Increasing Doses of Intraoperative Hydromorphone Do Not Reduce Postoperative Pain

Introduction: • Intermediate and long acting opioids are given intraoperatively to reduce pain during emergence from anesthesia. • Recent evidence suggests that intraoperative opioids have inconsistent effects on nociception and pain in the immediate postoperative period. • Multiple potent, short-acting opioids such as remifentanil, sufentanil and fentanyl have been shown to produce dose-related increases in pain scores and opioid consumption in the immediate postoperative recovery period. • Intraoperative doses of longer acting opioids such as morphine and methadone6 have been shown to reduce pain scores and narcotic requirements in the immediate postoperative period. • Hydromorphone is an intermediate duration narcotic which is commonly used intraoperatively but has not been studied for its potential to reduce pain in the immediate postoperative period

Process of discovery: A fourth-year translational science course

The Liaison Committee on Medical Education notes the importance of educating medical students on clinical and translational research principles.To describe a fourth-year course, “Process of discovery,” which addresses teaching these principles, and to discuss students’ perceptions of the course.Core components and pedagogical methods of this course are presented. Course assessment was performed with specific pre- and post-course assessments.During academic years 2004 to 2009, 562 students were enrolled, with assessment response rate of 94% pre-course and 85% post-course. The students’ self-assessment of their current understanding of clinical and translation research significantly increased, as well as their understanding of how clinical advances will take place over the next decade.A fourth-year course teaching clinical and translational research is successful, is seen as a positive experience and can meet the requirements for including clinical and translational research in the medical school curriculum

Holocene landscape intervention and plant food production strategies in island and mainland Southeast Asia

In the areas adjacent to the drowned Pleistocene continent of Sunda - present-day Mainland and Island SE Asia - the Austronesian Hypothesis of a diaspora of rice cultivators from Taiwan ~4200 years ago has often been linked with the start of farming. Mounting evidence suggests that these developments should not be conflated and that alternative explanations should be considered, including indigenous inception of complex patterns of plant food production and early exchange of plants, animals, technology and genes. We review evidence for widespread forest disturbance in the Early Holocene which may accompany the beginnings of complex food-production. Although often insubstantial, evidence for incipient and developing management of rainforest vegetation and of developing complex relationships with plants is present, and early enough to suggest that during the Early to mid-Holocene this vast region was marked by different approaches to plant food production. The trajectory of the increasingly complex relationships between people and their food organisms was strongly locally contingent and in many cases did not result in the development of agricultural systems that were recognisable as such at the time of early European encounters. Diverse resource management economies in the Sunda and neighbouring regions appear to have accompanied rather than replaced a reliance on hunting and gathering. This, together with evidence for Early Holocene interaction between these neighbours, gives cause for us to question some authors continued adherence to a singular narrative of the Austronesian Hypothesis and the 'Neolithisation' of this part of the world. It also leads us to suggest that the forests of this vast region are, to an extent, a cultural artefact

Swallowing, nutrition and patient-rated functional outcomes at 6 months following two non-surgical treatments for T1-T3 oropharyngeal cancer

Altered fractionation radiotherapy with concomitant boost (AFRT-CB) may be considered an alternative treatment for patients not appropriate for chemoradiation (CRT). As functional outcomes following AFRT-CB have been minimally reported, this exploratory paper describes the outcomes of patients managed with AFRT-CB or CRT at 6 months post-treatment

Interventions for preventing oral mucositis for patients with cancer receiving treatment

Interventions for preventing oral mucositis for patients with cancer receiving treatmentTreatment for cancer (including bone marrow transplant) can cause oral mucositis (severe ulcers in the mouth). This painful condition can cause difficulties in eating, drinking and swallowing, and may also be associated with infections which may require the patient to stay longer in hospital. Different strategies are used to try and prevent this condition, and the review of trials found that some of these are effective. Two interventions, cryotherapy (ice chips) and keratinocyte growth factor (palifermin®) showed some benefit in preventing mucositis. Sucralfate is effective in reducing the severity of mucositis, and a further seven interventions, aloe vera, amifostine, intravenous glutamine, granulocyte‐colony stimulating factor (G‐CSF), honey, laser and antibiotic lozenges containing polymixin/tobramycin/amphotericin (PTA) showed weaker evidence of benefit. These were evaluated in patients with different types of cancer, undergoing different types of cancer treatment. Benefits may be restricted to the disease and treatment combinations evaluated

Long-term functional outcomes and the patient perspective following altered fractionation with concomitant boost for oropharyngeal cancer

