J. Dunning - Academia.edu (original) (raw)

Papers by J. Dunning

Research paper thumbnail of Fast Track Recovery Following En Bloc Heart–Lung–Liver Transplantation in a Patient with Cystic Fibrosis Complicated by Severe Portal Hypertension

Heart Lung and Circulation, 2008

A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-dou... more A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-double lung-liver transplantation. An early extubation with an aggressive physiotherapy made an early ambulation feasible and contributed to an early discharge from the hospital.

Research paper thumbnail of An Australian tertiary referral center experience of the management of chronic thromboembolic pulmonary hypertension

Pulmonary Circulation, 2012

The objective of this study was to report the outcome of pulmonary endarterectomy (PEA) surgery p... more The objective of this study was to report the outcome of pulmonary endarterectomy (PEA) surgery performed for chronic thromboembolic pulmonary hypertension (CTEPH) at a single tertiary center. The prospective study consisted of 35 patients with surgically amenable CTEPH undergoing PEA between September 2004 and September 2010. The main outcome measures were Functional (New York Heart Association [NYHA] class, 6-Minute Walk Distance), hemodynamic (echocardiography, right heart catheterization, and cardiac MRI), and outcome data (morbidity and mortality). Following PEA, there were significant improvements in NYHA class (pre 2.9±0.7 vs. post 1.3±0.5, P < 0.0001), right ventricular systolic pressure (pre 77.4±24.8 mmHg vs. post 45.1±24.9 mmHg, P = 0.0005), 6-Minute Walk Distance (pre 419.6±109.4 m vs. post 521.6±83.5 m, P = 0.0017), mean pulmonary artery pressure (pre 41.8±15.3 mmHg vs. post 24.7±8.8 mmHg, P = 0.0006), and cardiac MRI indices (end diastolic volume pre 213.8±49.2 mL vs. post 148.1±34.5 mL, P < 0.0001; ejection fraction pre 40.7±9.8 mL vs. post 48.1±8.9 mL, P = 0.0069). The mean cardiopulmonary bypass time was 258.77±26.16 min, with a mean circulatory arrest time of 43.83±28.78 min, a mean ventilation time of 4.7±7.93 days (range 0.2-32.7)

Research paper thumbnail of 315: Renal Dysfunction Post Heart Transplantation – Mycophenolate Mofetil Plus Prednisolone Is Adequate Immunosuppression in Long-Term Survivors

The Journal of Heart and Lung Transplantation, 2009

Initial bolus of 150mg/kg of heparin was given to all patients to achieve an ACT Ͼ300s, followed ... more Initial bolus of 150mg/kg of heparin was given to all patients to achieve an ACT Ͼ300s, followed by systemic heparin to maintain a PTT of 50-80s. Results: A total of 20 devices were implanted into 18 patients (13 LP5.0, 2 LP2.5, 5 RD). Etiology of cardiogenic shock is shown in . The mean age was 55.7ϩ/-12.4 years with a mean BSA of 2.1ϩ/-0.2m 2 . The mean CI at implant was 1.7ϩ/-0.4L/min/m 2 with a mean SBP of 89ϩ/-18mmHg, supported by a mean of 3 inotropes. Nine patients had IABP, one had been on left heart bypass prior to Impella implantation. All patients were ventilated and 14 patients had acute renal failure. Patients were supported for a mean of 4ϩ/-3days (1 -11 days). Mean CI during support was 2.5ϩ/-0.5L/min/m 2 . Eight patients were successfully weaned and 3 patients were bridged to implantable VAD. Six patients expired during support. The overall 30-day mortality was 33%. There was no device related complications. Conclusions: We report the first North American experience with Impella Recovery System. Our initial experience with the Impella pumps in 18 patients is encouraging. No device related complication was observed in our case series. It appears to be a safe and effective device for short-term mechanical circulatory support in severe cardiogenic shock.

