipid profiles and initiate therapy is more effective in controlling dyslipidemia than leaving the management to the cardiologist.
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Affiliation(s)
- M P Senaratne
- Division of Cardiac Sciences, Grey Nuns Hospital, Edmonton, Alberta, Canada.
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Abstract
Planning for emergency medical services (EMS) coverage for the 2000 Republican National Convention in Philadelphia was a complex process that involved the cooperation of municipal, state, and federal agencies as well as local hospitals. The medical needs of the delegates, members of the media, and support personnel at the convention venue had to be met. Contingency plans for the possibility of large, organized political protests and associated injuries had to be developed. Steps had to be taken to ensure the safety of emergency personnel who may have to respond to such incidents. Because of the heightened threat of terrorist attacks on civilian populations in recent years, specialized training and material to respond to such incidents were required. The important role that local hospitals may play in providing care to victims of a large, multicasualty incident, especially one involving weapons of mass destruction, was recognized. Therefore, steps were taken to increase the awareness of hospital staff to patient decontamination and isolation techniques as well as specific therapies for the chemical, biological, and radioactive agents that terrorists might use. Finally, despite the focus placed on the convention, the day-to-day emergency medical needs of the citizens of Philadelphia had to be met. Through careful planning, flexibility, and cooperation, it was possible to successfully address all of these issues.
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Affiliation(s)
- C C Mechem
- Philadelphia Fire Department, Pennsylvania, USA.
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Abstract
This study indicated that a variety of survey techniques resulted in a modest return rate (66%) in a national survey of 455 exercise professionals. A $1.00 bill incentive was significantly more effective than no incentive in improving returns, and the rate of double responses in this anonymous mail survey was extremely low (< 1%).
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Affiliation(s)
- S Hare
- University of Toledo, Department of Health Promotion and Human Performance, Ohio 43606-3390, USA
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Hare S. CASE OF EXTREME LATERAL CURVATURE OF THE SPINE, OF MORE THAN FIFTEEN YEARS' DURATION. West J Med 1853; 1:481-4. [DOI: 10.1136/bmj.s3-1.22.481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hare S. On Certain Physiological and Other Facts: Observed during the Treatment of Spinal Disease. West J Med 1849; 13:591-5. [DOI: 10.1136/bmj.s1-13.22.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hare S. Cases Illustrative of the Beneficial Results Which May Be Obtained by Close Attention and Perseverance in Spinal Deformity. West J Med 1844; 8:211-3. [DOI: 10.1136/bmj.s1-8.15.211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hare S. Statistical Report of 190 Cases of Insanity Admitted into the Retreat, Near Leeds: During Ten Years, from 1830 to 1840. West J Med 1843. [DOI: 10.1136/bmj.s1-6.143.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hare S. Statistical Report of 190 Cases of Insanity Admitted into the Retreat, near Leeds: During Ten Years, from 1830 to 1840. West J Med 1843. [DOI: 10.1136/bmj.s1-6.142.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hare S. Statistical Report of 190 Cases of Insanity Admitted into the Retreat, Near Leeds: During Ten Years, from 1830 to 1840. West J Med 1843. [DOI: 10.1136/bmj.s1-6.141.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hare S. Case of Apparent Death of the F tus in Utero: With Remarks. West J Med 1842; 3:450-1. [DOI: 10.1136/bmj.s1-3.23.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Hare S. Case of Attempted Suicide. West J Med 1841; 2:190-1. [DOI: 10.1136/bmj.s1-2.36.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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