Does the Clinical Context Improve the Reliability of Rheumatologists Grading Digital Ulcers in Systemic Sclerosis?

OBJECTIVE

Digital ulcers (DUs) are often a primary end point in systemic sclerosis (SSc; scleroderma) clinical trials, although the reliability of rheumatologists grading DUs is poor to moderate at best. DU assessment in recent trials has been based upon visual inspection alone, which potentially misses "real-world" clinical contextual information. Our aim was to investigate whether this clinical information improves the reliability of rheumatologists grading DUs. A secondary aim was to assess agreement between patients and rheumatologists.

METHODS

Eighty images of a range of digital lesions were collected from patients with SSc with the clinical context: pain (severity and temporal relationship), lesion duration, and discharge (patient reported and clinician observed). Raters received all images either with or without the clinical context, and graded these images (using a custom-built interface) on an ordinal scale of severity: no ulcer, inactive ulcer, or active ulcer. Patients also graded their lesion(s) on the same scale.

RESULTS

Fifty-one rheumatologists from 15 countries completed the study (26 without and 25 with context): 4,590 (including 510 repeated) image gradings were obtained. Context did not significantly increase (without and with context) either intra- (0.64, 0.71) or interrater (0.32, 0.36) reliability. Pain (visual analog scale and temporal relationship) and discharge (patient reported and clinician observed) were associated with increased lesion severity, and duration with reduced severity. Agreement between individual patients and rheumatologists was poor without and with context (0.19, 0.28).

CONCLUSION

The overall intra- and interrater reliability of DU grading did not significantly improve with the clinical context. Agreement between patients and rheumatologists was poor.

Information in resource management: ward managers’ perceptions

With the third wave of UK National Health Service reforms now several years old and resource management firmly established, this study investigated ward managers’ perceptions of their clinical information needs and their information processes in relation to the management of resources. A convenience sample of 13 ward managers were interviewed, using semi-structured schedules, for between 20 and 45 minutes. The results were subjected to thematic and relationship analysis. Ward managers’ information needs appeared to be mainly influenced by the content of the budget statement. They also indicated that they had initial difficulty in reading the statement. They used several informal methods to obtain information but research literature and information technology were not perceived as valuable sources of information. The role of information in relation to resource management appears not to be wholly understood by ward managers.

Effect of analgesic modality on outcome following open liver surgery: a systematic review of postoperative analgesia

Postoperative analgesia following liver resection remains controversial. The traditional standard of care of thoracic epidural is increasingly questioned due to perceived associated complications and delays to recovery. Evidence supporting alternative analgesic techniques is emerging however best practice is not yet established. This review aimed to evaluate the literature to assess the optimum analgesic technique following liver resection. A systematic review was conducted of trials evaluating analgesic methods in open liver surgery. Primary outcome was the postoperative complication rate. Secondary outcomes were length of stay and pain scores. Fourteen trials matching the inclusion criteria were analysed. No difference was observed in systemic complication rates between analgesic modalities. Epidural was associated with prolonged length of stay when compared with continuous wound infiltration and intrathecal morphine. Epidural offered equivalent or superior pain scores when compared to alternative techniques. In summary current evidence suggests alternative analgesic modalities may provide favorable recovery outcomes following liver surgery but consistent evidence is limited. Epidurals provide superior pain relief to alternatives but this does not translate into reduced length of stay or complication rate following liver surgery.

The living with asthma study: issues affecting the perceived health and well-being of Irish adults with asthma

INTRODUCTION

Ireland has the fourth highest incidence of asthma in the world, with an estimated 14.7 % of the population having asthma, making it the most common chronic disease in childhood and the most common respiratory illness in Ireland.

METHOD

The aim of this qualitative enquiry, involving participant focus groups, was to investigate the health and well-being of Irish adults who have asthma, with particular interest in the influences on their health and well-being. The study population was recruited from the Asthma Society of Ireland database of members. Data were collected in eight focus group interviews and analysed for themes.

RESULTS

Asthma was found to have a significant impact on the health and well-being of participants due to symptom experience, treatments they had to undertake, and the repercussions of uncontrollable events or triggers. The unrelenting pressure of managing their asthma took a toll on many of the participants, who felt their lifestyle had changed dramatically and they had lost some or all of their control over their health and well-being.

An apparatus to manipulate and identify individual Ba ions from bulk liquid Xe

We describe a system to transport and identify barium ions produced in liquid xenon, as part of R&D towards the second phase of a double beta decay experiment, nEXO. The goal is to identify the Ba ion resulting from an extremely rare nuclear decay of the isotope (136)Xe, hence providing a confirmation of the occurrence of the decay. This is achieved through Resonance Ionization Spectroscopy (RIS). In the test setup described here, Ba ions can be produced in liquid xenon or vacuum and collected on a clean substrate. This substrate is then removed to an analysis chamber under vacuum, where laser-induced thermal desorption and RIS are used with time-of-flight mass spectroscopy for positive identification of the barium decay product.