Research paper thumbnail of Donation after Circulatory Death Lung Activity in the UK – 100 Transplants and Counting

The Journal of Heart and Lung Transplantation, 2013

ABSTRACT Purpose Whilst the number of donors after brain death (DBD) suitable for lung donation h... more ABSTRACT Purpose Whilst the number of donors after brain death (DBD) suitable for lung donation has decreased in the UK over the last ten years, the number of suitable donors after circulatory death (DCD) has increased by 346%. Four of the five adult lung centres in the UK now transplant DCD lungs, with 100 DCD lung transplants now performed. This study aims to examine the differences in donor, recipient and transplant characteristics between the two donor groups and compare the post-transplant outcome. Methods and Materials Data on all adult lung only transplants performed in the UK between January 2002 and October 2012 were obtained from the UK Transplant Registry. Transplant characteristics and outcome were compared using the Wilcoxon, chi-squared or log-rank tests, as appropriate. Results Over the last ten years, 1452 adult lung only transplants were performed in the UK, of which 100 (7%) involved DCD lungs. Over the last three years DCD lung transplants accounted for 14% of activity, which is similar to the DCD activity in Australia and the Netherlands. Where data were available, DCD lung transplants were all performed from controlled DCD, and the majority (87%) were not certified dead by brain stem tests. 84% of DCD lung transplants were bilateral sequential lung transplants (BSLT) compared with 72% of DBD lung transplants (p=0.01). In univariate analysis, DCD transplants also had significantly longer ischaemia times (p&lt;0.0001), more donors dying due to ‘other’ reasons (p=0.005), younger recipients (p=0.01) and, for BSLT, a higher maximum FEV1 at 1 year (p=0.03). There was no significant difference in post-transplant survival, with one-year survival of 79.2% (95% CI 76.8, 81.4) in the DBD group and 79.5% (95% CI 68.8, 86.8) in the DCD group (p=0.9). Conclusions DCD lung transplant activity has increased dramatically over the last ten years and now accounts for 14% of all UK adult lung only transplant activity. With the continuing shortage of DBD organs, DCD lungs provide a valuable additional resource with equivalent outcomes.

Research paper thumbnail of Fast Track Recovery Following En Bloc Heart–Lung–Liver Transplantation in a Patient with Cystic Fibrosis Complicated by Severe Portal Hypertension

Heart Lung and Circulation, 2008

A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-dou... more A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-double lung-liver transplantation. An early extubation with an aggressive physiotherapy made an early ambulation feasible and contributed to an early discharge from the hospital.

Research paper thumbnail of Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries

Emergency Medicine Journal, 2012

Many children present to emergency departments following head injury (HI), with a small number at... more Many children present to emergency departments following head injury (HI), with a small number at risk of avoidable poor outcome. Difficulty identifying such children, coupled with increased availability of cranial CT, has led to variation in practice and increased CT rates. Clinical decision rules (CDRs) have been derived for paediatric HI but there is no published comparison to assist in deciding which to implement. The content of the three of highest quality and accuracy are described and compared. Systematic reviews of paediatric HI CDRs were published in 2009 and 2011. To identify CDRs published since the most recent review, key databases were searched, selecting studies which included CDRs involving children aged 0-18 years with a history of HI. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies Tool, and performance evaluated by reported accuracy. Three high quality CDRs were identified: CATCH (Canadian Assessment of Tomography for Childhood Head Injury) CHALICE (Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Head Injury Algorithm for the Prediction of Important Clinical Events) and PECARN (Paediatric Emergency Care Applied Research Network). All were derived with high methodological standards but differed in key areas, including study population, outcomes and severity of HI. Each stated different predictor variables and only PECARN provided a separate algorithm for young children. CATCH and CHALICE identify children requiring CT and PECARN those who do not. All perform with high sensitivity and low specificity. PECARN is the only validated CDR, and none has undergone impact analysis. These three CDRs should undergo validation and comparison in a single population, with analysis of their impact on practice and financial implications, to aid relevant bodies in deciding which to implement.

Research paper thumbnail of Organ donation

Research paper thumbnail of Cumulative funnel plots for the early detection of interoperator variation: retrospective database analysis of observed versus predicted results of percutaneous coronary intervention

