Nicholas D. Gollop

National audit of the use of fibrinogen concentrate to correct hypofibrinogenaemia

Massive haemorrhage occurs in a variety of clinical settings resulting in consumptive and dilutional coagulopathies leading to hypofibrinogenaemia.

Prolonged length of hospital stay in Far-East Asian and Afro-Caribbean patients with cardiomyopathy

patients with cardiomyopathy Ben Green , Nicholas D. Gollop , Mudassar Baig , Hardeep Uppal , Suresh Chandran , Rahul Potluri d,⁎ a Department of Medicine, Leeds General Infirmary, Leeds, UK b Department of Medicine, Norfolk and Norwich University Hospital, Norwich, UK c Department of Cardiology, Blackpool Teaching Hospitals NHS Trust, Blackpool, UK d ACALM Study Unit in collaboration with Aston Medical School, Aston University, Birmingham, UK e Department of Acute Medicine, North Western Deanery, Manchester, UK

Length of hospital stay is shorter in South Asian patients with acute pulmonary embolism

Pulmonary embolism (PE) is a common diagnosis in UK hospitals and confers a significant hospital stay (LOS). There is very little evidence concerning ethnic variations on LOS in patients with PE. We sought to investigate ethnic variations in LOS in a large sample of 3440 patients with PE from 2000 to 2013 across seven hospitals in the north west of UK. We found that South Asian patients have significantly lower LOS compared with Caucasian patients. We discuss possible reasons for, and implications of, this finding.

Assessment of pulmonary artery pressure by echocardiography—A comprehensive review

Pulmonary hypertension is a pathological haemodynamic condition defined as an increase in mean pulmonary arterial pressure ≥ 25 mmHg at rest, assessed using gold standard investigation by right heart catheterisation. Pulmonary hypertension could be a complication of cardiac or pulmonary disease, or a primary disorder of small pulmonary arteries. Elevated pulmonary pressure (PAP) is associated with increased mortality, irrespective of the aetiology. The gold standard for diagnosis is invasive right heart catheterisation, but this has its own inherent risks. In the past 30 years, immense technological improvements in echocardiography have increased its sensitivity for quantifying pulmonary artery pressure (PAP) and it is now recognised as a safe and readily available alternative to right heart catheterisation. In the future, scores combining various echo techniques can approach the gold standard in terms of sensitivity and accuracy, thereby reducing the need for repeated invasive assessments in these patients.

Should infected laparotomy wounds be treated with negative pressure wound therapy

A best evidence topic in surgery was written according to a structured protocol. The question addressed whether there is any benefit in treating infected laparotomy wounds with negative pressure wound therapy (NPWT). Forty-five papers were found using the reported search; of which 4 represented the best evidence to answer the question. The evidence on this subject is limited; there is a single non-randomised controlled trial, 2 prospective cohort studies, and 1 retrospective cohort study discussed in this paper. From the available literature, the use of NPWT in infected laparotomy wounds does reduce the length of hospital stay, the number of dressing changes required and promote faster wound healing.

Difficulty accessing data from randomised trials of drugs for heart failure: a call for action

When Robert Fleetcroft and colleagues attempted a systematic review of the treatment of heart failure, they were unable to answer their research question because of poor reporting and non-disclosure of data. And yet the necessary studies had been done. Here they discuss their experience and possible solutions

Is periprocedural CK-MB a better indicator of prognosis after emergency and elective percutaneous coronary intervention compared with post-procedural cardiac troponins?

A best evidence topic in interventional cardiac surgery was written according to a structured protocol. The question we addressed related to the elevation of markers of cardiac damage associated with percutaneous coronary intervention (PCI). We explored and compared the clinical and prognostic relevance of the elevation of creatinine kinase-myocardial band (CK-MB) and cardiac troponin (cTn) levels during the periprocedural period and the post-procedural period, respectively, following an emergency or elective PCI. We found in excess of 390 papers after a systematic literature search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. From the best evidence available it appears that the monitoring of cardiac biomarkers following a PCI can provide important clinical information about the health of the myocardium, as well as prognostic information on short to mid-term outcomes of mortality up to 3 years. The narrow evidence base advocates the use of periprocedural CK-MB monitoring, recommending that an elevation in CK-MB is a significant predictor of adverse events. Troponins remain a precise and reliable marker of cardiac damage; however, current evidence argues that cTn holds little prognostic relevance until the degree of elevation is almost five times the upper limit of normal (ULN). Thus, the best evidence recommends the use of periprocedural CK-MB routinely during PCI to provide clinical and prognostic information about the degree of myocardial injury and risk of post-procedural morbidity and mortality.

Present and Future Pharmacotherapeutic Agents in Heart Failure: An Evolving Paradigm

Many conditions culminate in heart failure (HF), a multi‐organ systemic syndrome with an intrinsically poor prognosis. Pharmacotherapeutic agents that correct neurohormonal dysregulation and haemodynamic instability have occupied the forefront of developments within the treatment of HF in the past. Indeed, multiple trials aimed to validate these agents in the 1980s and early 1990s, resulting in a large and robust evidence‐base supporting their use clinically. An established treatment paradigm now exists for the treatment of HF with reduced ejection fraction (HFrEF), but there have been very few notable developments in recent years. HF remains a significant health concern with an increasing incidence as the population ages. We may indeed be entering the surgical era for HF treatment, but these therapies remain expensive and inaccessible to many. Newer pharmacotherapeutic agents are slowly emerging, many targeting alternative therapeutic pathways, but with mixed results. Metabolic modulation and manipulation of the nitrate/nitrite/nitric oxide pathway have shown promise and could provide the answers to fill the therapeutic gap between medical interventions and surgery, but further definitive trials are warranted. We review the significant evidence base behind the current medical treatments for HFrEF, the physiology of metabolic impairment in HF, and discuss two promising novel agents, perhexiline and nitrite.

Is open surgery or endovascular therapy best to treat acute mesenteric occlusive disease

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed whether endovascular treatment improved peri-operative outcomes when compared to an open approach to restore arterial perfusion in acute mesenteric occlusive disease. Four hundred and ninety seven papers were identified using the reported search; of which 4 represented the best evidence to answer the question and are discussed. The evidence on this subject is limited, comprising largely of non-randomised retrospective cohort studies. The evidence suggests that endovascular treatment is associated with reduced mortality and has better short-term peri-operative outcomes, as well as longer-term survival - however many endovascular cases require subsequent open surgery. There is also conflicting evidence to suggest endovascular therapy is associated with longer ICU stays. Aside from procedural complications, factors such as patient status, time delay to diagnosis and treatment may play a greater role in determining mortality rates. In summary, endovascular therapy appears to be a feasible treatment option with post-operative complications and inpatient mortality rates lower than those seen in open surgery.

How does subintimal angioplasty compare to transluminal angioplasty for the treatment of femoral occlusive disease

A best evidence topic in surgery was written according to a structured protocol. The question addressed how subintimal angioplasty (SIA) compares to transluminal angioplasty (TA) for the treatment of femoral occlusive disease. One hundred and thirty two papers were found using the reported search; the 5 which represented the best evidence to answer the question are discussed. The evidence on this subject is limited; there are no randomised controlled trials (RCTs) comparing SIA to TA for pathologically equivalent lesions. However SIA remains a safe and effective alternative to surgical bypass grafting when TA cannot be performed.