Effect of Ferric Sodium EDTA administration, in combination with vitamin C, folic acid, copper gluconate, zinc gluconate and selenomethionine, on cardiovascular risk evaluation: exploration of the HRV frequency domain

diseases. Using the Heart Rate Variability (HRV) analysis is possible to provide an evaluation of the safety and the effectiveness of intervention. Objective: To evaluate the efficacy and safety of Ferric Sodium EDTA in combination with vitamin C, folic acid, copper gluconate, zinc gluconate and selenomethionine (Ferachel forte®) 2 tabs/day for 24 days in elderly patients with secondary anaemia, by exploring the HRV frequency domain. Methods: In 45 elderly patients with secondary anaemia and/or low-moderate kidney failure, laboratory values after administration of Ferric Sodium EDTA, 2 tabs a day, in combination with vitamin C, folic acid, copper gluconate, zinc gluconate and selenomethionine (Ferachel forte®) for 24 days (N=16 patients) or ferrous gluconate 63 mg/day added to saline solution, administered using intravenous access during the hospitalization period of 15 ± 5 days (N=29 patients) were evaluated. Also, ECG signals and bioelectrical impedance (BIA) were measured. Results: Oral iron supplementation with Ferric Sodium EDTA, in combination with vitamin C, folic acid, copper gluconate, zinc gluconate and selenomethionine (Ferachel forte®) confirmed to be effective and safe about the cardiovascular risk in old patients. This study showed the real superiority of the oral administration about the cardiovascular risk in elderly patients in comparison with intravenous administration of ferrous gluconate. Conclusion: This study confirms that Ferric Sodium EDTA combination (Ferachel forte®) can be a valid alternative to ferrous gluconate intravenous therapy (gold standard) in the treatment of secondary anaemia in elderly patients. In fact, during the treatment, efficacy results have been maintained without statistically significant variations about cardiovascular risk, evaluated by exploring the HRV frequency domain

When does NICE recommend the use of health technologies within a programme of evidence development?

This article is made available through the Brunel Open Access Publishing Fund. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.This article has been made available through the Brunel Open Access Publishing Fund.Background: There is growing interest internationally in linking reimbursement decisions with recommendations for further research. In the UK, the National Institute for Health and Clinical Excellence (NICE) can issue guidance to approve the routine use of a health intervention, reject routine use or recommend use within a research programme. These latter recommendations have restricted use to ‘only in research’ (OIR) or have recommended further research alongside routine use (‘approval with research’ or AWR). However, it is not currently clear when such recommendations are likely to be made. Objectives: This study aims to identify NICE technology appraisals where OIR or AWR recommendations were made and to examine the key considerations that led to those decisions. Methods: Draft and final guidance including OIR/AWR recommendations were identified. The documents were reviewed to establish the characteristics of the technology appraisal, the cost effectiveness of the technologies, the key considerations that led to the recommendations and the types of research required. Results: In total, 29 final and 31 draft guidance documents included OIR/AWR recommendations up to January 2010. Overall, 86 % of final guidance included OIR recommendations. Of these, the majority were for technologies considered to be cost ineffective (83 %) and the majority of final guidance (66 %) specified the need for further evidence on relative effectiveness. The use of OIR/AWR recommendations is decreasing over time and they have rarely been used in appraisals conducted through the single technology appraisal process. Conclusion: NICE has used its ability to recommend technologies within research programmes, although predominantly within the multiple technology appraisal process. OIR recommendations have been most frequently issued for technologies considered cost ineffective and the most frequently cited consideration is uncertainty related to relative effectiveness. Key considerations cited for most AWR recommendations and some OIR recommendations included a need for further evidence on long-term outcomes and adverse effects of treatment.Medical Research Counci

Clinical implications of discordant early molecular responses in CML patients treated with imatinib

