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Introduction: Bystander cardiopulmonary resuscitation (BCPR) is strongly advocated by resuscitation councils for paediatric out-of-hospital cardiac arrests (OHCAs). However, there are limited reports on rates of BCPR in children and its relationship with return of spontaneous circulation (ROSC) or survival outcomes.Objective: We describe the rate of BCPR and its association with any ROSC and survival- to- hospital-discharge.Methods: We conducted retrospective analysis of prospectively collected paediatric (<18 years of age) OHCA cases in England; we included specialist registry patients treated by emergency medical services (EMS) with known BCPR status and outcome between January 2014 and November 2018. Data included patient demographics, aetiology, witness status, initial rhythm, EMS, season, time of day and bystander status. Associations between BCPR, and any ROSC and survival-to-hospital-discharge outcomes were explored using multivariable logistic regression.Results: There were 2363 paediatric OHCAs treated across 11 EMS regions. BCPR was performed in 69.6% (1646/2363) of the cases overall (range 57.7% (206/367) to 83.7% (139/166) across EMS regions). Only 34.9% (550/1572) of BCPR cases were witnessed. Overall, any ROSC was achieved in 22.8% (523/2289) and survival to hospital discharge in 10.8% (225/2066). Adjusted odds ratio (aOR) for any ROSC was significantly improved following BCPR compared to no BCPR (aOR 1.37, 95% CI 1.03-1.81), but adjusted odds ratio for survival-to-hospital-discharge were similar (aOR 1.01, 95% CI 0.66-1.55).Conclusions: BCPR was associated with improved rates of any ROSC but not survival-to-hospital-discharge. Variations in EMS BCPR rates may indicate opportunities for regional targeted increase in public BCPR education. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To temporally and externally validate our previously developed prediction model, which used data from University Hospitals Birmingham to identify inpatients with diabetes at high risk of adverse outcome (mortality or excessive length of stay), in order to demonstrate its applicability to other hospital populations within the UK. Methods: Temporal validation was performed using data from University Hospitals Birmingham and external validation was performed using data from both the Heart of England NHS Foundation Trust and Ipswich Hospital. All adult inpatients with diabetes were included. Variables included in the model were age, gender, ethnicity, admission type, intensive therapy unit admission, insulin therapy, albumin, sodium, potassium, haemoglobin, C‐reactive protein, estimated GFR and neutrophil count. Adverse outcome was defined as excessive length of stay or death. Results: Model discrimination in the temporal and external validation datasets was good. In temporal validation using data from University Hospitals Birmingham, the area under the curve was 0.797 (95% CI 0.785–0.810), sensitivity was 70% (95% CI 67–72) and specificity was 75% (95% CI 74–76). In external validation using data from Heart of England NHS Foundation Trust, the area under the curve was 0.758 (95% CI 0.747–0.768), sensitivity was 73% (95% CI 71‐74) and specificity was 66% (95% CI 65–67). In external validation using data from Ipswich, the area under the curve was 0.736 (95% CI 0.711–0.761), sensitivity was 63% (95% CI 59–68) and specificity was 69% (95% CI 67–72). These results were similar to those for the internally validated model derived from University Hospitals Birmingham. Conclusions: The prediction model to identify patients with diabetes at high risk of developing an adverse event while in hospital performed well in temporal and external validation. The externally validated prediction model is a novel tool that can be used to improve care pathways for inpatients with diabetes. Further research to assess clinical utility is needed. [ABSTRACT FROM AUTHOR]

The international normalised ratio is frequently raised in patients who have undergone major liver resection, and is assumed to represent a potential bleeding risk. However, these patients have an increased risk of venous thromboembolic events, despite conventional coagulation tests indicating hypocoagulability. This prospective, observational study of patients undergoing major hepatic resection analysed the serial changes in coagulation in the early postoperative period. Thrombin generation parameters and viscoelastic tests of coagulation (thromboelastometry) remained within normal ranges throughout the study period. Levels of the procoagulant factors II, V, VII and X initially fell, but V and X returned to or exceeded normal range by postoperative day five. Levels of factor VIII and Von Willebrand factor were significantly elevated from postoperative day one (p < 0.01). Levels of the anticoagulants, protein C and antithrombin remained significantly depressed on postoperative day five (p = 0.01). Overall, the imbalance between pro- and anticoagulant factors suggested a prothrombotic environment in the early postoperative period. [ABSTRACT FROM AUTHOR]

