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Pain control is an important element of care for patients after surgery, leading to better outcomes, quicker transitions to recovery, and improvement in quality of life. The purpose of this study was to evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs in children after cardiac surgery
Materials and Methods:
Patients between the ages of 1 month and 18 years of age, who received intravenous or oral non-steroidal anti-inflammataory drugs after cardiac surgery, from November 2015 until September 2017 were included in this study. The primary endpoints were non-steroidal anti-inflammataory drug-associated renal dysfunction and post-operative bleeding. Secondary endpoints examined the effect of non-steroidal anti-inflammataory drug use on total daily dose of narcotics, number of intravenous PRN narcotic doses received, and pain assessment score. Data were analysed using descriptive statistics for frequencies and ranges. Multivariate analysis was performed to measure the association of all predictors and outcomes. Wilcoxon singed-rank test was performed for secondary outcomes.
There was no association between the incidence of renal dysfunction and the use of or duration of non-steroidal anti-inflammataory drugs; in addition no association was found with increased chest tube output. There was a statistically significant reduction of patients’ median Face, Legs, Activity, Cry, Consolability (FLACC) scores (2–0; p = 0.003), seen within first 24 hours after initiation of ketorolac, and a significant reduction of morphine requirements seen from day 1 to day 2 (0.3 mg/kg versus 0.1 mg/kg; p < 0.001) and number of as-needed doses.
Non-steroidal anti-inflammataory drugs in paediatric cardiac surgery patients are safe and effective for post-operative pain management.
Background: Buprenorphine/naloxone (bup/nal) is a partial opioid agonist/antagonist and recommended first line treatment for opioid use disorder (OUD). Emergency departments (EDs) are a key point of contact with the healthcare system for patients living with OUD. Aim Statement: We implemented a multi-disciplinary quality improvement project to screen patients for OUD, initiate bup/nal for eligible individuals, and provide rapid next business day walk-in referrals to addiction clinics in the community. Measures & Design: From May to September 2018, our team worked with three ED sites and three addiction clinics to pilot the program. Implementation involved alignment with regulatory requirements, physician education, coordination with pharmacy to ensure in-ED medication access, and nurse education. The project is supported by a full-time project manager, data analyst, operations leaders, physician champions, provincial pharmacy, and the Emergency Strategic Clinical Network leadership team. For our pilot, our evaluation objective was to determine the degree to which our initiation and referral pathway was being utilized. We used administrative data to track the number of patients given bup/nal in ED, their demographics and whether they continued to fill bup/nal prescriptions 30 days after their ED visit. Addiction clinics reported both the number of patients referred to them and the number of patients attending their referral. Evaluation/Results: Administrative data shows 568 opioid-related visits to ED pilot sites during the pilot phase. Bup/nal was given to 60 unique patients in the ED during 66 unique visits. There were 32 (53%) male patients and 28 (47%) female patients. Median patient age was 34 (range: 21 to 79). ED visits where bup/nal was given had a median length of stay of 6 hours 57 minutes (IQR: 6 hours 20 minutes) and Canadian Triage Acuity Scores as follows: Level 1 – 1 (2%), Level 2 – 21 (32%), Level 3 – 32 (48%), Level 4 – 11 (17%), Level 5 – 1 (2%). 51 (77%) of these visits led to discharge. 24 (47%) discharged patients given bup/nal in ED continued to fill bup/nal prescriptions 30 days after their index ED visit. EDs also referred 37 patients with OUD to the 3 community clinics, and 16 of those individuals (43%) attended their first follow-up appointment. Discussion/Impact: Our pilot project demonstrates that with dedicated resources and broad institutional support, ED patients with OUD can be appropriately initiated on bup/nal and referred to community care.
To investigate a Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak event involving multiple healthcare facilities in Riyadh, Saudi Arabia; to characterize transmission; and to explore infection control implications.
Cases presented in 4 healthcare facilities in Riyadh, Saudi Arabia: a tertiary-care hospital, a specialty pulmonary hospital, an outpatient clinic, and an outpatient dialysis unit.
Contact tracing and testing were performed following reports of cases at 2 hospitals. Laboratory results were confirmed by real-time reverse transcription polymerase chain reaction (rRT-PCR) and/or genome sequencing. We assessed exposures and determined seropositivity among available healthcare personnel (HCP) cases and HCP contacts of cases.
In total, 48 cases were identified, involving patients, HCP, and family members across 2 hospitals, an outpatient clinic, and a dialysis clinic. At each hospital, transmission was linked to a unique index case. Moreover, 4 cases were associated with superspreading events (any interaction where a case patient transmitted to ≥5 subsequent case patients). All 4 of these patients were severely ill, were initially not recognized as MERS-CoV cases, and subsequently died. Genomic sequences clustered separately, suggesting 2 distinct outbreaks. Overall, 4 (24%) of 17 HCP cases and 3 (3%) of 114 HCP contacts of cases were seropositive.