With no long-term data available in published research to date, this study presents details of the swallowing outcomes as well as barriers to and facilitators of oral intake and weight maintenance at 2 years after altered fractionation radiotherapy with concomitant boost (AFRT-CB). Twelve patients with T1-T3 oropharyngeal cancer who received AFRT-CB were assessed at baseline, 6 months, and 2 years post-treatment for levels of dysphagia and salivary toxicity, food and fluid tolerance, functional swallowing outcomes, patient-reported function, and weight. At 2 years, participants were also interviewed to explore barriers and facilitators of oral intake. Outcomes were significantly worse at 2 years when compared to baseline for late toxicity, functional swallowing, and patient-rated physical aspects of swallowing. Most patients (83%) tolerated a full diet pretreatment, but the rate fell to 42% (remainder tolerated soft diets) at 2 years. Multiple barriers to oral intake that impacted on activity and participation levels were identified. Participants lost 11 kg from baseline to 2 years, which was not regained between 6 months and 2 years. Global, social, and emotional domains of patient-reported function returned to pretreatment levels. At 2 years post AFRT-CB, worsening salivary and dysphagia toxicity, declining functional swallowing, and multiple reported ongoing barriers to oral intake had a negative impact on participants' activity and participation levels relating to eating. These ongoing deficits contributed to significant deterioration in physical swallowing functioning determined by the MDADI. In contrast, patients perceived their broader functioning had improved at 2 years, suggesting long-term adjustment to ongoing swallowing deficits

Contextualising school readiness in South Africa: Stakeholders’ perspectives

Preparing children for mainstream school occurs in systems that act as an overarching context. The perspectives of stakeholders influence how they prepare children for mainstream education.The aim of this study was to develop an understanding of the contextual factors that affect school readiness as identified by stakeholders. School readiness was conceptualised as a function of contextual influences and connections between individual and systemic factors enabling the child to benefit from the curriculum

Health Disparities Between Appalachian and Non-Appalachian Counties in Virginia USA

The examination of health disparities among people within Appalachian counties compared to people living in other counties is needed to find ways to strategically target improvements in community health in the United States of America (USA). Methods: A telephone survey of a random sample of adults living in households within communities of all counties of the state of Virginia (VA) in the USA was conducted. Findings: Health status was poorer among those in communities within Appalachian counties in VA and health insurance did not make a difference. Health perception was significantly worse in residents within communities in Appalachian counties compared to non-Appalachian community residents (30.5 vs. 17.4% rated their health status as poor/fair), and was worse even among those with no chronic diseases. Within communities in Appalachian counties, black residents report significantly better health perception than do white residents. Conclusion: Residents living in communities in Appalachian counties in VA are not receiving adequate health care, even among those with health insurance. More research with a larger ethnic minority sample is needed to investigate the racial/ethnic disparities in self-reported health and health care utilization within communities

“They made me feel comfortable”: a comparison of methods to measure patient experience in a sexual health clinic

Background High quality sexual health services are needed to improve both individual and public health outcomes. This study set out to explore what is important to patients who visit a sexual health clinic, and examine their understanding of standard survey questions, in order to inform the collection and interpretation of patient experience data that are used to improve services. Methods We conducted a cross-sectional, qualitative study. In the first part of the interview, we used “discovery interviews” to explore patients’ experiences of attending a central London walk-in sexual health clinic. In the second part, we asked patients how they would respond to eight standard patient experience survey questions and to provide an explanation for each of their responses. We conducted a thematic analysis of the interview data. Results We interviewed seventeen participants (nine women, eight men) of different ethnicities and backgrounds. All interviewees were positive about their experience. They described how staff had made them feel “comfortable”, and talked about how staff spent time, listened and did not rush them, despite being a very busy clinic. In response to the survey questions, fourteen patients rated their as care excellent or very good overall. However, survey questions were interpreted in different ways and were not always easily understood. Conclusions The open-ended “discovery interviews” provided new insights into aspects of care that were most valued or could improve. Standard patient experience questions provide a rating but little elucidation of the experiences that lie behind patients’ responses. They do not always measure aspects of care valued by patients or identify areas for improvement. They are not uniformly understood and necessarily collapse a wide range of experiences and views into categories that may seem inappropriate. Qualitative methods have a key role in measuring patient experience and involving patients in service improvement

Physiological changes to the swallowing mechanism following (Chemo)radiotherapy for head and neck cancer: a systematic review

Emerging research suggests that preventative swallowing rehabilitation, undertaken before or during (chemo)radiotherapy ([C]RT), can significantly improve early swallowing outcomes for head and neck cancer (HNC) patients. However, these treatment protocols are highly variable. Determining specific physiological swallowing parameters that are most likely to be impacted post-(C)RT would assist in refining clear targets for preventative rehabilitation. Therefore, this systematic review (1) examined the frequency and prevalence of physiological swallowing deficits observed post-(C)RT for HNC, and (2) determined the patterns of prevalence of these key physiological deficits over time post-treatment. Online databases were searched for relevant papers published between January 1998 and March 2013. A total of 153 papers were identified and appraised for methodological quality and suitability based on exclusionary criteria. Ultimately, 19 publications met the study’s inclusion criteria. Collation of reported prevalence of physiological swallowing deficits revealed reduced laryngeal excursion, base-of-tongue (BOT) dysfunction, reduced pharyngeal contraction, and impaired epiglottic movement as most frequently reported. BOT dysfunction and impaired epiglottic movement showed a collective prevalence of over 75 % in the majority of patient cohorts, whilst reduced laryngeal elevation and pharyngeal contraction had a prevalence of over 50 %. Subanalysis suggested a trend that the prevalence of these key deficits is dynamic although persistent over time. These findings can be used by clinicians to inform preventative intervention and support the use of specific, evidence-based therapy tasks explicitly selected to target the highly prevalent deficits post-(C)RT for HNC