Medium-Fidelity Medical Simulators: Use in a Pre-Hospital,Operational, Military Environment

On Operation Telic 6, the UK Med Group consisting of 3 Close Support Medical Regiment and 205 Field Hospital (Volunteers) deployed to provide medical support to coalition forces in Iraq. Personnel were drawn from Regular and Territorial Units, plus additional medical support from Armies of the Czech Republic and Denmark. The efficient delivery of operational emergency medical care hinged upon the successful integration of personnel from these units. We report on the use of a medium-fidelity simulator, in a pre-hospital and hospital environment over a three month period on an operational tour. In conducting 42 exercises (12 of which commenced in a pre-hospital environment), we have demonstrated the feasibility of the system in rehearsing the management of the major trauma patient. This training was used to enhance teamwork, identify system deficiencies and practise solutions in a safe environment. This paper discusses our experiences in relation to the current literature on this expanding area of trauma training.

Novel Selective Inhibitors of Neutral Endopeptidase for the Treatment of Female Sexual Arousal Disorder. Synthesis and Activity of Functionalized Glutaramides

Female sexual arousal disorder (FSAD) is a highly prevalent sexual disorder affecting up to 40% of women. We describe herein our efforts to identify a selective neutral endopeptidase (NEP) inhibitor as a potential treatment for FSAD. The rationale for this approach, together with a description of the medicinal chemistry strategy, lead compounds, and SAR investigations are detailed. In particular, the strategy of starting with the clinically precedented selective NEP inhibitor, Candoxatrilat, and targeting low molecular weight and relatively polar mono-carboxylic acids is described. This led ultimately to the prototype development candidate R-13, for which detailed pharmacology and pharmacokinetic parameters are presented.(1)

Obstetric regional blocks for women with multiple sclerosis: a survey of UK experience

BACKGROUND

There has been a reluctance to use regional blocks for women with multiple sclerosis as effects on the course of the disease are unclear. We assessed the views of UK consultant obstetric anaesthetists regarding management of women with multiple sclerosis.

METHODS

Following Obstetric Anaesthetists' Association approval a questionnaire was sent to UK consultant members. Opinions were sought on antenatal assessment, labour analgesia, anaesthesia for elective and emergency caesarean section, and modification in technique for those with multiple sclerosis. Enquiries were made of postnatal problems ascribed to regional blocks.

RESULTS

Of the 592 replies analysed, 91% of respondents had seen fewer than 10 cases of multiple sclerosis in the past 10 years. Antenatal assessment was recommended by many with postnatal relapse most commonly discussed (64%). Many highlighted the need for informed consent and minimising local anaesthetic dose. For labour analgesia 79% would perform a regional block; a further 20% would do so in certain circumstances. For elective caesarean section, epidural rather than spinal anaesthesia was preferred by 4%; 2% would not use a regional block, preferring general anaesthesia. For emergency caesarean section with time only for single-shot spinal, 3% would give a general anaesthetic. Deterioration of symptoms after delivery were reported by 20% with 3% attributing symptoms such as prolonged block, leg weakness, bladder dysfunction and postnatal relapse to regional blocks.

CONCLUSION

Most UK anaesthetists would perform regional blocks for labour and caesarean section in multiple sclerosis, although the experience of each anaesthetist is limited. Many emphasised the need for thorough pre-assessment and informed consent.

Does pulse lavage reduce hip hemiarthroplasty infection rates?

This paper reports a prospective randomized trial involving four hospitals in the south of England, in which every hemiarthroplasty (American Association of Anaesthetists grade IV and above) was randomized to one of two limbs. In the first group, the patients received a 2-L pulse lavage normal saline washout; in the second group, they received a 2-L normal saline washout via a jug or a syringe. All wounds were reviewed during their time in hospital up to 30 days post surgery or discharge (using criteria from the Nosocomial Infection National Surveillance Survey). Any re-admissions for infection were recorded. The pulse lavage group had a significantly lower total infection rate and, specifically, a decreased 'joint space' or deep infection rate.

Correlates of persistent thinness in black and white young women

OBJECTIVE

To examine health and psychosocial correlates of persistent thinness in black and white young adult women.

RESEARCH METHODS AND PROCEDURES

1,830 females (n = 988 black, n = 842 white) who participated in the National Heart, Lung, and Blood Institute Growth and Health Study were asked to indicate their current body size from a series of nine pictograms (1, emaciated to 9, obese). Persistent thinness was defined as having at least seven non-missing measurement points between ages 9 to 18 with a body size rating of <4 at all points. Generalized linear models were used to examine whether persistently thin women differed from comparison women on cardiovascular disease risk factors measured at age 18.5 and psychosocial variables measured at age 21.5. Prospective associations between psychological measures in childhood and persistent thinness through the course of adolescence were also examined.

