Critical Care & Anaesthesia- December 2012

 

 

Critical Care & Anaesthesia – Update  

 

 


December 2012

Welcome to the December bulletin of 2012 highlighting new evidence published on selected topics relating to Critical Care, Anaesthesia, Pain and Resuscitation. This bulletin will continue in its current format following a positive evaluation by staff. Full text articles can be accessed via your HEFT Athens ID.

Anaesthesia

The following sub-topics are covered:

  • Cell salvage in surgery (including obstetric surgery)
  • Anaesthesia and surgical outcomes (including epidurals, regional anaesthesia)
  • Anaesthesia and Immunomodulation
  • Anaesthesia and post operative confusion

 

Title: Use of intraoperative cell salvage in neurosurgery

Citation: Transfusion Alternatives in Transfusion Medicine, December 2012, vol./is. 12/3-4(59-65), 1295-9022;1778-428X (December 2012) Author(s): Roberts H., Carroll C.

Abstract: Intraoperative cell salvage (ICS) is widely used in many surgical specialties, but uptake in neurosurgery has been slow. Little direct evidence exists to support the use of ICS in neurosurgical procedures; however, studies suggest that ICS may be safe and cost-effective in intracranial surgery and spinal fusion.


 

Title: Washing and filtering of cell-salvaged blood - does it make autotransfusion safer?

Citation: Transfusion Alternatives in Transfusion Medicine, December 2012, vol./is. 12/3-4(78-87), 1295-9022;1778-428X (December 2012) Author(s): Konig G., Waters J.H.

Abstract: In this paper the authros review the clinical data supporting the need for washing and filtering of salvaged blood.


 

Title: The economic benefits of cell salvage in obstetric haemorrhage

Citation: International Journal of Obstetric Anesthesia, October 2012, vol./is. 21/4(329-333), 0959-289X;1532-3374 (October 2012) Author(s): Brearton C., Bhalla A., Mallaiah S., Barclay P.

Abstract: Background: Cell salvage is increasingly used in the management of major obstetric haemorrhage. Its financial considerations were evaluated over a 5-year period.

Full Text: Available from Elsevier in International Journal of Obstetric Anesthesia; Note: ; Notes: You will need to register (free of charge) with Science Direct the first time you use it.


 

Title: Combined Femoral and Sciatic Nerve Block vs Combined Femoral and Periarticular Infiltration in Total Knee Arthroplasty. A Randomized Controlled Trial

Citation: Journal of Arthroplasty, December 2012, vol./is. 27/10(1806-1811), 0883-5403;1532-8406 (December 2012) Author(s): Mahadevan D., Walter R.P., Minto G., Gale T.C., McAllen C.J., Oldman M.

Abstract: This study tests the null hypothesis that there is no difference between sciatic nerve block (SNB) and periarticular anesthetic infiltration (PI) as adjuncts to femoral nerve blockade (FNB) in total knee arthroplasty in terms of postoperative opioid requirements.


Title: Is Femoral Nerve Block Necessary During Total Knee Arthroplasty?. A Randomized Controlled Trial

Citation: Journal of Arthroplasty, December 2012, vol./is. 27/10(1800-1805), 0883-5403;1532-8406 (December 2012) Author(s): Widmer B.J., Scholes C.J., Pattullo G.G., Oussedik S.I., Parker D.A., Coolican M.R.J.

Abstract: There remains a lack of randomized controlled trials comparing methods of perioperative analgesia for total knee arthroplasty. To address this deficiency, a blinded, randomized controlled trial was conducted to compare the use of femoral nerve block (group F) and local anesthetic (group L).


 

Title: The effect of perioperative intravenous lidocaine and ketamine on recovery after abdominal hysterectomy

Citation: Anesthesia and Analgesia, November 2012, vol./is. 115/5(1078-1084), 0003-2999 (November 2012) Author(s): Grady M.V., Mascha E., Sessler D.I., Kurz A.

Abstract: The study tested the primary hypothesis that perioperative IV lidocaine and/or ketamine in patients undergoing open abdominal hysterectomy improves rehabilitation as measured by a 6-minute walk distance (6-MWD) on the second postoperative morning.

