RSS 1.0Nottingham University Hospitals NHS Trust
Browse by
Sub-communities within this community
-
Ambulatory Care
The Ambulatory Care Division consists of 3 directorates, which are Outpatient, Admitted and Clinical Services
Recent Submissions
-
Enhancing the experience and outcomes of children with complex care needs in acute paediatric settings: A realist review protocolIntroduction The number of babies, children and young people with complex care needs (henceforth children with complex care needs (CCCN)) in England has increased in recent decades, and this has also been recognised globally. CCCN may have frequent and lengthy hospital admissions, but during these episodes, their needs are not always met, potentially resulting in suboptimal experiences and outcomes. Despite increased numbers of CCCN accessing acute care and displaying greater complexity, much of the contemporary literature has focused on primary care coordination between health, education and social care. Research specifically focused on CCCN in the acute care setting is largely absent. This realist review aims to understand how optimal experience and outcomes are achieved for CCCN during acute care, in different settings, for whom and why. Methods and analysis This realist review will proceed through six steps: (1) clarifying the scope of the review, (2) searching for evidence, (3) data selection and quality appraisal, (4) data extraction, (5) analysis and synthesis and (6) dissemination. We will search Medline, Cumulated Index in Nursing and Allied Health Literature and PsycINFO, alongside grey literature and other sources and will carry out citation tracking. Patient and public involvement and engagement have aided in the development of this protocol and will be maintained through regular consultations with a stakeholder group throughout the review. The review will result in a programme theory which will include context-mechanism-outcome configurations and provide data to support claims of generative causation. Ethics and dissemination Ethical approval is not required for this review as it does not involve primary research. The programme theory developed will be disseminated through peer-reviewed publications and relevant conferences. It will subsequently inform the development of an intervention to improve acute care for CCCN.
-
A new defense of brain death as the death of the human organismThis paper provides a new rationale for equating brain death with the death of the human organism, in light of well-known criticisms made by Alan D Shewmon, Franklin Miller and Robert Truog and a number of other writers. We claim that these criticisms can be answered, but only if we accept that we have slightly redefined the concept of death when equating brain death with death simpliciter. Accordingly, much of the paper defends the legitimacy of redefining death against objections, before turning to the specific task of defending a new rationale for equating brain death with death as slightly redefined. Copyright © The Author(s) 2023. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
-
The use of cerebral computed tomographic angiography as an ancillary investigation to support a clinical diagnosis of death using neurological criteria: A consensus guidelineThis multidisciplinary consensus statement was produced following a recommendation by the Faculty of Intensive Care Medicine to develop a UK guideline for ancillary investigation, when one is required, to support the diagnosis of death using neurological criteria. A multidisciplinary panel reviewed the literature and UK practice in the diagnosis of death using neurological criteria and recommended cerebral CT angiography as the ancillary investigation of choice when death cannot be confirmed by clinical criteria alone. Cerebral CT angiography has been shown to have 100% specificity in supporting a diagnosis of death using neurological criteria and is an investigation available in all acute hospitals in the UK. A standardised technique for performing the investigation is described alongside a reporting template. The panel were unable to make recommendations for ancillary testing in children or patients receiving extracorporeal membrane oxygenation. Copyright © 2023 Association of Anaesthetists.
-
Digitally-enabled remote critical care: The challenges of geography and history?The COVID-19 pandemic has rejuvenated interest in the possibility of using telemedicine as an approach to providing critical care services to patients in remote areas. Conceptual and governance considerations remain unaddressed. We summarise the first steps in a recent collaborative effort between key organisations in Australia, India, New Zealand, and the UK, and call for an international consensus on standards with due considerations to governance and regulation of this emerging clinical practice. Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
-
Predicting time to asystole following withdrawal of life-sustaining treatment: A systematic reviewThe planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole ( Copyright © 2024 The Authors. Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.
