Abstract Background For critical care to be effective it must have a system in place to achieve optimal care for the deteriorating ward patient. Objectives To systematically review the available ...literature to assess whether either early warning systems or emergency response teams improve hospital survival. In the event of there being a lack of evidence regarding hospital survival, secondary outcome measures were considered (unplanned ICU admissions, ICU mortality, length of ICU stay, length of hospital stay, cardiac arrest rates). Methods The Ovid Medline, EMBASE, CINAHL, Web of Science, Cochrane library and NHS databases were searched in September 2012 along with non-catalogued resources for papers examining the effect of early warning systems or emergency response teams on hospital survival. Inclusion criteria were original clinical trials and comparative studies in adult inpatients that assessed either an early warning system or emergency response team against any of the predefined outcome measures. Exclusion criteria were previous systematic reviews, non-English abstracts and studies incorporating paediatric data. Studies were arranged in to sections focusing on the following interventions: Early warning systems - Single parameter systems - Aggregate weighted scoring systems (AWSS) Emergency response teams - Medical emergency teams - Multidisciplinary outreach services In each section an appraisal of the level of evidence and a recommendation has been made using the SIGN grading system. Results 43 studies meeting the review criteria were identified and included for analysis. 2 studies assessed single parameter scoring systems and 4 addressed aggregate weighted scoring systems. A total of 20 studies examined medical emergency teams and 22 studies examined multidisciplinary outreach teams. Limitations The exclusion of non English studies and those including paediatric patients does limit the applicability of this review. Conclusions Much of the available evidence is of poor quality. It is clear that a ‘whole system’ approach should be adopted and that AWSS appear to be more effective than single parameter systems. The response to deterioration appears most effective when a clinician with critical care skills leads it. The need for service improvement differs between health care systems.
This book offers an original anthropological approach to the AIDS epidemic in South Africa, demonstrating why AIDS interventions in the former homeland of Venda have failed - and possibly even been ...counterproductive. It does so through a series of ethnographic encounters, from kings to condoms, which expose the ways in which biomedical understanding of the virus have been rejected by - and incorporated into - local understandings of health, illness, sex and death. Through the songs of female initiation, AIDS education and wandering minstrels, the book argues that music is central to understanding how AIDS interventions operate. This book elucidates a hidden world of meaning in which people sing about what they cannot talk about, where educators are blamed for spreading the virus, and in which condoms are often thought to cause AIDS. The policy implications are clear: African worldviews must be taken seriously if AIDS interventions in Africa are to become successful.
Summary
Contrast media (CM) are an indispensable part of modern medical imaging. Adverse reactions to CM are uncommon, but frequently involve cutaneous symptoms. This two‐part article reviews adverse ...events secondary to CM that are relevant to the practising dermatologist. Part 1 covers the classification of CM, immediate hypersensitivity reactions to CM and the newly described condition, gadolinium deposition disease. Given that there has only been two case reports to our knowledge of a delayed adverse reaction to gadolinium‐based CM, this second part will focus on cutaneous delayed reactions caused by iodinated CM (ICM). Delayed hypersensitivity reactions to ICM commonly present as maculopapular exanthems, but more rarely, they can manifest as fixed drug eruptions, acute generalized exanthematous pustulosis, drug‐related eosinophilia and systemic symptoms, Stevens–Johnson syndrome/toxic epidermal necrolysis, symmetrical drug‐related intertriginous and flexural exanthema, graft‐versus‐host disease, vasculitis and iododerma. Delayed reactions to ICM may be underdiagnosed, as cutaneous symptoms may be attributed to oral medications, particularly if patients are on multiple drugs.
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Problematic stress levels among medical students have been well established. This stress can lead to depression, suicidal ideation, substance abuse, burnout and cynicism, having a negative effect on ...students and their patients. This study proposes to move towards examining the processes underlying well being in some medical students and vulnerability in others. It draws upon social psychological literature to propose that self-complexity, medical student identity and associated norms all have the capacity to influence medical students' well being in both positive and negative ways. It identifies two key dilemmas facing medical students with regard to the social psychological factors investigated. First, a diverse set of interests and a high level of self-complexity is thought to buffer against the effects of stress and might also be beneficial for medical practitioners, but the intensive nature of medical education makes it difficult for students to pursue outside interests, leading to a strongly focused identity. Second, a strong group identity is associated with high levels of social support and improved well being, but unhealthy group norms may have a greater influence on individuals who have a strong group identity, encouraging them to engage in behaviours that place their well being at risk. A model is proposed outlining how these potentially contradictory social psychological processes may combine to impact upon medical students' well being. There is great scope for investigating the role of self-complexity, identity and norms in the medical education context, with room to investigate each of these factors alone and in combination. It highlights how the proposed model can inform medical educators as to the students who may be most vulnerable to the effects of stress and the potential interventions from which they may benefit. It concludes that social psychological factors make a valuable contribution to understanding the complex issue of well-being in medical education. Author abstract, ed
Angiomyolipomas (AMLs) are the most common benign renal neoplasm and are often discovered incidentally. Due to both an increase in the use of imaging, as well as advances in imaging technology, they ...are being increasing identified in the general population. As these lesions are benign, there is good evidence that the majority of them can be safely followed up without treatment. However, there is an increasing wealth of information available suggesting there are individuals with AMLs where prophylactic treatment is indicated to prevent complications such as haemorrhage. In such cases, treatment with radiological interventional techniques with subselective particle embolization has superseded surgical techniques in most cases. Even in emergency cases with catastrophic rupture, prompt embolization may save the patient with the additional benefit of renal salvage. Confident identification of a lesion as an AML is important as its benign nature obviates the need for surgery in most cases. The presence of fat is paramount in the confirmatory identification and characterization of these lesions. Although fat-rich AMLs are easy to diagnose, some lesions are fat poor and it is these cases where newer imaging techniques, such as in-phase and out-of-phase magnetic resonance imaging (MRI) may aid in making a confident diagnosis of AML. In this paper, we comprehensively review the imaging techniques in making a diagnosis of AML, including features of both characteristic lesions as well as atypical lesions. In addition, we discuss current guidelines for follow-up and prophylactic treatment of these lesions, as well as the increasing role that the interventional radiologist has to play in these cases.