BMJ, 2008

To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators... more To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators undertaking percutaneous coronary interventions with predicted results derived from a validated risk score to allow for early detection of variation in performance. Analysis of prospectively collected data. Tertiary centre NHS hospital in the north east of England. Five cardiologists carrying out percutaneous coronary interventions between January 2003 and December 2006. In-hospital major adverse cardiovascular and cerebrovascular events (in-hospital death, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accident) analysed against the logistic north west quality improvement programme predicted risk, for each operator. Results are displayed as funnel plots summarising overall performance for each operator and cumulative funnel plots for an individual operator&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s performance on a case series basis. The funnel plots for 5198 patients undergoing percutaneous coronary interventions showed an average observed rate for major adverse cardiovascular and cerebrovascular events of 1.96% overall. This was below the predicted risk of 2.06% by the logistic north west quality improvement programme risk score. Rates of in-hospital major adverse cardiovascular and cerebrovascular events for all operators were within the 3sigma upper control limit of 2.75% and 2sigma upper warning limit of 2.49%. The overall in-hospital major adverse cardiovascular and cerebrovascular events rates were under the predicted event rate. In-hospital rates after percutaneous coronary intervention procedure can be monitored successfully using funnel and cumulative funnel plots with 3sigma control limits to display and publish each operator&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s outcomes. The upper warning limit (2sigma control limit) could be used for internal monitoring. The main advantage of these charts is their transparency, as they show observed and predicted events separately. By this approach individual operators can monitor their own performance, using the predicted risk for their patients but in a way that is compatible with benchmarking to colleagues, encapsulated by the funnel plot. This methodology is applicable regardless of variations in individual operator case volume and case mix.

Research paper thumbnail of Treatment options and strategies for acute severe pulmonary embolism

Internal Medicine Journal, 2008

Pulmonary thromboembolism (PE) is the third most frequent cause of cardiovascular death after isc... more Pulmonary thromboembolism (PE) is the third most frequent cause of cardiovascular death after ischaemic heart disease and stroke. In fatal PE, 2/3 of patients die within first hour of presentation. There is a clinical impetus to rapidly recognize, risk-stratify and appropriately treat patients with acute severe PE. Current recommendations present conflicting classification systems, and there is often some confusion in the clinical evaluation and management of patients with acute severe PE. This review presents a series of real clinical cases, which illustrate the available treatment options, ranging from conservative therapy to thrombolysis through to percutaneous catheter fragmentation and open surgical embolectomy. We evaluate the evidence for the various strategies and propose an algorithm for clinicians with a focus on early risk stratification and timely referral. This is particularly relevant to regional and remote centres, as well as secondary and tertiary institutions.

Research paper thumbnail of Fast Track Recovery Following En Bloc Heart–Lung–Liver Transplantation in a Patient with Cystic Fibrosis Complicated by Severe Portal Hypertension

Heart Lung and Circulation, 2008

A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-dou... more A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-double lung-liver transplantation. An early extubation with an aggressive physiotherapy made an early ambulation feasible and contributed to an early discharge from the hospital.

Research paper thumbnail of An Australian tertiary referral center experience of the management of chronic thromboembolic pulmonary hypertension

Pulmonary Circulation, 2012

The objective of this study was to report the outcome of pulmonary endarterectomy (PEA) surgery p... more The objective of this study was to report the outcome of pulmonary endarterectomy (PEA) surgery performed for chronic thromboembolic pulmonary hypertension (CTEPH) at a single tertiary center. The prospective study consisted of 35 patients with surgically amenable CTEPH undergoing PEA between September 2004 and September 2010. The main outcome measures were Functional (New York Heart Association [NYHA] class, 6-Minute Walk Distance), hemodynamic (echocardiography, right heart catheterization, and cardiac MRI), and outcome data (morbidity and mortality). Following PEA, there were significant improvements in NYHA class (pre 2.9±0.7 vs. post 1.3±0.5, P < 0.0001), right ventricular systolic pressure (pre 77.4±24.8 mmHg vs. post 45.1±24.9 mmHg, P = 0.0005), 6-Minute Walk Distance (pre 419.6±109.4 m vs. post 521.6±83.5 m, P = 0.0017), mean pulmonary artery pressure (pre 41.8±15.3 mmHg vs. post 24.7±8.8 mmHg, P = 0.0006), and cardiac MRI indices (end diastolic volume pre 213.8±49.2 mL vs. post 148.1±34.5 mL, P < 0.0001; ejection fraction pre 40.7±9.8 mL vs. post 48.1±8.9 mL, P = 0.0069). The mean cardiopulmonary bypass time was 258.77±26.16 min, with a mean circulatory arrest time of 43.83±28.78 min, a mean ventilation time of 4.7±7.93 days (range 0.2-32.7)