Background Preoperative anaemia and perioperative blood transfusion are both identifiable and preventable surgical risks. Patient blood management is a multimodal approach to address this issue. It focuses on three pillars of care: the detection and treatment of preoperative anaemia; the reduction of perioperative blood loss; and harnessing and optimizing the patient-specific physiological reserve of anaemia, including restrictive haemoglobin transfusion triggers. This article reviews why patient blood management is needed and strategies for its incorporation into surgical pathways. Methods Studies investigating the three pillars of patient blood management were identified using PubMed, focusing on recent evidence-based guidance for perioperative management. Results Anaemia is common in surgical practice. Both anaemia and blood transfusion are independently associated with adverse outcomes. Functional iron deficiency (iron restriction due to increased levels of hepcidin) is the most common cause of preoperative anaemia, and should be treated with intravenous iron. Intraoperative blood loss can be reduced with antifibrinolytic drugs such as tranexamic acid, and cell salvage should be used. A restrictive transfusion practice should be the standard of care after surgery. Conclusion The significance of preoperative anaemia appears underappreciated, and its detection should lead to routine investigation and treatment before elective surgery. The risks of unnecessary blood transfusion are increasingly being recognized. Strategic adoption of patient blood management in surgical practice is recommended, and will reduce costs and improve outcomes in surgery. [ABSTRACT FROM AUTHOR]

Recent research in the management of haemorrhage has led to several changes in clinical practice. Evidence is accumulating that point-of-care testing results in fewer transfusions, improved patient outcomes, and reduced hospital costs. However, there is still insufficient high quality evidence to support transfusion guidelines and algorithms based on point-of-care tests alone, and more robust studies are needed. The implementation of point-of-care testing requires institutional support and senior clinical leadership to realise the benefits, with educational programmes, audit, and feedback regarding transfusion practice. A change in philosophy is required, from performing testing only when there is an obvious bleeding problem, towards the concept of routinely monitoring high-risk patients throughout the surgical procedure. This informs clinical practice, establishes normal ranges for that population, identifies patients at risk and allows early identification and treatment of evolving coagulopathy. [ABSTRACT FROM AUTHOR]

This study assessed the spawning activity of the threatened Australian lungfish Neoceratodus forsteri by measuring egg densities within the artificial habitat of a large impoundment (Lake Wivenhoe, Australia). Eggs were sampled (August to November 2009) from multiple locations across the impoundment, but occurred at highest densities in water shallower than 40 cm along shorelines with a dense cover of submerged terrestrial vegetation. The numbers of eggs declined over the study period and all samples were dominated by early developmental stages and high proportions of unviable eggs. The quality of the littoral spawning habitats declined over the study as flooded terrestrial grasses decomposed and filamentous algae coverage increased. Water temperatures at the spawning site exhibited extreme variations, ranging over 20·4° C in water shallower than 5 cm. Dissolved oxygen concentrations regularly declined to <1 mg l−1 at 40 and 80 cm water depth. Spawning habitats utilised by N. forsteri within impoundments expose embryos to increased risk of desiccation or excessive submergence through water-level variations, and extremes in temperature and dissolved oxygen concentration that present numerous challenges for successful spawning and recruitment of N. forsteri in large impoundment environments. [ABSTRACT FROM AUTHOR]

Background:Poor reporting compromises the reliability and clinical value of prognostic tumour marker studies. We review articles to assess the reporting of patients and events using REMARK guidelines, at the time of guideline publication.Methods:We sampled 50 prognostic tumour marker studies from higher impact cancer journals between 2006 and 2007. The inclusion criteria were cancer; focus on single biological tumour marker; survival analysis; multivariable analysis; and not gene array or proteomic data. Articles were assessed for the REMARK profile and other REMARK guideline items. We propose a reporting aid, the REMARK profile, motivated by the CONSORT flowchart.Results:In 50 studies assessed for the REMARK profile, the number of eligible patients (56% of articles), excluded patients (54%) and patients in analyses (98%) was reported. Only 50% of articles reported the number of outcome events. In multivariable analyses, 54% and 30% of articles reported patient and event numbers for all variables. Of the studies, 66% used archival samples, indicating a potentially biased patient selection. Only 36% of studies reported clearly defined outcomes.Conclusions:Good reporting is critical for the interpretability and clinical applicability of prognostic studies. Current reporting of key information, such as the number of outcome events in all patients and subgroups, is poor. Use of the REMARK profile would greatly improve reporting and enhance prognostic research. [ABSTRACT FROM AUTHOR]

