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Introduction and objectivesOptimal utilisation of critical care resources requires timely discharge of patients from critical care to appropriate wards. This represents a challenging and high risk transition. Local audits revealed that a few multimorbid patients with difficult respiratory weans accounted for 30% of critical care bed days. A weekly ventilation multidisciplinary team (VMDT) meeting combining respiratory and critical care expertise was established at a 692-bed hospital to improve management and resource use for this patient group. The effect was compared to a 2nd hospital within the same trust without VMDT.MethodA retrospective comparison of 6 month periods before (period 1: 1/10/07–31/3/08) and after (period 2: 1/10/12–31/3/13) introducing VMDT was carried out using data collected for Intensive Care National Audit and Research Centre. The same data was collected for a sister hospital, belonging to the same trust, without VMDT. The numbers of discharges to a respiratory ward with non- invasive ventilation (NIV) facilities were compared with Chi-Square test. The numbers of level 1 critical care bed days were compared with T test.ResultsIn period 1, hospital 1 discharged 458 patients from critical care and hospital 2 discharged 456. In period 2 these figures were 494 (p = 0.30) and 495 (p = 0.84) respectively. There was no change to background parameters. The number of discharges to respiratory ward with NIV facilities increased significantly in hospital 1 (36 to 65, p = 0,011) after VMDT. Whilst the number of patients discharged to respiratory ward increased in hospital 2 this was not significant (9 to 19, p = 0.13). The number of level 1 bed days fell significantly (208 to 18, p < 0.0000000001) in hospital 1. Hospital 2 saw an increase in level 1 days over the same period.ConclusionIntroduction of VMDT increased the proportion of respiratory patients discharged to a respiratory ward from critical care and reduced level one bed days in hospital 1 by expediting the discharge of complex respiratory wean patients thereby increasing patient flow and liberating critical care resources. The same reduction was not observed in the hospital 2 suggesting this effect was not due to trust wide changes in critical care practice.

Introduction Autophagy is well known as one of the biogenic responses against various stresses, which possesses the benefi cial roles for survival, but little is known about the dynamics and its signifi cance during the septic condition. We hypothesized that autophagy is induced during the septic condition, and contributes to protect from tissue damage which subsequently leads to organ dysfunction. We confi rm whether the autophagic process is accelerated or sustained in an acute phase of sepsis and we also determine its physiological role. Methods Sepsis was induced by cecal ligation and puncture (CLP) in mice. We examined the kinetics of autophagosome and auto lysosome formation which may explain the status of autophagy by western blotting, immunohistochemistry, and electron microscopy. To investigate a precise role of autophagy in CLP-induced sepsis, chloroquine, an autophagy inhibitor, was administered to the CLP-operated mice, and blood chemistry, pathology of the liver and survival were evaluated. Results Autophagy demonstrated by the ratio of LC3-II/LC3-I was induced over the time course up to 24 hours after CLP. The ratio was particularly increased in the liver, heart and spleen. Autophagosome formation became maximal at 6 hours and declined by 24 hours after CLP. Autolysosome formation as evaluated by both fusion of GFP-LC3 dots with LAMP1 immunohistochemistry and electron microscopy was also increased after the procedure. Furthermore, inhibition of autophagy by chloroquine during the CLP procedure resulted in elevation of serum AST levels, and signifi cantly increased mortality in mice. Conclusion Autophagy was induced in several organs over the time course of the CLP sepsis model and then the process was gradually completed to degradation of the components. Our data suggest autophagy plays a protective role in organ dysfunction in sepsis. P2Reversible depressive eff ect of TNFα on a model of isolated perfused rat heart BV Nguyen Introduction Acute myocardial depression in septic shock is common [1]. Myocardial depression is mediated by circulating depressant substances, which until now have been incompletely characterized [2].The aim of our study was to observe the eff ects of TNFα on the model of perfused rat heart. Methods After profound anesthesia with pentothal, the Wistar rats were killed by exsanguination. After sternotomy, the heart was taken and connected to the Langendorf column. The apex of the heart was hooked to a strength sensor. Biopac student laboratory software was used to record and analyse heart contractions. Contractions were recorded every 5 minutes during periods of 20 minutes. Control measurements were fi rst recorded. We measured four parameters: heart rate, contraction force, speeds of contraction and relaxation for control, during TNFα (20 ng/ml) exposure and after removal of TNFα. We express the variations of parameters as percentage of the control ± SEM. A paired t test was used to compare heart rate, contraction amplitude, speeds of contraction and relaxation with TNFα and ...