Full Text: Available from Ovid in Anesthesia and Analgesia


 

Title: Paravertebral blockade for day-case breast augmentation: A randomized clinical trial

Citation: Anesthesia and Analgesia, November 2012, vol./is. 115/5(1053-1059), 0003-2999 (November 2012) Author(s): Gardiner S., Rudkin G., Cooter R., Field J., Bond M.

Abstract: The study hypothesized that ropivacaine injected by experienced anesthesia providers into the paravertebral space as a PVB was more effective than ropivacaine injected by the operating surgeon (plastic surgeon) directly into the zone of surgical dissection.

Full Text: Available from Ovid in Anesthesia and Analgesia


 

Title: Continuous spinal anesthesia for lower limb surgery: A retrospective analysis of 1212 cases

Citation: Local and Regional Anesthesia, November 2012, vol./is. 5/1(63-67), 1178-7112 (07 Nov 2012) Author(s): Lux E.A.

Abstract: The aim of the present retrospective study was to analyze a large number of patients for the incidence of adverse events after continuous spinal anesthesia with a microcatheter.

Full Text: Available from National Library of Medicine in Local and Regional Anesthesia


 

Title: Anesthetic management during labor and delivery: A 21-year review of women with cancer in a tertiary care center

Citation: Journal of Clinical Anesthesia, November 2012, vol./is. 24/7(524-530), 0952-8180;1873-4529 (November 2012) Author(s): Tharmaratnam U., Balki M.

Abstract: Study objective was to describe the anesthetic management of labor and delivery in patients presenting with cancer during pregnancy at one institution.

Full Text: Available from MD Consult in Journal of Clinical Anesthesia; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.


 

Title: Total intravenous anesthesia with propofol reduces postoperative nausea and vomiting in patients undergoing robot-assisted laparoscopic radical prostatectomy: A prospective randomized trial

Citation: Yonsei Medical Journal, November 2012, vol./is. 53/6(1197-1202), 0513-5796 (November 2012) Author(s): Yoo Y.-C., Bai S.-J., Lee K.-Y., Shin S., Choi E.K., Lee J.W.

Abstract: The study investigated the effect of total intravenous anesthesia (TIVA) with propofol on postoperative nausea and vomiting (PONV) after robot-assisted laparoscopic radical prostatectomy (RLRP) in patients at low risk of developing PONV, in comparison to balanced anesthesia with desflurane.

Full Text: Available from EBSCOhost in Yonsei Medical Journal


 

Title: Does regional anaesthesia improve outcome after surgery?

Citation: Anaesthesia and Intensive Care Medicine, November 2012, vol./is. 13/11(563-566), 1472-0299;1878-7584 (November 2012) Author(s): Fischer B.

Abstract: There is conclusive evidence that regional anaesthesia provides better postoperative analgesia than systemic opioid techniques. Regional anaesthesia also has the potential to improve the functional outcome from surgery, although proving this in a clinically relevant way is challenging; many studies are inconclusive with methodological weaknesses making comparison difficult and offering conflicting evidence.


 

Title: Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: Effect of regional analgesia on quality of recovery

Citation: American Journal of Obstetrics and Gynecology, November 2012, vol./is. 207/5(419.e1-419.e5), 0002-9378;1097-6868 (November 2012) Author(s): Kane S.M., Garcia-Tomas V., Alejandro-Rodriguez M., Astley B., Pollard R.R.

Abstract: The objective of the study was to determine whether transversus abdominis plane (TAP) block improves the early postoperative quality of recovery (QoR-40). The secondary objectives measured postoperative pain, length of stay, and narcotic use.

Full Text: Available from MD Consult in American Journal of Obstetrics and Gynecology; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.


 

Title: Effect of thoracic epidural analgesia on clinical outcomes following transapical transcatheter aortic valve implantation

Citation: Heart, November 2012, vol./is. 98/21(1583-1590), 1355-6037;1468-201X (November 2012) Author(s): Amat-Santos I.J., Dumont E., Villeneuve J., Doyle D., Rheault M., Lavigne D., Lemieux J., St-Pierre A., Mok M., Urena M., Nombela-Franco L., Blackburn S., Simon M., Bourgault C., Carrasco J.L., Pibarot P., Cote M., DeLarochelliere R., Cohen D.J., Rodes-Cabau J.

