Medical School

Objective: Early identification of sepsis could enable prompt delivery of key interventions such as fluid resuscitation and antibiotic administration which, in turn, may lead to improved patient outcomes. Limited data indicate that recognition of sepsis by paramedics is often poor. We systematically reviewed the literature on prehospital sepsis screening tools to determine whether they improved sepsis recognition.

Introduction: Sepsis is a common and potentially life-threatening response to an infection. International treatment guidelines for sepsis advocate that treatment be initiated at the earliest possible opportunity. It is not yet clear if very early intervention by ambulance clinicians prior to arrival at hospital leads to improved clinical outcomes among sepsis patients. Methods: We systematically searched the electronic databases MEDLINE, EMBASE, CINAHL, the Cochrane Library and PubMed up to June 2015. In addition, subject experts were contacted. We adopted the GRADE (grading recommendations assessment, development and evaluation) methodology to conduct the review and follow PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) recommendations to report findings. Results: Nine studies met the eligibility criteria – one study was a randomized controlled trial while the remaining studies were observational in nature. There was considerable variation in

Despite its use since the 1960s, the safety or effectiveness of adrenaline as a treatment for cardiac arrest has never been comprehensively evaluated in a clinical trial. Although most studies have found that adrenaline increases the chance of return of spontaneous circulation for short periods, many studies found harmful effects on the brain and raise concern that adrenaline may reduce overall survival and/or good neurological outcome. The PARAMEDIC-2 trial seeks to determine if adrenaline is safe and effective in out-of-hospital cardiac arrest. This is a pragmatic, individually randomised, double blind, controlled trial with a parallel economic evaluation. Participants will be eligible if they are in cardiac arrest in the out-of-hospital environment and advanced life support is initiated. Exclusions are cardiac arrest as a result of anaphylaxis or life threatening asthma, and patient known or appearing to be under 16 or pregnant. 8000 participants treated by 5 UK ambulance services will be randomised between December 2014 and August 2017 to adrenaline (intervention) or placebo (control) through opening pre-randomised drug A Spanish translated version of the summary of this article appears as Appendix in the final online version at http://dx.

Please cite this article in press as: Rajagopal S, et al. Characteristics of patients who are not resuscitated in out of hospital cardiac arrests and opportunities to improve community response to cardiac arrest. Resuscitation (2016), a b s t r a c t Aim: This study explores why resuscitation is withheld when emergency medical staff arrive at the scene of a cardiac arrest and identifies modifiable factors associated with this decision. Methods: This is a secondary analysis of unselected patients who sustained an out of hospital cardiac arrest attended by ambulance vehicles participating in a randomized controlled trial of a mechanical chest compression device (PARAMEDIC trial). Patients were categorized as 'non-resuscitation' patients if there was a do-not-attempt-cardiopulmonary-resuscitation (DNACPR) order, signs unequivocally associated with death or resuscitation was deemed futile (15 min had elapsed since collapse with no bystander-CPR and asystole recorded on EMS arrival). Results: Emergency Medical Services attended 11,451 cardiac arrests. Resuscitation was attempted or continued by Emergency Medical Service staff in 4805 (42%) of cases. Resuscitation was withheld in 6646 cases (58%). 711 (6.2%) had a do not attempt resuscitation decision, 4439 (38.8%) had signs unequivocally associated with death and in 1496 cases (13.1%) CPR was considered futile. Those where resuscitation was withheld due to futility were characterised by low bystander CPR rates (7.2%) and by being female. Conclusions: Resuscitation was withheld by ambulance staff in over one in ten (13.1%) victims of out of hospital cardiac arrest on the basis of futility. These cases were associated with a very low rate of bystander CPR. Future studies should explore strengthening the 'Chain of Survival' to increase the community bystander CPR response and evaluate the effect on the numbers of survivors from out of hospital cardiac arrest.

Purpose:1)To assess the referral pattern and demographics of the early puberty population to a large secondary care centre. 2)To assess the radiological and clinical characteristics of this population.

Methods & Materials:The study group was collated by identifying all female patients under 10 years of age who had a bone age radiograph or a pelvic ultrasound. Data was retrieved from the radiology information system from 01/01/2006 to 30/07/2010. Clinical data was retrieved from clinic letters on the hospital information system.

Results:132 patients were identified; 24 patients with full datasets had ultrasound features in advance of their chronological age. Following LHRH test and pelvic ultrasound, the diagnosis changed in 41.7% of these patients at the second clinic appointment. The precocious puberty group presented with early breast development (90.9%), pubic hair growth (81.8% ) and axillary hair growth (27.3%).

Final diagnoses were precocious puberty (45.8%), thelarche (16.7%), adrenarche (16.7%), early onset of normal puberty (12.5%), vulvovaginitis (4.2%), and concerns of precocious puberty (4.2%).

Chronological age at presentation in the precocious puberty group was 7.57 years, the thelarche group 5.25 years, the adrenarche group 7.13 years, and in the early puberty group 8.72 years. The difference between chronological and bone age, measured in standard deviations was 2.23 in the precocious puberty group, 2.46 in the thelarche group, 1.18 in the adrenarche group, and 0.92 in the early puberty group.

Pelvic ultrasound uterine appearances were pubertal in 45.5% of precocious puberty cases. In 66.7% of the early puberty cases a cavitary echo was identified. Ovarian appearances were advanced in 54.5% of the precocious puberty cases, 50% of thelarche cases, 75% of adrenarche cases and 100% of the early puberty cases.

Conclusions:1)An average of 28.8 patients per year are referred to our secondary care centre to exclude precocious puberty, with a prevalence of 8.33%. 2)81.1% of our population have a pelvic ultrasound, the role of which is mostly to confirm clinical diagnosis, however if appearances are pubertal then further tests are instigated.

With the advent of DGHAL and PPH, treatments that purport to work by disrupting the arterial supply of haemorrhoids, there has been resurgence in interest in the vascular theory of pathogenesis of haemorrhoids. Significant uptake of the new surgical approach, with decreased pain experienced by the patient post-operatively, but with uncertainty surrounding recurrence and complication rates, has not been matched by discussion or evaluation of how haemorrhoidal disease and successful outcome should be evaluated.

This thesis evaluates different approaches to the measurement of the burden of haemorrhoidal disease to the patient. A patient reported outcome measure was designed, administered and evaluated by the investigator. Reliability, reproducibility, validity, responsiveness and acceptability have been demonstrated.

Three-dimensional ultrasound was used to acquire volumetric data and power Doppler angiography from the anal canal, which was shown to be reliable. Measures of power Doppler angiography were shown to be significantly lower in healthy volunteers than in patients. This technique represents promising value as an outcome measure of haemorrhoidal disease.
A dual isotope-surgical nuclear probe technique attempted to measure change in volume of haemorrhoids following rubber band liagtion, however consistent results were not obtained. Magnetic resonance imaging was able to demonstrate anal cushions and haemorrhoids, and the feasibility of this method has been demonstrated.