United Kingdom military aeromedical evacuation in the post-9/11 era.

BACKGROUND: Recent UK military operations in support of the fight against terrorism have resulted in UK military casualties. Movement of these casualties through the military medical chain requires a highly sophisticated aeromedical evacuation capability with worldwide reach. Recognition of the determinants of evacuation allows development to ensure optimal future configurations of military aeromedical evacuation services. METHODS: The database recording aeromedical evacuations undertaken by the Royal Air Force was searched to provide demographic and clinical data for evacuations between 1 April 2003 and 31 March 2010. Diagnoses leading to evacuation were categorized according to International Classification of Diseases codes. RESULTS: There were 21,477 medical evacuations undertaken. Analysis demonstrated 85.9% were for men and 86.5% were for military personnel, of whom 72.0% were in the army. The most common reasons for evacuation in military patients were musculoskeletal/connective tissue disorders (N = 9192; 50.0%), trauma (N = 1303; 7.1%), and mental health disorders (N = 1151; 6.3%). The most common reasons for evacuation in nonmilitary patients were musculoskeletal/connective tissue disorders (N = 734; 23.8%), genitourinary disorders (N = 325; 10.5%), and circulatory disorders (N = 255; 8.3%). Nontraumatic diagnoses were the determinants of evacuation in 92.9% of military and 95.1% of nonmilitary patients; 17.8% of trauma patients and 0.5% of nontrauma patients utilized high-dependency care. DISCUSSION: The UK aeromedical evacuation system must have the capacity to evacuate large numbers of patients with nontraumatic diagnoses, but also the flexibility to accommodate smaller, more variable numbers of higher dependency trauma patients. The military medical chain must continually review the differing requirements of civilian patients transferred within their aeromedical system.

Emerging therapies and respiratory infections: Focus on the impact of immunosuppressants and immunotherapies.

Host defences to infection are based upon an integrated system of physical and biochemical barriers, innate and adaptive immunity. Weakness in any of these defensive elements leads to increased susceptibility to specific pathogens. Understanding how medical therapies disrupt host defences is key to the successful prevention, diagnosis and management of respiratory infection in the immunocompromised host.

Conventional and Novel Approaches to Immunosuppression in Lung Transplantation.

Most therapeutic advances in immunosuppression have occurred over the past few decades. Although modern strategies have been effective in reducing acute cellular rejection, excess immunosuppression comes at the price of toxicity, opportunistic infection, and malignancy. As our understanding of the immune system and allograft rejection becomes more nuanced, there is an opportunity to evolve immunosuppression protocols to optimize longer term outcomes while mitigating the deleterious effects of traditional protocols.

Using a local early warning scoring system as a model for the introduction of a national system.

BACKGROUND: Chelsea and Westminster Hospital introduced the Chelsea Early Warning Score (CEWS) in 2007 to aid the recognition of acutely unwell patients. The Royal College of Physicians subsequently recommended a National Early Warning Score (NEWS) for implementation across the NHS. The aim of this study was to evaluate local adherence to CEWS to identify potential obstacles to the consistent implementation of NEWS. METHOD: Emergency Department (ED) and Acute Assessment Unit (AAU) notes were retrospectively reviewed for a convenience sample of 102 patients admitted to the AAU. Outcome measures were completeness of documentation of CEWS parameters, documentation and accuracy of aggregate CEWS scores. Aggregate NEWS scores were calculated from the documented observations and the calculated CEWS and NEWS scores were compared. RESULTS: Physiological observations were documented for all patients attending the ED and AAU. Heart rate, blood pressure, respiratory rate, oxygen saturation and conscious level were documented in over 95% of ED and AAU patients. Urine output was recorded for only 48% of ED and 69% of AAU patients. Aggregate CEWS scores were documented for 66% of ED and 84% of AAU patients. These were calculated accurately in 73% of ED and 79% of AAU patients. Calculation errors were eleven times more likely to result in under-scoring than over-scoring. NEWS scores were significantly higher than CEWS for the same observations and would have resulted in a 71% increase in patients requiring escalation of care in the ED and a 116% increase in AAU. CONCLUSION: Concerns highlighted with CEWS were the incomplete and inaccurate recording of aggregate scores, with underscoring resulting in the potential failure to recognise deteriorating patients. It is anticipated that NEWS will be accompanied by standardised documentation and training across the NHS which will support more complete and accurate recording of physiological data. Furthermore, NEWS appears from this study to be more sensitive than CEWS, thereby minimising the chance of missed deterioration.