Abstract: The study objective was to determine the impact of perioperative thoracic epidural analgesia (TEA) on acute and late outcomes following transapical transcatheter aortic valve implantation (TA-TAVI).

Full Text: Available from Highwire Press in Heart


 

Title: Does motor block related to long-acting brachial plexus block cause patient dissatisfaction after minor wrist and hand surgery? A randomized observer-blinded trial

Citation: British Journal of Anaesthesia, November 2012, vol./is. 109/5(809-815), 0007-0912;1471-6771 (November 2012) Author(s): Fredrickson M.J., Wolstencroft P.J., Chinchanwala S., Boland M.R.

Abstract: Patient dissatisfaction has been previously associated with motor block in shoulder surgery patients receiving brachial plexus block. For elective minor wrist and hand surgery, the authors tested whether a regional block accelerating the early return of upper extremity motor function would improve patient satisfaction compared with a long-acting proximal brachial plexus block.

Full Text: Available from EBSCOhost EJS in BJA: British Journal of Anaesthesia


 

 

 

 

Cardiac arrests/cardiopulmonary resuscitation (CPR)

The following sub-topics are covered:

  • Quality of CPR
  • Use of feedback devices
  • Leadership and team factors

 

Title: Real-time feedback systems in CPR

Citation: Trends in Anaesthesia and Critical Care, December 2012, vol./is. 2/6(287-294), 2210-8440 (December 2012) Author(s): Gruber J., Stumpf D., Zapletal B., Neuhold S., Fischer H.

Abstract: This review aims to give an overview of feedback devices for use by laypersons or healthcare providers during actual cardiac arrest. It summarizes the effect of such devices on CPR quality in simulation or real life and possible dangers or limitations.

Full Text: Available from Elsevier in Trends in Anaesthesia and Critical Care


 

Title: The delivery room of the future: The fetal and neonatal resuscitation and transition suite

Citation: Clinics in Perinatology, December 2012, vol./is. 39/4(931-939), 0095-5108;1557-9840 (December 2012) Author(s): Finer N.N., Rich W., Halamek L.P., Leone T.A.

Abstract: The authors' vision for the Fetal and Neonatal Resuscitation and Transition Suite of the future is marked by improvements in the amount of physical space, monitoring technologies, portable diagnostic and therapeutic technologies, communication systems, and capabilities and training of the resuscitation team. Human factors analysis will play an important role in the design and testing of the improvements for safe, effective, and efficient resuscitation of the newborn.

Full Text: Available from MD Consult in Clinics in Perinatology; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.


 

Title: Ability of code leaders to recall CPR quality errors during the resuscitation of older children and adolescents

Citation: Resuscitation, December 2012, vol./is. 83/12(1462-1466), 0300-9572;1873-1570 (December 2012) Author(s): McInnes A.D., Sutton R.M., Nishisaki A., Niles D., Leffelman J., Boyle L., Maltese M.R., Berg R.A., Nadkarni V.M.

AbstractThis study investigates code leader ability to recall CPR error during post-event interviews when CPR recording/audiovisual feedback-enabled defibrillators are deployed.

Full Text: Available from Elsevier in Resuscitation; Note: ; Notes: You will need to register (free of charge) with Science Direct the first time you use it.


 

Title: Team performance in resuscitation teams: Comparison and critique of two recently developed scoring tools

Citation: Resuscitation, December 2012, vol./is. 83/12(1478-1483), 0300-9572;1873-1570 (December 2012) Author(s): McKay A., Walker S.T., Brett S.J., Vincent C., Sevdalis N.

 Abstract: The aims of the study reported here were:. 1.To determine the inter-rater reliability of the tools in assessing performance within the context of resuscitation.2.To correlate scores of the same resuscitation teams episodes using both tools, thereby determining their concurrent validity within the context of resuscitation.3.To carry out a critique of both tools and establish how best each one may be utilised.

Full Text: Available from Elsevier in Resuscitation; Note: ; Notes: You will need to register (free of charge) with Science Direct the first time you use it.