Summary
Contrast media (CM) are commonly used worldwide to enhance the quality of imaging, which is invaluable for diagnostic accuracy. Adverse reactions to CM are uncommon, but frequently involve ...cutaneous symptoms. This two‐part article reviews adverse events secondary to CM that are relevant to the practising dermatologist. Part 1 will classify CM, address immediate hypersensitivity reactions and review the newly described condition, gadolinium deposition disease. Part 2 will cover the delayed hypersensitivity reactions of iodinated contrast medium including severe cutaneous adverse reactions and iododerma.
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Background: Associations between maternal vitamin E, vitamin D and zinc intakes during pregnancy and asthma, wheeze and eczema in 5-year-old children have previously been reported. A study was ...undertaken to investigate whether maternal intake of specific foods during pregnancy is associated with asthma and allergic outcomes in the same children. Methods: A longitudinal birth cohort study was conducted in 1924 children born to women recruited during pregnancy. Maternal diet during pregnancy was assessed by food frequency questionnaire (FFQ). Cohort children were followed up at 5 years by symptom questionnaire and FFQ. Food groups of interest were fruit, vegetables, fruit juice, whole grain products, fish, dairy products and fat spreads. Trends across outcome groups defined by level of food intake are presented. Results: 1253 children participated at 5 years and maternal FFQ data were available for 1212. No consistent associations were found between childhood outcomes and maternal intake of the analysed foods except for apples and fish. Maternal apple intake was beneficially associated with ever wheeze (OR highest vs lowest tertile 0.63, 95% CI 0.42 to 0.95), ever asthma (OR 0.54, 95% CI 0.32 to 0.92) and doctor-confirmed asthma (OR 0.47, 95% CI 0.27 to 0.82) in the children. Maternal fish consumption was beneficially associated with doctor-confirmed eczema (OR ⩾1/week vs never 0.57, 95% CI 0.35 to 0.92). Conclusion: There was no evidence for associations between maternal intake of most foods during pregnancy and asthma, respiratory and allergic outcomes in 5-year-old children, except for apples and fish. Consumption of apples and fish during pregnancy may have a protective effect against the development of childhood asthma and allergic disease.
Objectives To determine whether maternal obesity during pregnancy is associated with increased mortality from cardiovascular events in adult offspring. Design Record linkage cohort analysis. Setting ...Birth records from the Aberdeen Maternity and Neonatal databank linked to the General Register of Deaths, Scotland, and the Scottish Morbidity Record systems. Population 37 709 people with birth records from 1950 to present day. Main outcome measures Death and hospital admissions for cardiovascular events up to 1 January 2012 in offspring aged 34-61. Maternal body mass index (BMI) was calculated from height and weight measured at the first antenatal visit. The effect of maternal obesity on outcomes in offspring was tested with time to event analysis with Cox proportional hazard regression to compare outcomes in offspring of mothers in underweight, overweight, or obese categories of BMI compared with offspring of women with normal BMI. Results All cause mortality was increased in offspring of obese mothers (BMI >30) compared with mothers with normal BMI after adjustment for maternal age at delivery, socioeconomic status, sex of offspring, current age, birth weight, gestation at delivery, and gestation at measurement of BMI (hazard ratio 1.35, 95% confidence interval 1.17 to 1.55). In adjusted models, offspring of obese mothers also had an increased risk of hospital admission for a cardiovascular event (1.29, 1.06 to 1.57) compared with offspring of mothers with normal BMI. The offspring of overweight mothers also had a higher risk of adverse outcomes. Conclusions Maternal obesity is associated with an increased risk of premature death in adult offspring. As one in five women in the United Kingdom is obese at antenatal booking, strategies to optimise weight before pregnancy are urgently required.
Fertilizer nitrogen (N) contributes to ammonia (NH3) emissions, which European Union member states have committed to reduce. This study focused on evaluating NH3‐N loss from a suite of N fertilizers ...over multiple applications, and gained insights into the temporal and seasonal patterns of NH3‐N loss from urea in Irish temperate grassland using wind tunnels. The fertilizers evaluated were calcium ammonium nitrate (CAN), urea and urea with the N stabilizers N‐(n‐butyl) thiophosphoric triamide (NBPT), dicyandiamide (DCD), DCD+NBPT and a maleic and itaconic acid polymer (MIP). 200 (and 400 for urea only) kg N/ha/yr was applied in five equal applications over the growing season at two grassland sites (one for MIP). Mean NH3‐N losses from CAN were 85% lower than urea and had highly variable loss (range 45% points). The effect of DCD on NH3 emissions was variable. MIP did not decrease NH3‐N loss, but NBPT caused a 78.5% reduction and, when combined with DCD, a 74% reduction compared with urea alone. Mean spring and summer losses from urea were similar, although spring losses were more variable with both the lowest and highest losses. Maximum NH3‐N loss usually occurred on the second day after application. These data highlight the potential of stabilized urea to alter urea NH3‐N loss outcomes in temperate grassland, the need for caution when using season as a loss risk guide and that urea hydrolysis in temperate grassland initiates quickly. Micrometeorological measurements focused specifically on urea are needed to determine absolute NH3‐N loss levels in Irish temperate grassland.
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