Building on a novel bootstrapping modelling technique to predict region-wide critical care capacity requirements over the next decade.

We have previously described an open-source data-driven modelling technique that has been used to model critical care resource provision as well as expanded to elective surgery and even whole-hospital modelling. Here, we describe the use of this technique to model patient flow and resource use across the West Yorkshire Critical Care Network, with the advantage that recommendations can be made at an individual unit level for future resource provision, taking into account changes in population numbers and demography over the coming decade. We will be using this approach in other regions around the UK to help predict future critical care capacity requirements.

Urinothorax following percutaneous image-guided renal cryoablation.

A 69-year-old lady with 2 renal cell carcinomas, one sited at the upper pole of her solitary right kidney, underwent percutaneous image-guided cryoablation and developed urinothorax as a complication. This was diagnosed from pleural fluid analysis and radiology imaging with computed tomography (CT). Management included image-guided chest drain and retrograde ureteric stent insertion to divert the urine from entering the pleural cavity. CT images demonstrated a fistula between the site of renal puncture and the pleural cavity, indicating that the cryoprobes traversed the diaphragm during the procedure. This case highlights urinothorax as an unusual complication of cryoablation of renal cell carcinoma. Prompt diagnosis by interventional radiologists is crucial to avert from this potentially life-threatening complication.

Incidence of Post-ablation Syndrome Following Image-Guided Percutaneous Cryoablation of Renal Cell Carcinoma: A Prospective Study.

PURPOSE: To prospectively evaluate the incidence of post-ablation syndrome (fever and flu-like symptoms) and impact on the quality of life in the first 10 days following percutaneous image-guided cryoablation for renal cell carcinoma (RCC). MATERIALS AND METHODS: A prospective study of all cryoablation procedures with biopsy proven RCC was conducted with institutional review board approval between 08/2012 and 04/2016. Sixty-four patients (43 males and 21 females) underwent cryoablation. Mean age was 68 (range 24-86). A telephone questionnaire survey was conducted on days 1, 3, 5, 7 and 10 following cryoablation, and complications were recorded. Data collected included temperature, degree of flu-like symptoms, severity of pain, percentage of pain relief with analgesics, interference with general activity and with work (graded on a 0-10 Numeric Intensity Scale). RESULTS: Following cryoablation, six patients (9%) out of 64 developed post-ablation syndrome. Thirty-three patients (52%) developed flu-like symptoms only, which completely resolved by day 10 in 25 patients (39%). One patient had pyrexia only, which was self- limiting by day 10. Twenty-four patients (38%) were asymptomatic. Pain (mean score = 2.1) and interference on general activities (mean score = 1.8) and work (mean score = 2) following cryoablation peaked on day 3 and improved subsequently. Forty-six patients (72%) had 90-100% pain relief by day 10. No major complications were observed. CONCLUSION: The full spectrum of post-ablation syndrome following cryoablation occurs in approximately 9% of patients; however, 61% of patients experience flu-like symptoms in the first 10 days, which are self-limiting.

A call to incorporate systems theory and human factors into the existing investigation of harm in clinical research involving healthcare products.

This is a joint statement from individual pharmacology and pharmaceutical professionals acting in their own capacity, including members of the Alliance for Clinical Research Excellence and Safety (ACRES) and the International Society of Pharmacovigilance (ISoP). By building on the extensive pharmacological and regulatory investigations that already take place, we are calling for a fuller and more robust systems-based approach to the independent investigation of clinical research when serious incidents of harm occur, starting with first-in-human clinical trials. To complement existing activities and regulations, we propose an additional approach blending evidence derived from both pharmacological and organizational science, which addresses human factors and transparency, to enhance organizational learning and continuous improvement. As happens with investigations in other sectors of society, such as the chemical and aviation sector, this systems approach should be seen as an additional way to understand how problems occur and how they might be prevented in the future. We believe that repetition of potentially preventable and adverse outcomes during clinical research, by failing to identify and act upon all systematic vulnerabilities, is a situation that needs urgent change. As we will discuss further on, approaches based on applying systems theory and human factors are much more likely to improve objectivity and transparency, leading to better system design.

