The gamma-band activity model of the near-death experience: a critique and a reinterpretation.

Near-death experience (NDE) is a transcendent mental event of uncertain etiology that arises on the cusp of biological death. Since the discovery of NDE in the mid-1970s, multiple neuroscientific theories have been developed in an attempt to account for it in strictly materialistic or reductionistic terms. Therefore, in this conception, NDE is at most an extraordinary hallucination without any otherworldly, spiritual, or supernatural denotations. During the last decade or so, a number of animal and clinical studies have emerged which reported that about the time of death, there may be a surge of high frequency electroencephalogram (EEG) at a time when cortical electrical activity is otherwise at a very low ebb. This oscillatory rhythm falls within the range of the enigmatic brain wave-labelled gamma-band activity (GBA). Therefore, it has been proposed that this brief, paradoxical, and perimortem burst of the GBA may represent the neural foundation of the NDE. This study examines three separate but related questions concerning this phenomenon. The first problem pertains to the electrogenesis of standard GBA and the extent to which authentic cerebral activity has been contaminated by myogenic artifacts. The second problem involves the question of whether agents that can mimic NDE are also underlain by GBA. The third question concerns the electrogenesis of the surge in GBA itself. It has been contended that this is neither cortical nor myogenic in origin. Rather, it arises in a subcortical (amygdaloid) location but is recorded at the cortex via volume conduction, thereby mimicking standard GBA. Although this surge of GBA contains genuine electrophysiological activity and is an intriguing and provocative finding, there is little evidence to suggest that it could act as a kind of neurobiological skeleton for a phenomenon such as NDE.

What impact do structured educational sessions to increase emotional intelligence have on medical students? BEME Guide No. 17.

BACKGROUND: Emotional intelligence (EI) is a type of social intelligence that involves monitoring, discriminating between and using emotions to guide thinking and actions. EI is related to interpersonal and communication skills, and is important in the assessment and training of medical undergraduates. AIM: This review aimed to determine the impact of structured educational interventions on the EI of medical students. METHODS: We systematically searched 14 electronic databases and hand searched high yield journals. We looked at changes in EI and related behaviour of medical students, assessed using Kirkpatrick's hierarchy, provided they could be directly related to the content of the educational intervention. RESULTS: A total of 1947 articles were reviewed, of which 14 articles met the inclusion criteria. CONCLUSIONS: The use of simulated patients is beneficial in improving EI when introduced in interventions later rather than earlier in undergraduate medical education. Regardless of duration of intervention, interventions have the best effects when delivered: (1) over a short space of time; (2) to students later in their undergraduate education and; (3) to female students. This should be taken into account when designing and delivering interventions. Emphasising the importance of empathetic qualities, such as empathetic communication style should be made explicit during teaching.

Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22.

BACKGROUND: In the United Kingdom, there are approximately 300,000 healthcare-associated infections (HCAI) annually, costing an estimated £1 billion. Up to 30% of all HCAI are potentially preventable by better application of knowledge and adherence to infection prevention procedures. Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained improvements in hand hygiene compliance and reductions in HCAI. AIM: To determine the features of structured educational interventions that impact on compliance with hand hygiene in healthcare professionals within a hospital care setting. METHODS: Sixteen electronic databases were searched. Outcomes were assessed using Kirkpatrick's hierarchy and included changes in hand hygiene compliance of healthcare professionals, in service delivery and in the clinical welfare of patients involved. RESULTS: A total of 8845 articles were reviewed, of which 30 articles met the inclusion criteria. Delivery of education was separated into six groups. CONCLUSIONS: It was not possible to identify individual features of educational interventions due to each study reporting multicomponent interventions. However, multiple, continuous interventions were better than single interventions in terms of eliciting and sustaining behaviour change. Data were not available to determine the time, nature and type of booster sessions with feedback needed for a permanent change in compliance.

Respiratory morbidity, healthcare utilisation and cost of care at school age related to home oxygen status.

UNLABELLED: The aim of the study was to determine whether respiratory morbidity, lung function, healthcare utilisation and cost of care at school age in prematurely born children who had bronchopulmonary dysplasia (BPD) were influenced by use of supplementary oxygen at home after neonatal intensive care unit discharge. Healthcare utilisation and cost of care in years 5 to 7 and respiratory morbidity (parent-completed respiratory questionnaire) and lung function measurements at least at age 8 years were assessed in 160 children. Their median gestational age was 27 (range 22-31) weeks and 65 of them had received supplementary oxygen when discharged home (home oxygen group). The home oxygen group had more outpatient attendances (p = 0.0168) and respiratory-related outpatient attendances (p = 0.0032) with greater related cost of care (p = 0.0186 and p = 0.0030, respectively), their cost of care for prescriptions (p = 0.0409) and total respiratory related cost of care (p = 0.0354) were significantly greater. There were, however, no significant differences in cough, wheeze or lung function results between the two groups. CONCLUSION: Prematurely born children who had BPD and supplementary oxygen at home after discharge had increased healthcare utilisation at school age. Whether such children require greater follow, in the absence of excess respiratory morbidity, merits investigation.