Peri-operative guidelines exist for neuraxial anaesthesia and anticoagulant therapy. We describe the use of thromboelastography to assess the coagulation status of a patient with moderate renal impairment who had been receiving enoxaparin and was being managed in accordance with current recommendations. This report demonstrates that current guidelines for discontinuing treatment with enoxaparin may not allow a sufficient safety margin in all patient groups and that thromboelastography is a useful tool in such situations. [ABSTRACT FROM AUTHOR]

In 1996, we prospectively audited peri-operative transfusion practice in elective surgical patients over a 3-month period. Two-unit transfusions represented 60% of all transfusions. Haemoglobin was measured infrequently prior to transfusion and the main ‘trigger’ for transfusion was an estimated blood loss in excess of 500 ml. Transfusion guidelines that required the haemoglobin level to be measured immediately before transfusion were introduced. The audit was repeated in 1998; transfusion ‘triggers’ and the number of transfusions for the two periods were compared. In the second audit, the total number of transfusions decreased by 43%. The mean estimated blood loss associated with a 2-unit transfusion had increased from 608 (373) ml to 1320 (644) ml (p < 0.01) and the estimated haemoglobin concentration after transfusion had decreased from 12.4 (1.8) g.dl-1 to 9.9 (2.4) g.dl-1 (p < 0.01). These results suggest that transfusion guidelines can have a significant impact on clinical practice. [ABSTRACT FROM AUTHOR]

This narrative review describes our experience of working with Doug Altman, the most highly cited medical statistician in the world. Doug was particularly interested in diagnostics, and imaging studies in particular. We describe how his insights helped improve our own radiological research studies and we provide advice for other researchers hoping to improve their own research practice. • We describe how working with the statistician Doug Altman improved our research. • Medical statisticians should be consulted when preparing for research. • Medical statisticians help design unbiased, adequately powered studies. • High quality medical research is unlikely without statistical help. [ABSTRACT FROM AUTHOR]

A correction is presented to the article "Corrigendum to ‘Patient blood management and perioperative anaemia' [BJA Education 17 (2017) 28–34]" published in a previous issue of the periodical.

A response from the authors of the article "Alterations in Coagulation Following Major Liver Resection" that was published in a previous issue is presented.

Several letters to the editor are presented in response to studies on safe anaesthesia and magnesium, as well as rotational thromboelastometry.

The article discusses strategies for Patient Blood Management (PBM) by managing perioperative anaemia and minimisation of blood loss. Topics include Great Britain's National Institute for Health and Care Excellence (NICE) guidelines for blood transfusion, detection and management of preoperative anaemia, and management of coagulopathy and haemorrhage.

Comments on a paper about thienopyridine antiplatelet drugs. Problem faced by anesthetists in monitoring the effects of antiplatelet medication; Effectiveness of the platelet function analyzer in monitoring the effects of the drug.

Aim: To investigate the level of statistical support available to UK radiology trainees, and to gather opinions regarding how support may affect their current and future research aspirations.Materials and Methods: An online survey was developed, piloted, and distributed to radiology trainees via the UK Radiology Academic Network for Trainees and training programme directors. Research experience, research aspirations, available and desired statistical support, and attitudes to statistics were surveyed and responses were collated.Results: Seventy-nine responses were received, only two (3%) of whom had allocated time for research. Only three (4%) respondents were content with their statistical support whereas 25 (32%) reported insufficient statistical support; 13 (52%) of these believed this impacted "considerably" on research aspirations. Sixty-six (84%) respondents desired dedicated statistical support, 40 (61%) of whom stated the amount required would likely be "moderate" and 26 (39%) "significant". Respondents believed support would be most helpful to analyse data already collected (41 responses, 54%) rather than research planning (25, 33%). Most respondents (60, 76%) had used self-help methods to learn research statistics but only 21 (35%) found this useful.Conclusion: Training schemes must improve the provision, access to, and awareness of statistical support so that any research efforts are performed to a high standard. Trainees should not be expected to participate in research without sufficient time, mentorship, and statistical support. [ABSTRACT FROM AUTHOR]

