Guidelines in the era of realistic medicine

No abstract available

Investigation in haemodynamic stability during intermittent haemodialysis in the critically ill

No abstract available

An investigation into the effects of commencing haemodialysis in the critically ill

<b>Introduction:</b> We have aimed to describe haemodynamic changes when haemodialysis is instituted in the critically ill. 3 hypotheses are tested: 1)The initial session is associated with cardiovascular instability, 2)The initial session is associated with more cardiovascular instability compared to subsequent sessions, and 3)Looking at unstable sessions alone, there will be a greater proportion of potentially harmful changes in the initial sessions compared to subsequent ones. <b>Methods:</b> Data was collected for 209 patients, identifying 1605 dialysis sessions. Analysis was performed on hourly records, classifying sessions as stable/unstable by a cutoff of >+/-20% change in baseline physiology (HR/MAP). Data from 3 hours prior, and 4 hours after dialysis was included, and average and minimum values derived. 3 time comparisons were made (pre-HD:during, during HD:post, pre-HD:post). Initial sessions were analysed separately from subsequent sessions to derive 2 groups. If a session was identified as being unstable, then the nature of instability was examined by recording whether changes crossed defined physiological ranges. The changes seen in unstable sessions could be described as to their effects: being harmful/potentially harmful, or beneficial/potentially beneficial. <b>Results:</b> Discarding incomplete data, 181 initial and 1382 subsequent sessions were analysed. A session was deemed to be stable if there was no significant change (>+/-20%) in the time-averaged or minimum MAP/HR across time comparisons. By this definition 85/181 initial sessions were unstable (47%, 95% CI SEM 39.8-54.2). Therefore Hypothesis 1 is accepted. This compares to 44% of subsequent sessions (95% CI 41.1-46.3). Comparing these proportions and their respective CI gives a 95% CI for the standard error of the difference of -4% to 10%. Therefore Hypothesis 2 is rejected. In initial sessions there were 92/1020 harmful changes. This gives a proportion of 9.0% (95% CI SEM 7.4-10.9). In the subsequent sessions there were 712/7248 harmful changes. This gives a proportion of 9.8% (95% CI SEM 9.1-10.5). Comparing the two unpaired proportions gives a difference of -0.08% with a 95% CI of the SE of the difference of -2.5 to +1.2. Hypothesis 3 is rejected. Fisher’s exact test gives a result of p=0.68, reinforcing the lack of significant variance. <b>Conclusions:</b> Our results reject the claims that using haemodialysis is an inherently unstable choice of therapy. Although proportionally more of the initial sessions are classed as unstable, the majority of MAP and HR changes are beneficial in nature

Persistent pain after caesarean section and its association with maternal anxiety and socioeconomic background

Background: Pain, both from the surgical site, and from other sources such as musculoskeletal backache, can persist after caesarean section. In this study of a predominantly socially deprived population we have sought to prospectively examine the association between antenatal maternal anxiety and socioeconomic background and the development of persistent pain of all sources after caesarean section. Methods: Demographic details and an anxiety questionnaire were completed by 205 women before elective caesarean section. On the first postoperative day, pain scores were recorded, and at four months patients were asked to complete a Brief Pain Inventory and an Edinburgh Postnatal Depression Score. Results: Of 205 parturients recruited, 186 records were complete at the hospital admission phase and 98 (52.7%) were complete at the four-month follow-up phase. At recruitment, 15.1% reported pain. At four months 41.8% (95% CI 32.1 to 51.6%) reported pain, of whom pain was a new finding in 35.7% (95% CI 26.2 to 45.2%). Antenatal anxiety was not a significant predictor of severity of new pain at four months (P=0.43 for state anxiety, P=0.52 for trait anxiety). However, four-month pain severity did correlate with social deprivation (P=0.011), postnatal depression (P<0.001) and pain at 24 h (P=0.018). Conclusion: Persistent pain from a variety of sources after caesarean section is common. Our findings do not support the use of antenatal anxiety scoring to predict persistent pain in this setting, but suggest that persistent pain is influenced by acute pain, postnatal depression and socioeconomic deprivation

Using a Service Learning - Peer Mentoring Project to Prepare OT Students for their Role in Post-secondary Transition Services

A service-learning pilot project involving occupational therapy (OT) students and individuals with intellectual and developmental disabilities (IDD) is described. The purpose of this pilot project, developed using Transformative Learning Theory, was to determine if service-learning could be a viable approach to provide in-depth learning in areas only superficially covered in a typical OT curriculum. The objectives of this experience were focused on developing the knowledge and skills needed to address a noted gap in OT practice, post-secondary transition services for individuals with IDD. Using a peer-mentor approach, OT students were matched with young adults with IDD for a fieldwork Level I experience that continued for nine months. Weekly experiences for the mentees were planned by their mentors who also participated in advocacy on campus to facilitate an environment fostering social inclusiveness. Students engaged in 12 online threaded discussions and participated in a focus group interview one month after the program ended. Data were analyzed to examine the effectiveness of the peer mentor approach in expanding students’ knowledge and perception of their role in transition services. Data revealed increased knowledge of the diverse challenges and strengths of individuals with IDD, increased knowledge of the goals and activities provided by post-secondary transition services, and an understanding of how OT services could contribute to such services. These benefits are exactly those needed to contribute to transition services, demonstrating that, at least for this content area, service-learning is a viable approach to addressing noted gaps in practice

Evolution, Perfection, and Theories of Language

In this article it is argued that evolutionary plausibility must be made an important constraining factor when building theories of language. Recent suggestions that presume that language is necessarily a perfect or optimal system are at odds with this position, evolutionary theory showing us that evolution is a meliorizing agent often producing imperfect solutions. Perfection of the linguistic system is something that must be demonstrated, rather than presumed. Empirically, examples of imperfection are found not only in nature and in human cognition, but also in language — in the form of ambiguity, redundancy, irregularity, movement, locality conditions, and extra-grammatical idioms. Here it is argued that language is neither perfect nor optimal, and shown how theories of language which place these proper-ties at their core run into both conceptual and empirical problems

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

Ribonucleotide Reductase Inhibitors: A New Look at an Old Target for Radiosensitization

Ribonucleotide reductase (RR), the rate limiting enzyme in the synthesis and repair of DNA, has been studied as a target for inhibition in the treatment of cancer for many years. While some researchers have focused on RR inhibitors as chemotherapeutic agents, particularly in hematologic malignancies, some of the most promising data has been generated in the field of radiosensitization. Early pre-clinical studies demonstrated that the addition of the first of these drugs, hydroxyurea, to ionizing radiation (IR) produced a synergistic effect in vitro, leading to a large number of clinical studies in the 1970–1980s. These studies, mainly in cervical cancer, initially produced a great deal of interest, leading to the incorporation of hydroxyurea in the treatment protocols of many institutions. However, over time, the conclusions from these studies have been called into question and hydroxyurea has been replaced in the standard of care of cervical cancer. Over the last 10 years, a number of well-done pre-clinical studies have greatly advanced our understanding of RR as a target. Those advances include the elucidation of the role of p53R2 and our understanding of the temporal relationship between the delivery of IR and the response of RR. At the same time, new inhibitors with increased potency and improved binding characteristics have been discovered, and pre-clinical and early clinical data look promising. Here we present a comprehensive review of the pre-clinical and clinical data in the field to date and provide some discussion of future areas of research