Bariatric surgery or medicine for type 2 diabetes?

Diet and medical treatment are the standard treatment for type 2 diabetes. In obese subjects with type 2 diabetes, bariatric surgery is effective in resolving diabetes. Two clinical trials comparing bariatric surgery to medical treatment were evaluated. Both the Surgical Treatment And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial (laparoscopic Roux-En Y gastric bypass and sleeve gastrectomy) and the DIet and medical therapy versus BAriatric SurgerY in type 2 diabetes (DIBASY) trial (laparoscopic gastric bypass and biliopancreatic-diversion) showed that surgery was more effective than medical care in resolving or managing type 2 diabetes. Larger studies, or a compilation of studies, are needed to determine whether one of these procedures is better, or if they are all similarly effective, and this should also be weighed against the risk of the operations.

Management of delirium in medicine : experience of a close observation unit

Objective(s): A new model of care for the management of patients with delirium was developed and evaluated. Method: A 4-bedded Close Observation Unit (COU) was introduced. The model comprised an education strategy for assistants in nursing (AIN), environmental adaptations and AIN to patient ratio of 1:4. Outcomes in all patients with delirium before and after introduction of the new model of care were compared. Results: 105 patients were admitted to COU, of whom 100 (95%) were diagnosed with delirium. In-hospital mortality improved after introduction of the unit (15% versus 5%; p=0.002) without significant change in length of stay, discharge destination or falls frequency. Conclusion: A dedicated unit for delirium management within medicine achieved a reduction in mortality.

Towards an integrative framework for future research on small firm growth

Our review has demonstrated that small firm growth is a complex phenomenon. The concept ‘growth’ denotes both a change in amount and the process by which that change is attained. Further, the growth can be achieved in different ways and with varying degrees of regularity, and it manifests itself along several different dimensions such as sales, employment, and accumulation of assets. This complexity has naturally led researchers to adopt different approaches to studying growth and to use different measures to assess it. Further, although our review shows that it can fruitfully be regarded as a growth issue, the research on small firms' internationalization has largely developed as a separate stream. Similarly, other relatively separate literatures have evolved, which effectively focus on different modes of growth although mostly without regarding the studies first and foremost as growth studies. This goes for topics such as mergers and acquisitions, diversification, and integration - research streams which have largely ignored the particularities of small firms and which in turn have been largely ignored among researchers focusing on small firm growth.

Intern underperformance is detected more frequently in emergency medicine rotations

Objective: To determine the frequency and nature of intern underperformance as documented on in-training assessment forms. Methods: A retrospective review of intern assessment forms from a 2 year period (2009–2010) was conducted at a tertiary referral hospital in Brisbane, Queensland. The frequency of interns assessed as ‘requiring substantial assistance’ and/or ‘requires further development’ on mid- or end-of-term assessment forms was determined. Forms were analysed by the clinical rotation, time of year and domain(s) of clinical practice in which underperformance was documented. Results: During 2009 and 2010 the overall documented incidence of intern underperformance was 2.4% (95% CI 1.5–3.9%). Clinical rotation in emergency medicine detected significantly more underperformance compared with other rotations (P < 0.01). Interns predominantly had difficulty with ‘clinical judgment and decision-making skills’, ‘time management skills’ and ‘teamwork and colleagues’ (62.5%, 55% and 32.5% of underperforming assessments, respectively). Time of the year did not affect frequency of underperformance. A proportion of 13.4% (95% CI 9.2–19.0%) of interns working at the institution over the study period received at least one assessment in which underperformance was documented. Seventy-six per cent of those interns who had underperformance identified by mid-term assessment successfully completed the term following remediation. Conclusion: The prevalence of underperformance among interns is low, although higher than previously suggested. Emergency medicine detects relatively more interns in difficulty than other rotations.