 

 

 

Title: Wide variability in drug use in out-of-hospital cardiac arrest: A report from the resuscitation outcomes consortium

Citation: Resuscitation, November 2012, vol./is. 83/11(1324-1330), 0300-9572;1873-1570 (November 2012) Author(s): Glover B.M., Brown S.P., Morrison L., Davis D., Kudenchuk P.J., Van Ottingham L., Vaillancourt C., Cheskes S., Atkins D.L., Dorian P.

Abstract: Background: Despite the publication and dissemination of the Advanced Cardiac Life Support guidelines, variability in the use of drugs during resuscitation from out-of-hospital cardiac arrest may exist between different Emergency Medical Services throughout North America. The purpose of this study was to characterize the use of such drugs and evaluate their relationship to cardiac arrest outcomes.

Full Text: Available from Elsevier in Resuscitation; Note: ; Notes: You will need to register (free of charge) with Science Direct the first time you use it.


 

Title: Duration of hospital participation in Get With the Guidelines-Resuscitation and survival of in-hospital cardiac arrest

Citation: Resuscitation, November 2012, vol./is. 83/11(1349-1357), 0300-9572;1873-1570 (November 2012) Author(s): Bradley S.M., Huszti E., Warren S.A., Merchant R.M., Sayre M.R., Nichol G.

Abstract: Get With the Guidelines (GWTG-R) is a data registry and quality improvement program for in-hospital cardiac arrest (IHCA). It is unknown if duration of hospital participation in GWTG-R is associated with IHCA outcomes.

Full Text: Available from Elsevier in Resuscitation; Note: ; Notes: You will need to register (free of charge) with Science Direct the first time you use it.


 

Title: Impact of daily auditing and weekly feedback on process of care and patient outcome in resuscitation of severe sepsis and septic shock

Citation: Critical Care, November 2012, vol./is. 16/, 1364-8535 (14 Nov 2012) Author(s): Afessa B., Bowron C.B., Danielson R.D., Ramar K.

Abstract: The authors implemented a Quality Improvement Project based on daily auditing of patients admitted to a medical intensive care unit (MICU) for severe sepsis/septic shock followed by weekly feedback on compliance of the Institute for Healthcare Improvement (IHI) resuscitation bundle, and Sepsis Response Team (SRT) activation [4]. Once the Quality Improvement Project was completed, the daily audit and weekly feedback were stopped. This study aims to assess the impact of this change on the process of care and hospital mortality. Full Text: Available from Free Access Content in Critical Care


 

Critical Care

The following sub-topics are covered:

  • Sepsis – the use of statins, biomarker MMP9
  • Acute lung injury (ALI)/adult respiratory distress syndrome (ARDS)
  • Use of non invasive ventilation (NIV) in weaning
  • Ventilator associate pneumonia (including E.Coli)

 

Title: Distinct and replicable genetic risk factors for acute respiratory distress syndrome of pulmonary or extrapulmonary origin

Citation: Journal of Medical Genetics, November 2012, vol./is. 49/11(671-680), 0022-2593;1468-6244 (November 2012) Author(s): Tejera P., Meyer N.J., Chen F., Feng R., Zhao Y., O'Mahony D.S., Li L., Sheu C.-C., Zhai R., Wang Z., Su L., Bajwa E., Ahasic A.M., Clardy P.F., Gong M.N., Frank A.J., Lanken P.N., Thompson B.T., Christie J.D., Wurfel M.M., O'Keefe G.E., Christiani D.C.

Abstract: The aim of this study was to identify genetic variants contributing to ALI/ARDS from pulmonary or extrapulmonary causes.

Full Text:

Available from Free Access Content in Journal of Medical Genetics

Title: Longer duration of mechanical ventilation was found to be associated with ventilator-associated pneumonia in children aged 1 month to 12 years in India

Citation: Journal of Clinical Epidemiology, January 2013, vol./is. 66/1(62-66), 0895-4356;1878-5921 (January 2013) Author(s): Awasthi S., Tahazzul M., Ambast A., Govil Y.C., Jain A.

Abstract: The objective is to determine primarily (1) the incidence of ventilator-associated pneumonia (VAP) among ventilated patients aged 1 month to 12 years and secondarily (2) the risk factors for VAP and (3) common organisms causing VAP.


