Veno-arterial CO2 difference and lactate for prediction of early mortality after cardiac arrest

Patients admitted to intensive care after cardiac arrest are at risk of circulatory shock and early mortality due to cardiovascular failure. The aim of this study was to evaluate the ability of the veno-arterial pCO₂ difference (∆pCO₂; central venous CO₂ – arterial CO₂) and lactate to predict early mortality in postcardiac arrest patients. This was a pre-planned prospective observational sub-study of the target temperature management 2 trial. The sub-study patients were included at five Swedish sites. Repeated measurements of ∆pCO₂ and lactate were conducted at 4, 8, 12, 16, 24, 48, and 72 h after randomization. We assessed the association between each marker and 96-h mortality and their prognostic value for 96-h mortality. One hundred sixty-three patients were included in the analysis. Mortality at 96 h was 17%. During the initial 24 h, there was no difference in ∆pCO₂ levels between 96-h survivors and non-survivors. ∆pCO₂ measured at 4 h was associated with an increased risk of death within 96 h (adjusted odds ratio: 1.15; 95% confidence interval [CI]: 1.02–1.29; p = .018). Lactate levels were associated with poor outcome over multiple measurements. The area under the receiving operating curve to predict death within 96 h was 0.59 (95% CI: 0.48–0.74) and 0.82 (95% CI: 0.72–0.92) for ∆pCO₂ and lactate, respectively. Our results do not support the use of ∆pCO₂ to identify patients with early mortality in the postresuscitation phase. In contrast, non-survivors demonstrated higher lactate levels in the initial phase and lactate identified patients with early mortality with moderate accuracy.     

内镜下橡皮圈套扎术在上消化道广基息肉切除术中的应用

目的探讨橡皮圈套扎术在上消化道广基息肉切除术中的应用。方法回顾分析54例术前病理证实为良性病变的上消化道广基息肉,其中采用橡皮圈套扎术24例,为橡皮圈组,对照组30例单纯采用高频电凝电切术治疗。比较两组的术后出血发生率、穿孔率。结果所有患者均成功切除息肉,橡皮圈组无穿孔及出血发生,3 d后复查胃镜示息肉已脱落,溃疡形成。对照组有1例穿孔,5例早期出血,2例迟发性出血,均予钛夹钳夹创面后出血停止。两组比较,早期出血发生率有统计学差异(P<0.05),而迟发性出血发生率及穿孔率均无统计学差异(P>0.05)。结论橡皮圈套扎治疗广基息肉是一种安全有效的方法,能有效地避免早期出血等并发症。     

Contemporary Psychotherapy Research: Implications for Substance Misuse Treatment and Research

This article provides an overview of the major findings of psychotherapy research and discusses the possible implications of these findings for substance user treatment researchers and practitioners. While the centrality of relationship for human change processes was historically understood, twentieth century research tended to see relationship and person variables as secondary to operationalized “mechanisms of action” unique to particular psychotherapies. Interestingly, recent meta-analytic investigations have uncovered the weakness of randomized controlled trials (RCT) comparison investigations that have, until recently, represented the “gold standard” for the field. There has been a resurgent interest in the “common factors” that appear to be important across many effective psychotherapies. In addition, psychiatric anthropologists have contributed important information about the problems of client noncompliance with mental health treatment that parallel quantitative investigations. Substance misuse researchers have also found that client characteristics, especially clients' readiness to engage treatment, are important to investigate. The importance of the “therapeutic alliance” and the characteristics of clients and clinicians have become central areas for study, rather than variables to be controlled or excluded. Emphasis on these factors may represent the future for research in psychotherapy and substance user treatment, especially if researchers and community practitioners can join together to overcome methodological feasibility and dissemination problems that plague effectiveness research. However, the continued attractiveness of comparative studies and treatment efficacy studies may represent longstanding epistemological assumptions and responses to economic incentives that will be difficult to challenge.     

Impact of laparoscopic adjustable gastric banding on type 2 diabetes

Bariatric surgery is becoming an accepted option for obese people with type 2 diabetes. Our aim was to assess the impact of laparoscopic adjustable gastric banding (LAGB) through a systematic review of the literature. Data was sourced from Scopus, MEDLINE and EMBASE published from 2000 through May 2011, and five unpublished studies that were performed by industry for regulatory approval were also included. Studies were selected on the basis that they provide some detail of diabetes status before and after LAGB. There were 35 studies meeting the inclusion criteria. There was considerable heterogeneity in study design, sample size, length of follow‐up, attrition rates and classification of diabetes status. Weight loss was progressive over the first 2 years with a weighted average of 47% excess weight loss at 2 years. Remission or improvement in diabetes varied from 53% to 70% over different time periods. Results were broadly consistent, demonstrating clinically relevant improvements in diabetes outcomes with sustained weight loss in obese people with type 2 diabetes following LAGB surgery. However, there were significant shortcomings in the reviewed literature with few high‐quality studies, inconsistent reporting of diabetes outcomes and high attrition rates. Long‐term studies that address these limitations are needed.     

Effects of Clinical Experience and Explorer Type on Judged Crown Margin Acceptability

Purpose: This study was undertaken to simultaneously compare instrumentation type and operator characteristics in judgments of clinical acceptability of crowns exhibiting a controlled range of marginal gaps. The research was conducted in a laboratory setting and generalizability analysis was used as a statistical technique to identify the sources contributing to variation in the judgment outcome. Materials and Methods: A crown was seated on an ivorine tooth in a device that permitted continuous adjustment in intervals of 25 μm to produce known marginal gaps ranging from zero to 250 μm. Forty‐nine students and six faculty members used five types of explorers each to determine, by tactile examination, the point on the controlled increasing marginal gap where they would no longer regard the gap as clinically acceptable. Results: There were no differences across type of explorer. Operators with clinical experience had a threshold that rejected crowns at a smaller gap than did those operators without clinical experience (p= 0.007). Faculty members maintained a higher individual degree of consistency in their personal judgments than did students (p= 0.02); however, the inter‐operator consistency was significantly lower for faculty members than for students (p < 0.05). Conclusions: Differences among operators in a simulation of the decision regarding gaps in crowns accounted for 63% of the variance; type of explorer used in assisting this decision accounted for about half as much variance. Faculty members making such judgments exhibited high intra‐operator consistency but significantly lower inter‐operator consistency than did students. The study suggests that the internal standards dentists use for clinical decision making deserves further study as they may be as significant as the equipment used.