Background: Ventral hernias (VHs) often recur after surgical repair and subsequent attempts at repair are especially challenging. Rigorous research to reduce recurrence is required but such studies must be well-designed and report representative and comprehensive outcomes.Objective: We aimed to assesses methodological quality of non-randomised interventional studies of VH repair by systematic review.Methods: We searched the indexed literature for non-randomised studies of interventions for VH repair, January 1995 to December 2017 inclusive. Each prospective study was coupled with a corresponding retrospective study using pre-specified criteria to provide matched, comparable groups. We applied a bespoke methodological tool for hernia trials by combining relevant items from existing published tools. Study introduction and rationale, design, participant inclusion criteria, reported outcomes, and statistical methods were assessed.Results: Fifty studies (17,608 patients) were identified: 25 prospective and 25 retrospective. Overall, prospective studies scored marginally higher than retrospective studies for methodological quality, median score 17 (IQR: 14-18) versus 15 (IQR 12-18), respectively. For the sub-categories investigated, prospective studies achieved higher median scores for their, 'introduction', 'study design' and 'participants'. Surprisingly, no study stated that a protocol had been written in advance. Only 18 (36%) studies defined a primary outcome, and only 2 studies (4%) described a power calculation. No study referenced a standardised definition for VH recurrence and detection methods for recurrence varied widely. Methodological quality did not improve with publication year or increasing journal impact factor.Conclusion: Currently, non-randomised interventional studies of VH repair are methodologically poor. Clear outcome definitions and a standardised minimum dataset are needed. [ABSTRACT FROM AUTHOR]

Large ventral hernias are a significant surgical challenge. "Loss of domain" (LOD) expresses the relationship between hernia and abdominal volume, and is used to predict operative difficulty and success. This systematic review assessed whether different definitions of LOD are used in the literature. The PubMed database was searched for articles reporting large hernia repairs that explicitly described LOD. Two reviewers screened citations and extracted data from selected articles, focusing on the definitions used for LOD, study demographics, study design, and reporting surgical specialty. One hundred and seven articles were identified, 93 full-texts examined, and 77 were included in the systematic review. Sixty-seven articles were from the primary literature, and 10 articles were from the secondary literature. Twenty-eight articles (36%) gave a written definition for loss of domain. These varied and divided into six broad groupings; four described the loss of the right of domain, six described abdominal strap muscle contraction, five described the "second abdomen", five describing large irreducible hernias. Six gave miscellaneous definitions. Two articles gave multiple definitions. Twenty articles (26%) gave volumetric definitions; eight used the Tanaka method [hernia sac volume (HSV)/abdominal cavity volume] and five used the Sabbagh method [(HSV)/total peritoneal volume]. The definitions used for loss of domain were not dependent on the reporting specialty. Our systematic review revealed that multiple definitions of loss of domain are being used. These vary and are not interchangeable. Expert consensus on this matter is necessary to standardise this important concept for hernia surgeons. [ABSTRACT FROM AUTHOR]

Background: This systematic review assesses the perioperative variables and post-operative outcomes reported by randomised controlled trials (RCTs) of VH repair. This review focuses particularly on definitions of hernia recurrence and techniques used for detection.Objective: Our aim is to identify and quantify the inconsistencies in perioperative variable and postoperative outcome reporting, so as to justify future development of clear definitions of hernia recurrence and a standardised dataset of such variables.Methods: The PubMed database was searched for elective VH repair RCTs reported January 1995 to March 2016 inclusive. Three independent reviewers performed article screening, and two reviewers independently extracted data. Hernia recurrence, recurrence rate, timing and definitions of recurrence, and techniques used to detect recurrence were extracted. We also assessed reported post-operative complications, standardised operative outcomes, patient reported outcomes, pre-operative CT scan hernia dimensions, intra-operative variables, patient co-morbidity, and hernia morphology.Results: 31 RCTs (3367 patients) were identified. Only 6 (19.3%) defined hernia recurrence and methods to detect recurrence were inconsistent. Sixty-four different clinical outcomes were reported across the RCTs, with wound infection (30 trials, 96.7%), hernia recurrence (30, 96.7%), seroma (29, 93.5%), length of hospital stay (22, 71%) and haematoma (21, 67.7%) reported most frequently. Fourteen (45%), 11 (35%) and 0 trials reported CT measurements of hernia defect area, width and loss of domain, respectively. No trial graded hernias using generally accepted scales.Conclusion: VH RCTs report peri- and post-operative variables inconsistently, and with poor definitions. A standardised minimum dataset, including definitions of recurrence, is required. [ABSTRACT FROM AUTHOR]