 

Title: Achieving Zero Central Line-associated Bloodstream Infection Rates in Your Intensive Care Unit

Citation: Critical Care Clinics, January 2013, vol./is. 29/1(1-9), 0749-0704;1557-8232 (January 2013) Author(s): Sagana R., Hyzy R.C.

Abstract: Central line-associated bloodstream infection (CLABSI) is one of the most common health care-associated infections in the United States. The costs associated with CLABSIs include an estimated 28,000 deaths in the intensive care unit and up to $2.3 billion annually. Best practice guidelines, checklists, and establishing a culture of safety in hospitals are all initiatives designed to reduce the rate of CLABSI to zero.

Full Text: Available from MD Consult in Critical Care Clinics; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.


 

Title: Rapid detection of Staphylococcus aureus in lower respiratory tract secretions from patients with suspected ventilator-associated pneumonia: Evaluation of the Cepheid Xpert MRSA/SA SSTI assay

Citation: Journal of Clinical Microbiology, December 2012, vol./is. 50/12(4095-4097), 0095-1137;1098-660X (December 2012) Author(s): Cercenado E., Marin M., Burillo A., Martin-Rabadan P., Rivera M., Bouza E.

Abstract: A preclinical evaluation was conducted to evaluate the performance of the Cepheid Xpert assay on 135 lower respiratory tract secretions for detection of methicillin-resistant Staphylococcus aureus and S. aureus.

Full Text: Available from Free Access Content in Journal of Clinical Microbiology


 

Title: Objective surveillance definitions for ventilator-associated pneumonia

Citation: Critical Care Medicine, December 2012, vol./is. 40/12(3154-3161), 0090-3493;1530-0293 (December 2012) Author(s): Klompas M., Magill S., Robicsek A., Strymish J.M., Kleinman K., Evans R.S., Lloyd J.F., Khan Y., Yokoe D.S., Stevenson K., Samore M., Platt R.

Abstract: The authors explored the feasibility of creating objective surveillance definitions for ventilator-associated pneumonia.

Full Text: Available from Ovid in Critical Care Medicine


 

Title: Diagnosis of ventilator-associated pneumonia: Do we need surrogate parameters?

Citation: Critical Care Medicine, December 2012, vol./is. 40/12(3311-3312), 0090-3493;1530-0293 (December 2012) Author(s): Torres A., Bassi G.L., Ferrer M.

Full Text: Available from Ovid in Critical Care Medicine

Title: Aerosolized antibiotics for ventilator-associated pneumonia: Lessons from experimental studies

Citation: Anesthesiology, December 2012, vol./is. 117/6(1364-1380), 0003-3022;1528-1175 (December 2012) Author(s): Rouby J.-J., Bouhemad B., Monsel A., Brisson H., Arbelot C., Lu Q.

Abstract: The aim of this review is to perform a critical analysis of experimental studies on aerosolized antibiotics and draw lessons for clinical use in patients with ventilator-associated pneumonia.

Full Text: Available from Ovid in Anesthesiology

Title: Efficacy of high-dose nebulized colistin in ventilator-associated pneumonia caused by multidrug-resistant pseudomonas aeruginosa and acinetobacter baumannii

Citation: Anesthesiology, December 2012, vol./is. 117/6(1335-1347), 0003-3022;1528-1175 (December 2012) Author(s): Lu Q., Luo R., Bodin L., Yang J., Zahr N., Aubry A., Golmard J.-L., Rouby J.-J.

Abstract: The aim of the study was to assess efficacy of nebulized colistin for treating ventilator-associated pneumonia (VAP) caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii.

Full Text: Available from Ovid in Anesthesiology


 

Title: Patient Safety in the Critical Care Environment

Citation: Surgical Clinics of North America, December 2012, vol./is. 92/6(1369-1386), 0039-6109;1558-3171 (December 2012) Author(s): Rossi P.J., Edmiston Jr. C.E.

Abstract: Improving the quality and safety of intensive care unit (ICU) care in the United States is a significant challenge for the future. Improvement of device safety will be critical to reducing the large number of device-related complications that occur in US ICUs. Prospective collection of adverse events with rigorous analysis will be important to allow systematic errors to be exposed and corrected.

Full Text: Available from MD Consult in Surgical Clinics of North America, The; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.