We describe 2 distinct healthcare-associated outbreaks, each initiated by a unique index case and characterized by multiple superspreading events. Delays in recognition and in subsequent implementation of control measures contributed to secondary transmission. Prompt contact tracing, repeated testing, HCP furloughing, and implementation of recommended transmission-based precautions for suspected cases ultimately halted transmission.
The aim of this study was to update the literature on interventions for carers of people with dementia published between 2006 and 2016 and evaluate the efficacy of psychoeducational programs and psychotherapeutic interventions on key mental health outcomes (depression, anxiety, burden, and quality of life).
A meta-analysis was carried out of randomized controlled trials of carer interventions using MEDLINE, PsycINFO, Scopus, and Cochrane Central Register of Controlled Trials.
The majority of studies were conducted in Western and Southern Europe or the United States and recruited carers of people with Alzheimer's disease or dementia grouped as a whole. The most commonly used outcome measures were depression and burden across studies. The updated evidence suggested that psychoeducation-skill building interventions delivered face-to-face can better impact on burden. Psychotherapeutic interventions underpinned by Cognitive Behavior Therapy (CBT) models demonstrated strong empirical support for treating anxiety and depression and these effects were not affected by the mode of delivery (i.e. face-to-face vs. technology). A modern CBT approach, Acceptance and Commitment Therapy (ACT), seemed to be particularly beneficial for carers experiencing high levels of anxiety.
Future research needs to explore the efficacy of interventions on multiple clinical outcomes and which combination of interventions (components) would have the most significant effects when using CBT. The generalization of treatment effects in different countries and carers of different types of dementia also need to be addressed. More research is needed to test the efficacy of modern forms of CBT, such as ACT.
Recent research has demonstrated the challenges to self-identity associated with dementia, and the importance of maintaining involvement in decision-making while adjusting to changes in role and lifestyle. This study aimed to understand the lived experiences of couples living with dementia, with respect to healthcare, lifestyle, and “everyday” decision-making.
Semi-structured qualitative interviews using Interpretative Phenomenological Analysis as the methodological approach.
Community and residential care settings in Australia.
Twenty eight participants who self-identified as being in a close and continuing relationship (N = 13 people with dementia, N = 15 spouse partners). Nine couples were interviewed together.
Participants described a spectrum of decision-making approaches (independent, joint, supported, and substituted), with these approaches often intertwining in everyday life. Couples’ approaches to decision-making were influenced by “decisional,” “individual,” “relational,” and “external” factors. The overarching themes of “knowing and being known,” “maintaining and re-defining couplehood” and “relational decision-making,” are used to interpret these experiences. The spousal relationship provided an important context for decision-making, with couples expressing a history and ongoing preference for joint decision-making, as an integral part of their experience of couplehood. However, the progressive impairments associated with dementia presented challenges to maintaining joint decision-making and mutuality in the relationship.
This study illustrates relational perspectives on decision-making in couples with dementia. Post-diagnostic support, education resources, proactive dyadic interventions, and assistance for spouse care partners may facilitate more productive attempts at joint decision-making by couples living with dementia.
A controversy at the 2016 IUCN World Conservation Congress on the topic of closing domestic ivory markets (the 007, or so-called James Bond, motion) has given rise to a debate on IUCN's value proposition. A cross-section of authors who are engaged in IUCN but not employed by the organization, and with diverse perspectives and opinions, here argue for the importance of safeguarding and strengthening the unique technical and convening roles of IUCN, providing examples of what has and has not worked. Recommendations for protecting and enhancing IUCN's contribution to global conservation debates and policy formulation are given.
This study aimed to ascertain otolaryngologists’ current knowledge of new (e.g. apixaban, rivaroxaban) and old (e.g. warfarin) anticoagulant medications, and to provide an educational overview of new anticoagulants for use by surgeons.
A questionnaire survey was distributed across the Wessex region, UK, to ascertain the levels of knowledge of and confidence in managing patients taking various anticoagulants. In total, 50 questionnaires were completed (41 by trainees and 9 by consultants). A literature review of new anticoagulant medications was then conducted.
In general, there was poor clinical and pharmacokinetic knowledge of newly licensed anticoagulant medications. Respondents were more confident in the use of older vs newer forms of anticoagulants. This was true across all grades of doctors, but particularly at the senior level. All respondents stated that they would like to see an educational resource on anticoagulants.
Knowledge of newly licensed anticoagulation medications is poor. This study has produced an educational resource for the management of anticoagulant agents. A thorough knowledge of these drugs is essential for the acute management of bleeding patients and in peri-operative surgical planning.
