Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU):A randomised, double-blind, placebo-controlled trial

Background: Delirium is frequently diagnosed in critically ill patients and is associated with poor clinical outcomes. Haloperidol is the most commonly used drug for delirium despite little evidence of its effectiveness. The aim of this study was to establish whether early treatment with haloperidol would decrease the time that survivors of critical illness spent in delirium or coma. Methods: We did this double-blind, placebo-controlled randomised trial in a general adult intensive care unit (ICU). Critically ill patients (≥18 years) needing mechanical ventilation within 72 h of admission were enrolled. Patients were randomised (by an independent nurse, in 1:1 ratio, with permuted block size of four and six, using a centralised, secure web-based randomisation service) to receive haloperidol 2·5 mg or 0·9% saline placebo intravenously every 8 h, irrespective of coma or delirium status. Study drug was discontinued on ICU discharge, once delirium-free and coma-free for 2 consecutive days, or after a maximum of 14 days of treatment, whichever came first. Delirium was assessed using the confusion assessment method for the ICU (CAM-ICU). The primary outcome was delirium-free and coma-free days, defined as the number of days in the first 14 days after randomisation during which the patient was alive without delirium and not in coma from any cause. Patients who died within the 14 day study period were recorded as having 0 days free of delirium and coma. ICU clinical and research staff and patients were masked to treatment throughout the study. Analyses were by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Registry, number ISRCTN83567338. Findings: 142 patients were randomised, 141 were included in the final analysis (71 haloperidol, 70 placebo). Patients in the haloperidol group spent about the same number of days alive, without delirium, and without coma as did patients in the placebo group (median 5 days [IQR 0-10] vs 6 days [0-11] days; p=0·53). The most common adverse events were oversedation (11 patients in the haloperidol group vs six in the placebo group) and QTc prolongation (seven patients in the haloperidol group vs six in the placebo group). No patient had a serious adverse event related to the study drug. Interpretation: These results do not support the hypothesis that haloperidol modifies duration of delirium in critically ill patients. Although haloperidol can be used safely in this population of patients, pending the results of trials in progress, the use of intravenous haloperidol should be reserved for short-term management of acute agitation. Funding: National Institute for Health Research. © 2013 Elsevier Ltd.

Enacting National Concerns: Accounts of the 2002 Golden Jubilee

Although the study of national identity in social psychology has examined the various ways in which the national group is ‘imagined’, little attention has been paid to the many collective national commemorations, celebrations and rituals of state assumed to unite the nation. This is surprising given the number of celebrations and commemorations which fill the calendars of modern nations
throughout the world and which are assumed by social scientists to play some part in the reproduction of the national community. Taking the British Royal Golden Jubilee celebrations of 2002, the present study examines how understandings of Anglo-British national identity are manifest in conversational
interviews during and after these events. In line with previous examinations of Anglo-Britishness, our respondents typically resisted imagining the national community as a homogenous whole and distanced themselves from depictions of the Jubilee as a nationalistic event. Support for the Jubilee was contingent upon the event being apolitical and inclusive.We suggest that such collective
national events could potentially facilitate ways of imagining the national community in terms of diversity and inclusivity rather than homogeneity and exclusivity.

Attitudes of consultant ophthalmologists in the UK to initial management of glaucoma patients presenting with severe visual field loss: a national survey

BACKGROUND: Recent National Institute of Clinical Excellence guidance suggests primary surgery should be offered to patients presenting with glaucoma with severe visual field loss. We undertook a survey of UK consultant ophthalmologists to determine if this represents current practice and explore attitudes towards managing patients with advanced glaucoma at presentation.

DESIGN: Questionnaire evaluation study.

PARTICIPANTS: All consultant ophthalmologists currently practicing in the UK.

METHODS: A single-page questionnaire was posted to all consultants (n = 910) currently practicing in the UK along with a pre-paid return envelope. A second questionnaire was sent to non-responders (n = 459).

MAIN OUTCOME MEASURES: Questionnaire responses.

