Cretaceous gnetalean yields first preserved plant gum.

Some liquid plant exudates (e.g. resin) can be found preserved in the fossil record. However, due to their high solubility, gums have been assumed to dissolve before fossilisation. The visual appearance of gums (water-soluble polysaccharides) is so similar to other plant exudates, particularly resin, that chemical testing is essential to differentiate them. Remarkably, Welwitschiophyllum leaves from Early Cretaceous, Brazil provide the first chemical confirmation of a preserved gum. This is despite the leaves being exposed to water twice during formation and subsequent weathering of the Crato Formation. The Welwitschiophyllum plant shares the presence of gum ducts inside leaves with its presumed extant relative the gnetalean Welwitschia. This fossil gum presents a chemical signature remarkably similar to the gum in extant Welwitschia and is distinct from those of fossil resins. We show for the first time that a water-soluble plant exudate has been preserved in the fossil record, potentially allowing us to recognise further biomolecules thought to be lost during the fossilisation process.

Extracorporeal Membrane Oxygenation as Salvage Therapy in the Peripartum Period: A Case Series.

Despite considerable advances in maternity care, maternal death rates remain unacceptably high. Even with optimal care, unexpected complications can result in catastrophic consequences. Hemorrhage, cardiovascular and coronary conditions, and cardiomyopathy make up the three most common causes of pregnancy-associated deaths, followed by sepsis and thromboembolic disease. Although a number of deaths may be deemed to be potentially avoidable with appropriate education and infrastructure, others such as refractory hypoxia and peripartum cardiomyopathy are not. All possible interventions should be explored, including the use of more novel and aggressive life support technologies, such as extracorporeal membrane oxygenation. We report the successful use of extracorporeal membrane oxygenation in three cases of severe peripartum morbidity. The first case describes spontaneous coronary artery dissection supported with veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock after out-of-hospital cardiac arrest. The second is a case of severe pregnancy-related liver disease bridged to emergency liver transplantation with veno-venous extracorporeal membrane oxygenation. Finally, we report the use of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in a postpartum patient. Peripartum extracorporeal membrane oxygenation is feasible in carefully selected patients, and should be considered early when conventional therapy is failing, or as a salvage rescue therapy when it has failed.

A Unified Electronic Tool for CPR and Emergency Treatment Escalation Plans Improves Communication and Early Collaborative Decision Making for Acute Hospital Admissions.

The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) report 'Time to Intervene' (2012) stated that in a substantial number of cases, resuscitation is attempted when it was thought a 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision should have been in place. Early decisions about CPR status and advance planning about limits of care now form part of national recommendations by the UK Resuscitation Council (2016). Treatment escalation plans (TEP) document what level of treatment intervention would be appropriate if a patient were to become acutely unwell and were not previously formally in place at King's College Hospital. A unifying paper based form was successfully piloted in the Acute Medical Unit, introducing the TEP and bringing together decision making around both treatment escalation and CPR status. Subsequently an electronic order-set for CPR status and treatment escalation was launched in April 2015 which led to a highly visible CPR and escalation status banner on the main screen at the top of the patient's electronic record. Ultimately due to further iterations in the electronic process by December 2016, all escalation decisions for acutely admitted patients now have high quality supporting, explanatory documentation with 100% having TEPs in place. There is now widespread multidisciplinary engagement in the process of defining limits of care for acutely admitted medical patients within the first 14 hours of admission and a strategy for rolling this process out across all the divisions of the hospital through our Deteriorating Patient Group (DPG). The collaborative design with acute medical, palliative and intensive care teams and the high visibility provided by the electronic process in the Electronic Patient Record (EPR) has enhanced communication with these teams, patients, nursing staff and the multidisciplinary team by ensuring clarity through a universally understood process about escalation and CPR. Clarity and openness about these discussions have been welcomed by patient focus groups facilitated via our acute medicine patient experience committee. There has been a shift in medical culture where transparency about limits of care has contributed to improving patient safety and quality of care through reducing unnecessary CPR supported by focus groups of staff.

Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.

BACKGROUND: Drug administration errors in obstetric neuraxial anesthesia can have devastating consequences. Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors. METHODS: We identified case reports and case series from MEDLINE and performed a quantitative analysis of the involved drugs, error setting, source of error, the observed complications, and any therapeutic interventions. We subsequently performed a qualitative analysis of the human factors involved and proposed modifications to practice. RESULTS: Twenty-nine cases were identified. Various drugs were given in error, but no direct effects on the course of labor, mode of delivery, or neonatal outcome were reported. Four maternal deaths from the accidental intrathecal administration of tranexamic acid were reported, all occurring after delivery of the fetus. A range of hemodynamic and neurologic signs and symptoms were noted, but the most commonly reported complication was the failure of the intended neuraxial anesthetic technique. Several human factors were present; most common factors were drug storage issues and similar drug appearance. Four practice recommendations were identified as being likely to have prevented the errors. CONCLUSIONS: The reported errors exposed latent conditions within health care systems. We suggest that the implementation of the following processes may decrease the risk of these types of drug errors: (1) Careful reading of the label on any drug ampule or syringe before the drug is drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer lock connectors on all epidural/spinal/combined spinal-epidural devices. Further study is required to determine whether routine use of these processes will reduce drug error.

Improving critical care discharge summaries: a collaborative quality improvement project using PDSA.

Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care. An innovative form of enhanced capability critical care outreach called 'iMobile' is being provided at King's College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken. Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries. The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders. The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.

Portopulmonary hypertension: improved detection using CT and echocardiography in combination.

OBJECTIVES: To establish the relationship between CT signs of pulmonary hypertension and mean pulmonary artery pressure (mPAP) in patients with liver disease, and to determine the additive value of CT in the detection of portopulmonary hypertension in combination with transthoracic echocardiography. METHODS: Forty-nine patients referred for liver transplantation were retrospectively reviewed. Measured CT signs included the main pulmonary artery/ascending aorta diameter ratio (PA/AAmeas) and the mean left and right main PA diameter (RLPAmeas). Enlargement of the pulmonary artery compared to the ascending aorta was also assessed visually (PA/AAvis). CT measurements were correlated with right-sided heart catheter-derived mPAP. The ability of PA/AAvis combined with echocardiogram-derived right ventricular systolic pressure (RVSP) to detect portopulmonary hypertension was tested with ROC analysis. RESULTS: There were moderate correlations between mPAP and both PA/AAmeas and RLPAmeas (rs = 0.41 and rs = 0.42, respectively; p < 0.005). Compared to transthoracic echocardiography alone (AUC = 0.59, p = 0.23), a diagnostic algorithm incorporating PA/AAvis and transthoracic echocardiography-derived RVSP improved the detection of portopulmonary hypertension (AUC = 0.8, p < 0.0001). CONCLUSIONS: CT contributes to the non-invasive detection of portopulmonary hypertension when used in a diagnostic algorithm with transthoracic echocardiography. CT may have a role in the pre-liver transplantation triage of patients with portopulmonary hypertension for right-sided heart catheterisation. KEY POINTS: • CT signs correlate with right-sided heart catheter data in portopulmonary hypertension • CT adds to the transthoracic echocardiography detection of portopulmonary hypertension • CT may have a complementary role in pre-liver transplantation triage.