First year specialist trainees' engagement with reflective practice in the e-portfolio.

Doctors in specialist training posts in the Mersey Deanery are expected to reflect on their clinical practice and to document their learning experiences in an e-portfolio. This study aims specifically to explore how they have engaged in reflection on their practice and how they utilise their learning portfolio to document evidence of this. A modified Delphi technique was used to develop a grading system to identify the level of reflection recorded by participants in the e-portfolio. Transcripts of the reflective accounts were then analysed using a qualitative approach which involved coding and categorising the data. This study demonstrated a wide variation in both the quantity and quality of reflection. Of particular note in the qualitative data analysis were themes relating to clinical knowledge and skills, learning in practice, communication, feelings, types of learning experience reflected on and wider aspects of medical practice. Findings indicate there is variation is the extent to which doctors both engage in and document evidence of reflection. Further research is needed to explore factors that enable or inhibit the use of the e-portfolio for reflection and whether recorded reflection is a true picture of the cognitive process involved.

What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME Guide No. 15.

BACKGROUND: Up to 6000 patients per year in England acquire a central venous catheter (CVC)-related bloodstream infection (Shapey et al. 2008 ). Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained reductions in CVC-related blood stream infections (Pronovost et al. 2002), and cost (Hu et al. 2004 ). AIM: This review aimed to determine the features of structured educational interventions that impact on competence in aseptic insertion technique and maintenance of CV catheters by healthcare workers. METHODS: We looked at changes in infection control behaviour of healthcare workers, and considered changes in service delivery and the clinical welfare of patients involved, provided they were related directly to the delivery method of the educational intervention. RESULTS: A total of 9968 articles were reviewed, of which 47 articles met the inclusion criteria. CONCLUSIONS: Findings suggest implications for practice: First, educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback, and availability of new clinical supplies consistent with the content of the education provided. Second, educational interventions will have a greater impact if baseline compliance to best practice is low. Third, repeated sessions, fed into daily practice, using practical participation appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with the provision of formal responsibilities and motivation for change, may change healthcare worker practice.

A reference interval for sweat chloride in infants aged between five and six weeks of age.

BACKGROUND: This study was designed to establish a reference interval for sweat chloride for infants without evidence of cystic fibrosis (CF), aged between 5 wk and 6 wk, a time when sweat testing is an integral part of newborn screening for CF. In addition, we compared the gold standard method of sweat testing (quantitative pilocarpine iontophoresis [QPIT, coulometry]) with an emerging methodology (Macroduct [ISE]). METHODS: This was a prospective study on healthy infants at 5-6 wk of age. Sweat collection was undertaken at home on both outer thigh areas using two methods (QPIT and Macroduct ). The order of testing was randomly assigned. Filter paper samples (QPIT) were analysed using flame photometry and coulometry. Macroduct samples were analysed using ion-selective electrodes (ISE, Abbott Architect c8000, UK). RESULTS: Insufficient sweat was collected on 28 occasions with the QPIT (coulometry) method and on 31 with the Macroduct (ISE) capillary system. We achieved a 92% success rate in undertaking two sweat collections consecutively (n = 177). Sweat chloride concentrations were normally distributed with excellent limits of agreement between the two methods of sweat collection and analysis (n = 150). Median (IQR) sweat chloride was 11.2 mmol/L (8-13) with QPIT (coulometry) method with a 99.5th centile (n = 165) of 24 mmol/L. CONCLUSION: The Macroduct (ISE) capillary sweat collection system is valid in this age group. Sweat chloride concentrations above 30 mmol/L should prompt assessment in a specialist CF centre.

An investigation into specialty trainee engagement with e-learning.

AIM:: The objectives of this study were to determine paediatric specialty trainees' engagement with e-learning in Health Education England North West and the characteristics of sites accessed by specialty trainees, and to assess the quality of web interfaces being used and whether this aligns with the best evidence for e-learning provision. METHODS:: A two-phase mixed methods design was used: a scoping exercise to elicit specialty trainees' preferred e-learning tools and a quality assessment of the named sites, and specialty trainee telephone interviews. RESULTS:: A total of 135 respondents identified 86 sites. Quality assessment found considerable variation across sites and a number of barriers to access, one issue being uncertainty about quality and validity of sites. CONCLUSIONS:: E-learning is viewed as an integral part of both mandatory and speciality training but there is considerable variation in access to and quality of sites. Specialty trainees value the convenience and breadth of e-learning available but express concerns about assessing the validity and legitimacy of such sites.

