Intraoperative changes in blood coagulation and thrombelastographic monitoring in liver transplantation

The blood coagulation system of 66 consecutive patients undergoing consecutive liver transplantations was monitored by thrombelastograph and analytic coagulation profile. A poor preoperative coagulation state, decrease in levels of coagulation factors, progressive fibrinolysis, and whole blood clot lysis were observed during the preanhepatic and anhepatic stages of surgery. A further general decrease in coagulation factors and platelets, activation of fibrinolysis, and abrupt decrease in levels of factors V and VIII occurred before and with reperfusion of the homograft. Recovery of blood coagulability began 30-60 min after reperfusion of the graft liver, and coagulability had returned toward baseline values 2 hr after reperfusion. A positive correlation was shown between the variables of thrombelastography and those of the coagulation profile. Thrombelastography was shown to be a reliable and rapid monitoring system. Its use was associated with a 33% reduction of blood and fluid infusion volume, whereas blood coagulability was maintained without an increase in the number of blood product donors

Dying in the margins: Understanding palliative care and socioeconomic deprivation in the developed world

Context: Individuals from low socioeconomic (SE) groups have less resources and poorer health outcomes. Understanding the nature of access to appropriate end-of-life care services for this group is important. Objectives: To evaluate the literature in the developed world for barriers to access for low SE groups. Methods: Electronic databases searched in the review included MEDLINE (1996-2010), CINAHL (1996-2010), PsychINFO (2000-2010), Cochrane Library (2010), and EMBASE (1996-2010). Publications were searched for key terms "socioeconomic disadvantage," "socioeconomic," "poverty," "poor" paired with "end-of-life care," "palliative care," "dying," and "terminal Illness." Articles were analyzed using existing descriptions for dimensions of access to health services, which include availability, affordability, acceptability, and geographical access. Results: A total of 67 articles were identified for the literature review. Literature describing end-of-life care and low SE status was limited. Findings from the review were summarized under the headings for dimensions of access. Conclusion: Low SE groups experience barriers to access in palliative care services. Identification and evaluation of interventions aimed at reducing this disparity is required. © 2011 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved

Families, nurses and organisations contributing factors to medication administration error in paediatrics: a literature review

Background: Medication error is the most common adverse event for hospitalised children and can lead to significant harm. Despite decades of research and implementation of a number of initiatives, the error rates continue to rise, particularly those associated with administration. Objectives: The objective of this literature review is to explore the factors involving nurses, families and healthcare systems that impact on medication administration errors in paediatric patients. Design: A review was undertaken of studies that reported on factors that contribute to a rise or fall in medication administration errors, from family, nurse and organisational perspectives. The following databases were searched: Medline, Embase, CINAHL and the Cochrane library. The title, abstract and full article were reviewed for relevance. Articles were excluded if they were not research studies, they related to medications and not medication administration errors or they referred to medical errors rather than medication errors. Results: A total of 15 studies met the inclusion criteria. The factors contributing to medication administration errors are communication failure between the parents and healthcare professionals, nurse workload, failure to adhere to policy and guidelines, interruptions, inexperience and insufficient nurse education from organisations. Strategies that were reported to reduce errors were double-checking by two nurses, implementing educational sessions, use of computerised prescribing and barcoding administration systems. Yet despite such interventions, errors persist. The review highlighted families that have a central role in caring for the child and therefore are key to the administration process, but have largely been ignored in research studies relating to medication administration. Conclusions: While there is a consensus about the factors that contribute to errors, sustainable and effective solutions remain elusive. To date, families have not been included as key stakeholders in researching or developing effective interventions to reduce medication administration errors

The business of death: A qualitative study of financial concerns of widowed older women

