Alex Oldman - Academia.edu (original) (raw)

Papers by Alex Oldman

Cochrane Database of Systematic Reviews

Critical Care Explorations, 2022

OBJECTIVES: Patients admitted to intensive care often require treatment with invasive mechanical ... more OBJECTIVES: Patients admitted to intensive care often require treatment with invasive mechanical ventilation and high concentrations of oxygen. Mechanical ventilation can cause acute lung injury that may be exacerbated by oxygen therapy. Uncertainty remains about which oxygen therapy targets result in the best clinical outcomes for these patients. This review aims to determine whether higher or lower oxygenation targets are beneficial for mechanically ventilated adult patients. DATA SOURCES: Excerpta Medica dataBASE, Medical Literature Analysis and Retrieval System Online, and Cochrane medical databases were searched from inception through to February 28, 2021. STUDY SELECTION: Randomized controlled trials comparing higher and lower oxygen targets in adult patients receiving invasive mechanical ventilation via an endotracheal tube or tracheostomy in an intensive care setting. DATA EXTRACTION: Study setting, participant type, participant numbers, and intervention targets were captured. Outcome measures included “mortality at longest follow-up” (primary), mechanical ventilator duration and free days, vasopressor-free days, patients on renal replacement therapy, renal replacement free days, cost benefit, and quality of life scores. Evidence certainty and risk of bias were evaluated using Grading of Recommendations Assessment, Development and Evaluation and the Cochrane Risk of Bias tool. A random-effects models was used. Post hoc subgroup analysis looked separately at studies comparing hypoxemia versus normoxemia and normoxemia versus hyperoxemia. DATA SYNTHESIS: Data from eight trials (4,415 participants) were analyzed. Comparing higher and lower oxygen targets, there was no difference in mortality (odds ratio, 0.95; 95% CI, 0.74–1.22), but heterogeneous and overlapping target ranges limit the validity and clinical relevance of this finding. Data from seven studies (n = 4,245) demonstrated targeting normoxemia compared with hyperoxemia may reduce mortality at longest follow-up (0.73 [0.57–0.95]) but this estimate had very low certainty. There was no difference in mortality between targeting relative hypoxemia or normoxemia (1.20 [0.83–1.73]). CONCLUSIONS: This systematic review and meta-analysis identified possible increased mortality with liberal oxygen targeting strategies and no difference in morbidity between high or low oxygen targets in mechanically ventilated adults. Findings were limited by substantial heterogeneity in study methodology and further research is urgently required to define optimal oxygen therapy targets.

Cancer Research Journal, 2017

The purpose of this study was to examine whether a relationship exists between age, ethnicity, ge... more The purpose of this study was to examine whether a relationship exists between age, ethnicity, gender and survival of patients within a London Cancer Network. All patients with non metastatic colorectal cancer diagnosed and treated within the South West London Cancer Network between January 2001 and January 2006 were included for analysis. Consent was gained from all hospitals within the London Cancer Network, and data was subsequently requested from the Thames Cancer Registry. In total, 3151 patients were analysed. The results demonstrated that from 2003 there was a yearly increase in new cancer diagnosis. The ratio of male to female patients was approximately equal over the time period (51.5% male, 48.5% female). The overall mean patient age at diagnosis was 70.76 years. Asian, black and mixed race patients had better survival rates than white European patients (hazard ratios 0.96, 0.87, 0.96 respectively). Patients in the age cohort '50-59 years' had a 5 year survival rate of 57.8 months (hazard ratio 1.63), whilst the 'under 40 years' age cohort had the longest 5 year survival rate of 67.4 months. When comparing tumour sites, patients with rectosigmoid tumours had the lowest 5 year survival rate (hazard ratio 1.12), and those with rectal tumours (n=816, hazard ratio 0.88) had the longest 5 year survival rate. Median and overall survival for all patients was 38.84 months and 42.3% respectively. Surgery with neoadjuvant therapy resulted in the longest 5 year survival rate at 62.8%. Surgery alone had a 5 year survival rate of 43%. The results could be used to help design a prognostic indicator tool as a means by which to assist clinicians in providing patients with information on survival outcomes.

American Journal of Pediatrics, 2017

The use of on table cholangiogram (OTC) during laparoscopic cholecystectomy (LC) continues to be ... more The use of on table cholangiogram (OTC) during laparoscopic cholecystectomy (LC) continues to be a debated topic within surgical practice. Current National Institute for Health and Care Excellence (NICE) guidelines do not advocate its routine use in adult patients, and there is scarce evidence for its use in paediatric cases. We aimed to analyse the outcomes of OTC during laparoscopic cholecystectomy to see if the NICE guidance holds true for children. A retrospective case note review was performed with IRB approval of all children who underwent laparoscopic cholecystectomy between February 2005 and November 2014. A total of 65 patients were identified, 41 female (63%) and 24 male (37%). The median age was 12 years (IQR 6). None of the patients underwent OTC during their LC. Instead, pre-operative ultrasound scan (USS) was performed in all cases. From the cohort, 5 patients (13%) showed abnormalities; 3 of which had a dilated common bile duct, and 2 of which had bile duct stones. All 5 patients went on to receive additional imaging, 2 patients underwent a repeat USS both of which were normal on review; 1 patient had an Endoscopic Retrograde Cholangio-Pancreatectography (ERCP), stent and follow-up Magnetic Resonance Cholangio-Pancreatograthy (MRCP) which was normal; 1 patient had an MRCP, ERCP with sphincterotomy and a follow-up USS which was normal; and 1 patient had an ERCP with follow-up USS which was also normal. In line with current NICE guidance for adults, our study indicates that patients with common bile duct (CBD) stones or a dilated CBD can be identified and managed prior to laparoscopic cholecystectomy. This would suggest that there is no requirement for OTC in children. Similar NICE guidance in Paediatrics may be necessary to avoid unnecessary intervention.

