The incidence, severity, timing and circadian variation of hypophosphataemia in Glasgow Royal Infirmary Intensive Care Unit [poster]

No abstract available

A randomised, controlled, double blind, non-inferiority trial of ultrasound-guided fascia iliaca block vs. spinal morphine for analgesia after primary hip arthroplasty

We performed a single centre, double blind, randomised, controlled, non-inferiority study comparing ultrasound-guided fascia iliaca block with spinal morphine for the primary outcome of 24-h postoperative morphine consumption in patients undergoing primary total hip arthroplasty under spinal anaesthesia with levobupivacaine. One hundred and eight patients were randomly allocated to receive either ultrasound-guided fascia iliaca block with 2 mg.kg−1 levobupivacaine (fascia iliaca group) or spinal morphine 100 μg plus a sham ultrasound-guided fascia iliaca block using saline (spinal morphine group). The pre-defined non-inferiority margin was a median difference between the groups of 10 mg in cumulative intravenous morphine use in the first 24 h postoperatively. Patients in the fascia iliaca group received 25 mg more intravenous morphine than patients in the spinal morphine group (95% CI 9.0–30.5 mg, p < 0.001). Ultrasound-guided fascia iliaca block was significantly worse than spinal morphine in the provision of analgesia in the first 24 h after total hip arthroplasty. No increase in side-effects was noted in the spinal morphine group but the study was not powered to investigate all secondary outcomes

Effects of footedness and stance asymmetry confirm an inter-leg metastable coordination dynamics of standing posture

We investigated the patterns of coordination between the left and right legs that support the task of maintaining an upright standing posture. We used cross-wavelet analyses to assess coordination between the centers of pressure under the left and right feet. We recruited participants with a lateralized functional preference for their right leg, and we manipulated whether these participants stood with symmetric/asymmetric stances and whether their eyes were open or closed. Our hypotheses were derived from the Haken-Kelso-Bunz (HKB) model of interlimb coordination dynamics. Consistent with HKB model predictions, we observed (1) coordination taking the form of metastable, transient epochs of stable phase relations, (2) preferences for in-phase and anti-phase coordination patterns, and (3) changes in pattern stability and phase leads associated with both stance asymmetry and right-side lateral preference. The form and stability of observed coordination patterns were mediated by the availability of visual information. Our findings confirm the existence of a metastable coordination dynamic associated with the task of maintaining upright stance. We discuss the implications of these findings in the context of evaluating the utility of the HKB model for understanding the functional organization of the posture system

The incidence, severity, timing and circadian variation of hypophosphataemia in Glasgow Royal Infirmary Intensive Care Unit [poster]

No abstract available

Intensive Care Syndrome: Promoting Independence and Return to Employment (InS:PIRE). Early evaluation of a complex intervention

Background: Many patients suffer significant physical, social and psychological problems in the months and years following critical care discharge. At present, there is minimal evidence of any effective interventions to support this patient group following hospital discharge. The aim of this project was to understand the impact of a complex intervention for ICU survivors. Methods: Quality improvement project conducted between September 2014 and June 2016, enrolling 49 selected patients from one ICU in Scotland. To evaluate the impact of this programme outcomes were compared to an existing cohort of patients from the same ICU from 2008–2009. Patients attended a five week peer supported rehabilitation programme. This multidisciplinary programme included pharmacy, physiotherapy, nursing, medical, and psychology input. The primary outcome in this evaluation was the EQ-5D, a validated measure of health-related quality of life. The minimally clinically important difference (MCID) in the EQ-5D is 0.08. We also measured change in self-efficacy over the programme duration. Based on previous research, this study utilised a 2.4 (6%) point change in self-efficacy scores as a MCID. Results: 40 patients (82%) completed follow-up surveys at 12 months. After regression adjustment for those factors known to impact recovery from critical care, there was a 0.07–0.16 point improvement in quality of life for those patients who took part in the intervention compared to historical controls from the same institution, depending on specific regression strategy used. Self-efficacy scores increased by 2.5 points (6.25%) over the duration of the five week programme (p = 0.003), and was sustained at one year post intervention. In the year following ICU, 15 InS:PIRE patients returned to employment or volunteering roles (88%) compared with 11 (46%) in the historical control group (p = 0.15). Conclusions and relevance: This historical control study suggests that a complex intervention may improve quality of life and self-efficacy in survivors of ICU. A larger, multi-centre study is needed to investigate this intervention further

Comparison of ultra-low, low and high concentration local anaesthetic for labour epidural analgesia: a systematic review and network meta-analysis

Lumbar epidural is the gold standard for labour analgesia. Low concentrations of local anaesthetic are recommended. This network meta-analysis investigated whether further reducing the concentration of local anaesthetic can improve maternal and neonatal outcomes without compromising analgesia. We conducted a systematic search of relevant databases for randomised controlled trials comparing high (>0.1%), low (>0.08% to ≤0.1%) or ultra-low (≤0.08%) concentration local anaesthetic (bupivacaine or equivalent) for labour epidural. Outcomes included mode of delivery, duration of labour and maternal/neonatal outcomes. Bayesian network meta-analysis with random-effects modelling was used to calculate odds ratios or weighted mean differences and 95% credible intervals. A total of 32 studies met inclusion criteria (3665 women). The total dose of local anaesthetic received increased as the concentration increased; ultra-low compared with low (weighted mean difference −14.96 mg, 95% credible interval [−28.38 to −1.00]) and low compared with high groups (weighted mean difference −14.99 [−28.79 to −2.04]), though there was no difference in the number of rescue top-ups administered between the groups. Compared with high concentration, ultra-low concentration local anaesthetic was associated with increased likelihood of spontaneous vaginal delivery (OR 1.46 [1.18 to 1.86]), reduced motor block (Bromage score >0; OR 0.32 [0.18 to 0.54]) and reduced duration of second stage of labour (weighted mean difference −13.02 min [−21.54 to −4.77]). Compared with low, ultra-low concentration local anaesthetic had similar estimates for duration of second stage of labour (weighted mean difference −1.92 min [−14.35 to 10.20]); spontaneous vaginal delivery (OR 1.07 [0.75 to 1.56]; assisted vaginal delivery (OR 1.35 [0.75 to 2.26]); caesarean section (OR 0.76 [0.49 to 1.22]); pain (scale 1–100, weighted mean difference −5.44 [−16.75 to 5.93]); and maternal satisfaction. Although a lower risk of an Apgar score < 7 at 1 min (OR 0.43 [0.15 to 0.79]) was reported for ultra-low compared with low concentration, this was not sustained at 5 min (OR 0.12 [0.00 to 2.10]). Ultra-low concentration local anaesthetic for labour epidural achieves similar or better maternal and neonatal outcomes as low and high concentration, but with reduced local anaesthetic consumption

