WAT-A-GAME: sharing water and policies in your own basin

40th Annual Conference, Int. Simulation And Gaming Association, Singapour, SGP, 29-/06/2009 - 03/07/2009International audienceAfter having designed and used various games for learning and supporting water management and governance, many similarities appear. However, the components, topologies, and social and political setting of the basins are different. Therefore we have started designing andvalidating a new generic game platform, WAT-A-GAME, alias AMANZI. This new game aims at facilitating exploration and transformation of water management and water use at the small catchment scale. It gives a simple but enlightening view of the various consequences of individual and collective choices, including regulation policies. After comparing it with some previous games, we discuss its main rationales and features. We show how it can be adapted to very different settings, how players can usefully contribute to designing an instance, and how it can especially address dialogue between multi-level stakeholders. We describe an application in South-Africa, in the Inkomati basin and the preliminary results of this instance

Continuous renal replacement therapy: current practice in Australian and New Zealand intensive care units

BACKGROUND: Large multicentre studies of continuous renal replacement therapy (CRRT) in critically ill patients may influence its bedside prescription and practical application. Despite this, many aspects of CRRT may not be informed by evidence but remain a product of clinician preference. Little was known about current CRRT practice in Australia and New Zealand and it is not known if the evidence from recent studies has been integrated into practice. DESIGN AND SETTING: A prospective online survey of CRRT practice was sent to intensive care unit medical and nursing clinicians via three national databases in Australian and New Zealand ICUs in December 2013 to March 2014. RESULTS: There were 194 respondents from 106 ICUs; 49 ICUs (47%) were in tertiary metropolitan hospitals. One hundred and two respondents (54%) reported continuous venovenous haemodiafiltration as the most common CRRT technique, with a combination of predilution and postdilution of CRRT solutions. The prescription for CRRT was variable, with respondents indicating preferences for therapy based on L/hour (53%) or a weight-adjusted treatment in mL/kg/hour (47%). For all modes of CRRT, the common blood flow rates applied were 151-200mL/ minute and 201-250mL/minute. Few respondents reported preferring flow rates < 150 mL/minute or > 300mL/minute. Unfractionated heparin was the most commonly used anticoagulant (83%), followed by regional citrate. Femoral vein vascular access was preferred and, typically, a 20 cm length catheter was used. Bard Niagara and Arrow catheters were most frequently used. The Gambro Prismaflex was the dominant machine used (71%). CONCLUSIONS: Our results provide insight into existing clinical management of CRRT. There is considerable variation in the prescription of CRRT in Australian and New Zealand ICUs

Faster Blood Flow Rate Does Not Improve Circuit Life in Continuous Renal Replacement Therapy: A Randomized Controlled Trial

Objectives: To determine whether blood flow rate influences circuit life in continuous renal replacement therapy. Design: Prospective randomized controlled trial. Setting: Single center tertiary level ICU. Patients: Critically ill adults requiring continuous renal replacement therapy. Interventions: Patients were randomized to receive one of two blood flow rates: 150 or 250 mL/min. Measurements and Main Results: The primary outcome was circuit life measured in hours. Circuit and patient data were collected until each circuit clotted or was ceased electively for nonclotting reasons. Data for clotted circuits are presented as median (interquartile range) and compared using the Mann-Whitney U test. Survival probability for clotted circuits was compared using log-rank test. Circuit clotting data were analyzed for repeated events using hazards ratio. One hundred patients were randomized with 96 completing the study (150 mL/min, n = 49; 250 mL/min, n = 47) using 462 circuits (245 run at 150 mL/min and 217 run at 250 mL/min). Median circuit life for first circuit (clotted) was similar for both groups (150 mL/min: 9.1 hr [5.5–26 hr] vs 10 hr [4.2–17 hr]; p = 0.37). Continuous renal replacement therapy using blood flow rate set at 250 mL/min was not more likely to cause clotting compared with 150 mL/min (hazards ratio, 1.00 [0.60–1.69]; p = 0.68). Gender, body mass index, weight, vascular access type, length, site, and mode of continuous renal replacement therapy or international normalized ratio had no effect on clotting risk. Continuous renal replacement therapy without anticoagulation was more likely to cause clotting compared with use of heparin strategies (hazards ratio, 1.62; p = 0.003). Longer activated partial thromboplastin time (hazards ratio, 0.98; p = 0.002) and decreased platelet count (hazards ratio, 1.19; p = 0.03) were associated with a reduced likelihood of circuit clotting. Conclusions: There was no difference in circuit life whether using blood flow rates of 250 or 150 mL/min during continuous renal replacement therapy