RESULTS

In the sample, 145 women (7.9%) met criteria for persistent thinness and 1,685 women (92.1%) were classified as not persistently thin. Persistently thin women had a later age of menarche, fewer weight concerns, and healthier eating attitudes, were less likely to have had a child, came from higher socioeconomic backgrounds, and had significantly lower blood pressure and higher high-density lipoprotein-cholesterol than comparison women. Differences were not found on measures of depression or health services use. Girls with higher self-esteem in childhood were more likely to remain persistently thin throughout adolescence.

DISCUSSION

Persistently thin women seem to be healthier on several indicators relative to comparison women, and race did not moderate these differences.

Antenatal anaesthetic assessment of high-risk pregnancy: a survey of UK practice

BACKGROUND

Anaesthetists are frequently involved in the management of high-risk pregnancy. Antenatal referral permits time to prepare an appropriate management plan for labour and delivery. This survey looked at current methods of referral in the UK and the role of a formal clinic.

METHOD

A postal questionnaire was sent to lead consultant anaesthetists of 256 UK obstetric units enquiring into methods of referral for high-risk pregnancy.

RESULTS

Replies were received from 196 units (response rate 77%). Only 30% of units that responded ran a formal anaesthetic pre-assessment clinic, the remaining 70% relying on ad hoc referrals of high-risk cases. Larger units were more likely to run formal clinics. Some units wishing to introduce a formal clinic had not been able to do so because of financial constraints.

CONCLUSION

Most hospitals were satisfied with current arrangements for referral of high-risk pregnancy. A mechanism for anaesthetic referral of high-risk pregnancy is vital, but in many units is not via a formal clinic.

Motor block during epidural infusions for nulliparous women in labour: a randomized double-blind study of plain bupivacaine and low dose bupivacaine with fentanyl

Sixty nulliparous women received epidural infusions in labour of either 0.125% plain bupivacaine or 0.0625% bupivacaine containing 2.5 mcg/ml fentanyl both starting at 12 ml/h and titrated to maintain a sensory block to T10. Those women who received low dose bupivacaine with fentanyl took significantly longer to reach full cervical dilation (P < 0.05). There was no statistical difference between the groups in the number of additional epidural bolus doses required during the infusions. Of the women receiving low dose bupivacaine with fentanyl, 77% required one or no additional top-up doses compared to 87% in the plain bupivacaine group. There was no reduction in the incidence of perineal pain in the group who received fentanyl. Significantly more women who received 0.125% bupivacaine had motor block after 2 h of the infusion (P < 0.05). The mode of delivery was similar in the two groups as was the satisfaction with epidural analgesia in both the first and second stages of labour and with labour overall. There were no significant differences in Apgar scores, umbilical cord blood pH levels or neurologic and adaptive capacity scores at 2 or 24 h. There was no significant difference in the incidence of symptoms 24 h after delivery.

What height of block is needed for manual removal of placenta under spinal anaesthesia?

The technique of spinal anaesthesia for manual removal of placenta was examined prospectively in 101 women. Factors associated with maternal discomfort during surgery were the height of the block (P = 0.007) and the force applied by the surgeon in removing the placenta (P = 0.04). A sensory block to cold to T9 or T10 resulted in discomfort for six out of 27 women (22%). Only two women out of 38 experienced discomfort with a block to T6 or above. A block to cold to T6 or above is therefore recommended for manual removal of placenta under subarachnoid block. Factors not affecting maternal comfort were grade of the obstetrician, (P = 0.61), grade of the anaesthetist (P = 0.88), position of the mother during spinal injection (P = 0.32), volume of hyperbaric bupivacaine injected (P = 0.75), time from spinal injection to the start of surgery (P = 1.0), and duration of surgery (P = 0.77). Intraoperative hypotension was more common in those women with greater blood loss, (P = 0.002), but not with higher sensory levels (P = 0.31).

Asthma, diabetic ketoacidosis and fetal distress

A known insulin-dependent diabetic parturient at 32 weeks' gestation was treated with oral steroids for presumed exacerbation of asthma. This resulted in maternal ketoacidosis and a non-reassuring fetal heart rate trace for which caesarean section was considered. Cessation of steroids and aggressive management of ketoacidosis resulted in improved maternal and fetal condition without the need for emergency caesarean section.

