Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department.

BACKGROUND: Asthma is a chronic respiratory condition characterised by airways inflammation, constriction of airway smooth muscle and structural alteration of the airways that is at least partially reversible. Exacerbations of asthma can be life threatening and place a significant burden on healthcare services. Various guidelines have been published to inform management personnel in the acute setting; several include the use of a single bolus of intravenous magnesium sulfate (IV MgSO4) in cases that do not respond to first-line treatment. However, the effectiveness of this approach remains unclear, particularly in less severe cases. OBJECTIVES: To assess the safety and efficacy of IV MgSO4 in adults treated for acute asthma in the emergency department. SEARCH METHODS: We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to 2 May 2014. We also searched www.ClinicalTrials.gov and reference lists of other reviews, and we contacted trial authors to ask for additional information. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of adults treated in the emergency department (ED) for exacerbations of asthma if they compared any dose of IV MgSO4 with placebo. DATA COLLECTION AND ANALYSIS: All review authors screened titles and abstracts for inclusion, and at least two review authors independently extracted study characteristics, risk of bias and numerical data. Disagreements were resolved by consensus, and we contacted trial investigators to obtain missing information.We analysed dichotomous data as odds ratios using study participants as the unit of analysis, and we analysed continuous data as mean differences or standardised mean differences using fixed-effect models. We rated all outcomes using GRADE and presented results in Summary of findings table 1.We carried out subgroup analyses on the primary outcome for baseline severity of exacerbations and whether or not ipratropium bromide was given as a co-medication. Unpublished data and studies at high risk of bias for blinding were removed from the main analysis in sensitivity analyses. MAIN RESULTS: Fourteen studies met the inclusion criteria, randomly assigning 2313 people with acute asthma to the comparisons of interest in this review.Most studies were double-blinded trials comparing a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes versus a matching placebo. Eleven were conducted at a single centre, and three were multi-centre trials. Participants in almost all of the studies had already been given at least oxygen, nebulised short-acting beta2-agonists and IV corticosteroids in the ED; in some studies, investigators also administered ipratropium bromide. Ten studies included only adults, and four included both adults and children; these were included because the mean age of participants was over 18 years.Intravenous MgSO4 reduced hospital admissions compared with placebo (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.60 to 0.92; I(2) = 28%, P value 0.18; n = 972; high-quality evidence). In absolute terms, this odds ratio translates into a reduction of seven hospital admissions for every 100 adults treated with IV MgSO4 (95% CI two to 13 fewer). The test for subgroup differences revealed no statistical heterogeneity between the three severity subgroups (I(2) = 0%, P value 0.73) or between the four studies that administered nebulised ipratropium bromide as a co-medication and those that did not (I(2) = 0%, P value 0.82). Sensitivity analyses in which unpublished data and studies at high risk for blinding were removed from the primary analysis did not change conclusions.Within the secondary outcomes, high- and moderate-quality evidence across three spirometric indices suggests some improvement in lung function with IV MgSO4. No difference was found between IV MgSO4and placebo for most of the non-spirometric secondary outcomes, all of which were rated as low or moderate quality (intensive care admissions, ED treatment duration, length of hospital stay, readmission, respiration rate, systolic blood pressure).Adverse events were inconsistently reported and were not meta-analysed. The most commonly cited adverse events in the IV MgSO4 groups were flushing, fatigue, nausea and headache and hypotension (low blood pressure). AUTHORS' CONCLUSIONS: This review provides evidence that a single infusion of 1.2 g or 2 g IV MgSO4 over 15 to 30 minutes reduces hospital admissions and improves lung function in adults with acute asthma who have not responded sufficiently to oxygen, nebulised short-acting beta2-agonists and IV corticosteroids. Differences in the ways the trials were conducted made it difficult for the review authors to assess whether severity of the exacerbation or additional co-medications altered the treatment effect of IV MgSO4. Limited evidence was found for other measures of benefit and safety.Studies conducted in these populations should clearly define baseline severity parameters and systematically record adverse events. Studies recruiting participants with exacerbations of varying severity should consider subgrouping results on the basis of accepted severity classifications