Research paper thumbnail of 315: Renal Dysfunction Post Heart Transplantation – Mycophenolate Mofetil Plus Prednisolone Is Adequate Immunosuppression in Long-Term Survivors

The Journal of Heart and Lung Transplantation, 2009

Initial bolus of 150mg/kg of heparin was given to all patients to achieve an ACT Ͼ300s, followed ... more Initial bolus of 150mg/kg of heparin was given to all patients to achieve an ACT Ͼ300s, followed by systemic heparin to maintain a PTT of 50-80s. Results: A total of 20 devices were implanted into 18 patients (13 LP5.0, 2 LP2.5, 5 RD). Etiology of cardiogenic shock is shown in . The mean age was 55.7ϩ/-12.4 years with a mean BSA of 2.1ϩ/-0.2m 2 . The mean CI at implant was 1.7ϩ/-0.4L/min/m 2 with a mean SBP of 89ϩ/-18mmHg, supported by a mean of 3 inotropes. Nine patients had IABP, one had been on left heart bypass prior to Impella implantation. All patients were ventilated and 14 patients had acute renal failure. Patients were supported for a mean of 4ϩ/-3days (1 -11 days). Mean CI during support was 2.5ϩ/-0.5L/min/m 2 . Eight patients were successfully weaned and 3 patients were bridged to implantable VAD. Six patients expired during support. The overall 30-day mortality was 33%. There was no device related complications. Conclusions: We report the first North American experience with Impella Recovery System. Our initial experience with the Impella pumps in 18 patients is encouraging. No device related complication was observed in our case series. It appears to be a safe and effective device for short-term mechanical circulatory support in severe cardiogenic shock.

Research paper thumbnail of Donation after Circulatory Death Lung Activity in the UK – 100 Transplants and Counting

The Journal of Heart and Lung Transplantation, 2013

ABSTRACT Purpose Whilst the number of donors after brain death (DBD) suitable for lung donation h... more ABSTRACT Purpose Whilst the number of donors after brain death (DBD) suitable for lung donation has decreased in the UK over the last ten years, the number of suitable donors after circulatory death (DCD) has increased by 346%. Four of the five adult lung centres in the UK now transplant DCD lungs, with 100 DCD lung transplants now performed. This study aims to examine the differences in donor, recipient and transplant characteristics between the two donor groups and compare the post-transplant outcome. Methods and Materials Data on all adult lung only transplants performed in the UK between January 2002 and October 2012 were obtained from the UK Transplant Registry. Transplant characteristics and outcome were compared using the Wilcoxon, chi-squared or log-rank tests, as appropriate. Results Over the last ten years, 1452 adult lung only transplants were performed in the UK, of which 100 (7%) involved DCD lungs. Over the last three years DCD lung transplants accounted for 14% of activity, which is similar to the DCD activity in Australia and the Netherlands. Where data were available, DCD lung transplants were all performed from controlled DCD, and the majority (87%) were not certified dead by brain stem tests. 84% of DCD lung transplants were bilateral sequential lung transplants (BSLT) compared with 72% of DBD lung transplants (p=0.01). In univariate analysis, DCD transplants also had significantly longer ischaemia times (p&lt;0.0001), more donors dying due to ‘other’ reasons (p=0.005), younger recipients (p=0.01) and, for BSLT, a higher maximum FEV1 at 1 year (p=0.03). There was no significant difference in post-transplant survival, with one-year survival of 79.2% (95% CI 76.8, 81.4) in the DBD group and 79.5% (95% CI 68.8, 86.8) in the DCD group (p=0.9). Conclusions DCD lung transplant activity has increased dramatically over the last ten years and now accounts for 14% of all UK adult lung only transplant activity. With the continuing shortage of DBD organs, DCD lungs provide a valuable additional resource with equivalent outcomes.

Research paper thumbnail of Fast Track Recovery Following En Bloc Heart–Lung–Liver Transplantation in a Patient with Cystic Fibrosis Complicated by Severe Portal Hypertension

Heart Lung and Circulation, 2008

A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-dou... more A 36-year-old man with cystic fibrosis and severe portal hypertension underwent en bloc heart-double lung-liver transplantation. An early extubation with an aggressive physiotherapy made an early ambulation feasible and contributed to an early discharge from the hospital.

