Managing escalating demand for public services in a time of financial austerity: a case study of family interventions

The UK (along with many other countries) is facing the challenges of financial austerity with little or no growth in public funding for the foreseeable future. This creates particular challenges for public services as economic downturns often increase the demand for public services at a time when resources are constrained. A particular service of this type is the provision of support to ‘troubled’ families through what are termed family interventions, in one local authority area, and the impact of financial austerity on those services. It considers the strategic options available for dealing with the dilemma of increasing demand and declining resources, and assesses the implications of implementing these options. It also considers the key factors which inhibit the development and implementation of such approaches, in order to provide a starting point for developing a practical strategy for dealing with the challenges ahead. Finally, it considers how the findings related to family interventions can be applied to other services in a similar situation of increasing demand and decreasing resources

Clinical review: Optimal dose of continuous renal replacement therapy in acute kidney injury

Continuous renal replacement therapy (CRRT) is the preferred treatment for acute kidney injury in intensive care units (ICUs) throughout much of the world. Despite the widespread use of CRRT, controversy and center-specific practice variation in the clinical application of CRRT continue. In particular, whereas two single-center studies have suggested survival benefit from delivery of higher-intensity CRRT to patients with acute kidney injury in the ICU, other studies have been inconsistent in their results. Now, however, two large multi-center randomized controlled trials - the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) study and the Randomized Evaluation of Normal versus Augmented Level (RENAL) Replacement Therapy Study - have provided level 1 evidence that effluent flow rates above 25 mL/kg per hour do not improve outcomes in patients in the ICU. In this review, we discuss the concept of dose of CRRT, its relationship with clinical outcomes, and what target optimal dose of CRRT should be pursued in light of the high-quality evidence now available

Deserved attention for acute kidney injury after major trauma

This is a post-peer-review, pre-copyedit version of an article published in Intensive Care Medicine. The final authenticated version is available online at: https://doi.org/10.1007/s00134-019-05609-xDear Editor, The systematic review of acute kidney injury (AKI) after trauma by Søvik et al. [1] adds much-needed data on the incidence and outcomes of trauma-associated AKI. The authors reported a pooled incidence of AKI of 24%across 24 studies including over 25,000 patients. These results duplicate those of a recently published meta-analysis of AKI in trauma by Haines et al. [2]. Furthermore, data on AKI in 3111 patients from a French multicentre trauma registry has now been published by Harrois et al. [3] where an independent association between AKI and mortality persisted. When included amongst studies reporting adjusted odds ratios of death in trauma-ICU patients with AKI, the association with mortality is convincin

Socioeconomic deprivation and surgical outcomes: ISOS and VISION-UK sub-study (Statistical Analysis Plan)

In this paper, we aim to determine if socioeconomic deprivation in England is associated with outcomes after surgery: mortality, in-hospital complications at 30 days, and hospital length of stay. We will also identify clinical factors associated with social deprivation and assess whether adjustment for these factors modify the effect of socioeconomic deprivation on outcomes for a range of surgical categories

Meeting the Escalating Demands for Health and Social Care Services of Elderly Populations in Developing Countries: a Strategic Perspective

Population ageing is a phenomenon affecting developed and developing countries alike and represents a major global challenge. This paper is concerned with the impact of ageing populations, in developing countries, on the future provision of health and social care services to the growing elderly population. As well as reviewing previous research and available data, the paper presents the findings of a series of qualitative interviews with policy makers and clinicians in a small number of developing countries in various parts of the world. The paper argues that developing countries cannot expect to see major increases in financial resources available to health and social care for the foreseeable future. Thus, the key issue is establishing how best the available public funding for delivering health and social care services to the elderly can best be used to maximize public value at a time when public services around the world face ongoing austerity measures. The paper focuses on a number of key strategic themes to achieve this which are as follows: the strengthening of public health infrastructure and capabilities; the reconfiguration of existing health systems; a stronger focus on elderly medicine as a distinct specialty; a strengthened role for mobile healthcare, particularly in rural areas; the development of models of generic health and social care assistants; the promotion of community based social care; the utilization of appropriate public/ private health care partnerships

Subclinical cardiopulmonary dysfunction in stage 3 chronic kidney disease.