The distinctive phrase, domino in domino dominorum, shared by the salutations in the prefatory letter of Bede's revised metrical Vita Cuthberti and in the letter sent by Hwaetbert with his former abbot Ceolfrith to Rome, reflects an unexpected historical connection among Bede's revision, Ceolfrith's departure and, more tentatively, the abdication of John of Beverley of the bishopric of York. While only Ceolfrith's journey has been dated to 716, I argue that Bede was revising his poem in anticipation of this event, but under the false assumption that it would be John of Beverley who would lead the party. The salutation, drawn from one of Augustine of Hippo's letters, supports this claim by identifying, after the opening phrase that would be appropriate for a bishop, John as a priest, a playful conjunction of terms used by Bede to call attention to the bishop of York's changing status. This opening, then, was in Bede's mind when the need for a letter from Hwaetbert to Pope Gregory II arose. Bede's revision and, probably, some discussion of John's retirement can be dated to 716.
This book synthesizes and reviews the evidence in support of seven generic principles for enhancing the resilience of ecosystem services, i.e. the capacity of a social–ecological system to sustain a desired set of ecosystem services in the face of disturbance and ongoing change. Although some principles are better established than others, there is evidence that all are important. At the same time, none of the principles are universally beneficial, and all require a nuanced understanding of how, when and where they apply. Furthermore, the principles are often highly interdependent. Context matters and promoting the enhanced resilience of ecosystem services depends as much on how the individual principles are applied as on achieving an appropriate combination of principles. The nature of social–ecological systems as interdependent complex adaptive systems calls for governance and management that enhances aspects of a social–ecological system that help shape trajectories in desirable directions and enable adaptive responses to unexpected events. The principles are thus not final outcomes in themselves but rather features relevant for building resilience that should be considered when designing governance structures and management policies. More research is needed to better understand the individual principles, how they interact and how they can be operationalized and applied in different contexts.
The degree to which humans are shaping ecosystems at local to global scales poses significant challenges in providing for the wellbeing of the planet's growing number of people (MA 2005; Martin 2007). One of the critical issues is ensuring the adequate and reliable provision of essential ecosystem services, such as freshwater, food and climate regulation, to meet the needs of society in a world that is expected to continue changing rapidly over the coming century. Social–ecological resilience is one growing body of research that seeks to provide insights and understanding to help address this challenge, premised on the assumption that the functioning of ecosystems and the provision of ecosystem services cannot be understood without accounting for the actions of people who live in these systems.
This study prospectively assesses the mental health outcomes among women seeking abortions, by comparing women having later abortions with women denied abortions, up to 2 years post-abortion seeking.
We present the first 2 years of a 5-year telephone interview study that is following 956 women who sought an abortion from 30 facilities throughout the USA. We use adjusted linear mixed-effects regression analyses to assess whether symptoms of depression and anxiety, as measured by the Brief Symptom Inventory-short form and the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, differ over time among women denied an abortion due to advanced gestational age, compared with women who received abortions.
Baseline predicted mean depressive symptom scores for women denied abortion (3.07) were similar to women receiving an abortion just below the gestational limit (2.86). Depressive symptoms declined over time, with no difference between groups. Initial predicted mean anxiety symptoms were higher among women denied care (2.59) than among women who had an abortion just below the gestational limit (1.91). Anxiety levels in the two groups declined and converged after 1 year.
Women who received an abortion had similar or lower levels of depression and anxiety than women denied an abortion. Our findings do not support the notion that abortion is a cause of mental health problems.
The correspondences between the names in the Scylding genealogy at the beginning of Beowulf and three names in the upper reaches of the genealogy of Æthelwulf in the Anglo-Saxon Chronicle, Beaw, Sceldwa and Sceaf, frequently appear in arguments for a late dating of Beowulf. But these arguments overlook many aspects of Æthelwulf's genealogy that disrupt their case for a late dating. As H. Munro Chadwick pointed out over a century ago, the forms Sceldwa and Beaw found in the Chronicle for Scyld and Beow are not West Saxon spellings, and the -wa suffix of Sceldwa and Tætwa suggests that these forms may be archaic. Thus spelling alone indicates that these names were probably copied from an older, non-West Saxon text. Furthermore, the very presence of these names in the royal pedigree is puzzling. On one level the presence of Scyld is easy to explain: Scyld and the Scyldings were famous in heroic legend, and his inclusion in Æthelwulf's pedigree provides reflected glory for the West Saxon dynasty and implies genealogical, political and cultural connections between the West Saxons and the Danes that could be useful for Alfred and his heirs to foster. But on another level his inclusion is rather surprising: according to genealogical conventions, the presence of Scyld implies that the West Saxon royal family is a cadet branch of the Scylding dynasty, and is thus potentially subordinate to Scandinavian rulers in England claiming direct descent from Scyld.