-
Decision-making about premortem interventions for donation: Navigating legal and ethical complexitiesPremortem interventions (PMIs) for organ donation play a vital role in preserving opportunities for deceased donation or increasing the chances of successful transplantation of donor organs. Although ethical considerations relating to use of particular PMIs have been well explored, the ethical and legal aspects of decision-making about the use of PMIs have received comparatively little attention. In many countries, there is significant uncertainty regarding whether PMIs are lawful or, if they are, who can authorize them. Furthermore, emphasis on consideration of therapeutic goals in substitute decision-making frameworks may discourage consideration of donation goals. In this article, we examine the fundamental questions of who should have the authority to make decisions about the use of PMIs on behalf of a potential donor and how such decisions should be made. We draw on international examples of legal reform that have sought to clarify the legal position in relation to administering PMIs and identify potential elements of an effective regulatory model for PMIs. In doing so, we argue that reforms are needed in many countries to provide legal certainty for clinicians who are responsible for supporting decision-making about PMIs and to ensure that the goals and preferences of potential donors are accorded due consideration in the decision-making process. Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
-
Donor time to death and kidney transplant outcomes in the setting of a 3-hour minimum wait policyImportance: Lengthening waiting lists for organ transplant mandates the development of strategies to expand the deceased donor pool. Due to concerns regarding organ viability, most organ donation organizations internationally wait no longer than 1 to 2 hours for potential donation after circulatory death (DCD), possibly underutilizing an important organ source; UK policy mandates a minimum 3-hour wait time. Objective: To assess whether time to death (TTD) from withdrawal of life-sustaining treatment (WLST) is associated with kidney transplant outcomes. Design, Setting, and Participants: This population-based cohort study used data from the prospectively maintained UK Transplant Registry from all 23 UK kidney transplant centers from January 1, 2013, to December 31, 2021; follow-up was until the date of data extraction (October 2023). Participants comprised 7183 adult recipients of DCD kidney-alone transplants. Exposure: Duration of TTD, defined as time from WLST to donor mechanical asystole. Main Outcomes and Measures: Primary outcome was 12-month estimated glomerular filtration rate (eGFR; for the main eGFR model, variables with significant right skew histogram visual assessment] were analyzed on the log2 scale), with secondary outcomes of delayed graft function and graft survival (censored at death or 5 years). Results: This study included 7183 kidney transplant recipients (median age, 56 years IQR, 47-64 years]; 4666 men 65.0%]). Median donor age was 55 years (IQR, 44-63 years). Median TTD was 15 minutes (range, 0-407 minutes), with 885 kidneys transplanted from donors with TTD over 1 hour and 303 kidneys transplanted from donors with TTD over 2 hours. Donor TTD was not associated with recipient 12-month eGFR on adjusted linear regression (change per doubling of TTD, -0.25; 95% CI, -0.68 to 0.19; P = .27), nor with delayed graft function (adjusted odds ratio, 1.01; 95% CI, 0.97-1.06; P = .65) or graft survival (adjusted hazard ratio, 1.00; 95% CI, 0.95-1.07; P = .92). These findings were confirmed with restricted cubic spline models (assessing nonlinear associations) and tests of interaction (including normothermic regional perfusion). In contrast, donor asystolic time, cold ischemic time, and reperfusion time were independently associated with outcomes. Compared with a theoretical 1-hour maximum wait time, the UK policy (minimum 3-hour wait time) has been associated with 885 extra DCD transplants compared with 6298 transplants (14.1% increase). Conclusions and Relevance: In this cohort study of DCD kidney recipients, donor TTD was not associated with posttransplant outcomes, in contrast to subsequent ischemic times. Altering international transplant practice to mandate minimum 3-hour donor wait times could substantially increase numbers of kidney transplants performed without prejudicing outcomes.