Accelerated sea-level rise from West Antarctica

Recent aircraft and satellite laser altimeter surveys of the Amundsen Sea sector of West Antarctica show that local glaciers are discharging about 250 cubic kilometers of ice per year to the ocean, almost 60% more than is accumulated within their catchment basins. This discharge is sufficient to raise sea level by more than 0.2 millimeters per year. Glacier thinning rates near the coast during 2002-2003 are much larger than those observed during the 1990s. Most of these glaciers flow into floating ice shelves over bedrock up to hundreds of meters deeper than previous estimates, providing exit routes for ice from further inland if ice-sheet collapse is under way.

Management of accidental dural puncture in labour with intrathecal catheters: an analysis of 10 years' experience

The records of 15030 labour epidural blocks were analysed. Seventy-two accidental dural punctures (ADP) were recognised at the time of the procedure. In 34 women an epidural catheter was inserted intrathecally through the Tuohy needle and continuous spinal analgesia provided. In a further 37 women the primary management of ADP was to resite an epidural catheter. One woman who received a microspinal catheter later in labour was excluded from analysis. There were no significant differences in maternal characteristics, quality of labour analgesia and anaesthesia, or mode of delivery between the groups. Three repeat ADPs occurred during attempts to resite the epidural. Two women developed high blocks after epidural resiting, one of whom required intubation and ventilation. There was one high block in the intrathecal catheter group. The incidence of postdural puncture headache was 71% in the intrathecal catheter group compared with 81% in the non-intrathecal catheter group (P = 0.45). Epidural blood patch was performed on 50% of women managed with intrathecal catheters compared with 73% of those managed without (P = 0.08). Following ADP in labour an intrathecal catheter is a simple and effective alternative to resiting an epidural. Recognition of ADP is important as it allows appropriate management avoiding possible complications of administering epidural top-ups in the presence of a dural tear.

Seasonal changes of redox potential and microbial activity in two agricultural soils of tropical Australia: some implications for soil-to-plant transfer of radionuclides

Very little is known of the factors controlling soil-to-plant transfer of radionuclides in tropical environments. As part of an IAEA/FAO coordinated research project (CRP) designed to elucidate some of those factors, near-surface samples of two agricultural red-earth soils (Blain and Tippera) were collected from a study site in the Northern Territory. The climate is tropical monsoonal with crops being grown over the wet season from December to March/April. It is important to understand soil variables that may be related to this dramatic seasonality. In this investigation, soil redox state and microbial populations were assessed before and after the growing season with a view to generating hypotheses for future evaluation. The X-ray absorption near edge structure (XANES) technique was used to determine overall changes in the solid-state redox speciation of Fe and Mn in soils across the growing period. Fe speciation did not change but approximately 10% of the total Mn was oxidised from Mn(II) to Mn(III) and Mn(IV) in both soils between October 1999 and April 2000. An apparent disconnect between Fe and Mn was not unexpected given the >10 times higher concentration of Fe in the soils compared with Mn. These results have implications for the bioavailability of redox sensitive radionuclides such as Tc and Pu. Similarly, microbial population estimates were derived before and after the growing period. Total bacterial populations did not vary from 10(6) to 10(7) colonies per gram. Fungal populations increased over the growing season from 3-6 x 10(5) to 1-4 x 10(6) colonies per gram of soil. Fungi have the potential to decrease soil pH and hence increase the bioavailability of radionuclides such as Cs. In addition, fungi act to facilitate plant nutrition. This could lead to enhanced accumulation of nutrient analogues (e.g. Sr and Ra for Ca; Tc for Mn), but this effect may be masked by improved biomass production.

Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care.

SEARCH STRATEGY

The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus*. The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care.

DATA COLLECTION AND ANALYSIS

Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply.

MAIN RESULTS

No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population.

REVIEWERS' CONCLUSIONS

The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.

Radionuclide applications in laboratory studies of environmental surface reactions

The advantages of using radionuclides for laboratory studies of environmental processes include the wide range of element concentrations that can be studied, the capability to simultaneously study several isotopes in a single experiment, the direct applicability to the behaviour of radioactive waste or fallout, and the ability to study the mechanisms, reversibility and kinetics of environmental reactions under controlled conditions. These attributes are demonstrated using specific examples drawn from case studies in Australia, including radionuclide fallout onto tropical soils, the association of trace metals with harbour sediments and the behaviour of uranium in natural and contaminated systems.

Coastal oceanography sets the pace of rocky intertidal community dynamics

The structure of ecological communities reflects a tension among forces that alter populations. Marine ecologists previously emphasized control by locally operating forces (predation, competition, and disturbance), but newer studies suggest that inputs from large-scale oceanographically modulated subsidies (nutrients, particulates, and propagules) can strongly influence community structure and dynamics. On New Zealand rocky shores, the magnitude of such subsidies differs profoundly between contrasting oceanographic regimes. Community structure, and particularly the pace of community dynamics, differ dramatically between intermittent upwelling regimes compared with relatively persistent down-welling regimes. We suggest that subsidy rates are a key determinant of the intensity of species interactions, and thus of structure in marine systems, and perhaps also nonmarine communities.

