An alternative pathway for preclinical research in fluid management

Recent meta-analyses have created uncertainties regarding the appropriate clinical role of colloid resuscitation fluids in critically ill patients and prompted changes in fluid management practice. Such changes may not be justified in view of methodological limitations inherent in the meta-analyses. Further research is nevertheless needed to resolve the questions raised concerning the relationship between choice of resuscitation fluid and patient outcome. Animal studies can play an important part by reliably indicating whether particular fluids are likely to prove effective and safe in clinical trials. It is important to avoid costly large-scale clinical trials that fail to demonstrate the clinical utility of the tested therapy, as resources expended in failed trials raise overall development costs and thereby restrict the range of therapies meeting criteria of commercial feasibility. Promising therapies may thus not be pursued, even though an urgent clinical need may exist. An alternative pathway of preclinical research may be of value in avoiding some of the major clinical trial failures of recent years, particularly in the area of sepsis. This alternative pathway commences with the formulation of hypotheses by therapeutics developers. Independent preclinical investigators are challenged, by means of a competitive request for proposals, to test the hypotheses in rigorous randomized studies employing clinically relevant animal models. Promising proposals would then be selected for further development with the aid of peer review. The results of the randomized animal studies, along with other preclinical data, could also be evaluated using accepted principles of 'critical appraisal' commonly applied to clinical trial results. This critical appraisal might, where appropriate, include meta-analysis of animal study findings. This alternative preclinical pathway to new product evaluation should be completed before the commencement of large-scale clinical trials

Case 12 : Policy Meets Practice – People Who Inject Drugs (PWID)

Dr. Silverman is the Chief of Infectious Diseases at London Health Sciences Centre (LHSC) and St. Joseph’s Health Care in London, Ontario. He is concerned about the increasing prevalence of people who inject drugs (PWID) in London, and the risk to PWID of bacterial infections due to contamination (e.g., improperly or unsterilized injection equipment, skin not being sterilized before injection). Of primary concern is the risk of infective endocarditis (IE), an infection in a patient’s heart. Treatment for IE entails antibiotics administered through the intravenous (IV) route. IE is generally treated through home care; in London, the South West Community Care Access Centre (CCAC) is responsible for delivering home care. To treat IE at home, a patient would need a peripherally inserted central catheter (a PICC-line) and assistance from a CCAC nurse to administer the antibiotics. This option, however, is not viable for some patients, including those who fall under the category of PWID or who may not have a fixed address. In the case of PWID, the PICC-line, in effect, becomes a “highway” for injecting other drugs; in instances where a patient may not have secure housing or be homeless, the CCAC nurse may not be able to track down the individual. When a patient in one of these situations is being treated for IE, it puts the care team in a difficult position. The alternatives to home care are hospital admittance or no treatment at all, neither of which are ideal solutions. Dr. Silverman is currently in this position, as he must decide on a treatment plan for Mr. W., a patient who has IE, has struggled with drug addiction (the likely cause of his IE), and who does not have stable housing. In making his decision, Dr. Silverman has included on Mr. W.’s care team two other physicians from LHSC, a representative from the CCAC, and the managing director of London CAReS, a community-based housing-first organization. The care team must determine the best treatment plan for Mr. W

Case 17 : Can Hospitals do Health Promotion? Making Hospitals a Place for both Care and Health through Health Promotion

Lauren Kitsman trained as a health promoter and is now working for a hospital. She has been tasked with implementing a health promotion approach in her hospital and has tried to understand the health issues at the hospital and identified potential areas to inform health promotion action. She turned to the ‘health promoting hospitals (HPH) approach’ in order to bridge the gap between acute care and health promotion in the hospital setting. As she looked deeper into HPHs in Ontario, she discovered an advocacy network, the Ontario Health Promoting Hospitals Network (OHPHN). While the initiative had largely been unsuccessful in Ontario, Health Promoting Hospital Networks had been successful and continue to have momentum in Europe and around the world. There seemed to be success stories from other provinces (Quebec, in particular). Why is Ontario so different, and what could be done to overcome the barriers to make the work of this network successful? What can Lauren learn from international HPH efforts to apply in her local context? Lauren wants to make changes that are sustainable and in-line with HPH approaches but needs to remain true to the acute mandate of her hospital. She is unsure of next steps

Case 14 : Development of an Electronic Health Record Strategy at the Glenburn Public Health Unit

Medical or electronic health records (EHR) are electronic databases that capture an individual’s health and care history throughout their life. EHRs are often used as a single repository of patient information that is shared among multiple health care providers (such as hospitals, laboratories, and family physicians). The Ontario Ministry of Health and Long-Term Care requires all EHR systems in public health units be provincially certified; however, their budget does not provide units with the necessary funding for EHR implementation. The Glenburn Public Health Unit (GPHU) is conducting a review of their recordkeeping practices and has identified a need to streamline their methods for client documentation. There are currently inconsistencies across the unit’s many health teams that result in communication, logistical, and technical issues with respect to document storage and delivery. To address these issues, GPHU must develop an EHR strategy that seeks to improve current recordkeeping practices and, as a result, improves client service delivery