Extracorporeal life support as a bridge to lung transplantation: Where are we now?

The number of lung transplant procedures performed internationally is increasing but the donor organ pool is insufficient to meet demand and waiting list mortality is unacceptably high. As survival rates for patients with acute respiratory distress syndrome managed on extracorporeal life support (ECLS) have steadily improved, a potential role for ECLS to support critically ill patients awaiting a donor organ match has emerged. We explore the rapidly evolving landscape of ECLS as a bridge to lung transplantation with review of the patient selection criteria, predictors of survival, modes of pre and peri-transplant support, and the importance of a holistic multidisciplinary approach to care. Finally, we consider innovations that are envisaged to increase the accessibility, safety, and effectiveness of ECLS delivery for future lung transplant candidates.

Early warning systems in the UK: variation in content and implementation strategy has implications for a NHS early warning system.

The Royal College of Physicians report Acute medical care: the right person, in the right setting--first time advocates the introduction of a standardised NHS Early Warning Score (NEWS). Recommendations for the optimum scoring system have been released by NHS Quality Improvement Scotland (NHS QIS) and the National Institute for Health and Clinical Excellence (NICE). This study reviewed clinical practice in London and Scotland against national guidelines. All hospitals responsible for acute medical admissions completed a telephone survey (n = 25 London; n = 23 Scotland). All used an early warning system at point of entry to care. Eleven different systems were used in London and five in Scotland. Forty per cent of London hospitals and 70% of Scottish hospitals incorporated the minimum data set recommended by NICE. Overall, Scotland was closer to achieving standardisation. If NEWS is implemented, consideration of the NHS QIS approach may support a more consistent response.

Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation.

Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.

ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part I: Epidemiology, assessment of extrapulmonary conditions, candidate evaluation, selection criteria, and pathology statements.

Patients with connective tissue disease (CTD) and advanced lung disease are often considered suboptimal candidates for lung transplantation (LTx) due to their underlying medical complexity and potential surgical risk. There is substantial variability across LTx centers regarding the evaluation and listing of these patients. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization aims to clarify definitions of each disease state included under the term CTD, to describe the extrapulmonary manifestations of each disease requiring consideration before transplantation, and to outline the absolute contraindications to transplantation allowing risk stratification during the evaluation and selection of candidates for LTx.

Severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation support: a consequence of vaping.

In the past decade, vaping has become more prevalent globally. Since mid-2019, reports have linked the use of vaping devices to lung injury (EVALI). This is the first reported adult case outside the USA to require ECMO for a severe vaping complication. https://bit.ly/39hf2ZY.

Combined heart-lung transplantation from a donation after circulatory death donor.

Combined heart-lung transplantation is the optimal treatment option for many patients with end-stage heart failure and fixed severe pulmonary hypertension. It offers the only possibility of long-term survival and a return to a normal quality of life. Unfortunately, it is rarely performed because of donor organ allocation policies. We present the case of a critically ill 24-year-old man, who after waiting for >100 days in-hospital on the urgent transplant list, deteriorated further and underwent the first successful heart-lung transplant with organs from a donation after circulatory death.

An Incidental Finding at Transplant Assessment: Case Report.

A 43-year-old woman with chronic hypersensitivity pneumonitis was referred for lung transplant assessment. An echocardiogram as part of her work-up revealed a large left atrial myxoma, presenting a conundrum on how best to manage her combined pathology. Because of the level of pulmonary disease, early intervention to remove the myxoma was not thought be viable without postoperative support. Use of extracorporeal membrane oxygenation to bridge patients for lung transplant is feasible, yet risks increased perioperative mortality. We present the first reported case of simultaneous cardiac myxoma removal and lung transplant.

