Routine CT scanning of patients retrieved to a tertiary centre on veno-venous extracorporeal membrane oxygenation: a retrospective risk benefit analysis.

INTRODUCTION: Comprehensive clinical examination can be compromised in patients on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Adjunctive diagnostic imaging strategies range from bedside imaging only to routine computed tomography (CT). The risk-benefit of either approach remains to be evaluated. Patients retrieved to the Royal Brompton Hospital (RBH) on VV-ECMO routinely undergo admission CT imaging of head, chest, abdomen and pelvis. This study aimed to identify how frequently changes in therapy or adverse events could be attributed to routine CT scanning. METHODS: Demographic and clinical data were gathered retrospectively from patients retrieved to RBH on VV-ECMO (January 2014-2016). Scans were categorized as 'routine' or requested to clarify a specific clinical uncertainty. Clinical records were reviewed to identify attributable management changes and CT- related adverse events. Seventy-two patients were retrieved on VV-ECMO (median age 44 years) and 65 scanned on admission (mean radiation dose 2344mGy-cm). Routine head CT head yielded novel clinical information in 11 patients, 10 of whom had unexpected intracranial haemorrhage and, subsequently, had their anticoagulation withheld. Routine thoracic CT identified unexpected positive findings in three patients (early fibrosis, pulmonary vasculitis, pneumomediastinum), eliciting management variation in one (steroid administration). Routine abdomen/pelvis CT identified new information in three patients (adrenal haemorrhage, hepatosteatosis, splenic infarction), changing the management in one (withholding anticoagulation). RESULTS: CT scanning was not associated with consequential adverse events (e.g. accidental decannulation, gas entrainment into the circuit, hypoxia, hypotension). Median transfer/scan time was 78 minutes, requiring five ITU staff-members. In our cohort, a policy of routine head CT changed the management in 17% of patients; the yield from routine chest, abdomen and pelvis CT was modest. CT transfer was safe, but resource intensive. CONCLUSION: Prospective studies should evaluate whether routine CT impacts outcome.

Androgen receptor expression is a biological marker for androgen sensitivity in high grade serous epithelial ovarian cancer.

OBJECTIVES: In the present study we explore the effects of androgens and anti-androgens on primary cultures of EOC cells. We also investigate the effects of chemotherapy on AR expression. Epithelial ovarian cancer (EOC) arises from ovarian surface epithelial cells (OSE), which express the androgen receptor (AR). Androgen stimulation of OSE cells results in increased proliferation and protection from apoptosis. Nevertheless, in clinical trials anti-androgens have had a low objective response rate in relapsed ovarian cancer. METHODS: 1. Androgen receptor (AR) expression and response to androgenic stimulation were correlated in primary ovarian cancer cells derived from ascitic fluid from patients with advanced ovarian cancer, 2. AR expression in primary epithelial ovarian cancer was investigated before and after chemotherapy using paired histological samples which had been incorporated into a tissue microarray. RESULTS: Eleven primary ovarian cancer cultures were established from ascitic fluid. There was wide variation of expression of androgen receptor mRNA between cultures. Cell division increased after dihydro-testosterone (DHT) stimulation in 6 out of 11 primary cultures. The fraction of cells in S-phase increased from 4.4% in cells grown in serum-free medium to 8.3% in cells stimulated with 100 nM of DHT (P<0.001). The increase in S-phase fraction was abrogated after treatment with the anti-androgen, bicalutamide in 4 out of 5 responsive cultures. There was a strong correlation (r(2)=0.7) between nuclear AR expression by immunohistochemistry and S-phase fraction changes in primary cultures. Paired pre- and post-chemotherapy histological samples from 29 patients were incorporated into a tissue microarray (TMA). Nuclear and cytoplasmic AR expression by immunohistochemistry (IHC) decreased significantly after chemotherapy (P<0.01). CONCLUSION: AR expression correlates with increased S-phase fraction in response to androgenic stimulation. Immunohistochemical analysis of AR expression needs to be further tested in clinical trials to select AR positive EOC for anti-androgen therapy. Anti-androgen use early in the course of ovarian cancer is more likely to be effective as these data suggest that androgen receptor expression decreases with exposure to chemotherapy and this may explain the low response rates seen in clinical trials of patients heavily pre-treated with multiple courses of chemotherapy.

Physicians' views on current legislation around euthanasia and assisted suicide: Results of surveys commissioned by the Royal College of Physicians.

Euthanasia and physician-assisted suicide have always been the subject of intense debate across society. In 2006 and in 2014, the Royal College of Physicians surveyed its members for their opinions on the subject. The results of these surveys are summarised here.

An overview of the spiritual importances of end-of-life care among the five major faiths of the United Kingdom.

For many who pertain to particular theological paradigms, their faith cannot be compartmentalised, but is mobilised to inform all aspects of their being, most notably their ethical and moral persuasions. As clinicians, the concept that there are good and bad deaths is already known; understanding the origin and depth of non-physical suffering, and aiming to alleviate it is not possible without learning the individual experiences and beliefs that go with it. Spiritual care forms a fundamental consideration in the endeavor to address the holistic experience of those patients receiving palliative care. Good palliative care seeks to promote the wellbeing and priorities of those with faltering health in a way that continues to support individualised notions of self-determination. The last few decades have resulted in a multicultural and multi-ethnic patient population. Addressing the spiritual and physical needs of patients allows healthcare professionals to deliver truly holistic care. Exploring and understanding the specific nuances of the five major religions of the UK provides healthcare professionals the opportunity to comfort the religiously observant patient at the end of life.

Training the generals of the future.

The Future Hospital Commission acknowledges that the principal challenge for healthcare organisations and professionals is to accept the fundamental requirement that patients must be treated with compassion, kindness and respect while having their physical and emotional needs met at all times. The recognition that clinical outcomes alone are an insufficient guide to the adequacy of health service provision demands cultural, organisational and individual change. In the Future Hospital Forum we scan the world literature for papers on systems of care that might best ensure these principles are delivered, and to critically evaluate their potential impact. The theme in this edition is generalism.

Challenging blood transfusion practice: effect of targeted behavioural intervention on red cell transfusion in a district general hospital.

Existing evidence shows that restrictive blood transfusion is safe and may avert potential harm associated with more liberal transfusion strategies. A significant number of patients are being both unnecessarily transfused and over-transfused for their age, diagnosis and comorbidities. We describe the implementation of a behavioural strategy through educational sessions and the provision of individualised patient-centred advice, offering haematinic investigation and supplementation where appropriate. We compared our interventional data with a retrospective analysis of patients receiving blood transfusion for number of units transfused, haemoglobin triggers and incidence of haematinic investigations. The data were also analysed for patient length of stay and cost effectiveness. There was a significant reduction in the number of red cell units transfused across all specialties (p=0.003). In total, 431 units were transfused in the interventional group compared with 571 in the control group. There was a significant reduction in over-transfusion (p=0.003). Patients undergoing haematinic testing increased by 16.6% (p=0.0002). There was no change in length of hospital stay and our strategy has been shown to not only be cost effective, but provide significant monetary saving. Our patient-centred approach, through clinician engagement and challenging outdated behaviours, has been shown to significantly reduce inappropriate blood transfusions.