The gradual loss of vision

Gradual loss of vision is a clinical problem that is encountered fairly regularly in most primary healthcare settings. Patients present with chronic, slowly progressive and generally painless visual loss. The reduction in vision is usually bilateral, though frequently asymmetrical, and occurs over weeks to years. A goal-directed assessment of the patient presenting with gradual loss of vision is required. A history of the type of visual loss, e.g. central or peripheral, and whether it is worse for near vision or distance vision, is helpful. The examination should focus on visual acuity, confrontation visual field testing, pupil testing for the presence of an afferent pupil defect and assessment of the red reflex and fundoscopy. The more common conditions that cause gradual loss of vision can be divided into two groups based on the reversibility of the visual loss. Cataracts, refractive error, corneal blindness and early diabetic macular oedema are generally reversible. Optic atrophy, glaucoma, retinal degeneration and age-related macular degeneration usually cause permanent loss of vision. Most of these conditions are briefly discussed in this article. This has been performed at a level that is suitable to primary care

The gradual loss of vision

Gradual loss of vision is a clinical problem that is encountered fairly regularly in most primary healthcare settings. Patients present with chronic, slowly progressive and generally painless visual loss. The reduction in vision is usually bilateral, though frequently asymmetrical, and occurs over weeks to years. A goal-directed assessment of the patient presenting with gradual loss of vision is required. A history of the type of visual loss, e.g. central or peripheral, and whether it is worse for near vision or distance vision, is helpful. The examination should focus on visual acuity, confrontation visual field testing, pupil testing for the presence of an afferent pupil defect and assessment of the red reflex and fundoscopy. The more common conditions that cause gradual loss of vision can be divided into two groups based on the reversibility of the visual loss. Cataracts, refractive error, corneal blindness and early diabetic macular oedema are generally reversible. Optic atrophy, glaucoma, retinal degeneration and age-related macular degeneration usually cause permanent loss of vision. Most of these conditions are briefly discussed in this article. This has been performed at a level that is suitable to primary care.Keywords: gradual, loss of vision, cataracts, refractive error, optic atrophy, glaucoma, age-related macular degeneratio

Sudden loss of vision

Sudden loss of vision, which causes consternation for both the patient and clinician, is a clinical problem that is encountered fairly regularly in most primary healthcare settings. Sudden visual loss or obscuration which is transient may simply be a symptom of a dry eye or a migraine, but it may also be the onset of irreversible visual loss or a stroke. Most cases of sudden loss of vision are serious, require referral and have an associated underlying systemic disease. Visual loss is usually unilateral, but may be bilateral. This clinical problem may present a diagnostic challenge. No cause may be found in some instances. However, it is important to remember that the more sinister causes of sudden visual loss, such as temporal arteritis, carotid or cardiac emboli that cause retinal vascular occlusion, retinal detachment, vitreous haemorrhage and orbital masses, need to be identified early. Using the duration of the visual loss as the primary differentiating factor, with associated symptoms and signs as supplementary factors, the causes can be narrowed down. A thorough history, goal-directed examination, proper investigation and appropriate referral should enable early diagnosis and adequate management. This will prevent further ocular morbidity, and even patient mortality

Evaluation of Urea and Creatinine change during Continuous Renal Replacement Therapy: Effect of blood flow rate

OBJECTIVE: To determine if faster blood flow rate (BFR) has an effect on solute maintenance in continuous renal replacement therapy. DESIGN: Prospective randomised controlled trial. SETTING: 24-bed, single centre, tertiary level intensive care unit. PARTICIPANTS: Critically ill adults requiring continuous renal replacement therapy (CRRT). INTERVENTIONS: Patients were randomised to receive one of two BFRs: 150 mL/min or 250 mL/min. MAIN OUTCOME MEASURES: Changes in urea and creatinine concentrations (percentage change from baseline) and delivered treatment for each 12-hour period were used to assess solute maintenance. RESULTS: 100 patients were randomised, with 96 completing the study (49 patients, 150 mL/min; 47 patients, 250 mL/min). There were a total of 854 12-hour periods (421 periods, 150 mL/min; 433 periods, 250 mL/ min). Mean hours of treatment per 12 hours was 6.3 hours (standard deviation [SD], 3.7) in the 150 mL/min group, and 6.7 hours (SD, 3.9) in the 250 mL/min group (P = 0.6). There was no difference between the two BFR groups for change in mean urea concentration (150 mL/min group, –0.06%; SD, 0.015; v 250 mL/min group, –0.07%; SD, 0.01; P = 0.42) or change in mean creatinine concentration (150 mL/min, –0.05%; SD, 0.01; v 250 mL/min, –0.08%; SD, 0.01; P = 0.18). Independent variables associated with a reduced percentage change in mean serum urea and creatinine concentrations were low haemoglobin levels (–0.01%; SD, 0.005; P = 0.002; and 0.01%; SD, 0.005; P = 0.006, respectively) and less hours treated (–0.023%; SD, 0.001; P = 0.000; and –0.02%; SD, 0.002; P = 0.001, respectively). No effect for bodyweight was found. CONCLUSIONS: Faster BFR did not affect solute control in patients receiving CRRT; however, differences in urea and creatinine concentrations were influenced by serum haemoglobin and hours of treatment