One lithium level >1.0 mmol/L causes an acute decline in eGFR: findings from a retrospective analysis of a monitoring database

Objectives Lithium is a mainstay of bipolar disorder treatment, however, there are still differences in opinion on the effects of lithium use on renal function. The aim of this analysis was to determine if there is an association between short-term exposure to various elevated lithium levels and estimated-glomerular filtration rate (eGFR) at ≤3 months, 6 months (±3 months) and 1 year (±3 months) follow-up. Setting Norfolk-wide (UK) lithium register and database. Participants 699 patients from the Norfolk database. Primary outcome measures eGFR change from baseline at ≤3 months, 6 months (±3 months) and 1 year (±3 months) after exposure to a lithium level within these ranges: 0.81–1.0 mmol/L (group 2), 1.01–1.2 mmol/L (group 3) and 1.21–2.0 mmol/L (group 4). The reference group was patients whose lithium levels never exceeded 0.8 mmol/L. Results Compared to the reference group, groups 3 and 4 showed a significant decrease in eGFR in the first 3 months after exposure (p=0.047 and p=0.040). At 6 months (±3 months) postexposure group 4 still showed a decline in eGFR, however, this result was not significant (p=0.298). Conclusions These results show for the first time that a single incident of a lithium level >1.0 mmol/L is associated with a significant decrease in eGFR in the following 3 months when compared to patients whose lithium levels never exceeded 0.8 mmol/L. It is still not known whether the kidneys can recover this lost function and the impact that more than a single exposure to a level within these ranges can have on renal function. These results suggest that lithium level monitoring should be undertaken at least every 3 months, in line with current UK guidelines and not be reduced further until the impact of more than one exposure to these lithium levels has been fully established

The case for critical thought: an investigation into contemporary determinist knowledge, its social effects, and the alternative offered by a 'mode 2' approach to teaching, learning and research.

Thesis (Ph.D.)-University of Natal, Durban, 2002.This thesis is centrally concerned with the current nee-liberal world order and its effects upon society. It is concerned to expose the contradictions and weaknesses within the knowledge systems that underpin our political reality. It considers economics as the determining discourse of neo-liberal politics, analytic biology as its determining discourse of individual persons, and analytic and neo-pragmatist philosophy as its leading systems of thought. In each case it finds a linear rationalism compatible with the determinist materialism of noo-Darwinism, and indeed explicitly invoking Darwin. This seems to vindicate Manuel Castells's fmding of this 'Knowledge Society' as driven by 'an abstract, universal instrumentalism'. The thought systems of this economic liberalism have seen politics subsumed within economics, de-humanising most of the institutions of the earlier Liberal tradition, to the detriment of both freedom and democracy. But it disputes Castells's assumption that this is a necessary reality and finds in neo-liberal education the exception to this dehumanising trend. Revitalised as 'Mode 2' knowledge production, this form of teaching, learning and research is found to be ideally suited to challenge the underpinnings of the very social order which initially produced it. The thesis as a whole is designed to employ Mode 2 methods in order to support this contention. Using this approach it seeks to demonstrate that in place of neo-Darwinism the ideas of the South African natural scientist Eugene Marais, concerning the significance of conscious thought itself within evolution, can provide a more convincing epistemoloy than the behaviourism and materialism of analytic biology. It finds John Maynard Keynes's acceptance of economics as a moral and not a natural science, more logically convincing and more inherently useful for social reconstruction than the current mathematicisation of economic theory. Prevalent philosophical approaches appear to serve only to reinforce the systems of thought already found (and found wanting) in politics, biology and economics. But again these philosophies are shown to be vulnerable to a Mode 2 critique, particularly employing the ontological understanding of the contemporary pragmatist philosopher Joseph Margolis, whose strong version of relativism allows for both bivalent and multivalent truth values more appropriate to understanding the complex realities of ethical and democratic societies

Student Selected Components - a modern curriculum to complement a systems-based medical degree

The 2009 version of the GMC’s Tomorrows Doctors describes student selected components as “an integral part of the curriculum, enabling students to demonstrate mandatory competences while allowing choice in studying an area of particular interest to them”. The definition of SSCs and guidance for their delivery and assessment have been interpreted in a variety of ways by individual medical schools and by regional consortia of medical schools. To complement our systems-based MBBS modules we have developed a longitudinal Student Selected Studies (SSS) curriculum which has been reviewed and modified since 2011. Throughout the SSS curriculum, students develop academic skills and competences such as literature review or developing a clinical or research question. In years 1 to 3 these competences are acquired whilst focusing on topics from a given theme of study, for example physiology, pharmacology or ethics. In year 4 the students apply the skills acquired in the earlier years to the evaluation of a case described in their own clinical-placement log-book. In the first three years when students learn how to deliver formal presentations, using PowerPoint, conference-style posters, or anatomy demonstrations, they are given specialist tutor support, and feedback is given in formative assessments; allowing the students to make corrections and refine their skills before summative assessments take place. Our curriculum development has been shaped by the use of a competency-based teaching and assessment strategy with a focus on the student’s longitudinal development through the use of a feedforward strategy (Hattie, 2007) during and after formative assessments

The Effect of Structured Exercise Compared with Education on Neuropathic Signs and Symptoms in People at Risk of Neuropathic Diabetic Foot Ulcers: A Randomized Clinical Trial

