Acute renal failure in the critically I11: Management by continuous veno-venous hemodiafiltration

The consequences of newer techniques of continuous renal replacement therapy in critically ill patients are not yet fully known. The clinical and biochemical impact of continuous veno-venous hemodiafiltration (CVVHD) was, therefore, prospectively studied in 60 critically ill patients with acute renal failure. Prospective clinical, biochemical, and hematological data were collected from patients receiving CVVHD. Over the initial 24 hours of therapy, CVVHD resulted in a decrease in mean plasma urea from 34.5 mmol/L (95% confidence interval [CI], 29.4 to 39.6) to 25 mmol/L (95% CI, 21.8 to 28.2). With continued CVVHD, the mean plasma urea reached a plateau level of 17.6 mmol/L (95% CI, 15.8 to 19.4) at 72 hours. This degree of azotemia control was achieved with ease and essentially without complications during 8,360 hours of therapy despite the presence of multi-organ failure and the aggressive administration of protein nitrogen (0.25 to 0.35 g/kg/day). No abnormalities of serum electrolytes developed during treatment. Survival to intensive care discharge was 46.6% and to hospital discharge 41.6%, despite a mean Acute Physiology and Chronic Health Evaluation (APACHE) Il score at presentation of 27.7. Continuous veno-venous hemodiafiltration offers superior azotemia control and a safe approach to renal replacement therapy in critically ill patients. Its use is associated with a comparatively favorable outcome. CVVHD may be regarded as the treatment of choice in such patients.     

Recognising and developing students as teachers: Introduction of a novel Undergraduate Certificate in Veterinary Medical Education

A key responsibility of healthcare professionals is the education of clients/patients, colleagues and students undertaking placements. Peer-assisted learning (PAL) has been incorporated in our veterinary medicine programme for a number of years. The aim of this project was to develop a mechanism to formally recognise the important role that students play in the School’s teaching and learning processes and foster students as partners in education through the development of a novel Undergraduate Certificate in Veterinary Medical Education (UCVME). Students and veterinarians were surveyed in order to inform the design of the programme. The programme is modular and aligned with the UK Professional Standards Framework (UKPSF). Students enrol in their third year, undertaking core and elective components, with completion over the final three years of the degree. The UCVME has been positively received, with 30 of 160 third year students enrolling in the programme’s first year. Activities receiving credit and designed in partnership between staff and students have included: PAL sessions, widening participation school educational workshops and client education events. This initiative has created numerous student-driven educational opportunities. It is hoped that this programme will facilitate the educational training of students and enhance employability and career satisfaction.     

Non-metric multidimensional performance indicator scaling reveals seasonal and team dissimilarity within the National Rugby League

Objectives

Analysing the dissimilarity of seasonal and team profiles within elite sport may reveal the evolutionary dynamics of game-play, while highlighting the similarity of individual team profiles. This study analysed seasonal and team dissimilarity within the National Rugby League (NRL) between the 2005 to 2016 seasons.

Evidence of impaired pain modulation in adolescents with idiopathic scoliosis and chronic back pain

BACKGROUND CONTEXT

Although 40% of adolescent idiopathic scoliosis (AIS) patients present with chronic back pain, the pathophysiology and underlying pain mechanisms remain poorly understood. We hypothesized that development of chronic pain syndrome in AIS is associated with alterations in pain modulatory mechanisms.

Neurosurgical applications of radiotherapy

The term ‘radiosurgery’ (RS) indicates a high precision localized technique of irradiation used as an alternative to surgical excision in patients with malignant or benign conditions, both in the brain and in the body. Brain RS has been historically identified with ‘stereotactic radiotherapy’. The term refers to the long-established neurosurgical technique of localizing the position of a lesion in the brain by using a system of external 3D co-ordinates coupled with rigid head immobilization device (often fixed to the skull). A high dose of radiation is delivered to the target stereotactically identified and a safe and accurate treatment is achieved, minimizing the dose of radiation to the surrounding brain. While for some techniques the traditional stereotactic localization has been replaced by the integration of modern imaging with non-invasive accurate immobilization, the term ‘stereotactic’ is still maintained in the clinical practice. Over the past 30 years, the implementation of powerful diagnostic imaging devices and of new radiotherapy equipment has contributed to the large diffusion of brain RS. RS plays an important role in the management of brain tumours, vascular and functional brain lesions and the expertise of the multidisciplinary treating team (clinical oncologists, neurosurgeons, neuro-radiologists and medical physics) contributes to the treatment success rate.     

Trimodal therapy vs. radical cystectomy for muscle-invasive bladder cancer: A Markov microsimulation model

IntroductionRadical cystectomy (RC) is the historic gold standard treatment for muscle-invasive bladder cancer (MIBC), but trimodal therapy (TMT) has emerged as a valid therapeutic option for select patients. Given that prospective clinical trials have been difficult to perform in this area, our aim was to compare these two primary treatment strategies using decision analytic methods.MethodA two-dimensional Markov microsimulation model was constructed using TreeAge Pro to compare RC and TMT for patients with newly diagnosed MIBC. A comprehensive literature search was used to populate model probabilities and utilities. Our primary outcome was quality-adjusted life expectancy (QALE). Secondary outcomes included crude life expectancy (LE) and bladder cancer recurrences. The simulated patient for our model was an adult with MIBC (pT2-4 N0 M0) who was a candidate for either RC or TMT.ResultsA total of 500 000 patients were simulated. TMT resulted in an estimated mean QALE of 7.48 vs. 7.41 for RC. However, the average LE for patients treated with TMT was lower compared with RC (10.20 vs. 10.74 years). A sensitivity analysis evaluating the impact of age showed that younger patients treated with RC had greater QALE and longer LE than those treated with TMT; inverse findings were observed for elderly patients. Overall, 39.4% of patients treated with TMT experienced a bladder recurrence.ConclusionsRC results in a longer LE compared to TMT (0.54 years), but with a lower QALE (−0.07 years). The preferred treatment strategy varied with patient age.     

The use of a novel perfusion-based cadaveric simulation model with cerebrospinal fluid reconstitution comparing dural repair techniques: a pilot study

Background Context

Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery.

Post‐Traumatic Heterotopic Ossification: An Old Problem in Need of New Solutions

Heterotopic ossification (HO) is the formation of pathological bone in ectopic sites and it can have serious consequences for functional outcomes. For many years, its main clinical relevance was as a rare complication of elective joint arthroplasty or CNS injury and a number of prophylaxes were developed to mitigate against it in these settings. As a consequence of changes in patterns of wounding and survival in conflicts since the turn of the century, post‐traumatic HO has become much more common and case severity has increased. It represents one of the main barriers to rehabilitation in a large cohort of combat‐injured patients. However, extant prophylaxes have not been shown to be effective or appropriate in this patient cohort. In addition, the lack of reliable early detection or means of predicting which patients will develop HO is another barrier to effective prevention. This review examines the current state of understanding of post‐traumatic HO including the historical context, epidemiology, pathophysiology, clinical issues, currently prophylaxis and detection, management, and potential future approaches. Our aims are to highlight the current lack of effective means of early detection and prevention of HO after major trauma and to stimulate research into novel solutions to this challenging problem. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1061–1068, 2018.