The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

Purpose: This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting.<p></p> Methods: This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed.<p></p> Results: Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86).<p></p> Conclusions: This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores

Maternal perceptions of supervision in preschool-aged children: a qualitative approach to understanding differences between families living in affluent and disadvantaged areas

Aim: To explore maternal perceptions of supervision and childhood unintentional injury in order to develop understanding and explanation for differences in unintentional injury rates between an advantaged and disadvantaged area. Background: Unintentional injury is the second cause of mortality and a significant cause of morbidity in the zero to four year age group. Children living in socio economic disadvantage are at a greater risk of unintentional injury than their more affluent counter-parts. Methods: Qualitative study using semi-structured interviews; content data analysis was undertaken. Participants included 37 mothers with a child aged less than five years; 16 living in an area of disadvantage (and high rate of childhood unintentional injury) and 21= living in an advantaged area (and low rate of childhood unintentional injury). Findings: Parents in both areas described the importance of parental supervision in reducing child unintentional injury risks. Parents in both areas used listening as a supervision strategy. Parents in both areas described how ‘when the child goes quiet’ that is a cue for them to make a visual check on the child. Listening was used more for boys than girls in both areas, but parents in the advantaged area used listening as a supervision strategy more frequently than those in the disadvantaged area. Parents described supervision strategies as being shaped by child character and age rather than child gender. Parents in both areas described similar strategies for managing distractions. An important difference was found with regard to older siblings; parents living in the advantaged area described older siblings as an injury risk to younger children. Parents in the disadvantaged area described older siblings as providing some supervision for younger children. Parents living in disadvantaged circumstances may face greater challenges with regard to supervision than parents living in advantaged circumstances and this may partly explain differences in injury risk

Small-scale spatial and temporal variability in growth and mortality of fish larvae in the subtropical northcentral Gulf of Mexico: implications for assessing recruitment success

Extensive plankton collections were taken during seven September cruises (1990–93) along the inner continental shelf of the northcentral Gulf of Mexico (GOM). Despite the high productivity and availability of food during these cruises, significant small-scale spatial variability was found in larval growth rates for both Atlantic bumper (Chloroscombrus chrysurus, Carangidae) and vermilion snapper (Rhomboplites aurorubens, Lutjanidae). The observed variability in larval growth rates was not correlated with changes in water temperature or associated with conspicuous hydrographic features and suggested the existence of less-recognizable regions where conditions for growth vary. Cruise estimates of mortality coefficients (Z) for larval Atlantic bumper (n=32,241 larvae from six cruises) and vermilion snapper (n= 2581 larvae from four cruises) ranged from 0.20 to 0.37 and 0.19 to 0.29, respectively. Even in a subtropical climate like the GOM, where larval-stage durations may be as short as two weeks, observed variability in growth rates, particularly when combined with small changes in mortality rates, can cause order-of-magnitude differences in cumulative larval survival. To what extent the observed differences in growth rates at small spatial scales are fine-scale “noise” that ultimately is smoothed by larger-scale processes is not known. Future research is needed to further characterize the small-scale variability in growth rates of larvae, particularly with regard to microzooplankton patchiness and the temporal and spatial pattern of potential predators. Small-scale spatial variability in larval growth rates may in fact be the norm, and understanding the implications of this subtle mosaic may help us to better evaluate our ability to partition the causes of recruitment variability

Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process

Purpose: People with cancer and their families experience high levels of psychological morbidity. However many cancer services do not routinely screen patients for anxiety and depression and there are no standardized clinical referral pathways. This study aimed to establish consensus on elements of a draft clinical pathway tailored to the Australian context. Methods: A two-round Delphi study was conducted to gain consensus among Australian oncology and psycho-oncology clinicians about the validity of 39 items that form the basis of a clinical pathway that includes screening, assessment, referral and stepped-care management of anxiety and depression in the context of cancer. The expert panel comprised 87 multidisciplinary clinician members of the Australian Psycho-oncology Cooperative Research Group (PoCoG). Respondents rated their level of agreement with each statement on a 5-point likert scale. Consensus was defined as >80% of respondents scoring within 2 points on the likert scale. Results: Consensus was reached for 21 of 39 items, and a further 15 items approached consensus except for specific contextual factors, after 2 Delphi rounds. Formal screening for anxiety and depression, a stepped care model of management and recommendations for inclusion of length of treatment and time to review were endorsed. Consensus was not reached on items related to roles and responsibilities, particularly those not applicable across cancer settings. Conclusions: This study identified a core set of evidence- and consensus-based principles considered essential to a stepped care model of care incorporating identification, referral and management of anxiety and depression in adult cancer patients.This study was funded by Sydney Catalyst Translational Cancer Research Centr

Safety of extubating mechanically ventilated patients on vasoactive infusions: a retrospective cohort study

No abstract available

Playing with the future: social irrealism and the politics of aesthetics

In this paper we wish to explore the political possibilities of video games. Numerous scholars now take seriously the place of popular culture in the remaking of our geographies, but video games still lag behind. For us, this tendency reflects a general response to them as imaginary spaces that are separate from everyday life and 'real' politics. It is this disconnect between abstraction and lived experience that we complicate by defining play as an event of what Brian Massumi calls lived abstraction. We wish to short-circuit the barriers that prevent the aesthetic resonating with the political and argue that through their enactment, video games can animate fantastical futures that require the player to make, and reflect upon, profound ethical decisions that can be antagonistic to prevailing political imaginations. We refer to this as social irrealism to demonstrate that reality can be understood through the impossible and the imagined

Making it ‘APP’en: service user feedback: developing and implementing a service user APP: reflections from Northern Ireland, England and Scotland

Despite the advent of social media and increasing use of smart phone technology amongst global and UK populations, APP’s for social work remain in their infancy. Several have been developed which focus on the education of social workers and practitioners providing information on specific social work issues, and one we are aware of that explores ethics and values using a games-based approach. In this paper, we discuss the importance of service user perspective in social work practice and how this informed the development of the feedback App. We reflect on developing this instrument using digital technologies which social workers can use to gather anonymous feedback from service users about their experiences of social work interventions. This project, developed in response to demands placed on social work agencies to evidence the effectiveness of service interventions, provide robust data from service users for inspection regimes and sustain service user involvement in improving services. The evaluation model is designed to document the implementation process, exploring what works and what barriers, challenges and lessons were learned by the project team together with how some of the tensions in the process were addressed and resolved