RESULTS: 626 responses were received representing 68.8% of the population surveyed. 152 (24%) volunteered a specialist interest in glaucoma. Consensus opinion for both glaucoma specialists (64.9%) and non-glaucoma specialists (62.4%) was to start with primary medical therapy, most commonly citing surgical risk as the primary reason (23% and 22%, respectively) for this approach. Most felt the highest intraocular pressure measurement during follow up (measured in clinic) was the most important variable for prevention of further visual loss (60% of glaucoma specialists and 55% of non-glaucoma specialists). Eighty-three per cent of all responders suggested they would change their practice if evidence supporting primary surgery as a safe and more effective approach existed.

CONCLUSIONS: Recent National Institute of Clinical Excellence guidance does not reflect the current management approach of UK ophthalmologists. The primary concern was related to potential complications of surgery although most practitioners would be willing to change their practice if evidence existed supporting primary surgery in patients presenting with advanced glaucoma.

Simvastatin in the Acute Respiratory Distress Syndrome

Background

Studies in animals and in vitro and phase 2 studies in humans suggest that statins may be beneficial in the treatment of the acute respiratory distress syndrome (ARDS). This study tested the hypothesis that treatment with simvastatin would improve clinical outcomes in patients with ARDS.

Methods

In this multicenter, double-blind clinical trial, we randomly assigned (in a 1:1 ratio) patients with an onset of ARDS within the previous 48 hours to receive enteral simvastatin at a dose of 80 mg or placebo once daily for a maximum of 28 days. The primary outcome was the number of ventilator-free days to day 28. Secondary outcomes included the number of days free of nonpulmonary organ failure to day 28, mortality at 28 days, and safety.

Results

The study recruited 540 patients, with 259 patients assigned to simvastatin and 281 to placebo. The groups were well matched with respect to demographic and baseline physiological variables. There was no significant difference between the study groups in the mean (±SD) number of ventilator-free days (12.6±9.9 with simvastatin and 11.5±10.4 with placebo, P=0.21) or days free of nonpulmonary organ failure (19.4±11.1 and 17.8±11.7, respectively; P=0.11) or in mortality at 28 days (22.0% and 26.8%, respectively; P=0.23). There was no significant difference between the two groups in the incidence of serious adverse events related to the study drug.

Conclusions

Simvastatin therapy, although safe and associated with minimal adverse effects, did not improve clinical outcomes in patients with ARDS. (Funded by the U.K. National Institute for Health Research Efficacy and Mechanism Evaluation Programme and others; HARP-2 Current Controlled Trials number, ISRCTN88244364.)

The Houses of the Oireachtas:Parliament in Ireland

The Irish parliament - the Oireachtas - is nearing the centenary year of its foundation, making it one of the oldest continuously surviving parliaments in the world. As the most important national institution in the state, it plays an essential role in giving voice to a diversity of views and opinions, providing stable governments, approving law and national budgets and upholding democratic values. For much of its existence, however, and most pointedly in the context of recent banking and economic crises, it has been subject to criticism concerning its ability to adequately hold the executive to account, to act as a coherent policy-making forum, to meet the challenges arising from European Union membership, to embrace wide-ranging reforms and to develop with purpose and ambition.

This comprehensive new volume considers all aspects of the Houses of the Oireachtas - including their evolution, composition, organisation, financing, administration and reform. Contributors include academics, administrators and sitting and former parliamentarians. Contemporary challenges brought about by transformations in media style, increased inter-parliamentarism and the changing character of politics are also addressed. The book questions a number of assumptions about parliament and its work, including the efficacy of the legislative and budgetary processes, the nature of executive-legislative relations and the perceived encroachment of the courts on the legislature. Combined, this wide-ranging and detailed study fills a long-standing void, and provides essential reading not alone for those interested in Irish politics and government, but also for students and scholars of legislative studies.

Hardware Comparison of the ISO/IEC 29192-2 Block Ciphers

As ubiquitous computing becomes a reality, sensitive information is increasingly processed and transmitted by smart cards, mobile devices and various types of embedded systems. This has led to the requirement of a new class of lightweight cryptographic algorithm to ensure security in these resource constrained environments. The International Organization for Standardization (ISO) has recently standardised two low-cost block ciphers for this purpose, Clefia and Present. In this paper we provide the first comprehensive hardware architecture comparison between these ciphers, as well as a comparison with the current National Institute of Standards and Technology (NIST) standard, the Advanced Encryption Standard.