Serum ischaemia-modified albumin increases in critical lower limb ischaemia

BACKGROUND

Ischaemia is a common phenomenon in the pathogenesis of a wide range of medical and surgical conditions, including myocardial infarction, mesenteric vascular occlusion and compartment syndrome. Ischaemia modified albumin has been suggested as an aid to clinical decision making in various clinical settings. This study examines the usefulness of IMA in the diagnosis of limb ischaemia (LI).

METHODS

This case-controlled study was performed in the emergency department of Karadeniz Technical University Hospital, Turkey. 22 patients presenting to the emergency departments and definitively diagnosed with LI were enrolled in the study. A control group of 22 healthy volunteers served as a reference for biochemical parameters.

RESULTS

The mean serum IMA level for LI patients was 0.295 (SD 0.062) ABSU. The mean serum IMA level for control patients was 0.174 (SD 0.061) ABSU. There was a statistically significant difference between the mean LI patient and mean control patient IMA levels (p<0.0005). A ROC curve analysis reveals the relationship between sensitivity and specificity for IMA in limb ischaemia.

CONCLUSION

There is a significant increase in serum IMA in limb ischaemia. Furthermore, using a cutoff of 0.22 ABSU, ROC curve analysis shows that IMA is 81.8% sensitive and 81.8% specific 81.8% in patients with clinically severe lower limb ischaemia. Future studies would be needed to determine if IMA would be clinically useful in the diagnosis of subtle limb ischaemia.

WITHDRAWN: Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment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.

AUTHORS' 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.

Compensatory dynamics are rare in natural ecological communities

In population ecology, there has been a fundamental controversy about the relative importance of competition-driven (density-dependent) population regulation vs. abiotic influences such as temperature and precipitation. The same issue arises at the community level; are population sizes driven primarily by changes in the abundances of cooccurring competitors (i.e., compensatory dynamics), or do most species have a common response to environmental factors? Competitive interactions have had a central place in ecological theory, dating back to Gleason, Volterra, Hutchison and MacArthur, and, more recently, Hubbell's influential unified neutral theory of biodiversity and biogeography. If competitive interactions are important in driving year-to-year fluctuations in abundance, then changes in the abundance of one species should generally be accompanied by compensatory changes in the abundances of others. Thus, one necessary consequence of strong compensatory forces is that, on average, species within communities will covary negatively. Here we use measures of community covariance to assess the prevalence of negative covariance in 41 natural communities comprising different taxa at a range of spatial scales. We found that species in natural communities tended to covary positively rather than negatively, the opposite of what would be expected if compensatory dynamics were important. These findings suggest that abiotic factors such as temperature and precipitation are more important than competitive interactions in driving year-to-year fluctuations in species abundance within communities.

Intravenous versus oral iron therapy for postpartum anaemia

OBJECTIVE

Postpartum iron deficiency anaemia (IDA) is common in women. Most women are treated with either oral iron supplementation or blood transfusion. Hence, the aim of our study was to compare the effect of treatment with either oral ferrous sulphate or intravenous ferrous sucrose on postpartum IDA.

DESIGN

A single centre, prospective randomised controlled trial.

SETTING

Women's Centre, John Radcliffe Hospital, Oxford, UK.

POPULATION

Forty-four women with haemoglobin (Hb) of <9 g/dl and ferritin of <15 microgram/l at 24-48 hours postdelivery.

METHODS

Women were randomised to receive either oral ferrous sulphate 200 mg twice daily for 6 weeks (group O) or intravenous ferrous sucrose 200 mg (Venofer; Vifor International Ltd, St Gallen, Switzerland), two doses given on days 2 and 4 following recruitment (group I).

RESULTS

were analysed by the Students t-test, chi-square test and analysis of variance.

MAIN OUTCOME MEASURES

Hb, haematocrit, red cell indices, ferritin and serum iron levels were measured on days 0, 5, 14 and 40. Results By day 5, the Hb level in women treated with intravenous iron had risen from 7.3 +/- 0.9 to 9.9 +/- 0.7 g/dl, while there was no change in those treated with oral iron. Women treated with intravenous iron had significantly higher Hb levels on days 5 and 14 (P < 0.01) than those treated with oral iron; although by day 40, there was no significant difference between the two groups. Throughout the study, ferritin levels rose rapidly in those treated with intravenous iron and remained significantly higher than in those treated with oral iron (P < 0.01).

CONCLUSIONS

Intravenous iron sucrose increases the Hb level more rapidly than oral ferrous sulphate in women with postpartum IDA. It also appears to replenish iron stores more rapidly. However, this study was not large enough to address the safety of this strategy.

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.

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.

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.