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Adequate pain relief at the scene of injury and during transport to hospital is a major challenge in all acute traumas, especially for those with hip fractures, whose injuries are difficult to immobilize and long-term outcomes may be adversely affected by administration of opiate analgesics. Fascia Iliaca Compartment Block (FICB) is a procedure routinely undertaken by clinicians in emergency departments for hip fracture patients, but use by paramedics at the scene of emergency calls, is not yet evaluated (1).
We undertook a randomized controlled feasibility trial using novel audited scratchcard randomization to allocate eligible patients to FICB or usual care. Paramedics are recruited and trained to assess patients for hip fracture and carry out FICB. We will follow up patients to assess accuracy of paramedic diagnosis, acceptability to patients and paramedics, compliance of paramedics and also measures of pain, side effects, time in hospital and quality of life in order to plan a full trial if appropriate. The primary outcome measure is health related quality of life, measured using Short Form (SF)-12 at 1 and 6 months. Interviews and focus groups will be used to understand acceptability of FICB to patients and paramedics. This study was funded by Health and Care Research Wales (1003).
We have developed:
•paramedic pathway to assess patients for hip fracture and FICB
•paramedic training package, delivered by Consultant Anaesthetist
To date we have recruited nineteen paramedics; ten are fully trained and recruiting patients, the remainder are being trained. Fifty-four patients have been randomized and thirty-five have consented to follow-up. Thirteen 1-month and five 6-month follow-up questionnaires have been received.
This study will enable us to recommend whether to undertake a definitive multi-centre randomized controlled trial of FICB by paramedics for hip fracture to determine if the procedure is effective for patients and worthwhile for the National Health Service.
Patients who experience Transient Ischaemic Attack (TIA) should be assessed and treated in a specialist clinic to reduce risk of further TIA or stroke. But referrals are often delayed. We aimed to identify published studies describing pathways for emergency assessment and referral of patients with suspected TIA at first medical contact: primary care; ambulance services; and emergency department.
We conducted a scoping literature review. We searched four databases (PubMed, CINAHL, Web of Science, Scopus). We screened studies for eligibility. We extracted and analysed data to describe setting, assessment and referral processes reported in primary research on referral of suspected TIA patients directly to specialist outpatient services.
We identified eight studies in nine papers from five countries: 1/9 randomized trial; 6/9 before-and-after designs; 2/9 descriptive account. Five pathways were used by family doctors and three by Emergency Department (ED) physicians. None were used by paramedics. Clinicians identified TIA patients using a checklist incorporating the ABCD2 tool to describe risk of further stroke, online decision support tool or clinical judgement. They referred to a specialist clinic, either directly or via a telephone helpline. Anti-platelet medication was often given, usually aspirin unless contraindicated. Some patients underwent neurological and blood tests before referral and discharge. Five studies reported reduced incident of stroke at 90 days, from 6–10 percent predicted rate to 1.2-2.1 percent actual rate. Between 44 percent and 83 percent of suspected TIA cases in these studies were directly referred to stroke clinics through the pathways.
Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalization of TIA patients. No pathways for paramedic use were reported. Since many suspected TIA patients present to ambulance services, effective pre-hospital assessment and referral pathways are needed. We will use review results to develop a paramedic referral pathway to test in a feasibility trial.
Transient Ischaemic Attack (TIA) is a neurologic event with symptom resolution within 24 hours. Early specialist assessment of TIA reduces risk of stroke and death. National United Kingdom (UK) guidelines recommend patients with TIA are seen in specialist clinics within 24 hours (high risk) or seven days (low risk).
We aimed to develop a complex intervention for patients with low risk TIA presenting to the emergency ambulance service. The intervention is being tested in the TIER feasibility trial, in line with Medical Research Council (MRC) guidance on staged development and evaluation of complex interventions.
We conducted three interrelated activities to produce the TIER intervention:
•Survey of UK Ambulance Services (n = 13) to gather information about TIA pathways already in use
•Scoping review of literature describing prehospital care of patients with TIA
•Synthesis of data and definition of intervention by specialist panel of: paramedics; Emergency Department (ED) and stroke consultants; service users; ambulance service managers.
The panel used results to define the TIER intervention, to include:
1.Protocol for paramedics to assess patients presenting with TIA and identify and refer low risk patients for prompt (< 7day) specialist review at TIA clinic
2.Patient Group Directive and information pack to allow paramedic administration of aspirin to patients left at home with referral to TIA clinic
3.Referral process via ambulance control room
4.Training package for paramedics
5.Agreement with TIA clinic service provider including rapid review of referred patients
We followed MRC guidance to develop a clinical intervention for assessment and referral of low risk TIA patients attended by emergency ambulance paramedic. We are testing feasibility of implementing and evaluating this intervention in the TIER feasibility trial which may lead to fully powered multicentre randomized controlled trial (RCT) if predefined progression criteria are met.
