Key components of anaphylaxis management plans: consensus findings from a national electronic Delphi study

OBJECTIVES: There is no international consensus on the components of anaphylaxis management plans and responsibility for their design and delivery is contested. We set out to establish consensus among relevant specialist and generalist clinicians on this issue to inform future randomized controlled trials. DESIGN: A two-round electronic Delphi study completed by a 25-person, multidisciplinary expert panel. Participants scored the importance of a range of statements on anaphylaxis management, identified from a systematic review of the literature, on a five-point scale ranging from 'very important' to 'irrelevant'. Consensus was defined a priori as being achieved if 80% or more of panel members rated a statement as 'important' or 'very important' after Round 2. SETTING: Primary and secondary care and academic settings in the UK and Ireland. PARTICIPANTS: Twenty-five medical, nursing and allied health professionals. MAIN OUTCOME MEASURES: Consensus on the key components of anaphylaxis management plans. RESULTS: The response rate was 84% (n = 21) for Round 1 and 96% (n = 24) for Round 2. The key components of emergency care on which consensus was achieved included: awareness of trigger factors (100%); recognition and emergency management of reactions of different severity (100%); and clear information on adrenaline (epinephrine) use (100%). Consensus on longer-term management issues included: clear written guidelines on anaphylaxis management (96%); annual review of plans (87%); and plans that were tailored to individual needs (82%). CONCLUSIONS: This national consensus-building exercise generated widespread agreement that emergency plans need to be simple, clear and generic, making them easy to implement in a crisis. In contrast, long-term plans need to be negotiated between patient/carers and professionals, and tailored to individual needs. The effectiveness of this expert-agreed long-term plan now needs to be evaluated rigorously

2019 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations : summary from the basic life support; advanced life support; pediatric life support; neonatal life support; education, implementation, and teams; and first aid task forces

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research

Effects of backpacking holidays in Australia on alcohol, tobacco and drug use of UK residents

BACKGROUND: Whilst alcohol and drug use among young people is known to escalate during short holidays and working breaks in international nightlife resorts, little empirical data are available on the impact of longer backpacking holidays on substance use. Here we examine changes in alcohol, tobacco and drug use when UK residents go backpacking in Australia. METHODS: Matched information on alcohol and drug use in Australia and the UK was collected through a cross sectional cohort study of 1008 UK nationals aged 18–35 years, holidaying in Sydney or Cairns, Australia, during 2005. RESULTS: The use of alcohol and other drugs by UK backpackers visiting Australia was common with use of illicit drugs being substantially higher than in peers of the same age in their home country. Individuals showed a significant increase in frequency of alcohol consumption in Australia compared to their behaviour in the UK with the proportion drinking five or more times per week rising from 20.7% (UK) to 40.3% (Australia). Relatively few individuals were recruited into drug use in Australia (3.0%, cannabis; 2.7% ecstasy; 0.7%, methamphetamine). However, over half of the sample (55.0%) used at least one illicit drug when backpacking. Risk factors for illicit drug use while backpacking were being regular club goers, being male, Sydney based, travelling without a partner or spouse, having been in Australia more than four weeks, Australia being the only destination on their vacation and drinking or smoking five or more days a week. CONCLUSION: As countries actively seek to attract more international backpacker tourists, interventions must be developed that target this population's risk behaviours. Developing messages on drunkenness and other drug use specifically for backpackers could help minimise their health risks directly (e.g. adverse drug reactions) and indirectly (e.g. accidents and violence) as well as negative impacts on the host country

Symplasmic transport and phloem loading in gymnosperm leaves

Despite more than 130 years of research, phloem loading is far from being understood in gymnosperms. In part this is due to the special architecture of their leaves. They differ from angiosperm leaves among others by having a transfusion tissue between bundle sheath and the axial vascular elements. This article reviews the somewhat inaccessible and/or neglected literature and identifies the key points for pre-phloem transport and loading of photoassimilates. The pre-phloem pathway of assimilates is structurally characterized by a high number of plasmodesmata between all cell types starting in the mesophyll and continuing via bundle sheath, transfusion parenchyma, Strasburger cells up to the sieve elements. Occurrence of median cavities and branching indicates that primary plasmodesmata get secondarily modified and multiplied during expansion growth. Only functional tests can elucidate whether this symplasmic pathway is indeed continuous for assimilates, and if phloem loading in gymnosperms is comparable with the symplasmic loading mode in many angiosperm trees. In contrast to angiosperms, the bundle sheath has properties of an endodermis and is equipped with Casparian strips or other wall modifications that form a domain border for any apoplasmic transport. It constitutes a key point of control for nutrient transport, where the opposing flow of mineral nutrients and photoassimilates has to be accommodated in each single cell, bringing to mind the principle of a revolving door. The review lists a number of experiments needed to elucidate the mode of phloem loading in gymnosperms

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial

Objective: To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA). Methods: We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical–surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge. Results: One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%, P < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%, P < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones. Conclusion: Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge

Resummation of small-x double logarithms in QCD: semi-inclusive electron-positron annihilation

We have derived the coefficients of the highest three 1/x-enhanced small-x logarithms of all timelike splitting functions and the coefficient functions for the transverse fragmentation function in one-particle inclusive e^+e^- annihilation at (in principle) all orders in massless perturbative QCD. For the longitudinal fragmentation function we present the respective two highest contributions. These results have been obtained from KLN-related decompositions of the unfactorized fragmentation functions in dimensional regularization and their structure imposed by the mass-factorization theorem. The resummation is found to completely remove the huge small-x spikes present in the fixed-order results for all quantities above, allowing for stable results down to very small values of the momentum fraction and scaling variable x. Our calculations can be extended to (at least) the corresponding as^n ln^(2n-l) x contributions to the above quantities and their counterparts in deep-inelastic scattering.Comment: 27 pages, LaTeX, 6 eps-figure

