Three model curricula for teaching clinicians to use the ICF

PURPOSE: Three systematic programmes to train health professionals to use the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) are described, along with efforts to evaluate their effectiveness. METHODS: The first programme was a randomized study comparing the effects of a 2-hour instructor-led programme and a self-directed learning module on ICF-related knowledge, attitudes, and coding skills among occupational therapy graduate students. The second programme was a series of intensive 3.5-day workshops for public sector rehabilitation professionals in South Africa. The third programme involved a series of internet-based teaching modules regarding the ICF for graduate students in rehabilitation counselling. RESULTS: The first project found that both instructor-led and self-guided training formats were effective in improving basic ICF-related knowledge, but only instructor-led training led to a significant improvement in coding skill. It also had more positive effects on ICF-related attitudes. This approach to learning assessment was generalizable to multidisciplinary health professionals in South Africa, who achieved a relatively high degree of coding accuracy after the 3.5-day workshop. Participant evaluations supported the structure, content, and length of the training. Students in the third programme also reported a very positive learning experience and positive views of the ICF. CONCLUSIONS: An empirical basis is important for identifying the best and most efficient training methods for particular audiences and specific purposes. The length and format of training can be differentially related to specific training goals (i.e., knowledge, attitudes, and coding skills). Interactive distance learning methods may help to overcome the weaknesses of self-directed training in comparison to face-to-face training.     

Traumatic occurrence of chest wall tamponade secondary to subcutaneous emphysema

Subcutaneous emphysema is a physical finding that itself is usually perceived as benign yet rarely may, in and of itself, be life-threatening. We present an unusual case of a 67-year-old woman who developed delayed severe subcutaneous emphysema and tension pneumothorax from a rib fracture subsequent to a fall. We review the pathophysiology, manifestations and management options of this disorder. In patients whose clinical condition allows it, chest tube placement prior to intubation should be considered. Furthermore, positive end-expiratory pressure should be minimized. We present a case that illustrates how subcutaneous emphysema itself can be a potential cause of respiratory failure and tamponade physiology. In our case, a patient with traumatic subcutaneous emphysema developed respiratory failure and clinical deterioration after the introduction of positive pressure ventilation. In such rare scenarios, care should be taken to consider the absolute need for positive pressure ventilation without surgical decompression.     

Airway management for the uninitiated

The 21(st) century has witnessed burgeoning interest in airway management. Pertinent basic sciences are covered in numerous texts and lectures. This article presents clinical information required to perform airway management. It serves as a primer for those interested in learning airway management skills. It does not replace extensive practice under the tutelage of expert airway managers.     

Limited effects of beta-endorphin compared to loperamide or fentanyl in a neuroendocrine biomarker assay in non-human primates

The in vivo pharmacodynamics of the opioid neuropeptide beta-endorphin (a major endogenous agonist at the mu-opioid receptor) is difficult to determine in non-human primate models with translational value, or in humans. The present studies therefore employed a neuroendocrine biomarker assay, prolactin release, to systematically compare the in vivo profile of i.v. beta-endorphin (0.01-0.32 mg/kg; i.v.) in gonadally intact male rhesus monkeys (n=4) to that of the peripherally selective mu-agonist loperamide (0.01-0.32 mg/kg; i.v.) and the centrally penetrating mu-agonist fentanyl (0.0056-0.018 mg/kg; i.v.). Studies utilized a standardized time course design (measuring prolactin levels 5-120 min after agonist administration). Beta-endorphin displayed only limited effectiveness in causing prolactin release when tested over this 30-fold dose range, compared to loperamide or fentanyl. Furthermore, two of the four subjects were only minimally responsive to beta-endorphin. This differential responsiveness was not due to the presence of a previously described single nucleotide polymorphism at the OPRM1 gene (C77G), known to affect beta-endorphin pharmacodynamics in vitro. In vivo biotransformation studies with MALDI-mass spectrometry determined that full-length beta-endorphin was detectable in all subjects up to at least 5 min after i.v. administration. Thus, the relative ineffectiveness of i.v. beta-endorphin in this assay does not appear to be principally due to rapid generation of non-opioid fragments of this neuropeptide.     

Major lower extremity amputation after multiple revascularizations: was it worth it?

Lower extremity revascularization is often described as excessively lesion-centric, with insufficient focus on the patient. We investigated patients' perspectives of multiple procedures for limb salvage that culminated in major lower extremity amputation. A prospective vascular surgery database was queried from January 2000 to December 2005 for patients who had undergone below-knee (BKA) or above-knee (AKA) amputation after failed lower extremity revascularization. Patients were surveyed via telephone by a vascular nurse regarding thoughts on undergoing multiple procedures for limb salvage, involvement in decision making, functional status (work, meal preparation, shopping, driving), use of prosthesis, and independence. The Social Security Death Index was utilized to verify patient survival. Amputations for infection were excluded. Seventy-eight patients underwent AKA or BKA after failed revascularization. Forty-six patients (59%) were alive at 5 years. Thirteen patients were lost to follow-up, leaving 33 available for survey. A total of 142 lower extremity revascularizations (median = 4/patient) were performed on these patients including 94 surgical bypasses (median = 3/patient) and 48 percutaneous interventions (median = 1/patient). Eighty-five percent (28 of 33 patients) of amputees surveyed would do everything to save the leg if faced with a similar scenario, regardless of the number of procedures. Fifty-four percent (18/33) of patients actively used a prosthesis, and 91% (30/33) resided at home. In retrospect, patients are willing to undergo multiple revascularizations--percutaneous or open--to attempt limb salvage even if the eventual result is major amputation. Independence and functional status appear to be obtainable in a majority of patients. Patient-oriented outcomes are necessary to guide revascularization, whether it is by a percutaneous or open technique.