Historians have long been aware that patronage is a crucial factor in interpreting the social meaning of art. The late Middle Ages knew a variety of patrons, each employing art to communicate different sorts of concern: royal and aristocratic courts emphasized political messages, urban communes created governmental myths, cathedrals and monasteries gave expression to spiritual ideas—and all used art to convey notions of social identity. Recent investigations into the process of choosing and procuring works of art in these contexts have not only added perspective to formal art criticism, they have also deepened our understanding of the groups interested in the creation of art. One area in which questions of patronage could perhaps be better illuminated is the community of the parish. The parish served as the primary religious community for the majority of men and women for most of the Middle Ages. It was complex in composition, involving both laity and clergy, encompassing other religious associations, such as gilds, and including the devout and the indifferent, the orthodox and the dissenters.
Diets rich in fruits and vegetables (FV), which contain (poly)phenols, protect against age-related inflammation and chronic diseases. T-lymphocytes contribute to systemic cytokine production and are modulated by FV intake. Little is known about the relative potency of different (poly)phenols in modulating cytokine release by lymphocytes. We compared thirty-one (poly)phenols and six (poly)phenol mixtures for effects on pro-inflammatory cytokine release by Jurkat T-lymphocytes. Test compounds were incubated with Jurkat cells for 48 h at 1 and 30 µm, with or without phorbol ester treatment at 24 h to induce cytokine release. Three test compounds that reduced cytokine release were further incubated with primary lymphocytes at 0·2 and 1 µm for 24 h, with lipopolysaccharide added at 5 h. Cytokine release was measured, and generation of H2O2 by test compounds was determined to assess any potential correlations with cytokine release. A number of (poly)phenols significantly altered cytokine release from Jurkat cells (P<0·05), but H2O2 generation did not correlate with cytokine release. Resveratrol, isorhamnetin, curcumin, vanillic acid and specific (poly)phenol mixtures reduced pro-inflammatory cytokine release from T-lymphocytes, and there was evidence for interaction between (poly)phenols to further modulate cytokine release. The release of interferon-γ induced protein 10 by primary lymphocytes was significantly reduced following treatment with 1 µm isorhamnetin (P<0·05). These results suggest that (poly)phenols derived from onions, turmeric, red grapes, green tea and açai berries may help reduce the release of pro-inflammatory mediators in people at risk of chronic inflammation.
Over 40 years of archaeological investigations along the south coast of Papua New Guinea has identified a rapid succession of cultural changes during the late Holocene. The so-called ‘Papuan Hiccup’ (c. 1200–800 cal bp) is a poorly understood period of socio-economic upheaval along the coast, identified mainly from changes in archaeological ceramic styles and settlement patterns. During this period, the region-wide Early Papuan Pottery (EPP) tradition diverges into separate, localised ceramic sequences that have generic associations with local ethnographic wares. A correspondence between the timing of the Papuan Hiccup and a period of peak El Niño-Southern Oscillation (ENSO) activity implies a link between cultural and climate change. This paper explores this relationship further by examining changes in interaction networks along the south coast of Papua New Guinea, specifically focusing on chert artefacts. Chemical characterisation (portable X-Ray Fluorescence; pXRF) and technological analysis are used to map changes in lithic technology over time, including access to raw materials and technological organisation, at the site of Taurama, a prehistoric coastal village site that was occupied both prior to and after the Papuan Hiccup. Although the sample sizes are small and the interpretations necessarily circumscribed, it is argued that changes in the number of chert sources being exploited and in the intensity of core reduction at Taurama may be related to climate change in the region.
Acute psychological stress is positively associated with a cold/flu. The present randomised, double-blind, placebo-controlled study examined the effect of three potentially probiotic bacteria on the proportion of healthy days over a 6-week period in academically stressed undergraduate students (n 581) who received Lactobacillus helveticus R0052, Bifidobacterium longum ssp. infantis R0033, Bifidobacterium bifidum R0071 or placebo. On each day, participants recorded the intensity (scale: 0 = not experiencing to 3 = very intense) for nine cold/flu symptoms, and a sum of symptom intensity >6 was designated as a day of cold/flu. B. bifidum resulted in a greater proportion of healthy days than placebo (P≤ 0·05). The percentage of participants reporting ≥ 1 d of cold/flu during the 6-week intervention period was significantly lower with B. bifidum than with placebo (P< 0·05). There were no effects of B. infantis or L. helveticus compared with placebo on either outcome. A predictive model accounted for influential characteristics and their interactions on daily reporting of cold/flu episodes. The proportion of participants reporting a cold on any given day was lower at weeks 2 and 3 with B. bifidum and B. infantis than with placebo for the average level of stress and the most commonly reported number of hours of sleep. Daily intake of bifidobacteria provides benefit related to cold/flu outcomes during acute stress.