Time-of-flight measurement techniques for airborne ultrasonic ranging.

Airborne ultrasonic ranging is used in a variety of different engineering applications for which other positional metrology techniques cannot be used, for example in closed-cell locations, when optical line of sight is limited, and when multipath effects preclude electromagnetic-based wireless systems. Although subject to fundamental physical limitations, e.g., because of the temperature dependence of acoustic velocity in air, these acoustic techniques often provide a cost-effective solution for applications in mobile robotics, structural inspection, and biomedical imaging. In this article, the different techniques and limitations of a range of airborne ultrasonic ranging approaches are reviewed, with an emphasis on the accuracy and repeatability of the measurements. Simple time-domain approaches are compared with their frequency-domain equivalents, and the use of hybrid models and biologically inspired approaches are discussed.

Immediate extubation of children following liver transplantation is safe and may be beneficial.

BACKGROUND: Immediate tracheal extubation of selected adult patients after orthotopic liver transplant (OLT) is common practice. We hypothesized that selected children may be safely extubated immediately after OLT and avoid potentially deleterious effects of artificial ventilation and sedation. METHODS: After June 2002, we chose immediate extubation unless a specific contraindication was identified. Charts of all children undergoing OLT between June 2002 and February 2005 were reviewed to audit safety and outcome of this approach. Comparative data were obtained for children undergoing first elective OLT at other UK centers. RESULTS: Forty-six cadaveric liver transplants were performed in 40 patients: 26 of 34 (76%) elective transplants and 4 of 12 (33%) urgent transplants were extubated immediately after surgery. Eight of 14 (57%) children weighing less than 10 kg were successfully extubated. One child required reintubation after developing transfusion-related acute lung injury. There were no other events compromising patient or graft. Small recipient size, split/reduced grafts, preexisting respiratory disease, retransplantation, and acute liver failure did not individually preclude successful immediate extubation. After elective OLT, the mean duration of intensive care stay was significantly shorter in the extubated group than in those who were ventilated (2.5 vs. 6.1 days, P<0.01). All children receiving a liver transplant at other UK centers in 2003 were ventilated postoperatively. However, the median duration of intensive care stay (2 days) was the same as in our series. CONCLUSIONS: Immediate extubation of selected children after OLT is safe. It may enhance patient recovery, benefit graft physiology, and reduce intensive care requirement.

Reinnervation of the pretectum in adult rats by regenerated retinal ganglion cell axons: anatomical and functional studies.

We have investigated the specificity of reinnervation and terminal arborization of injured retinal ganglion cell (RGC) axons in the brainstem with the object of studying in a simple situation the degree to which regenerating axons are able to replicate the characteristic patterns of terminal arborization and restore normal function. We have focussed here on the pathway that is responsible for the pupillary light reflex, which is mediated through the olivary pretectal nucleus (OPN). In adult rats, the left optic nerve was transected and a segment of peripheral nerve (PN) graft was used to bridge between the retina and different regions of the ipsilateral brainstem, including the superior colliculus. After 4-13 months, regenerated RGC axons were examined in coronal sections stained for cholera toxin B subunit. RGC axons were found extending into the ipsilateral brainstem for distances of up to 6 mm. Within the pretectum, axons innervated the OPN and the nucleus of the optic tract preferentially, and formed distinctive terminal arbors within each. Within the SC axons extended laterally into the visual layers and formed a different type of arborization. On testing the pupillary light reflex, it was found in best cases to show response amplitudes which were comparable to those recorded from control intact animals. However, unlike normals, the response amplitude tended to diminish with repeated stimulation and also appeared to deteriorate with age, although responses could still be detected in some cases as long as 15 months after grafting. These results indicate that regenerating axons can selectively reinnervate denervated nuclei, where they form typical terminal arborizations, and provide the substrates for restoring functional circuitry.