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The dangers presented by antibiotic resistance (ABR) have now established themselves as a global health security issue. From an international policy perspective, three key pillars have been established: responsible access, conservation, and innovation. These pillars are intrinsically linked, meaning that any attempt to address one must take into account the implications for the other two.
An urgent need exists to address the innovation failure in ABR. In the field of anti-bacterials, the pipeline remains anemic in terms of therapeutics with novel mechanisms of action, new drug classes and strategies involving radically different, innovative approaches. The key reasons for this failure have already been well established. The slow development of new antibiotics is the result of a poor and uncertain commercial market and scientific challenges in research and development (R&D).
As the population ages, older people account for a greater proportion of the health and social care budget. Whereas some research has been conducted on the use of music therapy for specific clinical populations, little rigorous research has been conducted looking at the value of community singing on the mental health-related quality of life of older people.
To evaluate the effectiveness and cost-effectiveness of community group singing for a population of older people in England.
A pilot pragmatic individual randomised controlled trial comparing group singing with usual activities in those aged 60 years or more.
A total of 258 participants were recruited across five centres in East Kent. At 6 months post-randomisation, significant differences were observed in terms of mental health-related quality of life measured using the SF12 (mean difference = 2.35; 95% CI = 0.06–4.76) in favour of group singing. In addition, the intervention was found to be marginally more cost-effective than usual activities. At 3 months, significant differences were observed for the mental health components of quality of life (mean difference = 4.77; 2.53–7.01), anxiety (mean difference =–1.78; –2.5 to –1.06) and depression (mean difference =–1.52; –2.13 to –0.92).
Community group singing appears to have a significant effect on mental health-related quality of life, anxiety and depression, and it may be a useful intervention to maintain and enhance the mental health of older people.
The three common forms of presentation for acute gastrointestinal (GI) bleeds are: haematemesis, melaena, and haematochezia. This chapter discusses the complications associated with GI bleeding and management of GI bleeding. It lists the commonest causes of upper GI bleeding, and explains management of non-variceal upper GI bleeding and upper GI bleeding indications for surgery. Gastro-oesophageal varices are dilated submucosal veins which occur in approximately 40-60% of patients with cirrhosis. Control of active variceal bleeding has been shown to be achievable with sclerotherapy (80%) or band ligation (94%). The chapter discusses the incidence of upper GI perforation and lower GI perforation. Approximately 15% of patients with diverticulitis develop bowel perforation. The mortality rate is high (20-40%) as patients may suffer from sepsis and multiorgan failure. The chapter discusses initial management, specific management and post-operative complications of bowel perforation. Endoscopic treatment achieves haemostasis in the majority of patients with non-variceal bleeding.
After gallstones, alcohol is the second most common cause of acute pancreatitis. The mechanism of alcohol-induced acute pancreatitis is incompletely understood, although some evidence points to increased sensitivity of acinar cell cholecystokinin receptors leading to increased release of trypsin. Patients typically present with pepigastric pain, often radiating to the back, accompanied by nausea and vomiting. On account of the wide spectrum of disease severity in acute pancreatitis there is particular interest in prognostic indicators that may help to determine the requirement for therapeutic interventions. A number of scoring systems such as Glasgow score, have been developed to attempt risk stratification in acute pancreatitis. The mainstay of treatment in severe acute pancreatitis is supportive care. The mortality associated with the first peak in the biphasic mortality curve is attributable to systemic inflammatory response and multiple organ failure. Full intensive care support may be necessary including ventilatory, cardiovascular and renal support.
Obstetrics describes the care related to pregnancy. An understanding of the changes in maternal physiology and pathophysiology of pregnancy-related disorders is essential to provide safe, effective obstetric care. This chapter summarises the implications the physiological changes occurring in pregnancy will have on anaesthetic practice. The physiological changes include changes in cardiovascular and haematological system, respiratory system, gastrointestinal system and central nervous system. Patients with cardiovascular disease need close monitoring and multidisciplinary care throughout the pregnancy with the involvement of obstetricians, anaesthetists, intensivists and cardiologists. Pregnant patients should be considered to be at risk from aspiration from approximately 16/40 (before if symptoms of reflux). Patients should be premedicated with an H2-blocking drug the evening before and on the morning of Caesarean section. 30ml 0.3 Mol sodium citrate should be given immediately before a rapid sequence induction with cricoid pressure, which is used when administering general anaesthesia.
John Clift, Consultant Anaesthetist, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham,
Alexander Heazell, Clinical Research Fellow, Maternal and Fetal Health Research Centre, St Mary's Hospital, University of Manchester, Manchester, UK
Anaesthetists on labour ward form an important part of a multi disciplinary team that includes obstetricians, midwives, paediatricians and theatre staff. This role is becoming ever important as anaesthetists now participate in the management of over 50% of patients in a typical unit. As well as traditional roles of providing analgesia and anaesthesia, anaesthetists are also involved in the acute management of conditions related to pregnancy, such as pre-eclampsia and major obstetric haemorrhage, and also coordinating and planning the care of patients with coexisting medical diseases.
Good communication on labour ward is vital to ensure clear, early decision making, and to be able to communicate the anaesthetist must be able to understand the basics of obstetrics. In common with most medical specialities obstetrics has terms and conditions unique to the speciality. In addition, there are a specialised set of procedures, many of which have important differences compared to normal medical and surgical practice. A lack of understanding of obstetric terminology and the significance of obstetricians' observations may lead to inefficient functioning of the team. Most anaesthetists, including trainees and consultants, have had no formal obstetric training since they were medical students.
The aim of this book is to provide anaesthetists with a basic knowledge of obstetrics and, more importantly, the implications this will have on their anaesthetic practice. This book is intended to complement, rather than replace, standard texts on obstetric anaesthesia and will hopefully provide a greater insight into the obstetric mysteries of labour ward!
We are keen to receive comments or suggestions about the book.
Anaesthetists on labour wards form an important part of the multi-disciplinary team. In addition to providing analgesia and anaesthesia, they are also involved in the acute management of conditions related to pregnancy, and coordinate and plan the care of patients with coexisting medical diseases. This requires an understanding of specialized obstetric procedures and the terminology and conditions unique to obstetrics. Obstetrics for Anaesthetists is a practical manual designed to provide anaesthetists with a clear knowledge of obstetrics and the implications this will have on their anaesthetic practice. Each chapter includes algorithms for the management of obstetric emergencies and text boxes highlighting the anaesthetic implications of a condition. Edited by an obstetric anaesthetist and an obstetrician, and with contributions from many leading practitioners, Obstetrics for Anaesthetists is an invaluable practical guide to all aspects of obstetrics relevant to anaesthetic practice.