Does the use of low dose bupivacaine/opioid epidural infusion increase the normal delivery rate?

To investigate whether using low dose epidural infusion improves the normal delivery rate, outcome of labour was studied in women with singleton vertex presentations randomised to receive either 0.0625% bupivacaine opioid, or plain bupivacaine 0.125% for labour. The infusion rate was titrated to maintain analgesia and a sensory level to T10. Data were analysed using the unpaired t test, Mann-Whitney U test and for categorical variables chi2 test. Adjusted odds ratios for factors significantly associated with non-normal delivery were calculated using stepwise logistic regression. There were 291 women in the low dose and 296 in the plain bupivacaine group. There were no significant differences between groups in parity, race, induction of labour, use of augmentation, cervical dilatation at epidural insertion, duration of any stage of labour or duration or volume of infusion. Total dose of bupivacaine (126 +/- 47 mg versus 91 +/- 32 mg) and the proportion of women with motor block at the end of labour (45% versus 27%) were significantly greater in the plain bupivacaine than in the low dose group (P < 0.0001). The adjusted odds ratios (95% CI) for factors significantly associated with non-normal delivery were primiparity: 4.68 (2.78-7.88), older maternal age: 1.1 (1.05-1.14), longer active second stage of labour: 1.01 (1.005-1.017), total bupivacaine dose: 1.01 (1.005-1.016) and greater cervical dilatation at epidural insertion 1.22 (1.08-1.37). Treatment group and motor block at the end of labour had no significant effect. We found no increase in normal delivery rate with low dose infusions.

Combined spinal epidural analgesia is the preferred technique for labour analgesia

To justify its place as the preferred method of pain relief in labour, CSE must demonstrated a clear superiority over epidural analgesia. Looking at the relative efficacy of the two techniques failure rates appear to be equal. Speed of onset may be faster with an initial spinal injection although perhaps only clinically relevant in advanced labour where the quality of analgesia may sometimes be better. CSE would not seem to offer significant advantage in terms of mode of delivery or the ability to ambulate. The side effects of the technique are somewhat more concerning as CSE would appear to carry slightly greater risk than epidural analgesia, most notably in neurological sequelae and the effects of intrathecal opioids. Certainly CSE confers no benefit in terms of cost. What then is the place of CSE in labour analgesia? Its potential benefit makes it a reasonable option when there is a clear clinical advantage such as requests for analgesia in late labour or where maternal distress is extreme or where epidural analgesia has been ineffective. However even in such situations the slight increase in risk must be weighed against the possible advantage. Consequently the CSE cannot at the present time be recommended as the preferred option for labour analgesia.

Distal calcific uremic arteriolopathy in a hemodialysis patient responds to lowering of Ca x P product and aggressive wound care

Calcific uremic arteriolopathy (CUA; calciphylaxis), is reported in approximately 4% of patients receiving hemodialysis, and is characterized by skin lesions that may include firm plaques or subcutaneous nodules. The syndrome has been associated with the use of calcium-containing phosphate binders, high serum phosphorus levels, and elevated calcium x phosphorus (Ca x P) product. This report describes a 73-year-old white male with chronic renal failure due to diabetes mellitus and hypertension, who had been on home hemodialysis for 3 years. He developed CUA after an acute elevation in serum phosphorus (8.1 mg/dl) and Ca x P product (84.2), with painful skin lesions that rapidly progressed to become circumferentially located around the entire lower left extremity. The patient declined amputation, opting for a treatment approach that included aggressive management of phosphorus and calcium, more frequent dialysis, and rigorous wound care. All calcium-containing phosphate binders were discontinued. The patient was switched from calcitriol to paricalcitol, a less calcemic form ofvitamin D replacement therapy, from which he was slowly weaned. Dialysis dose and frequency was also increased to 4 hours, 6 times weekly. The patient was given sevelamer hydrochloride (Renagel)--a calcium-free phosphate binder--with meals at an initial dose of 6.4 g/day. After 5 months, the dose was increased to 8 g/day, with additional dietary counseling to restrict phosphorus intake. At this point, serum phosphorus decreased to 4.9 mg/dl and calcium levels had fallen to 8.5 mg/dl, compared to 9.5 - 10.4 mg/dl prior to diagnosis of CUA with an overall decline in the Ca x P product. Significant healing of the lesions was noted at 8 months following diagnosis, with near-total healing by 12 months. Our studies support that lowering of elevated serum phosphorus, calcium, and Ca x P product, together with aggressive wound care may contribute to the successful outcome of patients with CUA.