Many viral infections that cause minor illness in younger adults can lead to significant mortality and morbidity in older people, particularly as co-morbidities tend to accumulate with increased age. Respiratory and gastrointestinal viruses are ubiquitous and frequently cause outbreaks, with major impact on those in care homes or residential accommodation. Advances in medicine have opened the way for increased impact of the herpes viruses (varicella zoster virus, herpes simplex virus, Epstein–Barr virus and cytomegalovirus), as immune systems are manipulated. People are also leading more active lives in older age; human immunodeficiency virus (HIV) will be increasingly prevalent, as those living with HIV grow older in good health. In addition, new diagnoses of HIV, viral hepatitis and travel-related infections will present to those working in health care of older people. This review article of viral infections aims to highlight relevant pathology, with specific reference to management in older people.
Using concepts from the literature on individual and collective identity, we argue that organizational psychologists are at a tipping point with regard to identity. Assertions regarding a lack of distinctiveness from other fields, ambiguity in individual identification with the field among new entrants, hyperadaptation to external forces, and a failure to manage within-identity dynamics associated with science and practice are presented. These assertions are supported with descriptions of the nature of growth in the field, challenges in academic psychology departments, and calls for changing research agendas. With the aim of engaging others in collective sensemaking, alternative future scenarios for organizational psychology are presented.
The commentaries provided an array of perspectives on identity management in our profession. However, there was general agreement on what should be central and distinctive about our field and on the need to cultivate a positive identity for the profession. The commentators also suggested a number of ways to cultivate this identity. For us, the commentaries also stimulated further reflection on our approach to training graduate students. We share our reflections and encourage readers to take the time to reflect on their own efforts to contribute to the profession's management of identity.
‘… by defaulte of bokus and sympulnys of letture …’
(‘… by absence of books and limited skill with letters …’)
John Mirk, Prologue
Telling Stories: Sermon Literature and Popular Culture
It might be thought that a text that enjoyed the popularity of the Festial would be a natural choice for scholarly investigation, but although the collection is well known it has attracted surprisingly little analysis. Certainly, its sermons are often cited by scholars who study religion in late-medieval England. Historians such as Eamon Duffy and Michael Camille refer to the Festial, as do literary critics such as David Aers. R. N. Swanson's collection of documents illustrating religion in medieval England includes one of Mirk's sermons in its entirety. The Festial is widely known and little studied in the modern academic community in spite of its medieval popularity, because popularity has not emerged as a significant criterion in the selection of sermons analyzed for the light they can shed on late-medieval religion, even in works professing to study popular movements.
It might be claimed that Mirk's sermons have attracted little attention because some scholars assume the Festial is merely a translation of The Golden Legend. The use of a Latin or other source text does not normally deflect scholarly attention. The literary works of Chaucer and Shakespeare were frequently based upon existing stories, yet no one claims Hamlet to be unworthy of study because it is a reworking of older Danish material. The derivative nature of Mirk's collection would not have been unusual for sermons at the time of its creation. As Fletcher and Powell note,
Originality was not to be praised in the Middle Ages, even in the field of literature proper. Appreciation was directed at a man's skill in the re-working of established material rather than his ability to invent new material. In the sermon field, moreover, originality and heresy were too closely linked for comfort.
And while one might object that Mirk simply reworked one conventionally orthodox text to create another conventionally orthodox text, an answer to such an objection may be found in the cautionary words of David Aers and Lynn Staley:
'Marvellously perceptive and insightful'. FIONA SOMERSET, Duke University. Written with largely uneducated rural congregations in mind, John Mirk's Festial became the most popular vernacular sermon collection of late-medieval England, yet until relatively recently it has been neglected by scholars -- despite the fact that the question of popular access to the Bible, undoubtedly regarded as the preserve of learned culture, along with the related issue of the relative authority of written text and tradition, is at the heart of both late-medieval heresy and the resultant reformulation of orthodoxy. It offers, in fact, an unparalleled opportunity to analyze the religious ideology communicated by the orthodox church to the vast majority of people in fourteenth-century England: the ordinary country folk. This book represents the first major examination of the Festial, looking in particular at the issues of popular culture and piety; the oral tradition; biblical and secular authority; and clerical power.
JUDY ANN FORD is Associate Professor in the History Department of Texas A&M University-Commerce.