Adenocarcinoma of the vermiform appendix is a rare malignant neoplasm of the gastrointestinal tract encountered rarely within general surgical practice. We present the case of a 49-year-old man who, while undergoing investigations for haematuria, was diagnosed with an appendicular adenocarcinoma following bladder biopsy. Consequently he underwent right hemicolectomy and partial cystectomy followed by adjuvant chemotherapy. By discussing this case we hope to raise awareness within the medical profession of this rare presentation so that it may be considered within clinicians' differential diagnoses.

interested in further information about HNS/nES, 2) if they would be willing to try HNS/nES, and 3) if they were to choose only one of the four listed treatments, which one would they prefer to use every night. Results 162 patients completed the survey (81 males, mean age 52 (12) years, BMI 34 (7.3) kg/m 2 , ESS 10.2 (6.0) points, FOSQ10 28.5 (8.1) points). The majority of the respondents (89.5%) had been diagnosed with OSA, with 95.4% of those being treated with CPAP. 91.3% of the respondents were interested in more information and were willing to try HNS/nES. Most respondents preferred the potential use of nES (56.7%), while 21.7% chose HNS, 17.8% CPAP, and 3.8% the MAD. There were no differences in the characteristics of the patients who preferred nES compared to those who preferred other treatments; however, a regression analysis showed that a low ESS score was a predictor of patients choosing nES (p < 0.05). Conclusion Although the CPAP is the established treatment for OSA, most patients would prefer alternatives for long-term treatment. The majority of the respondents were interested in emerging technologies, with less sleepy patients more likely to choose less invasive treatment options. Background Adaptive Servo Ventilation (ASV) was developed to treat Central Sleep Apnea in patients with heart failure, which is usually associated with a low or normal PaCO2. The aim of ASV is to stabilise rather than increase overall ventilation. Evidence is limited regarding the use of ASV not only in heart failure patients but central sleep apnea of other aetiologies. The current study therefore explored this therapy in a regional sleep centre in the UK. Method A retrospective review of the outcomes of 42 patients who were treated with ASV between January 2012 and December 2013, either following conventional positive airway pressure (PAP) or as an initial therapy. Measurements included the Apnea Hypopnea Index (AHI), compliance (measured by hours of machine use/night) and subjective sleep quality, pre and post ASV. P296Results All patients demonstrated evidence of central sleep apnea with a reduced or normal transcutaneous CO2 during daytime spontaneous ventilation. Seven patients (16%) met the criteria for complex sleep apnea. 16 (38%) had evidence of heart failure whilst opioids were in use in six patients (14%). The majority of patients, (n = 36, 86%), were on PAP prior to ASV (mean duration 2.4 years), 22 patients (53%) were on Bi-level and 14 (33%) were on CPAP. Six patients (14%) had ASV as an initial therapy. The mean AHI improved from 31.7/h (range 2-84/h) to 5.1/h (Range 0-50/h) with ASV [ Figure 1]. Compliance improved from 5.2 h/night to 6.4 h/night with ASV. 22 patients (52%) reported a subjective improvement in their sleep quality using ASV. Conclusion ASV appeared superior to traditional PAP in improving AHI, compliance and sleep quality for patients with central sleep apnea of various aetiologies. Introduction NIV is now part of standard acute care in the UK. "Door-to-mask" time has been discussed as a p...