Near peer teachers GP Specialty Trainees (GPSTs) as teachers and career pathfinder

Introduction; Junior doctors are key providers of medical student teaching in hospital settings, yet rarely do so in primary care as part of their GP specialty training. There is evidence that the reduced distance between teacher & learner in such near-peer teaching (NPT) fosters learning (Ten Cate & Durning). However, postgraduate (PG) medical training is situated in an “externally regulated learning” environment where self-regulated and externally regulated learning interact to influence students’ learning. (de la Fuente) GP training schemes in N. London offer 6 month Innovative Training Posts (ITP) for GP specialist trainees (GPSTs) combining their clinical training with regular student teaching. We evaluated this educational innovation to explore the impact on GPSTs & their students. / Methods; We carried out focus groups and semi-structured interviews with the GPSTs, their students & stakeholders in GP education (education leads), to explore the perspective of GPSTs as UG teachers. Interviews were transcribed & data thematically analysed; deductively from Ten Cate & inductively from our novel data. / Results; Data were obtained from 26 individual stakeholders. We identified elements of role modelling and socialization into the discipline, and identified the role of external regulated learning. All stakeholders perceived tangible benefits to students from NPTs; they adopted more student centred approaches and were more likely to take on board students’ immediate goals, contrasting with senior doctors (social congruence). Students valued GPSTs’ generalist clinical expertise, who could make explicit their knowledge of medicine. GPSTs expressed benefits to their own development, forming their identity as learners & teachers. GPSTs & educational stakeholders explored this acquisition of “expertise”. The role of education; both teaching & learning for GPSTs was key; articulated as “to teach something well is to understand it well”. GPSTs also provided students with sign posting for GP careers. Discussion & Conclusion. Formalised near peer teaching in GP for students is relatively novel (Rushforth). There are strong educational benefits to learners & teachers, while not disrupting GPSTs own training. Take home message Near peer learning provided by GPSTs to students aids their learning and role modelling and is accepted (and encouraged) by senior educators

Near peer teaching in general practice: option or expectation?

GP trainees who teach medical students do so as near peers with established educational benefits for all concerned. Through teaching, GP trainees consolidate their own knowledge and skills whilst students value the experience of learning from teachers closer in age and stage. Importantly, involving GP trainees as teachers also increases primary care teaching capacity and promotes general practice as a potential career option for undergraduates. However, whilst junior doctors are often to be found teaching on hospital wards and in clinics, GP trainees based in primary care appear to have fewer opportunities to teach. This article encourages the promotion of near peer teaching in primary care on a number of levels. We make practical suggestions that may be of benefit to the individual GP trainee, trainer and practice; and also discuss ways in which key stakeholders, including medical schools and those responsible for organising post-graduate primary care training programmes, may promote near peer teaching in general practice. We propose that all medical students should have experience of being taught by GP trainees, and likewise that all future GPs should have training and experience of teaching undergraduate medical students

Forensic Psychotherapy in Forensic Mental Health

Forensic psychotherapy is a talking cure that aims to work with meaning making processes and defensive manoeuvres in offenders, in order to make them progress in their search for the meaning of the offence. An offence can be understood and contextualized once it is considered from the perspective of the life history of the offender. At the same time, the question of where the violent or sexual motives come from, are much more difficult to grasp. This paradox is problematic to society, that wants an answer from the criminal, but it is also problematic to the criminal him- or herself. The development of the embeddedness of forensic psychotherapy in English and Dutch forensic mental health institutions and the relevance of training are described and explained. For Belgium, two small scale projects are discussed that cater for mentally ill offenders who have difficulties to cope with more intensive psychiatric care. Within these projects, patients are offered the possibility to take part in therapeutic activities on a voluntary basis. The aim is to motivate people, who have difficulties to socialize, participate in group and reconnect with other