© DiGiacomo et al.; licensee BioMed Central. Background: The feminisation of ageing and increasing number of widowed women in contemporary society has significant implications. Older women are at risk of poor health, social, and economic outcomes upon widowhood. The aim of the study was to describe women's experiences in the period soon after their husbands' death, including their financial issues and concerns, and the ways in which these experiences impacted on the transition to widowhood late in life. Methods: This was a longitudinal study using serial in-depth semi-structured interviews with 21 community-dwelling women over the age of 65 in Australia. Verbatim transcripts underwent Interpretive Phenomenological Analysis. Results: Thematic analysis revealed: 1) administrative burden increases vulnerability; 2) gender roles impact on transitions; and 3) financial adjustments render housing insecurity and health risk. High administrative burden within the context of significant grief and mourning was a defining feature of the early bereavement period. Complicated protracted administrative processes, insensitive interactions, and reminders of loss contributed to distress, anxiety and feelings of demoralisation. Several women identified assumption of household financial management as the most difficult aspect of coping with their husband's death. Conclusions: Older women may have unmet needs for assistance with administrative, financial, and legal issues immediately following spousal death and potentially for years afterward. Lack of familiarity and absence of instrumental support with financial and legal issues signal the need for policy reform, resources to improve financial literacy in women throughout the life course, increased advocacy, and consideration of different support and service models

Transitioning from caregiving to widowhood

Context: Older women commonly assume a caregiving role for their husbands at the end of life and are more vulnerable to poorer health, well-being, and social and economic challenges. Objectives: The aim of this study was to ascertain older women's experiences of spousal caregiving at the end of life and the ways in which this experience impacts on the transition to widowhood. Methods: Longitudinal, in-depth, semistructured interviews were conducted with older women three times over a one-year period after the death of their husbands. This report focuses on the initial interviews that examined the transition from caregiving to widowhood. Transcripts were analyzed using interpretive phenomenological analysis methods. Participants were community-dwelling women older than 65 years who had recently been caregivers for their husbands who died within the past two years. Results: Older women caregivers described their caregiver role as taxing, particularly in light of their own chronic conditions that they failed to prioritize and address. They did not ask for help in managing their roles and health problems, but quietly endured. Hence, they did not communicate their needs or strains explicitly. The degree of perceived adequacy of communication and interaction with health professionals were important factors impacting on their bereavement. Conclusion: It is imperative for health professionals to appreciate that older women caregivers may need more supportive interaction and information during the end-of-life caregiving, they may have expectations of communication, and they may deny or fail to focus on their own health issues. A patient/family/carer- centered approach could negate this oversight and improve the outcomes for these women as they transition into widowhood. © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved

Interpretation and Knowledge Maximization

Timothy Williamson has proposed that we should give a ‘knowledge first’ twist to David Lewis’s account of content, maintaining that for P to be the content of one’s belief is for P to be the content that would be attributed by an idealized interpreter working under certain constraints, and that the fundamental constraint on interpretation is a principle of knowledge maximization. According to this principle, an interpretation is correct to the extent that it maximizes the number of knowledgeable judgments the subject comes out as making. Here I will argue against knowledge maximization and two fallback positions suggested by Williamson’s discussion. Williamson intends the principle of knowledge maximization to form the basis of an argument against a certain sort of skepticism about judgment. In the final section I argue that the kind of general response to judgment skepticism envisaged by Williamson is neither desirable nor necessary

Towards precision medicine for hypertension: a review of genomic, epigenomic, and microbiomic effects on blood pressure in experimental rat models and humans

Compelling evidence for the inherited nature of essential hypertension has led to extensive research in rats and humans. Rats have served as the primary model for research on the genetics of hypertension resulting in identification of genomic regions that are causally associated with hypertension. In more recent times, genome-wide studies in humans have also begun to improve our understanding of the inheritance of polygenic forms of hypertension. Based on the chronological progression of research into the genetics of hypertension as the "structural backbone," this review catalogs and discusses the rat and human genetic elements mapped and implicated in blood pressure regulation. Furthermore, the knowledge gained from these genetic studies that provide evidence to suggest that much of the genetic influence on hypertension residing within noncoding elements of our DNA and operating through pervasive epistasis or gene-gene interactions is highlighted. Lastly, perspectives on current thinking that the more complex "triad" of the genome, epigenome, and the microbiome operating to influence the inheritance of hypertension, is documented. Overall, the collective knowledge gained from rats and humans is disappointing in the sense that major hypertension-causing genes as targets for clinical management of essential hypertension may not be a clinical reality. On the other hand, the realization that the polygenic nature of hypertension prevents any single locus from being a relevant clinical target for all humans directs future studies on the genetics of hypertension towards an individualized genomic approach

