Objectives: The aims of this study is firstly to analyse the impact of prehospital time related variables on mortality, in a specific subset of HEMS patients and secondly to demonstrate any interactions between time related variables and factors taking place in the prehospital setting.Methods: Retrospective analysis of 688 consecutive London HEMS transfers with severe thoracic trauma and mean injury severity score (ISS) of 35, during a 9-year period (1994-2002). We have analysed the effect of the following time related variables on mortality: activation time, arrival on scene time (AoS), stay on scene time (SoS), total time (ToT), rush-hour time (RhT) and leisure-hour time (LhT). We have also investigated the interaction of the above mentioned variables with observations and interventions taken place on scene and at accident and emergency department (A&E) following adjustment for type and severity of injury. For statistical analysis the time variables were grouped into quintiles.Results: Six hundred eighty eight victims (510 males) with mean age of 38.5 +/- 17.5 had total survival rate of 59.6%. The mean AoS and SoS were 11.6 +/- 5.8 min and 36.6 +/- 16.8 min, respectively. ToT > 65 min, as in quintiles III, IV and V with mean ToT of 65.3 min, 74.9 min and 102.7 min respectively, had an influence on mortality with calculated adjusted OR of 1.37 (95% CI = 0.47-3.94), 3.36 (95% CI = 1.22-9.23) and 1.43 (95% CI = 0.52-3.92) respectively with concomitant adjustment for type of injury, severity of injury, age, physiological variables on scene and on scene emergency thoracotomy (ET). ET on scene was an independent predictor for mortality (OR 3.94, 95% CI = 1.03-15.06). SoS of more than 34 min can lead to harmful changes on patients' pathophysiological status. ISS has no significant effect on AoS or SoS. RhT and LhT have no significant effect on mortality and they did not influence the AoS and SoS.Conclusion: This study suggests that time related variables have a complex and heterogeneous effect on mortality. Thoracic trauma victims usually have high ISS, in such population, ToT <65 min may be associated with lower possibility of death. Neither AoS nor SoS was influenced by time of incident or severity of injury. (C) 2011 Elsevier Ltd. All rights reserved.

Medical gases used in anaesthesia and intensive care include oxygen, nitrous oxide, medical air, entonox, carbon dioxide, heliox and nitric oxide. Breathable gases administered to patients are stored either in bulk outside the hospital or in cylinders within the hospital. Medical gases are then distributed throughout the hospital via a pipeline network.

On 18 September 2004, The Wildlife Society (TWS) published an official policy statement on economic growth and wildlife conservation. We believe this policy statement did not adequately address the issues. Thus, TWS missed an opportunity to lead the natural resource profession in refuting the fallacious rhetoric that "there is no conflict between economic growth and wildlife conservation" through the adoption of a strong policy statement on economic growth. Although we commend TWS Council for adopting a policy statement on economic growth, we believe the final wording contains several weaknesses. Here, we take a closer look at the statement and further evaluate how it might be strengthened in the future.

OBJECTIVE:Consent for surgical procedures has assumed increasing importance in surgical practice in recent days especially following the public inquiry into paediatric cardiac surgery deaths at Bristol in the UK. This study examines patient perceptions and recollections following surgical consent as currently practised in a UK cardiac unit.METHODS:One hundred consecutive patients who underwent cardiac surgery in a London teaching hospital from January to February 2003 were studied. Patients completed questionnaires a day before their discharge from the hospital.RESULTS:The majority of patients (89/100) responded that the information given at consent had been adequate or more than adequate. The time spent on the consent process was thought to be adequate by 91 patients. Eleven patients felt the consent had been insensitive. Several patients (38/100) felt use of booklets in preference to verbal explanations would be less intimidating. For most patients (94/100) the operation and postoperative course met their expectations; although 12 patients experienced untold complications, only five felt that they should have been informed of the possibility of the complication. Although most patients were informed of the risk of death during consent, at time of discharge 43 had forgotten the figure that had been quoted. Regarding the influence of media and publicity, 19 patients said that media had influenced their expectations of the consent process, 59 would have liked to see hospital league tables while 26 would have liked to know the mortality figures for their surgeon prior to giving consent.CONCLUSIONS:Our study shows that patients undergoing cardiac surgery are largely satisfied with our improved consent procedures in the post-Bristol era. Use of booklets may be a useful adjunct to verbal consent as currently practised.

Background. Despite limitations the transvalvular gradient (TVG) still is commonly used in aortic stenosis when patients are referred for aortic valve replacement. We wished to ascertain if it had a role in predicting outcome from valve replacement rather than as an indicator of severity, specifically investigating if the TVG affected renal dysfunction, hospital stay, and medium-term survival after valve replacement.Methods. Six hundred and twenty-three consecutive patients who had aortic valve replacement were identified and 211 of these patients were isolated as first time replacement for aortic stenosis that formed the final study group, and were followed up for up to 48 months. Variables significant (p < 0.05) on univariate analysis were included in the logistic regression multivariate analysis (renal dysfunction, prolonged hospital stay) or Cox proportional hazard regression model (medium-term mortality).Results. A significant association was present between TVG and age (p = 0.001). Multivariate analysis demonstrated angina greater than or equal to grade 3 Canadian Cardiovascular Society (CCS 3; p = 0.014) and having nonelective surgery (p < 0.001) to be independent predictors of renal dysfunction. Angina greater than or equal to CCS 3 (p = 0.013) was the only independent predictor of prolonged hospital stay. Independent predictors of medium-term mortality on multivariate analysis were age (p = 0.043) and having a size 19 valve prosthesis (p 0.015).Conclusions. The TVG is inadequate as an independent predictor of the degree of aortic stenosis and outcome from aortic valve replacement in aortic stenosis. In contrast, the TVG may be a useful screening tool for detecting aortic stenosis in targeted elderly populations.