Perioperative Medicine, 2019

Perioperative medicine (London, England), 2018

Considerable controversy remains about how much oxygen patients should receive during surgery. Th... more Considerable controversy remains about how much oxygen patients should receive during surgery. The 2016 World Health Organization (WHO) guidelines recommend that intubated patients receive a fractional inspired oxygen concentration (FIO) of 0.8 throughout abdominal surgery to reduce the risk of surgical site infection. However, this recommendation has been widely criticised by anaesthetists and evidence from other clinical contexts has suggested that giving a high concentration of oxygen might worsen patient outcomes. This retrospective multi-centre observational study aimed to ascertain intraoperative oxygen administration practice by anaesthetists across parts of the UK. Patients undergoing general anaesthesia with an arterial catheter in situ across hospitals affiliated with two anaesthetic trainee audit networks (PLAN, SPARC) were eligible for inclusion unless undergoing cardiopulmonary bypass. Demographic and intraoperative oxygenation data, haemoglobin saturation and positive ...

Journal of Health Organization and Management, 2016

Purpose Although medical leadership and management (MLM) is increasingly being recognised as impo... more Purpose Although medical leadership and management (MLM) is increasingly being recognised as important to improving healthcare outcomes, little is understood about current training of medical students in MLM skills and behaviours in the UK. The paper aims to discuss these issues. Design/methodology/approach This qualitative study used validated structured interviews with expert faculty members from medical schools across the UK to ascertain MLM framework integration, teaching methods employed, evaluation methods and barriers to improvement. Findings Data were collected from 25 of the 33 UK medical schools (76 per cent response rate), with 23/25 reporting that MLM content is included in their curriculum. More medical schools assessed MLM competencies on admission than at any other time of the curriculum. Only 12 schools had evaluated MLM teaching at the time of data collection. The majority of medical schools reported barriers, including overfilled curricula and reluctance of staff t...

Cochrane Database of Systematic Reviews, 2020

Background Supplemental oxygen is frequently administered to patients with acute respiratory dist... more Background Supplemental oxygen is frequently administered to patients with acute respiratory distress syndrome (ARDS), including ARDS secondary to viral illness such as coronavirus disease 19 (COVID-19). An up-to-date understanding of how best to target this therapy (e.g. arterial partial pressure of oxygen (PaO 2) or peripheral oxygen saturation (SpO 2) aim) in these patients is urgently required. Objectives To address how oxygen therapy should be targeted in adults with ARDS (particularly ARDS secondary to COVID-19 or other respiratory viruses) and requiring mechanical ventilation in an intensive care unit, and the impact oxygen therapy has on mortality, days ventilated, days of catecholamine use, requirement for renal replacement therapy, and quality of life. Search methods We searched the Cochrane COVID-19 Study Register, CENTRAL, MEDLINE, and Embase from inception to 15 May 2020 for ongoing or completed randomized controlled trials (RCTs). Selection criteria Two review authors independently assessed all records in accordance with standard Cochrane methodology for study selection. We included RCTs comparing supplemental oxygen administration (i.e. different target PaO 2 or SpO 2 ranges) in adults with ARDS and receiving mechanical ventilation in an intensive care setting. We excluded studies exploring oxygen administration in patients with different underlying diagnoses or those receiving non-invasive ventilation, high-flow nasal oxygen, or oxygen via facemask. Data collection and analysis One review author performed data extraction, which a second review author checked. We assessed risk of bias in included studies using the Cochrane 'Risk of bias' tool. We used the GRADE approach to judge the certainty of the evidence for the following outcomes; mortality at longest follow-up, days ventilated, days of catecholamine use, and requirement for renal replacement therapy. Main results We identified one completed RCT evaluating oxygen targets in patients with ARDS receiving mechanical ventilation in an intensive care setting. The study randomized 205 mechanically ventilated patients with ARDS to either conservative (PaO 2 55 to 70 mmHg, or SpO 2 88% to 92%) or liberal (PaO 2 90 to 105 mmHg, or SpO 2 ≥ 96%) oxygen therapy for seven days. Overall risk of bias was high (due to lack of blinding, small numbers of participants, and the trial stopping prematurely), and we assessed the certainty of the evidence as very low. The available data suggested that mortality at 90 days may be higher in those participants receiving a lower oxygen target (odds ratio (OR) 1.83, 95% confidence interval (CI) 1.03 to 3.27). There was no evidence of a difference between the lower and higher target groups in mean number of days ventilated (14.0, 95% CI 10.0 to 18.0 versus 14.5, 95% CI 11.8 to 17.1); number of days of catecholamine use (8.0, 95% CI 5.5 to 10.5 versus 7.2, 95% CI 5.9 to 8.4); or participants receiving renal replacement therapy (13.7%, 95% CI 5.8% to 21.6% versus 12.0%, 95% CI 5.0% to 19.1%). Quality of life was not reported.