Research paper thumbnail of Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries

Emergency Medicine Journal, 2012

Many children present to emergency departments following head injury (HI), with a small number at... more Many children present to emergency departments following head injury (HI), with a small number at risk of avoidable poor outcome. Difficulty identifying such children, coupled with increased availability of cranial CT, has led to variation in practice and increased CT rates. Clinical decision rules (CDRs) have been derived for paediatric HI but there is no published comparison to assist in deciding which to implement. The content of the three of highest quality and accuracy are described and compared. Systematic reviews of paediatric HI CDRs were published in 2009 and 2011. To identify CDRs published since the most recent review, key databases were searched, selecting studies which included CDRs involving children aged 0-18 years with a history of HI. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies Tool, and performance evaluated by reported accuracy. Three high quality CDRs were identified: CATCH (Canadian Assessment of Tomography for Childhood Head Injury) CHALICE (Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Head Injury Algorithm for the Prediction of Important Clinical Events) and PECARN (Paediatric Emergency Care Applied Research Network). All were derived with high methodological standards but differed in key areas, including study population, outcomes and severity of HI. Each stated different predictor variables and only PECARN provided a separate algorithm for young children. CATCH and CHALICE identify children requiring CT and PECARN those who do not. All perform with high sensitivity and low specificity. PECARN is the only validated CDR, and none has undergone impact analysis. These three CDRs should undergo validation and comparison in a single population, with analysis of their impact on practice and financial implications, to aid relevant bodies in deciding which to implement.

Research paper thumbnail of Organ donation

Research paper thumbnail of Cumulative funnel plots for the early detection of interoperator variation: retrospective database analysis of observed versus predicted results of percutaneous coronary intervention

BMJ, 2008

To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators... more To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators undertaking percutaneous coronary interventions with predicted results derived from a validated risk score to allow for early detection of variation in performance. Analysis of prospectively collected data. Tertiary centre NHS hospital in the north east of England. Five cardiologists carrying out percutaneous coronary interventions between January 2003 and December 2006. In-hospital major adverse cardiovascular and cerebrovascular events (in-hospital death, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accident) analysed against the logistic north west quality improvement programme predicted risk, for each operator. Results are displayed as funnel plots summarising overall performance for each operator and cumulative funnel plots for an individual operator&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s performance on a case series basis. The funnel plots for 5198 patients undergoing percutaneous coronary interventions showed an average observed rate for major adverse cardiovascular and cerebrovascular events of 1.96% overall. This was below the predicted risk of 2.06% by the logistic north west quality improvement programme risk score. Rates of in-hospital major adverse cardiovascular and cerebrovascular events for all operators were within the 3sigma upper control limit of 2.75% and 2sigma upper warning limit of 2.49%. The overall in-hospital major adverse cardiovascular and cerebrovascular events rates were under the predicted event rate. In-hospital rates after percutaneous coronary intervention procedure can be monitored successfully using funnel and cumulative funnel plots with 3sigma control limits to display and publish each operator&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s outcomes. The upper warning limit (2sigma control limit) could be used for internal monitoring. The main advantage of these charts is their transparency, as they show observed and predicted events separately. By this approach individual operators can monitor their own performance, using the predicted risk for their patients but in a way that is compatible with benchmarking to colleagues, encapsulated by the funnel plot. This methodology is applicable regardless of variations in individual operator case volume and case mix.

Research paper thumbnail of Treatment options and strategies for acute severe pulmonary embolism

Internal Medicine Journal, 2008

Pulmonary thromboembolism (PE) is the third most frequent cause of cardiovascular death after isc... more Pulmonary thromboembolism (PE) is the third most frequent cause of cardiovascular death after ischaemic heart disease and stroke. In fatal PE, 2/3 of patients die within first hour of presentation. There is a clinical impetus to rapidly recognize, risk-stratify and appropriately treat patients with acute severe PE. Current recommendations present conflicting classification systems, and there is often some confusion in the clinical evaluation and management of patients with acute severe PE. This review presents a series of real clinical cases, which illustrate the available treatment options, ranging from conservative therapy to thrombolysis through to percutaneous catheter fragmentation and open surgical embolectomy. We evaluate the evidence for the various strategies and propose an algorithm for clinicians with a focus on early risk stratification and timely referral. This is particularly relevant to regional and remote centres, as well as secondary and tertiary institutions.