Background: Eosinophilic granulomatosis with polyangiitis is an eosinophilic vasculitis. Mepolizumab, an anti-interleukin-5 monoclonal antibody, reduces blood eosinophil counts and may have value in the treatment of eosinophilic granulomatosis with polyangiitis.Methods: In this multicenter, double-blind, parallel-group, phase 3 trial, we randomly assigned participants with relapsing or refractory eosinophilic granulomatosis with polyangiitis who had received treatment for at least 4 weeks and were taking a stable prednisolone or prednisone dose to receive 300 mg of mepolizumab or placebo, administered subcutaneously every 4 weeks, plus standard care, for 52 weeks. The two primary end points were the accrued weeks of remission over a 52-week period, according to categorical quantification, and the proportion of participants in remission at both week 36 and week 48. Secondary end points included the time to first relapse and the average daily glucocorticoid dose (during weeks 48 through 52). The annualized relapse rate and safety were assessed.Results: A total of 136 participants underwent randomization, with 68 participants assigned to receive mepolizumab and 68 to receive placebo. Mepolizumab treatment led to significantly more accrued weeks of remission than placebo (28% vs. 3% of the participants had ≥24 weeks of accrued remission; odds ratio, 5.91; 95% confidence interval [CI], 2.68 to 13.03; P<0.001) and a higher percentage of participants in remission at both week 36 and week 48 (32% vs. 3%; odds ratio, 16.74; 95% CI, 3.61 to 77.56; P<0.001). Remission did not occur in 47% of the participants in the mepolizumab group versus 81% of those in the placebo group. The annualized relapse rate was 1.14 in the mepolizumab group, as compared with 2.27 in the placebo group (rate ratio, 0.50; 95% CI, 0.36 to 0.70; P<0.001). A total of 44% of the participants in the mepolizumab group, as compared with 7% of those in the placebo group, had an average daily dose of prednisolone or prednisone of 4.0 mg or less per day during weeks 48 through 52 (odds ratio, 0.20; 95% CI, 0.09 to 0.41; P<0.001). The safety profile of mepolizumab was similar to that observed in previous studies.Conclusions: In participants with eosinophilic granulomatosis with polyangiitis, mepolizumab resulted in significantly more weeks in remission and a higher proportion of participants in remission than did placebo, thus allowing for reduced glucocorticoid use. Even so, only approximately half the participants treated with mepolizumab had protocol-defined remission. (Funded by GlaxoSmithKline and the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT02020889 .). [ABSTRACT FROM AUTHOR]

Background: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe.Methods: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013.Results: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl(-1) and increased to 9.8 (1.8) g dl(-1) after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2).Conclusion: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl(-1)), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold.Clinical Trial Registration: NCT 01604083. [ABSTRACT FROM AUTHOR]