The impact of a pharmacist intervention at an intensive care rehabilitation clinic

Objective: While disruptions in medications are common among patients who survive critical illness, there is limited information about specific medication-related problems among survivors of critical care. This study sought to determine the prevalence of specific medication-related problems detected in patients, seen after critical care discharge. Design: Consecutive patients attending an intensive care unit (ICU) follow-up programme were included in this single-centre service evaluation. Setting: Tertiary care regional centre in Scotland (UK). Participants: 47 patients reviewed after critical care discharge at an ICU follow-up programme. Interventions: Pharmacists conducted a full medication review, including: medicines reconciliation, assessing the appropriateness of each prescribed medication, identification of any medication-related problems and checking adherence. Measurements: Medication-related problems in patients following critical care discharge. Interventions and medication-related problems were systematically graded and risk factors were identified using an adapted version of the National Patient Safety Agency Risk Matrix. Main results: 69 medication-related problems were identified in 38 (81%) of the 47 patients. The most common documented problem was drug omission (29%). 64% of the medication-related problems identified were classified as either moderate or major. The number of pain medications prescribed at discharge from intensive care was predictive of medication-related problems (OR 2.02, 95% CI 1.14 to 4.26, p=0.03). Conclusions: Medication problems are common following critical care. Better communication of medication changes both to patients and their ongoing care providers may be beneficial following a critical care admission. In the absence of highly effective communication, a pharmacy intervention may contribute substantially to an intensive care rehabilitation or recovery programme

Community-based arts research for people with learning disabilities: challenging misconceptions about learning disabilities

This article presents some of the community-based artwork of a group of men with learning disabilities, who aimed to challenge some of the misconceptions associated with learning disabilities. People with learning disabilities regularly face many forms of direct and indirect stigma. The consequences of such negative perceptions may affect individuals’ social relationships and ensure that barriers are strengthened which prevent their full inclusion. The men in this project used a series of visual and creative methods to challenge some of these misconceptions by telling stories through art, demonstrating skill through photography, using poetry to talk about sexual identity and improvising drama and filmmaking to challenge stigma, and through sculpture expressed their voices. Thus, by doing so, they were able to challenge some of the stigma associated with learning disabilities, indicating that community-based arts research is a valuable way in which to promote the voices of people with learning disabilities

Randomized phase II – study evaluating EGFR targeting therapy with Cetuximab in combination with radiotherapy and chemotherapy for patients with locally advanced pancreatic cancer – PARC: study protocol [ISRCTN56652283]

BACKGROUND: Pancreatic cancer is the fourth commonest cause of death from cancer in men and women. Advantages in surgical techniques, radiation therapy techniques, chemotherapeutic regimes, and different combined-modality approaches have yielded only a modest impact on the prognosis of patients with pancreatic cancer. Thus there is clearly a need for additional strategies. One approach involves using the identification of a number of molecular targets that may be responsible for the resistance of cancer cells to radiation or to other cytotoxic agents. As such, these molecular determinants may serve as targets for augmentation of the radiotherapy or chemotherapy response. Of these, the epidermal growth factor receptor (EGFR) has been a molecular target of considerable interest and investigation, and there has been a tremendous surge of interest in pursuing targeted therapy of cancers via inhibition of the EGFR. METHODS/DESIGN: The PARC study is designed as an open, controlled, prospective, randomized phase II trial. Patients in study arm A will be treated with chemoradiation using intensity modulated radiation therapy (IMRT) combined with gemcitabine and simultaneous cetuximab infusions. After chemoradiation the patients receive gemcitabine infusions weekly over 4 weeks. Patients in study arm B will be treated with chemoradiation using intensity modulated radiation therapy (IMRT) combined with gemcitabine and simultaneous cetuximab infusions. After chemoradiation the patients receive gemcitabine weekly over 4 weeks and cetuximab infusions over 12 weeks. A total of 66 patients with locally advanced adenocarcinoma of the pancreas will be enrolled. An interim analysis for patient safety reasons will be done one year after start of recruitment. Evaluation of the primary endpoint will be performed two years after the last patient's enrolment. DISCUSSION: The primary objective of this study is to evaluate the feasibility and the toxicity profile of trimodal therapy in pancreatic adenocarcinoma with chemoradiation therapy with gemcitabine and intensity modulated radiation therapy (IMRT) and EGFR-targeted therapy using cetuximab and to compare between two different methods of cetuximab treatment schedules (concomitant versus concomitant and sequential cetuximab treatment). Secondary objectives are to determine the role and the mechanism of cetuximab in patient's chemoradiation regimen, the response rate, the potential of this combined modality treatment to concert locally advanced lesions to potentially resectable lesions, the time to progression interval and the quality of life