The potential contributions of traditional Chinese medicine to emergency medicine

BACKGROUND: Despite the fact that traditional Chinese medicine (TCM) has been developed and used to treat acute and urgent illness for many thousands of years. TCM has been widely perceived in western societies that TCM may only be effective to treat chronic diseases. The aim of this article is to provide some scientific evidence regarding the application of TCM in emergency medicine and its future potential. METHODS: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) were searched using the terms: Traditional Chinese Medicine/ Chinese Medicine, Emergency Medicine, China. In addition, three leading TCM Journals in China were searched via Oriprobe Information Services for relevant articles (published from 1990—2012). Particular attention was paid to those articles that are related to TCM treatments or combined medicine in dealing with intensive and critical care. RESULTS: TCM is a systematic traditional macro medicine. The clinical practice of TCM is guided by the TCM theoretical framework – a methodology founded thousands of years ago. As the methodologies between TCM and Biomedicine are significantly different, it provides an opportunity to combine two medicines, in order to achieve clinical efficacy. Nowadays, combined medicine has become a common clinical model particular in TCM hospitals in China. CONCLUSIONS: It is evident that TCM can provide some assistance in emergency although to combine them in practice is stillits infant form and is mainly at TCM hospitals in China. The future effort could be put into TCM research, both in laboratories and clinics, with high quality designs, so that TCM could be better understood and then applied in emergency medicine.

Use of thermal imaging in sports medicine research : a short report

The assessment of skin temperature (Tsk) in athletic therapy and sports medicine research is an extremely important physiological outcome measure.Various methodsof recording Tsk, including thermistors, thermocouples and thermocrons are currently being used for research purposes. These techniques are constrained by their wires limiting the freedom of the subject, slow response times, and/or sensors falling off. Furthermore, as these products typically are directly attached to the skin and cover the measurement site, their validity may be questionable.This manuscript addresses the use and potential benefits of using thermal imaging (TI) in sport medicine research.Non-contact infrared TI offers a quick, non-invasive, portable and athlete-friendly method of assessing Tsk. TI is a useful Tsk diagnostic tool that has potential to be an integral part of sport medicine research in the future. Furthermore, as the technique is non-contact it has several advantages over existing methods of recording skin temperature

Nurse-administered procedural sedation and analgesia in the cardiac catheter laboratory : an integrative review

Objectives: To identify and appraise the literature concerning nurse-administered procedural sedation and analgesia in the cardiac catheter laboratory. Design and data sources: An integrative review method was chosen for this study. MEDLINE and CINAHL databases as well as The Cochrane Database of Systematic Reviews and the Joanna Briggs Institute were searched. Nineteen research articles and three clinical guidelines were identified. Results: The authors of each study reported nurse-administered sedation in the CCL is safe due to the low incidence of complications. However, a higher percentage of deeply sedated patients were reported to experience complications than moderately sedated patients. To confound this issue, one clinical guideline permits deep sedation without an anaesthetist present, while others recommend against it. All clinical guidelines recommend nurses are educated about sedation concepts. Other findings focus on pain and discomfort and the cost-savings of nurse-administered sedation, which are associated with forgoing anaesthetic services. Conclusions: Practice is varied due to limitations in the evidence and inconsistent clinical practice guidelines. Therefore, recommendations for research and practice have been made. Research topics include determining how and in which circumstances capnography can be used in the CCL, discerning the economic impact of sedation-related complications and developing a set of objectives for nursing education about sedation. For practice, if deep sedation is administered without an anaesthetist present, it is essential nurses are adequately trained and have access to vital equipment such as capnography to monitor ventilation because deeply sedated patients are more likely to experience complications related to sedation. These initiatives will go some way to ensuring patients receiving nurse-administered procedural sedation and analgesia for a procedure in the cardiac catheter laboratory are cared for using consistent, safe and evidence-based practices.