Background and Objectives: Lifestyle interventions such as exercise prescription and education may play a role in the management of peripheral neuropathy in people with diabetes. The aim of this study was to determine the effect of undertaking an exercise program in comparison with an education program on the signs and symptoms of peripheral neuropathy in people with diabetes at risk of neuropathic foot ulceration. Materials and Methods: Twenty-four adult participants with diabetes and peripheral neuropathy were enrolled in this parallel-group, assessor blinded, randomised clinical trial. Participants were randomly allocated to one of two 8-week lifestyle interventions, exercise or education. The primary outcome measures were the two-part Michigan Neuropathy Screening Instrument (MNSI) and vibratory perception threshold (VPT). Secondary outcome measures included aerobic fitness, balance and lower limb muscular endurance. Results: Participants in both lifestyle interventions significantly improved over time for MNSI clinical signs (MD: −1.04, 95% CI: −1.68 to −0.40), MNSI symptoms (MD: −1.11, 95% CI: −1.89 to −0.33) and VPT (MD: −4.22, 95% CI: −8.04 to −0.40). Although the interaction effects did not reach significance, changes in values from pre to post intervention favoured exercise in comparison to control for MNSI clinical signs (MD −0.42, 95% CI −1.72 to 0.90), MNSI clinical symptoms (MD −0.38, 95% CI −1.96 to 1.2) and VPT (MD −4.22, 95% CI −12.09 to 3.65). Conclusions: Eight weeks of exercise training or lifestyle education can improve neuropathic signs and symptoms in people with diabetes and peripheral neuropathy. These findings support a role for lifestyle interventions in the management of peripheral neuropathy

Dental Hygienist's Role in Assessing Peri-Implantitis.

PosterThe objective of this clinical case presentation is to discuss peri-implantitis due to its increasing prevalence in dental hygiene practice. Assessment: A 79 year old Caucasian female presented to the Dental Hygiene Clinic for periodontal maintenance and a dental exam. The medical history reveals a history of hypertension, atrial fibrillation, and the patient is taking Coumadin. The patient presented with generalized mild plaque-induced marginal and papillary gingivitis, however, the gingiva around the implant replacing #19 showed moderate gingival inflammation as evidenced by dark pink, bulbous, and spongy tissue with moderate bleeding on probing (BOP). The patient also presented with generalized chronic periodontitis as evidenced by 4-5mm clinical attachment level (CAL). Peri-implantitis was diagnosed on the implant with 6-9mm probing depths, 85% bone loss present on radiographs, and suppuration. DH Care Plan: Routine periodontal maintenance, oral hygiene instruction, and referral to the Graduate Periodontics Clinic for further evaluation of the implant. Follow up: The implant was diagnosed with a hopeless prognosis and scheduled for removal in the Graduate Periodontics Clinic. However, before the scheduled extraction, the patient reported that the implant had "fallen out" and it was not present at the 3 month periodontal maintenance appointment. Conclusion: Early recognition and intervention of peri-implant mucositis and peri-implantitis is crucial for the survival of the implant. Once peri-implantitis has reached an advanced stage, the prognosis of the implant is very poor and may require surgical treatment

Dietary Magnesium May Be Protective for Aging of Bone and Skeletal Muscle in Middle and Younger Older Age Men and Women: Cross-Sectional Findings from the UK Biobank Cohort.

Although fragility fractures, osteoporosis, sarcopenia, and frailty are becoming more prevalent in our aging society the treatment options are limited and preventative strategies are needed. Despite magnesium being integral to bone and muscle physiology, the relationship between dietary magnesium and skeletal muscle and bone health has not been investigated concurrently to date. We analysed cross-sectional associations between dietary magnesium and skeletal muscle mass (as fat free mass-FFM), grip strength, and bone density (BMD) in 156,575 men and women aged 39-72 years from the UK Biobank cohort. FFM was measured with bioelectrical impedance and was expressed as the percentage of body weight (FFM%) or as divided by body mass index (FFMBMI). Adjusted mean grip strength, FFM%, FFMBMI, and BMD were calculated according to quintiles of dietary magnesium, while correcting for covariates. Significant inter-quintile differences across intakes of magnesium existed in men and women, respectively, of 1.1% and 2.4% for grip strength, 3.0% and 3.6% for FFM%, 5.1% and 5.5% for FFMBMI, and 2.9% and 0.9% for BMD. These associations are as great or greater than annual measured losses of these musculoskeletal outcomes, indicating potential clinical significance. Our study suggests that dietary magnesium may play a role in musculoskeletal health and has relevance for population prevention strategies for sarcopenia, osteoporosis, and fractures

Using GIS for spatial analysis of rectal lesions in the human body

Abstract Background Geographic Information Systems (GIS) have been used in a wide variety of applications to integrate data and explore the spatial relationship of geographic features. Traditionally this has referred to features on the surface of the earth. However, it is possible to apply GIS in medicine, at the scale of the human body, to visualize and analyze anatomic and clinical features. In the present study we used GIS to examine the findings of transanal endoscopic microsurgery (TEM), a minimally-invasive procedure to locate and remove both benign and cancerous lesions of the rectum. Our purpose was to determine whether anatomic features of the human rectum and clinical findings at the time of surgery could be rendered in a GIS and spatially analyzed for their relationship to clinical outcomes. Results Maps of rectal topology were developed in two and three dimensions. These maps highlight anatomic features of the rectum and the location of lesions found on TEM. Spatial analysis demonstrated a significant relationship between anatomic location of the lesion and procedural failure. Conclusion This study demonstrates the feasibility of rendering anatomical locations and clinical events in a GIS and its value in clinical research. This allows the visualization and spatial analysis of clinical and pathologic features, increasing our awareness of the relationship between anatomic features and clinical outcomes as well as enhancing our understanding and management of this disease process. </p