HIPAD - A Hybrid Interior-Point Alternating Direction algorithm for knowledge-based SVM and feature selection

We consider classification tasks in the regime of scarce labeled training data in high dimensional feature space, where specific expert knowledge is also available. We propose a new hybrid optimization algorithm that solves the elastic-net support vector machine (SVM) through an alternating direction method of multipliers in the first phase, followed by an interior-point method for the classical SVM in the second phase. Both SVM formulations are adapted to knowledge incorporation. Our proposed algorithm addresses the challenges of automatic feature selection, high optimization accuracy, and algorithmic flexibility for taking advantage of prior knowledge. We demonstrate the effectiveness and efficiency of our algorithm and compare it with existing methods on a collection of synthetic and real-world data.Comment: Proceedings of 8th Learning and Intelligent OptimizatioN (LION8) Conference, 201

Compact, directional neutron detectors capable of high-resolution nuclear recoil imaging

We report on the design, production, and performance of compact 40-cm3 Time Projection Chambers (TPCs) that detect fast neutrons by measuring the three-dimensional (3D) ionization distribution of nuclear recoils in 4He:CO2 gas at atmospheric pressure. We use these detectors to characterize the fast-neutron flux inside the Belle II detector at the SuperKEKB electron–positron collider in Tsukuba, Japan, where the primary design constraint is a small form factor. We find that the TPCs meet or exceed all design specifications, and are capable of measuring the 3D surface shape and charge density profile of ionization clouds from nuclear recoils and charged tracks in exquisite detail. Scaled-up detectors based on the detection principle demonstrated here may be suitable for directional dark matter searches, measurements of coherent neutrino–nucleus scattering, and other experiments requiring precise detection of neutrons or nuclear recoils

GALA:an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery

BACKGROUND: Patients who have severe narrowing at or near the origin of the internal carotid artery as a result of atherosclerosis have a high risk of ischaemic stroke ipsilateral to the arterial lesion. Previous trials have shown that carotid endarterectomy improves long-term outcomes, particularly when performed soon after a prior transient ischaemic attack or mild ischaemic stroke. However, complications may occur during or soon after surgery, the most serious of which is stroke, which can be fatal. It has been suggested that performing the operation under local anaesthesia, rather than general anaesthesia, may be safer. Therefore, a prospective, randomised trial of local versus general anaesthesia for carotid endarterectomy was proposed to determine whether type of anaesthesia influences peri-operative morbidity and mortality, quality of life and longer term outcome in terms of stroke-free survival. METHODS/DESIGN: A two-arm, parallel group, multicentre randomised controlled trial with a recruitment target of 5000 patients. For entry into the study, in the opinion of the responsible clinician, the patient requiring an endarterectomy must be suitable for either local or general anaesthesia, and have no clear indication for either type. All patients with symptomatic or asymptomatic internal carotid stenosis for whom open surgery is advised are eligible. There is no upper age limit. Exclusion criteria are: no informed consent; definite preference for local or general anaesthetic by the clinician or patient; patient unlikely to be able to co-operate with awake testing during local anaesthesia; patient requiring simultaneous bilateral carotid endarterectomy; carotid endarterectomy combined with another operation such as coronary bypass surgery; and, the patient has been randomised into the trial previously. Patients are randomised to local or general anaesthesia by the central trial office. The primary outcome is the proportion of patients alive, stroke free (including retinal infarction) and without myocardial infarction 30 days post-surgery. Secondary outcomes include the proportion of patients alive and stroke free at one year; health related quality of life at 30 days; surgical adverse events, re-operation and re-admission rates; the relative cost of the two methods of anaesthesia; length of stay and intensive and high dependency bed occupancy. TRIAL REGISTRATION: Current Controlled Trials ISRCTN00525237