OBJECTIVE: Reduced exercise capacity is well documented in end-stage chronic kidney disease (CKD), preceded by changes in cardiac morphology in CKD stage 3. However, it is unknown whether subclinical cardiopulmonary dysfunction occurs in CKD stage 3 independently of heart failure. METHODS: Prospective observational cross-sectional study of exercise capacity assessed by cardiopulmonary exercise testing in 993 preoperative patients. Primary outcome was peak oxygen consumption (VO2peak). Anaerobic threshold (AT), oxygen pulse and exercise-evoked measures of autonomic function were analysed, controlling for CKD stage 3, age, gender, diabetes mellitus and hypertension. RESULTS: CKD stage 3 was present in 93/993 (9.97%) patients. Diabetes mellitus (RR 2.49 (95% CI 1.59 to 3.89); p<0.001), and hypertension (RR 3.20 (95% CI 2.04 to 5.03); p<0.001)) were more common in CKD stage 3. Cardiac failure (RR 0.83 (95% CI 0.30 to 2.24); p=0.70) and ischaemic heart disease (RR 1.40 (95% CI 0.97 to 2.02); p=0.09) were not more common in CKD stage 3. Patients with CKD stage 3 had lower predicted VO2peak (mean difference: 6% (95% CI 1% to 11%); p=0.02), lower peak heart rate (mean difference:9 bpm (95% CI 3 to 14); p=0.03)), lower AT (mean difference: 1.1 mL/min/kg (95% CI 0.4 to 1.7); p<0.001) and impaired heart rate recovery (mean difference: 4 bpm (95% CI 1 to 7); p<0.001)). CONCLUSIONS: Subclinical cardiopulmonary dysfunction in CKD stage 3 is common. This study suggests that maladaptive cardiovascular/autonomic dysfunction may be established in CKD stage 3, preceding pathophysiology reported in end-stage CKD

Acute kidney injury in the critically ill: an updated review on pathophysiology and management.

Acute kidney injury (AKI) is now recognized as a heterogeneous syndrome that not only affects acute morbidity and mortality, but also a patient's long-term prognosis. In this narrative review, an update on various aspects of AKI in critically ill patients will be provided. Focus will be on prediction and early detection of AKI (e.g., the role of biomarkers to identify high-risk patients and the use of machine learning to predict AKI), aspects of pathophysiology and progress in the recognition of different phenotypes of AKI, as well as an update on nephrotoxicity and organ cross-talk. In addition, prevention of AKI (focusing on fluid management, kidney perfusion pressure, and the choice of vasopressor) and supportive treatment of AKI is discussed. Finally, post-AKI risk of long-term sequelae including incident or progression of chronic kidney disease, cardiovascular events and mortality, will be addressed

Report of the first AKI Round Table meeting: an initiative of the ESICM AKI Section.

Critical Care Nephrology is an emerging sub-specialty of Critical Care. Despite increasing awareness about the serious impact of acute kidney injury (AKI) and renal replacement therapy (RRT), important knowledge gaps persist. This report represents a summary of a 1-day meeting of the AKI section of the European Society of Intensive Care Medicine (ESICM) identifying priorities for future AKI research. International Members of the AKI section of the ESICM were selected and allocated to one of three subgroups: "AKI diagnosis and evaluation", "Medical management of AKI" and "Renal Replacement Therapy for AKI." Using a modified Delphi methodology, each group identified knowledge gaps and developed potential proposals for future collaborative research. The following key research projects were developed: Systematic reviews: (a) epidemiology of AKI with stratification by patient cohorts and diagnostic criteria; (b) role of higher blood pressure targets in patients with hypertension admitted to the Intensive Care Unit, and (c) specific clearance characteristics of different modalities of continuous renal replacement therapy (CRRT). Observational studies: (a) epidemiology of critically ill patients according to AKI duration, and (b) current clinical practice of CRRT. Intervention studies:( a) Comparison of different blood pressure targets in critically ill patients with hypertension, and (b) comparison of clearance of solutes with various molecular weights between different CRRT modalities. Consensus was reached on a future research agenda for the AKI section of the ESICM