Is it time for implementation of tight glycaemia control by intensive insulin therapy in every ICU?

The second study on tight glycaemia control by intensive insulin therapy (IIT) confirmed in medical intensive care unit patients the decrease in hospital mortality reported by the same team in the first IIT trial in surgical patients. However, methodological concerns, the high rate of hypoglycaemia in spite of the infusion of large doses of parenteral glucose and the frequent use of steroids presently preclude considering these results as recommendations in other intensive care units, but rather argue for the need for large-scale assessment of the IIT approach by multi-centre studies to confirm the efficacy and safety of this therapeutic modality.     

Is it time for medical therapy for aortic valve disease?

Calcific aortic stenosis is the most common indication for surgical valve replacement. Currently there are no medical therapies approved for the treatment of this disease. This review will summarize the clinical and experimental studies published over the past 5 years that indicate that medical therapy may be an option for this patient population.     

In-hospital cardiac arrest: Is it time for an in-hospital ‘chain of prevention’?

The ‘chain of survival’ has been a useful tool for improving the understanding of, and the quality of the response to, cardiac arrest for many years. In the 2005 European Resuscitation Council Guidelines the importance of recognising critical illness and preventing cardiac arrest was highlighted by their inclusion as the first link in a new four-ring ‘chain of survival’. However, recognising critical illness and preventing cardiac arrest are complex tasks, each requiring the presence of several essential steps to ensure clinical success. This article proposes the adoption of an additional chain for in-hospital settings - a ‘chain of prevention’ - to assist hospitals in structuring their care processes to prevent and detect patient deterioration and cardiac arrest. The five rings of the chain represent ‘staff education’, ‘monitoring’, ‘recognition’, the ‘call for help’ and the ‘response’. It is believed that a ‘chain of prevention’ has the potential to be understood well by hospital clinical staff of all grades, disciplines and specialties, patients, and their families and friends. The chain provides a structure for research to identify the importance of each of the various components of rapid response systems.     

Is it time to revisit routine administration of antibiotic for preterm prelabor rupture of membranes?

Preterm prelabor rupture of membranes (pPROM) is the precursor of up to 40% of preterm deliveries and an independent risk factor for neonatal disease, death and long-term pulmonary and neurodevelopmental deficits. A significant proportion of cases of pPROM are infection driven, although these are difficult to delineate in clinical practice. Our understanding of the natural history of intrauterine infection/inflammation is rudimentary at best. Even less is our knowledge of the influence of antibiotic therapy on the course of intrauterine infection. Yet, evidence that suggested that antibiotic therapy for pPROM delayed preterm delivery and reduced maternal and neonatal morbidity was adopted, and routine administration of broad-spectrum antibiotic is now part of the standard of care for patients with pPROM. This article evaluates the findings of a recent small but, in my opinion, very important study that aimed to determine whether antibiotic administration to the mother eradicated intra-amniotic infection and/or inflammation, both recognized potent risk factors for preterm delivery and adverse neonatal/childhood outcomes.     

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

Background and Objective

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

Methods

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

Results and Conclusion

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

Significance

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.