Background: There has been no reported use of Thromboelastography® (TEG®) in assessing thrombocytopenic haematological malignancy (HM) patients experiencing bleeding. Objectives: To assess whether there are differences in TEG® variables in thrombocytopenic HM patients experiencing clinically significant bleeding compared with those not experiencing bleeding. Methods: Thirty adult patients with HM and a total platelet count (TPC) of ≤30 × 109 L-1 were observed for greater than or equal to grade two World Health Organisation (WHO) bleeding episodes for 72 h. They had TPC, TEG® parameters [maximal amplitude (MA), reaction time (R-time), alpha (α-angle) and functional fibrinogen (FF) levels], activated partial thromboplastin time (APTT) and prothrombin time (PT)measured at inclusion, 24 and 48 h. Results: Five patients had nine significant bleeding episodes. Patients bleeding (n) were all more hypocoaguable when measured by TEG® than patients not bleeding at inclusion n=4 (MA: 16.9 vs 31.8mm, P <0.01; R-time: 10.1 vs 7.5min, P =0.02; α-angle: 18.8 vs 28.4, P <0.01; FF: 182.4 vs 204mg dL-1, P <0.01), at 24 h n=3 (MA 18 vs 29.4mm, P =0.02; R-time: 9.4 vs 7.4mins, P =0.02; α-angle: 21.6 vs 26.5, P =0.04 and FF: 168 vs 201mg dL-1, P =0.01) and at 48 h n=2 (MA: 29.7 vs 23.0, P =0.02; R-time: 8.1 vs 6.7mins, P =0.05; α-angle: 22.6 vs 26.5, P =0.04; FF: 170 vs 208mg dL-1, P =0.01). There were no significant differences in TPC, APTT or PT between patients that bled and those that did not at each time point. Conclusions: Thrombocytopenic HM patients experiencing bleeding are hypocoaguable on TEG®. [ABSTRACT FROM AUTHOR]

SUMMARY Background After hepatic resection, post-operative increases in international normalised ratio ( INR) are frequent, but rarely associated with bleeding complication. Coagulation as assessed by thrombin generation may be normal, despite the increased INR. This study tests the hypothesis that viscoelastic tests (VET) of coagulation remain normal, despite mild elevations in INR, examines the efficacy of fresh frozen plasma ( FFP) in reversing prolongation of INR in such patients and determines the effect of FFP on VET. Methods A prospective cohort study of 47 patients undergoing major hepatectomy. In vitro spiking with FFP (7·5 and 15 mL kg−1) was carried out if post-operative day 2 ( POD2) INR levels were ≥1·5. Thromboelastography ( TEG®) and INR were measured before and after FFP spiking. Results Blood from patients with an INR ≥ 1·5 on POD2 was spiked with FFP. There was a significant reduction in the INR from 1·94 [standard deviation ( SD): 0·59] to 1·46 ( SD: 0·27, P = 0·005) and 1·36 ( SD: 0·18, P = 0·0007) with FFP 7·5 or 15 mL kg−1, respectively. At baseline, the TEG R-time [6·17 min ( NR, 9-27 min)] and maximum amplitude (MA) [66·9 mm ( NR, 44-64 mm)] were hypercoagulable, and remained so on POD2 for the R-time (6·7 min), but fell to within the normal range for the MA (54·0 mm). FFP spiking had no significant effect on TEG variables. Conclusions Despite the rise in INR after hepatectomy, VET do not show evidence of hypocoagulability. In vitro addition of FFP had no significant effect on TEG parameters. Clinical use of FFP in this situation is questionable. [ABSTRACT FROM AUTHOR]

Background Patients often fail to stop clopidogrel appropriately before non-cardiac surgery. Thromboelastography platelet mapping ( TEG-PM) can be used to measure the percentage adenosine 5′-diphosphate platelet receptor inhibition ( ADP-PRI) by clopidogrel in these patients. Methods This prospective case-control study investigated the risk of bleeding in patients who had taken clopidogrel within 7 days of scheduled operation. Patients underwent TEG-PM to stratify their bleeding risk. Low-risk ( ADP-PRI below 30 per cent) and urgent priority high-risk ( ADP-PRI 30 per cent or more) patients proceeded to surgery. The outcomes of these patients were compared with those of matched controls. Regression analysis, with bootstrapping validation, was used to identify independent risk factors for bleeding and an optimal cut-off value of ADP-PRI for cancellation of surgery. Results From May 2008 to October 2013, 182 patients failed to discontinue clopidogrel. No correlation was observed between duration of clopidogrel omission and percentage ADP-PRI; 112 low-risk and 19 high-risk patients proceeded to surgery. High-risk patients had significantly greater intraoperative packed red blood cell ( PRBC) transfusion in comparison with their matched controls, and a strong positive correlation between percentage ADP-PRI and units of intraoperative PRBCs transfused ( r = 0·749, 95 per cent confidence interval (c.i.) 0·410 to 0·940; P < 0·001). Percentage ADP-PRI was the only independent risk factor for intraoperative PRBC transfusion (odds ratio 1·07, 95 per cent c.i. 1·02 to 1·13; P = 0·005). Conclusion An objective measure of platelet inhibition with TEG-PM, using an ADP-PRI cut-off of 34 per cent, can be used to prevent unnecessary cancellations, while minimizing patient risk. [ABSTRACT FROM AUTHOR]