High precision determination of the gluon fusion Higgs boson cross-section at the LHC

We present the most precise value for the Higgs boson cross-section in the gluon-fusion production mode at the LHC. Our result is based on a perturbative expansion through N$^3$LO in QCD, in an effective theory where the top-quark is assumed to be infinitely heavy, while all other Standard Model quarks are massless. We combine this result with QCD corrections to the cross-section where all finite quark-mass effects are included exactly through NLO. In addition, electroweak corrections and the first corrections in the inverse mass of the top-quark are incorporated at three loops. We also investigate the effects of threshold resummation, both in the traditional QCD framework and following a SCET approach, which resums a class of $\pi^2$ contributions to all orders. We assess the uncertainty of the cross-section from missing higher-order corrections due to both perturbative QCD effects beyond N$^3$LO and unknown mixed QCD-electroweak effects. In addition, we determine the sensitivity of the cross-section to the choice of parton distribution function (PDF) sets and to the parametric uncertainty in the strong coupling constant and quark masses. For a Higgs mass of $m_H = 125~{\rm GeV}$ and an LHC center-of-mass energy of $13~{\rm TeV}$, our best prediction for the gluon fusion cross-section is \[ \sigma = 48.58\,{\rm pb} {}^{+2.22\, {\rm pb}\, (+4.56\%)}_{-3.27\, {\rm pb}\, (-6.72\%)} \mbox{ (theory)} \pm 1.56 \,{\rm pb}\, (3.20\%) \mbox{ (PDF+$\alpha_s$)} \

Remote ischaemic preconditioning versus sham procedure for abdominal aortic aneurysm repair: An external feasibility randomized controlled trial

© 2015 Mouton et al. Background: Despite advances in perioperative care, elective abdominal aorta aneurysm (AAA) repair carries significant morbidity and mortality. Remote ischaemic preconditioning (RIC) is a physiological phenomenon whereby a brief episode of ischaemia-reperfusion protects against a subsequent longer ischaemic insult. Trials in cardiovascular surgery have shown that RIC can protect patients' organs during surgery. The aim of this study was to investigate whether RIC could be successfully introduced in elective AAA repair and to obtain the information needed to design a multi-centre RCT. Methods: Consecutive patients presenting for elective AAA repair, using an endovascular (EVAR) or open procedure, in a single large city hospital in the UK were assessed for trial eligibility. Patients who consented to participate were randomized to receive RIC (three cycles of 5 min ischaemia followed by 5 min reperfusion in the upper arm immediately before surgery) or a sham procedure. Patients were followed up for 6 months. We assessed eligibility and consent rates, the logistics of RIC implementation, randomization, blinding, data capture, patient and staff opinion, and variability and frequency of clinical outcome measures. Results: Between January 2010 and December 2012, 98 patients were referred for AAA repair, 93 were screened, 85 (91 %) were eligible, 70 were approached for participation and 69 consented to participate; 34 were randomized to RIC and 35 to the sham procedure. There was a greater than expected variation in the complexity of EVAR that impacted the outcomes. Acute kidney injury occurred in 28 (AKIN 1: 23 %; AKIN 2: 15 % and AKIN 3: 3 %) and 7 (10 %) had a perioperative myocardial infarction. Blinding was successful, and interviews with participants and staff indicated that the procedure was acceptable. There were no adverse events secondary to the intervention in the 6 months following the intervention. Conclusions: This study provided essential information for the planning and design of a multi-centre RCT to assess effectiveness of RIC for improving clinical outcomes in elective AAA repair. Patient consent was high, and the RIC intervention was carried out with minimal disruption to clinical care. The allocation scheme for a definite trial should take into account both the surgical procedure and its complexity to avoid confounding the effect of the RIC, as was observed in this study. Trial registration: Current Controlled Trials ISRCTN19332276(date of registration: 16 March 2012). The trial protocol is available from the corresponding author

The physicianelderly patient relationship: challenges and perspectives

O objetivo deste artigo é expor os desafios e perspectivas da relação médico-paciente idoso. Nas relações interpessoais, inerentes ao exercício profissional da medicina, é a qualidade do encontro que determina sua eficiência. Assim, na formação e na identificação do bom profissional, a relação médico-paciente idoso é fundamental na promoção da qualidade do atendimento. Os mé dicos devem privilegiar sentimentos e valores dos pacientes idosos e de seus familiares, estimu lando a tomada das decisões necessárias em conjunto, ou seja, a democratização da relação médi co-paciente, resgatando sua humanização. Esta proposta aspira ao nascimento de uma nova imagem deste profissional responsável pela efetiva promoção da saúde, ao considerar o paciente idoso em sua integridade física, psíquica e social, e não somente do ponto de vista biológico.The aim of this article was to discuss challenges and perspectives in the physician-elderly patient relationship. In interpersonal relations, inherent to medical practice, it is the quality of the encounter that determines its efficiency. Thus, in training and identifying good medical professionals, the physician-elderly patient relationship is essential for promoting quality of care. Physicians should prioritize the feelings and values of elderly patients and their families, encouraging the necessary joint decision-making, that is, democratization of the physician-patient relations hip, reclaiming its humanization. This proposal aspires to the birth of a new image for these professionals, who are responsible for effective health promotion, by considering elderly patients in their physical, psychological, and social entirety, and not merely from the biological point of view