Since the date of the Beowulf manuscript is widely agreed upon, the very question which prompts this volume (and the conference it derives from, and even the 1980 conference with its 1981 proceedings volume) must assume that the date of the poem may not be the same as the date of the manuscript. It is certain that there must have been a moment of first inscription for the poem, and that the time and place of that moment remains a central point of interest for students of the poem. In this essay, I will bring new evidence to bear on this venerable question, and my argument shall be that Beowulf is metrically conservative according to a variety of independent metrical criteria. Further, I will suggest that that conservatism is so varied and consistent as to strongly indicate that the original version of Beowulf must be placed among the very earliest of the longer narrative Old English poems that survive, probably in the eighth century.
Of course, it remains true, I believe, that the moment of inscription is only one of the moments of interest which might engage modern scholars of the poem. As I argued in Authors, Audiences, and Old English Verse, our focus on authorship (and on moments of authorship) may sometimes cause us to lose sight of what can be gained by also considering audience, and I proposed there two later audiences for Beowulf, one located at Alfred's Wessex court in the late ninth century, and another, sometime around the turn of the eleventh century, perhaps in Canterbury, represented most clearly by the author of Maldon.
As the introduction to this collection makes clear, the various forms of linguistic and metrical evidence bearing on the dating of Beowulf point to a date of composition fairly early in the Anglo-Saxon period. In his article for The Dating of Beowulf in 1980, Thomas Cable proposed a rough guide to the metrical dating of poems using the incidence of type C, D, and E verses, which decline in frequency over the Anglo-Saxon period. Cable's criterion places Beowulf toward the beginning of a relative chronology. Since then, much additional metrical and linguistic evidence has been gathered that places Beowulf in the early to mid-eighth century. R.D. Fulk's A History of Old English Meter is the most substantial work of this kind, for it examines the presence of archaic metrical features through-out the corpus of Old English poetry and finds that Beowulf is by far the most archaic poem. Since that work, other scholars have written articles on individual metrical or linguistic features of the poetic corpus, which have corroborated the conclusions that Fulk so carefully reached.
Some scholars, however, remain dubious about the reliability of this type of evidence. At this point, the force of linguistic scholarship is too formidable to be undermined by the doubts raised by E.G. Stanley, who urged that the poem should not be dated by means of sundry linguistic oddities that could well be scribal error or just a few bad lines.
From the publication of the poem's editio princeps in 1815 to the emergence of the present collection two centuries later, few topics in Anglo-Saxon studies have generated as much speculation and scholarship as the dating of Beowulf. Marshaling disparate forms of evidence and argumentation, scholars have assigned dates to Beowulf that range from the seventh to the eleventh century. Various individuals have been unpersuasively identified as the author of Beowulf and dozens of kings, clerics, and contexts have been associated with the poem's genesis. Scholarship on the dating of Beowulf is markedly uneven in quality: alongside sober and thoughtful argumentation, there has been a great deal of improbable hypothesizing about the author of the poem or the milieu in which it was composed. Awareness of the qualitative differences in the scholarly literature is tacitly registered in the relative frequency with which publications are cited, but these differences have rarely received explicit discussion. This introduction to the dating of Beowulf controversy examines the changing standards of evidence, methodology, and argumentation that have attended this topic, particularly in the past thirty years. The dating of Beowulf has not been a static or monolithic subject, but has undergone considerable change in the disputes it connotes and the practices it encompasses. In the following account, emphasis will be given to the reasons for prevailing opinions rather than to the multiplicity of opinions as such.
Arguments about the date of Beowulf are more impassioned than the question seems to merit. Even so, the controversy has its uses. Beowulf is a great work, all agree, but it constitutes only a sliver of the poetic canon and is doubtless more important to Anglo-Saxon culture now than it was a thousand years ago. For all its glory, Beowulf provides no better an index to Anglo-Saxon poetry than Hamlet to Renaissance drama, which is to say that one can know both works well without knowing much about the corpus to which either belongs. It is to welcome and good effect, then, that several chapters in this volume link the date of Beowulf to the date of everything else, which, for purposes of this discussion, is the rest of Old English poetry.
At the Harvard conference, R.D. Fulk argued that the date of the poem's composition is less significant than the means used to hypothesize the date. The introduction to Fulk's Chapter 1 in this volume sums up an extended discussion regarding probability, proof, and linguistic evidence drawn from his History of Old English Meter. Fulk observes that the criteria for dating verse are not uniformly rigorous and that they have not been subjected to uniformly rigorous testing. Words can be counted and their forms analyzed, so that exceptions to linguistic and metrical criteria emerge quickly; in these cases, the relative probability of competing hypotheses can be readily gauged.