Integrative genomic profiling reveals conserved genetic mechanisms for tumorigenesis in common entities of non-Hodgkin's lymphoma

Recent developments in genomic technologies have resulted in increased understanding of pathogenic mechanisms and emphasized the importance of central survival pathways. Here, we use a novel bioinformatic based integrative genomic profiling approach to elucidate conserved mechanisms of lymphomagenesis in the three commonest non-Hodgkin's lymphoma (NHL) entities: diffuse large B-cell lymphoma, follicular lymphoma, and B-cell chronic lymphocytic leukemia. By integrating genome-wide DNA copy number analysis and transcriptome profiling of tumor cohorts, we identified genetic lesions present in each entity and highlighted their likely target genes. This revealed a significant enrichment of components of both the apoptosis pathway and the mitogen activated protein kinase pathway, including amplification of the MAP3K12 locus in all three entities, within the set of genes targeted by genetic alterations in these diseases. Furthermore, amplification of 12p13.33 was identified in all three entities and found to target the FOXM1 oncogene. Amplification of FOXM1 was subsequently found to be associated with an increased MYC oncogenic signaling signature, and siRNA-mediated knock-down of FOXM1 resulted in decreased MYC expression and induced G2 arrest. Together, these findings underscore genetic alteration of the MAPK and apoptosis pathways, and genetic amplification of FOXM1 as conserved mechanisms of lymphomagenesis in common NHL entities. Integrative genomic profiling identifies common central survival mechanisms and highlights them as attractive targets for directed therapy.

Clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory : A modified Delphi study

Aim To develop clinical practice guidelines for nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory. Background Numerous studies have reported that nurse-administered procedural sedation and analgesia is safe. However, the broad scope of existing guidelines for the administration and monitoring of patients who receive sedation during medical procedures without an anaesthetist presents means there is a lack of specific guidance regarding optimal nursing practices for the unique circumstances in which nurse-administered procedural sedation and analgesia is used in the cardiac catheterisation laboratory. Methods A sequential mixed methods design was utilised. Initial recommendations were produced from three studies conducted by the authors: an integrative review; a qualitative study; and a cross-sectional survey. The recommendations were revised in accordance with responses from a modified Delphi study. The first Delphi round was completed by nine senior cardiac catheterisation laboratory nurses. All but one of the draft recommendations met the pre-determined cut-off point for inclusion. There were a total of 59 responses to the second round. Consensus was reached on all recommendations. Implications for nursing The guidelines that were derived from the Delphi study offer twenty four recommendations within six domains of nursing practice: Pre-procedural assessment; Pre-procedural patient and family education; Pre-procedural patient comfort; Intra-procedural patient comfort; Intra-procedural patient assessment and monitoring; and Post-procedural patient assessment and monitoring. Conclusion These guidelines provide an important foundation towards the delivery of safe, consistent and evidence-based nursing care for the many patients who receive sedation in the cardiac catheterisation laboratory setting.

Cardiac safety concerns for domperidone, an antiemetic and prokinetic, and galactogogue medicine

Introduction: Domperidone is a dopamine D2-receptor antagonist developed as an antiemetic and prokinetic agents. Oral domperidone is not approved in the US, but is used in many countries to treat nausea and vomiting, gastroparesis, and as a galactogogue (to promote lactation). The US Food and Drug Administration (FDA) have issued a warning about the cardiac safety of domperidone. Areas covered: The authors undertook a review of the cardiac safety of oral domperidone. Expert opinion: The data from preclinical studies are unambiguous in identifying domperidone as able to produce marked hERG channel inhibition and action potential prolongation at clinically relevant concentrations. The compound’s propensity to augment instability of action potential duration and action potential triangulation are also indicative of proarrhythmic potential. Domperidone should not be administered to subjects with pre-existing QT prolongation/LQTS, subjects receiving drugs that inhibit CYP3A4, subjects with electrolyte abnormalities or with other risk factors for QT-prolongation. With these provisos, it is possible that domperidone may be used as a galactogogue without direct risk to healthy breast feeding women but more safety information should be sought in this situation. Also, more safety information is required regarding risk to breast feeding infants or before domperidone is routinely used in gastroparesis or gastroesphageal reflux in children.

Biological values of acupuncture and Chinese herbal medicine : impact on the life science

Editorial paper