A reduction in BCR-ABL1/ABL1IS transcript levels to <10% after 3 months or <1% after 6 months of tyrosine kinase inhibitor therapy are associated with superior clinical outcomes in chronic myeloid leukemia (CML) patients. In this study, we investigated the reliability of multiple BCR-ABL1 thresholds in predicting treatment outcomes for 184 subjects diagnosed with CML and treated with standard-dose imatinib mesylate (IM). With a median follow-up of 61 months, patients with concordant BCR-ABL1/ABL1IS transcripts below the defined thresholds (10% at 3 months and 1% at 6 months) displayed significantly superior rates of event-free survival (86.1% vs. 26.6%) and deep molecular response (≥ MR4; 71.5% vs. 16.1%) compared to individuals with BCR-ABL1/ABL1IS levels above these defined thresholds. We then analyzed the outcomes of subjects displaying discordant molecular transcripts at 3-and 6-month time points. Among these patients, those with BCR-ABL1/ABL1IS values >10% at 3 months but <1% at 6 months fared significantly better than individuals with BCR-ABL1/ABL1IS <10% at 3 months but >1% at 6 months (event-free survival 68.2% vs. 32.7%; p < 0.001). Likewise, subjects with BCR-ABL1/ABL1IS at 3 months >10% but <1% at 6 months showed a higher cumulative incidence of MR4 compared to patients with BCR-ABL1/ABL1IS <10% at 3 months but >1% at 6 months (75% vs. 18.2%; p < 0.001). Finally, lower BCR-ABL1/GUSIS transcripts at diagnosis were associated with BCR-ABL1/ABL1IS values <1% at 6 months (p < 0.001). Our data suggest that when assessing early molecular responses to therapy, the 6-month BCR-ABL1/ABL1IS level displays a superior prognostic value compared to the 3-month measurement in patients with discordant oncogenic transcripts at these two pivotal time points

The Study of Adequacy of Clinical Trainings To work as a Family Physician From the Viewpoint of Graduates in Ardabil Province

Introduction and Objective: By Considering the fact that the graduated doctors tackle with job problems in providing medical services, In this study periods, they are given some clinical medicine trainings to solve those problems. The present study investigates the issues, especially regarding family medical services from the viewpoint of graduates. The aim of the study to identify efficacious factors, and offer the necessary recommendations to improve the quality of medical training. Conducting an opinion poll among the graduates of the university is one of the easiest and most reliable ways to discover the problems and resolve them. Therefore, the purpose of this research is to identify these problems and offer some suggestions to solve them. Method: This research is a descriptive study. The participants were medical doctors who have worked as a family physician in Ardabil province in 1389. The research instrument was a questionnaire containing 114 questions using Likert scale. The data was analyzed by SPSS for calculation of frequency. The results are presented by frequency tables. Results: In this study, most of the doctors were calling for fundamental changes in the process of clinical education. In addition, according to the doctors, the degree of clinic effect in better learning as well as the degree of watch-doctor effect was optimal in experience obtaining. Evaluation showed that the efficiency of management sector with mean 2/6 of 5 was poor, while the efficiency of emergency wards, referral, childcare, care for adolescents and youths, elderly care, family planning and most respondents' health with mean respectively 3/3, 3/2, 3/6, 3/8, 3/4, 3 and 2/8 was average. Moreover, based on the performed evaluation, the efficiency of visit departments, surgery, counseling, training, middle-aged care, maternal care and care of specific diseases, with respectively means 3/7, 3, 3/1, 3/5, 4/2 and 3/8 was good. Conclusion: Taking necessary actions to correct teaching methods for practical courses and a possible increase in training periods are suggested so that doctors could gain the ability needed to treat the patients. In health management sector, major revision should be done in training curriculum, and in counseling sectors, medical emergencies, referral, family planning and work-environment health, changes have also to be applied in clinical training

Designing theoretically-informed implementation interventions.