Measurement of outcomes from medical or surgical interventions is part of good practice, but publication of individual doctors' results remains controversial. The authors discuss this issue in die context of cardiothoracic surgery.

OBJECTIVES We sought to assess the relationship between completeness of revascularization and adverse events at one year in the ARTS (Arterial Revascularization Therapies Study) trial.BACKGROUND There is uncertainty to what extent degree of completeness of revascularization, using up-to-date techniques, influences medium-term outcome.METHODS After consensus between surgeon and cardiologist regarding the potential for equivalence in the completeness of revascularization, 1,205 patients with multivessel disease were randomly assigned to either bypass surgery or stent implantation. All baseline and procedural angiograms and surgical case-record forms were centrally assessed for completeness of revascularization.RESULTS Of 1,205 patients randomized, 1,172 underwent the assigned treatment. Complete data for review were available in 1,143 patients (97.5%). Complete revascularization was achieved in 84.1% of the surgically treated patients and 70.5% of the angioplasty patients (p < 0.001). After one year, the stented angioplasty patients with incomplete revascularization showed a significantly lower event-free survival than stented patients with complete revascularization (i.e., freedom from death, myocardial infarction, cerebrovascular accident and repeat revascularization) (69.4% vs. 76.6%; p < 0.05). This difference was due to a higher incidence of subsequent bypass procedures (10.0% vs. 2.0%; p < 0.05). Conversely, at one year, bypass surgery patients with incomplete revascularization showed only a marginally lower event-free survival rate than those with complete revascularization (87.8% vs. 89.9%).CONCLUSIONS Complete revascularization was more frequently accomplished by bypass surgery than by stent implantation. One year after bypass, there was no significant difference in event-free survival between surgically treated patients with complete revascularization and those with incomplete revascularization, but patients randomized to stenting with incomplete revascularization had a greater need for subsequent bypass surgery. (C) 2002 by the American College of Cardiology.

Background: There is no clear consensus as to the correct screening procedure to identify patients undergoing cardiac surgery and who are at greatest risk of stroke because of the presence of significant carotid artery stenosis. Such screening is important because some patients benefit from combined carotid and cardiac surgery and, regardless of this, the information gained puts the cardiac surgeon in a position to provide an accurate assessment of surgical risk. Our objective was to examine current clinical practice of carotid artery investigation prior to urgent cardiac surgery and to review this illustrative practice in the context of the world literature.Hypothesis: The study aimed to establish that current typical practice for screening cardiac surgical patients fur carotid artery disease is illogical according to the evidence in the world Literature.Methods: The study consisted of a retrospective assessment of all patients undergoing urgent cardiac surgery and a Medline-derived literature review, and included all patients undergoing urgent cardiac surgery at a tertiary cardiothoracic center between January 1 and December 31, 1997.Results: Of 529 patients undergoing urgent cardiac surgery, 43 (8%) were screened preoperatively by duplex Doppler ultrasonography for carotid disease. The indications for screening were asymptomatic carotid bruit in 24 patients, history of stroke or transient ischemic attack (TIA) in 12 patients, and neither stroke, TIA, or bruit in 7 patients. The tests were requested either by the attending cardiologists or by the cardiac surgeon to whom they were referred. One patient had already been diagnosed as having carotid artery disease in the past. Thirteen patients underwent additional carotid investigations. Eleven patients were demonstrated to have internal carotid artery stenosis greater than or equal to 60% and 3 patients underwent combined cardiac and carotid surgery. Review of the: literature revealed the following groups to be at increased risk of future stroke unrelated to surgery, and of postoperative stroke: those with a history of stroke or TIA, those with carotid bruits, and, of importance, all patients with significant carotid stenosis. Recent data suggest that symptomatic patients and the elderly are at greatest risk.Conclusions: Only 8% of patients undergoing urgent cardiac surgery in a1I-year period were screened for carotid artery disease. We suggest that screening should definitely be performed in all patients with a history of stroke or TIA, all patients with a bruit, and all patients aged > 65 years. The literature suggests, however, that significant reductions in stroke rate could be achieved by screening the whole cardiac surgical population, although there is a paucity of data that rue specifically pertinent to this patient subgroup. Further data are therefore required for the construction of a scientifically valid and medicolegally sound policy.

Right ventricular failure may complicate isolated left ventricular assistance. In a series of 8 patients undergoing left ventricular assistance in postcardiotomy cardiogenic shock, right ventricular failure developed in 5, directly contributing to death in all cases despite initially satisfactory support. Difficulty in grafting a dominant right coronary artery was a common factor in all cases. Early consideration should be given to biventricular support under these circumstances.