Construction of artificial pigment-protein antennae

Photosynthesis is a complex process which results in the conversion of solar radiation into chemical energy. This chemical energy is then used as the free energy source for all living organisms. In its basic form, photosynthesis can be described as the light-activated synthesis of carbohydrates from the simple molecules of water and carbon dioxide: 6H{sub 2}O + 6 CO{sub 2} light C{sub 6}H{sub 12}O{sub 6} + 6 O{sub 2} This basic mechanism actually requires numerous reaction steps. The two primary steps being: the capture of light by pigment molecules in light-harvesting antenna complexes and the transfer of this captured energy to the so-called photochemical reaction center. While the preferred pathway for energy absorbed by the chromophores in the antenna complexes is transfer to the reaction center, energy can be lost to competing processes such as internal conversion or radiative decay. Therefore, the energy transfer must be rapid, typically on the order of picoseconds, to successfully compete. The focus of the present work is on the construction of light-harvesting antenna complexes incorporating modular pigment-proteins

Construction of artificial pigment-protein antennae

Photosynthesis is a complex process which results in the conversion of solar radiation into chemical energy. This chemical energy is then used as the free energy source for all living organisms. In its basic form, photosynthesis can be described as the light-activated synthesis of carbohydrates from the simple molecules of water and carbon dioxide: 6H{sub 2}O + 6 CO{sub 2} light C{sub 6}H{sub 12}O{sub 6} + 6 O{sub 2} This basic mechanism actually requires numerous reaction steps. The two primary steps being: the capture of light by pigment molecules in light-harvesting antenna complexes and the transfer of this captured energy to the so-called photochemical reaction center. While the preferred pathway for energy absorbed by the chromophores in the antenna complexes is transfer to the reaction center, energy can be lost to competing processes such as internal conversion or radiative decay. Therefore, the energy transfer must be rapid, typically on the order of picoseconds, to successfully compete. The focus of the present work is on the construction of light-harvesting antenna complexes incorporating modular pigment-proteins

Search dog handlers show positive bias when scoring their own dog's performance

Self-assessments of performance are commonly used in the human workplace, although compared to peer or supervisor ratings, they may be subject to positive biases or leniency. The use of subjective ratings scales in animal sciences is also common, although little consideration is usually given to possible rater bias. Dog handlers, work very closely and form strong relationships with their dogs and are also best placed to monitor dog performance since they often work in isolation. Previous work found ratings of search dog performance correlated well between experienced dog trainers, instructors, and scientists; but until now, there has been no investigation into ratings made by a dog's own handler. We compared handlers' subjective assessment of their own dog's search performance to scores given by other handlers and in a second study, to scores made by impartial raters. We found that handlers generally showed leniency; for example scoring their own dogs more favorably for Control (responsiveness to commands) and Strength of Indication. But the degree of bias varied with the trait being scored and between raters. Such differences may be attributable to greater desirability or importance of favorable scores for certain traits, or a lack of clarity of their precise meaning. Handlers may vary in susceptibility to bias due to differing levels of experience and the extent to which they view their dog's ability as dependent on their own. The exact causes require further investigation. We suggest working dog agencies provide rater-training to overcome leniency, improve reliability and validity, and to increase handler's motivation to provide accurate assessments. This study represents one of a series of steps to formulate robust, validated and evidence-based performance rating systems and has relevance to any situation where raters assess their own performance or others (particularly where they may have a vested interest in, or loyalty toward, the ratee)

Checklists improve experts' diagnostic decisions

Context Checklists are commonly proposed tools to reduce error. However, when applied by experts, checklists have the potential to increase cognitive load and result in expertise reversal'. One potential solution is to use checklists in the verification stage, rather than in the initial interpretation stage of diagnostic decisions. This may avoid expertise reversal by preserving the experts' initial approach. Whether checklist use during the verification stage of diagnostic decision making improves experts' diagnostic decisions is unknown. Methods Fifteen experts interpreted 18 electrocardiograms (ECGs) in four different conditions: undirected interpretation; verification without a checklist; verification with a checklist, and interpretation combined with verification with a checklist. Outcomes included the number of errors, cognitive load, interpretation time and interpretation length. Outcomes were compared in two analyses: (i) a comparison of verification conditions with and without a checklist, and (ii) a comparison of all four conditions. Standardised scores for each outcome were used to calculate the efficiency of a checklist and to weigh its relative benefit against its relative cost in terms of cognitive load imposed, interpretation time and interpretation length. Results In both analyses, checklist use was found to reduce error (more errors were corrected in verification conditions with checklists [0.29 +/- 0.77 versus 0.03 +/- 0.61 errors per ECG], and fewer net errors occurred in all conditions with checklists [0.39 +/- 1.14 versus 1.04 +/- 1.49 errors per ECG];