Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community.

BACKGROUND: Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline (epinephrine) auto-injectors are recommended as the initial, potentially life-saving treatment of choice for anaphylaxis in the community, but they are not universally available and have limitations in their use. OBJECTIVES: To assess the effectiveness of adrenaline (epinephrine) auto-injectors in relieving respiratory, cardiovascular, and other symptoms during episodes of anaphylaxis that occur in the community. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (Ovid SP) (1950 to January 2012), EMBASE (Ovid SP) (1980 to January 2012 ), CINAHL (EBSCO host) (1982 to January 2012 ), AMED (EBSCO host) (1985 to January 2012 ), LILACS, (BIREME) (1980 to January 2012 ), ISI Web of Science (1950 to January 2012 ). We adapted our search terms for other databases. We also searched websites listing on-going trials: the World Health Organization International Clinical Trials Registry Platform, the UK Clinical Research Network Study Portfolio, and the meta Register of Controlled Trials; and contacted pharmaceutical companies who manufacture adrenaline auto-injectors in an attempt to locate unpublished material. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing auto-injector administration of adrenaline with any control including no intervention, placebo, or other adrenergic agonists were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two authors independently assessed articles for inclusion. MAIN RESULTS: None of the 1328 studies that were identified satisfied the inclusion criteria. AUTHORS' CONCLUSIONS: Based on this review, we cannot make any new recommendations on the effectiveness of adrenaline auto-injectors for the treatment of anaphylaxis. Although randomized, double-blind, placebo-controlled clinical trials of high methodological quality are necessary to define the true extent of benefits from the administration of adrenaline in anaphylaxis via an auto-injector, such trials are unlikely to be performed in individuals experiencing anaphylaxis because of ethical concerns associated with randomization to placebo. There is, however, a need to consider trials in which, for example, auto-injectors of different doses of adrenaline and differing devices are compared in order to provide greater clarity on the dose and device of choice. Such trials would be practically challenging to conduct. In the absence of appropriate trials, we recommend that adrenaline administration by auto-injector should still be regarded as the most effective first-line treatment for the management of anaphylaxis in the community. In countries where auto-injectors are not commonly used, it may be possible to conduct trials to compare administration of adrenaline via auto-injector with adrenaline administered by syringe and ampoule, or comparing the effectiveness of two different types of auto-injector.

Improving door to CT scanner times for potential stroke thrombolysis candidates - The Emergency Department's role.

Stroke thrombolysis is an important treatment in the management of acute strokes. Its' effectiveness is reliant on prompt administration after stroke onset. Disability free survival at 3-6 months increases by 10% when administered within 3 hours. There is also an economic benefit from early administration with reduced institutional care. New Scottish care standards have been introduced which suggest a target that 50% of suitable patients should receive thrombolysis within 30 minutes, and 80% within one hour 6. Processes in the Emergency Department play a key role in determining the time a patient waits between arrival and reaching the CT scanner. The project team looked at Ninewells Emergency Department times to CT scanner between May and August 2015 and found that only 20% of patients had their scan within 20 minutes, and 70% within 45 minutes. The team went on to conduct a quality improvement project. This involved initial patient mapping and short interviews with staff. A multi action approach was developed involving education in the form of emails, presentations and visual charts, and the final step was to simplify the paperwork involved. The project was conducted over 11 months and successfully reduced the times to CT, with 60% having had their CT scan within 20 minutes, and 100% within 45 minutes, with a very noticeable reduction in variation around the mean. It is hoped to take this approach forward and apply it to other processes in the department.

Models for estimating projections for disease prevalence and burden: a systematic review focusing on chronic obstructive pulmonary disease.

OBJECTIVE: Epidemiological models for estimating the prevalence and burden of disease inform health policy and service planning decisions. Our aim was to describe the challenges in evaluating such models using the example of epidemiological models for chronic obstructive pulmonary disease (COPD). METHODS: Two reviewers searched Medline, Embase, CAB Abstracts and World Health Organization (WHO) Databases from 1980 to November 2013 for epidemiological models of COPD prevalence and burden. Two reviewers extracted data and assessed the quality of the studies. We then undertook a descriptive and narrative synthesis of data. RESULTS: We identified 22 models employing a variety of techniques to calculate the prevalence and/or burden of COPD. Models calculated prevalence and/or mortality or other facet of disease burden using demographics and risk factors or trends, Markov-type modelling and microsimulation modelling. The six models which scored highly on the quality framework were: the Peabody model, which generated estimates of COPD prevalence; the WHO DISMOD II model which produced burden estimates in terms of disability adjusted life years with COPD and life years lost to COPD; the Atsou model which gave the life expectancy gains of individual smokers who quit smoking and associated costs; two Dutch COPD models which produced estimates of mortality and health care costs related to COPD; and the Pichon-Riviere model which gave the costs and cost effectiveness of smoking quit programmes. CONCLUSIONS: The field of chronic disease modelling is burgeoning. As a result, policy makers need to understand how to interpret epidemiological models and their data sources.

Fatigue after Stroke: The Patient's Perspective.

Background. Fatigue after stroke is common and distressing to patients. Aims. Our aims were to explore patients' perceptions of post-stroke fatigue, including the causes of fatigue and the factors that alleviate fatigue, in a mixed methods study. Results. We interviewed 15 patients who had had a stroke and were inpatients on stroke rehabilitation wards. A substantial proportion of patients reported that their fatigue started at the time of their stroke. Various different factors were reported to improve fatigue, including exercise, good sleep, rehabilitation and rest. Fatigue influences patients' sense of "control" after their stroke. Conclusion. Our results are consistent with the possibility that poststroke fatigue might be triggered by factors that occur at the time of the stroke (e.g., the stroke lesion itself, or admission to hospital) and then exacerbated by poor sleep and boredom. These factors should be considered when developing complex interventions to improve post-stroke fatigue.