-
When is directed deceased donation justified? Practical, ethical, and legal issuesThis paper explores whether directed deceased organ donation should be permitted, and if so under which conditions. While organ donation and allocation systems must be fair and transparent, might it be "one thought too many" to prevent directed donation within families? We proceed by providing a description of the medical and legal context, followed by identification of the main ethical issues involved in directed donation, and then explore these through a series of hypothetical cases similar to those encountered in practice. Ultimately, we set certain conditions under which directed deceased donation may be ethically acceptable. We restrict our discussion to the allocation of organs to recipients already on the waiting list. Copyright © The Intensive Care Society 2024.
-
A single-center exploration of attitudes to deceased organ donation over time among healthcare staff in intensive careBackground: Changes to deceased organ donation in the United Kingdom, including establishment of the specialist nurse for organ donation (SNOD) role, have resulted in increased numbers of donations. Have increasing numbers of donations altered attitudes among intensive care unit (ICU) healthcare professionals (ICU staff) to organ donation over time? Methods: A written survey of ICU staff at Nottingham University Hospitals National Health Service Trust was conducted across 2 wk in 2015, 2018, and 2020 (pre-COVID-19). Participants were asked to submit descriptors (words/phrases) they associated with 3 aspects of donation: donation after brain death (DBD), donation after circulatory death (DCD), and SNOD role. Three independent and blinded assessors categorized the descriptors as positive or negative in favorability. Thematic analysis was used to identify trends within each group of descriptors. Results: Across the 3 surveys, 281 responses were returned, containing a total of 2095 descriptors. Positive descriptors were found in 65% of DBD responses, 46% of DCD responses, and 92% of SNOD role. Over time, there was some evidence of increased polarization of opinion for DCD and to a smaller degree DBD. Attitude toward the SNOD role remained consistently highly favorable over time. Thematic analysis was correlated with the assessor favorability ratings to identify specific factors for positive or negative attitudes; this demonstrated the themes that were the most common causes of positive or negative attributions for each aspect of organ donation. Conclusions: ICU staff were found to be highly favorably positive toward the SNOD role, positive toward DBD, and negative toward DCD. Although we found broadly positive perceptions of the benefits of deceased organ donation, negative attitudes toward DCD centered on timescale and complexity of the donation process. Measurement of staff attitudes to organ donation may allow targeted interventions that support staff and improve patient and family care through the organ donation process. Copyright © 2023 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.
-
Noise suppression of proton magnetic resonance spectroscopy improves paediatric brain tumour classificationProton magnetic resonance spectroscopy (1H-MRS) is increasingly used for clinical brain tumour diagnosis, but suffers from limited spectral quality. This retrospective and comparative study aims at improving paediatric brain tumour classification by performing noise suppression on clinical 1H-MRS. Eighty-three/forty-two children with either an ependymoma (ages 4.6 5.3/9.3 5.4), a medulloblastoma (ages 6.9 3.5/6.5 4.4), or a pilocytic astrocytoma (8.0 3.6/6.3 5.0), recruited from four centres across England, were scanned with 1.5T/3T short-echo-time point-resolved spectroscopy. The acquired raw 1H-MRS was quantified by using Totally Automatic Robust Quantitation in NMR (TARQUIN), assessed by experienced spectroscopists, and processed with adaptive wavelet noise suppression (AWNS). Metabolite concentrations were extracted as features, selected based on multiclass receiver operating characteristics, and finally used for identifying brain tumour types with supervised machine learning. The minority class was oversampled through the synthetic minority oversampling technique for comparison purposes. Post-noise-suppression 1H-MRS showed significantly elevated signal-to-noise ratios (P < .05, Wilcoxon signed-rank test), stable full width at half-maximum (P > .05, Wilcoxon signed-rank test), and significantly higher classification accuracy (P < .05, Wilcoxon signed-rank test). Specifically, the cross-validated overall and balanced classification accuracies can be improved from 81% to 88% overall and 76% to 86% balanced for the 1.5T cohort, whilst for the 3T cohort they can be improved from 62% to 76% overall and 46% to 56%, by applying Naïve Bayes on the oversampled 1H-MRS. The study shows that fitting-based signal-to-noise ratios of clinical 1H-MRS can be significantly improved by using AWNS with insignificantly altered line width, and the post-noise-suppression 1H-MRS may have better diagnostic performance for paediatric brain tumours.