 

Title: Decreasing ventilator-associated pneumonia in the intensive care unit: A sustainable comprehensive quality improvement program

Citation: American Journal of Infection Control, November 2012, vol./is. 40/9(877-879), 0196-6553;1527-3296 (November 2012) Author(s): Heck K.

Abstract: An intensive care unit implemented an oral care bundle to decrease ventilator-associated pneumonia (VAP).

Full Text: Available in American Journal of Infection Control at Heartlands Staff Library; Note: ; Notes: Available in print at Heartlands Library. Collection notes: Available in print at Heartlands Library


 

Title: Backrest position in prevention of pressure ulcers and ventilator-associated pneumonia: Conflicting recommendations

Citation: Heart and Lung: Journal of Acute and Critical Care, November 2012, vol./is. 41/6(536-545), 0147-9563;1527-3288 (November 2012) Author(s): Burk R.S., Grap M.J.

Abstract: To prevent pressure ulcers, guidelines limit bed backrest elevation to less than 30 degrees, whereas recommendations to reduce VAP include use of backrest elevations of 30 degrees or more. This article will focus on summarizing the major evidence for each of these apparently conflicting positioning strategies and discuss implications for practice in managing mechanically ventilated patients with risk factors for both pressure ulcers and VAP.

Full Text: Available from ProQuest in Heart and Lung


 

Title: Pseudomonas aeruginosa-catecholamine inotrope interactions: A contributory factor in the development of ventilator-associated pneumonia?

Citation: Chest, November 2012, vol./is. 142/5(1200-1210), 0012-3692;1931-3543 (November 2012) Author(s): Freestone P.P., Hirst R.A., Sandrini S.M., Sharaff F., Fry H., Hyman S., O'Callaghan C.

Abstract: Despite intensive research, it is still unclear why Pseudomonas aeruginosa, a microbe that rarely causes pneumonia outside of intensive care, is responsible for so many of these infections.

Full Text: Available from MD Consult in Chest; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.


Title: Impact of oral care with versus without toothbrushing on the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials

Citation: Critical Care, October 2012, vol./is. 16/5, 1364-8535;1466-609X (12 Oct 2012)

Author(s): Gu W.-J., Gong Y.-Z., Pan L., Ni Y.-X., Liu J.-C.

Abstract: The study undertook a systematic review and meta-analysis of randomized controlled trials to assess the effect of tooth brushing as a component of oral care on the prevention of VAP in adult critically ill patients.

Full Text:

Available from Free Access Content in Critical Care


 

Title: Lack of efficacy of probiotics in preventing ventilator-associated pneumonia: A systematic review and meta-analysis of randomized controlled trials

Citation: Chest, October 2012, vol./is. 142/4(859-868), 0012-3692;1931-3543 (October 2012) Author(s): Gu W.-J., Wei C.-Y., Yin R.-X.

Abstract: The study undertook a systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy and safety of probiotics for the prevention of VAP.

Full Text: Available from MD Consult in Chest; Note: ; Notes: You will need to register (free of charge) with MD Consult the first time you use it.


 

New Books Added to the HEFT Libraries

 

To reserve any of the above books, please go to www.base-library.nhs.uk and reserve them using your library ID and PIN number.

 

Wishing you all a Merry Christmas and a very Happy New Year 2013

                                       

Further Information:

The following sources have been scanned for evidence published in the previous 4 weeks: Lancet, BMJ, JAMA, NEJM and American Journal of Critical Care Medicine; and articles from other journals as retrieved via searches on MEDLINE and EMBASE are also listed.

For a detailed list of sources that have been scanned, please contact [email protected]

To access the full text links in this bulletin, login with your HEFT Athens ID at

http://www.evidence.nhs.uk/nhs-evidence-content/journals-and-databases ‘before’ clicking on them in order to make them seamless

 

NEW WEB BASED ARTICLE REQUEST SYSTEM-  From 1st November 2012, the HEFT Library services introduced a new system for requesting journal articles, leading to a faster and more efficient service.  Register now at http://www.basedoc.co.uk/ using your Library ID no.

For more information on how to register for Athens, access the Athens Registration leaflet via HEFT Library website www.heftlibrary.nhs.uk

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