Lung transplantation for idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease with a poor prognosis. Lung transplantation is the only intervention shown to increase life expectancy for patients with IPF, but it is associated with disease-specific challenges. In this Review, we discuss the importance of a proactive approach to the management of IPF comorbidities, including gastro-oesophageal reflux, pulmonary hypertension, coronary artery disease, and malignancy. With a donor pool too small to meet demand and unacceptably high mortality on transplant waiting lists, we discuss different systems used internationally to facilitate organ allocation. We explore the rapidly evolving landscape of transplantation for patients with IPF with regards to antifibrotic therapy, technological advances in extracorporeal life support, advances in understanding of the genetics of the disease, and the importance of a holistic multidisciplinary approach to care. Finally, we consider potential advances over the next decade that are envisaged to improve transplantation outcomes in patients with advanced IPF.

Men's experiences of early life trauma and pathways into long-term homelessness.

Previous studies that have explored the association between childhood trauma and homelessness indicate that traumatic events can lead to survivor distrust of interpersonal relationships and institutions, prolonged homelessness and poor health and social outcomes. The majority of this literature relies on quantitative data and fails to investigate the personal experiences of childhood trauma that are found to impact housing status later in life. Semi-structured, qualitative interviews were conducted with 25 men living in an urban area in Ontario who had spent more than 30 consecutive nights in an emergency shelter over the course of their housing histories. During data analysis, it was observed that all of the men had experienced some form of trauma or neglect in childhood which contributed to their entries into homelessness. Using a case study approach, three entry pathways into long term homelessness are described: 1) youth; 2) emerging or early adulthood; and 3) middle adulthood. Participants are classified into the pathways by the developmental period at which they first entered homelessness. These findings have implications for policy makers and service providers, as key intervention points are identified. Establishing effective interventions that address crises experienced at these points could assist with homelessness prevention across the life course.

Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population.

OBJECTIVE: To describe the clinical outcomes of patients for whom National Institute for Health and Care Excellence (NICE) recent-onset chest pain guidance would not have recommended further investigation, compared with those of patients where further investigation would have been recommended. METHODS: 557 consecutive patients with recent-onset chest pain attending rapid-access chest pain clinics (RACPC) in two district general hospitals over a 9-month period were retrospectively reviewed. Likelihood of coronary artery disease (CAD) was calculated according to NICE-defined modified Diamond-Forrester criteria. Patients were categorised into those for whom NICE guidelines recommend (NICE-Y) and do not recommend (NICE-N) further investigation. Main outcome measures were subsequent diagnosis of significant CAD and major adverse cardiac events (MACE) at 6 months. RESULTS: 187/557 (33.6%) patients comprised NICE-Y group, with 370/557 (66.4%) in NICE-N group. 360/370 (97.3%) of NICE-N group would have been excluded from further investigation due to non-anginal chest pain. Of 92/557 (16.5%) patients subsequently diagnosed with significant CAD, 35/557 (9.5%) were from NICE-N group versus 57/557 (30.5%, p<0.0001) from NICE-Y group. Of 11 patients experiencing at least one MACE, 7/557 (1.9%) were from NICE-N group, versus 4/557 (2.1%, p=1.000) from NICE-Y group. CONCLUSIONS: The rigid application of NICE chest pain guidance to a RACPC population may result in up to two-thirds of patients being excluded from further cardiac investigation. Potentially, up to 10% of these patients may subsequently be diagnosed with significant CAD, with up to 2% potentially experiencing a major adverse cardiac event.

Indications and interventional options for non-resectable tracheal stenosis.

Non-specific presentation and normal examination findings in early disease often result in tracheal obstruction being overlooked as a diagnosis until patients present acutely. Once diagnosed, surgical options should be considered, but often patient co-morbidity necessitates other interventional options. Non-resectable tracheal stenosis can be successfully managed by interventional bronchoscopy, with therapeutic options including airway dilatation, local tissue destruction and airway stenting. There are common aspects to the management of tracheal obstruction, tracheomalacia and tracheal fistulae. This paper reviews the pathogenesis, presentation, investigation and management of tracheal disease, with a focus on tracheal obstruction and the role of endotracheal intervention in management.