-
Comparison of echo planar and turbo spin echo diffusion-weighted imaging in intraoperative MRIBACKGROUND: Diffusion-weighted imaging (DWI) is routinely used in brain tumor surgery guided by intraoperative MRI (IoMRI). However, conventional echo planar imaging DWI (EPI-DWI) is susceptible to distortion and artifacts that affect image quality. Turbo spin echo DWI (TSE-DWI) is an alternative technique with minimal spatial distortions that has the potential to be the radiologically preferred sequence., PURPOSE: To compare via single- and multisequence assessment EPI-DWI and TSE-DWI in the IoMRI setting to determine whether there is a radiological preference for either sequence., STUDY TYPE: Retrospective., POPULATION: Thirty-four patients (22 female) aged 2-61 years (24 under 18 years) undergoing IoMRI during surgical resection of intracranial tumors., FIELD STRENGTH/SEQUENCE: 3-T, EPI-DWI, and TSE-DWI., ASSESSMENT: Patients were scanned with EPI- and TSE-DWI as part of the standard IoMRI scanning protocol. A single-sequence assessment of spatial distortion and image artifact was performed by three neuroradiologists blinded to the sequence type. Images were scored regarding distortion and artifacts, around and remote to the resection cavity. A multisequence radiological assessment was performed by three neuroradiologists in full radiological context including all other IoMRI sequences from each case. The DWI images were directly compared with scorings of the radiologists on which they preferred with respect to anatomy, abnormality, artifact, and overall preference., STATISTICAL TESTS: Wilcoxon signed-rank tests for single-sequence assessment, weighted kappa for single and multisequence assessment. A P-value : Wilcoxon signed-rank tests for single-sequence assessment, weighted kappa for single and multisequence assessment. A P-value RESULTS: For the blinded single-sequence assessment, the TSE-DWI sequence was scored equal to or superior to the EPI-DWI sequence for distortion and artifacts, around and remote to the resection cavity for every case. In the multisequence assessment, all radiologists independently expressed a preference for TSE-DWI over EPI-DWI sequences on viewing brain anatomy, abnormalities, and artifacts., DATA CONCLUSION: The TSE-DWI sequences may be favored over EPI-DWI for IoMRI in patients with intracranial tumors., LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 5. Copyright © 2024 The Author(s). Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.
-
Predictors of long-term disability in multiple sclerosis patients using routine magnetic resonance imaging data: A 15-year retrospective studyINTRODUCTION: Early identification of patients at high risk of progression could help with a personalised treatment strategy. Magnetic resonance imaging (MRI) measures have been proposed to predict long-term disability in multiple sclerosis (MS), but a reliable predictor that can be easily implemented clinically is still needed., AIM: Assess MRI measures during the first 5 years of the MS disease course for the ability to predict progression at 10+ years., METHODS: Eighty-two MS patients (53 females), with >=10 years of clinical follow-up and having two MRI scans, were included. Clinical data were obtained at baseline, follow-up and at >=10 years. White matter lesion (WML) counts and volumes, and four linear brain sizes were measured on T2/FLAIR 'Fluid-Attenuated-Inversion-Recovery' and T1-weighted images., RESULTS: Baseline and follow-up inter-caudate diameter (ICD) and third ventricular width (TVW) measures correlated positively with Expanded Disability Status Scale, >=10 or more of WMLs showed a high sensitivity in predicting progression, at >=10 years. A steeper rate of lesion volume increase was observed in subjects converting to secondary progressive MS. The sensitivity and specificity of both ICD and TVW, to predict disability at >=10 years were 60% and 64%, respectively., CONCLUSION: Despite advances in brain imaging and computerised volumetric analysis, ICD and TVW remain relevant as they are simple, fast and have the potential in predicting long-term disability. However, in this study, despite the statistical significance of these measures, the clinical utility is still not reliable.