Objective: Eye tracking in three dimensions is novel, but established descriptors derived from two-dimensional (2D) studies are not transferable. We aimed to develop metrics suitable for statistical comparison of eye-tracking data obtained from readers of three-dimensional (3D) "virtual" medical imaging, using CT colonography (CTC) as a typical example. Methods: Ten experienced radiologists were eye tracked while observing eight 3D endoluminal CTC videos. Subsequently, we developed metrics that described their visual search patterns based on concepts derived from 2D gaze studies. Statistical methods were developed to allow analysis of the metrics. Results: Eye tracking was possible for all readers. Visual dwell on the moving region of interest (ROD was defined as pursuit of the moving object across multiple frames. Using this concept of pursuit, five categories of metrics were defined that allowed characterization of reader gaze behaviour. These were time to first pursuit, identification and assessment time, pursuit duration, ROI size and pursuit frequency. Additional subcategories allowed us to further characterize visual search between readers in the test population. Conclusion: We propose metrics for the characterization of visual search of 3D moving medical images. These metrics can be used to compare readers' visual search patterns and provide a reproducible framework for the analysis of gaze tracking in the 3D environment. Advances in knowledge: This article describes a novel set of metrics that can be used to describe gaze behaviour when eye tracking readers during interpretation of 3D medical images. These metrics build on those established for 2D eye tracking and are applicable to increasingly common 3D medical image displays. [ABSTRACT FROM AUTHOR]

Although epidural analgesia is routinely used in many institutions for patients undergoing hepatic resection, there are unresolved issues regarding its safety and efficacy in this setting. We performed a review of papers published in the area of anaesthesia and analgesia for liver resection surgery and selected four areas of current controversy for the focus of this review: the safety of epidural catheters with respect to postoperative coagulopathy, a common feature of this type of surgery; analgesic efficacy; associated peri-operative fluid administration; and the role of epidural analgesia in enhanced recovery protocols. In all four areas, issues are raised that question whether epidural anaesthesia is always the best choice for these patients. Unfortunately, the evidence available is insufficient to provide definitive answers, and it is clear that there are a number of areas of controversy that would benefit from high-quality clinical trials. [ABSTRACT FROM AUTHOR]

The article presents an abstract of the study "Point-of-care assessment of platelet function in the peri-operative period," by C. N. Melikian, K. James and S. V. Mallett.

The article presents a reply of E. A. Hirvonen to the comment made by Dr. K. Karamchandani regarding the report of a thyroid storm in a patient prior to induction of anesthesia. He said that the management of the patient did not strictly follow suggested guidelines. He also stresses that a patient with uncontrolled systematic hypertension without compromised heart function or signs of coronary heart disease can proceed with the scheduled operation. The author also wants to emphasize that the operation was postponed and performed after treatment of the thyroid storm.

Continuing aspirin up until surgery in cardiac surgical patients may increase peri-operative blood loss. It is possible that there is a subset of patients particularly sensitive to aspirin. The platelet function analyser (PFA-100®) can demonstrate the antiplatelet effect of aspirin. This study was designed to assess the effect of daily 75 mg aspirin on platelet function, as measured by the PFA-100®, in 92 patients with ischaemic heart disease. Patients were classified into three groups according to their PFA-100® results; aspirin hyper-responders (16%), aspirin normal responders (33%) and aspirin non-responders (51%). The PFA-100® has potential as a screening tool to identify patients who are either hyper-responsive or resistant to aspirin. Pre-operative PFA-100® screening to isolate aspirin hyper-responders could enable the vast majority of patients to continue with aspirin therapy pre-operatively, avoiding the risks of stopping treatment. [ABSTRACT FROM AUTHOR]