Canadian Institutes of Health Research; Ontario Ministry of Healt

Effects of exercise-induced arterial hypoxemia on limb muscle fatigue and performance

1. Reductions in arterial O2 saturation (−5% to −10% SaO2 below rest) occur over time during sustained heavy-intensity exercise in a normoxic environment, caused primarily by the effects of acid pH and increased temperature on the position of the HbO2 dissociation curve. 2. We prevented the desaturation incurred during exercise at ∼90% √O2 MAX via increased fraction of inspired O2 (FiO2) (0.23 to 0.29) and showed that exercise time to exhaustion was increased. 3. We used supramaximal magnetic stimulation (1–100 Hz) of the femoral nerve to test for quadriceps fatigue. We used mildly hyperoxic inspirates (FiO2 0.23 to 0.29) to prevent O2 desaturation. We then compared the amount of quadriceps fatigue incurred following cycling exercise at SaO2 91% vs 98% with each trial carried out at identical work rates and for equal durations. 4. Preventing the normal exercise-induced O2 desaturation prevented about one-half the amount of exercise-induced quadriceps fatigue; plasma lactate and effort perception were also reduced. In a subset of less fit subjects who showed only minimal arterial hypoxaemia during sustained exercise (SaO2 ∼95%), breathing a mildly hypoxic inspirate (FiO2 0.17; SaO2 ∼88%) exacerbated the quadriceps fatigue. 5. We conclude that the normal exercise-induced O2 desaturation during heavy-intensity endurance exercise contributes significantly to exercise performance limitation in part because of its effect on locomotor muscle fatigue

Safer clinical systems : interim report, August 2010

Safer Clinical Systems is the Health Foundation’s new five year programme of work to test and demonstrate ways to improve healthcare systems and processes, to develop safer systems that improve patient safety. It builds on learning from the Safer Patients Initiative (SPI) and models of system improvement from both healthcare and other industries. Learning from the SPI highlighted the need to take a clinical systems approach to improving safety. SPI highlighted that many hospitals struggle to implement improvement in clinical areas due to inherent problems with support mechanisms. Clinical processes and systems, rather than individuals, are often the contributors to breakdown in patient safety. The Safer Clinical Systems programme aimed to measure the reliability of clinical processes, identify defects within those processes, and identify the systems that result in those defects. Methods to improve system reliability were then to be tested and re-developed in order to reduce the risk of harm being caused to patients. Such system-level awareness should lead to improvements in other patient care pathways. The relationship between system reliability and actual harm is challenging to identify and measure. Specific, well-defined, small-scale processes have been used in other programmes, and system reliability has been shown to have a direct causal relationship with harm (e.g. care bundle compliance in an intensive care unit can reduce the incidence of ventilator-associated pneumonia). However, it has become evident that harm can be caused by a variety of factors over time; when working in broader, more complex and dynamic systems, change in outcome can be difficult to attribute to specific improvements and difficulties are also associated with relating evidence to resulting harm. The overall aim of Phase 1 of the Safer Clinical Systems programme was to demonstrate proof-of-concept that using a systems-based approach could contribute to improved patient safety. In Phase 1, experienced NHS teams from four locations worked together with expert advisers to co-design the Safer Clinical Systems programme

Simulation in clinical education: a reflective and critical account

Simulation. A complex tool employed to immerse learners in a reality created specifically to elicit actions, behaviours and thought processes which can then be discussed with peers and reflected upon by the learner immediately and at leisure. This was my understanding of what simulation has to offer as an educational intervention. I viewed simulation through the lens of Honey and Mumford's (1986) experiential learning typology, seeing it satisfy all four learning styles - activist and reflector most obviously so, but theorist because of the observational element and pragmatist as the scenario unravels. It externalises what is often the internal parts of the cycle – reflection and abstract conceptualisation – through the debriefing process. I also believed that high fidelity environments offered the greatest return in terms of learning – being rather dismissive of lower fidelity tools. However, through active observation of simulation – both in a setting I am familiar with (mannequin based scenarios) and in one I am not (dental student lab-based simulation) – I am recognising that this view may be only a small aspect of what simulation has to offer and that fidelity is not everything