Views of National Health Service (NHS) Ethics Committee members on how education research should be reviewed.

BACKGROUND: A Local Research Ethics Committee (LREC) may not be appropriate for reviewing research projects involving trainees as participants. AIMS: This study aimed to obtain views of LREC members regarding education research being reviewed by LRECS. METHODS: A questionnaire describing six medical education research projects was sent to an opportunistic sample of LRECs. Respondents were asked to indicate the type of ethics review and consent that would be required for each project. Free text comments were also invited. RESULTS: The majority of the 68 respondents felt that committee review (LREC or institutional) was required for contacting trainees to obtain taped or written interviews. Most felt that some form of consent was appropriate for all the studies. Themes arising from the free text responses were that: there were concerns about this study itself; the requirements for ethical approval for education research should be no different from those of clinical research; there are problems defining 'research', 'audit' and 'course evaluation'; ethical approval should be acquired for education research but not through LRECs; the COREC system is over-complex; and, high standards of research have to be maintained. CONCLUSION: The majority of ethics committee members feel that most education research needs independent review but not necessarily by LRECs.

The neurophysiology of concussion.

Cerebral concussion is both the most common and most puzzling type of traumatic brain injury (TBI). It is normally produced by acceleration (or deceleration) of the head and is characterized by a sudden brief impairment of consciousness, paralysis of reflex activity and loss of memory. It has long been acknowledged that one of the most worthwhile techniques for studying the acute pathophysiology of concussion is by the recording of neurophysiological activity such as the electroencephalogram (EEG) and sensory evoked potentials (EPs) from experimental animals. In the first parts of this review, the majority of such studies conducted during the past half century are critically reviewed. When potential methodological flaws and limitations such as anesthetic protocols, infliction of multiple blows and delay in onset of recordings were taken into account, two general principles could be adduced. First, the immediate post-concussive EEG was excitatory or epileptiform in nature. Second, the cortical EP waveform was totally lost during this period. In the second parts of this review, five theories of concussion which have been prominent during the past century are summarized and supportive evidence assessed. These are the vascular, reticular, centripetal, pontine cholinergic and convulsive hypotheses. It is concluded that only the convulsive theory is readily compatible with the neurophysiological data and can provide a totally viable explanation for concussion. The chief tenet of the convulsive theory is that since the symptoms of concussion bear a strong resemblance to those of a generalized epileptic seizure, then it is a reasonable assumption that similar pathobiological processes underlie them both. Further, it is demonstrated that EPs and EEGs recorded acutely following concussive trauma are indeed the same or similar to those obtained following the induction of a state of generalized seizure activity (GSA). According to the present incarnation of the convulsive theory, the energy imparted to the brain by the sudden mechanical loading of the head may generate turbulent rotatory and other movements of the cerebral hemispheres and so increase the chances of a tissue-deforming collision or impact between the cortex and the boney walls of the skull. In this conception, loss of consciousness is not orchestrated by disruption or interference with the function of the brainstem reticular activating system. Rather, it is due to functional deafferentation of the cortex as a consequence of diffuse mechanically-induced depolarization and synchronized discharge of cortical neurons. A convulsive theory can also explain traumatic amnesia, autonomic disturbances and the miscellaneous collection of symptoms of the post-concussion syndrome more adequately than any of its rivals. In addition, the symptoms of minor concussion (a.k.a. being stunned, dinged, or dazed) are often strikingly similar to minor epilepsy such as petit mal. The relevance of the convulsive theory to a number of associated problems is also discussed. These include the relationship between concussion and more serious types of closed head injury, the utility of animal models of severe brain trauma, the etiology of the cognitive deficits which may linger long after a concussive injury, the use of concussive (captive bolt) techniques to stun farm animals prior to slaughter and the question of why some animals (such as the woodpecker) can tolerate massive accelerative forces without being knocked out.

Acute life threatening events among infants on home oxygen.

BACKGROUND: Chronic lung disease (CLD) of prematurity is associated with significant morbidity, and infants discharged home in oxygen are particularly vulnerable. AIM: To assess the incidence of acute life threatening events (ALTEs) during 12-month follow-up of CLD infants discharged home receiving supplemental oxygen. METHOD: All infants discharged over a one-year period were studied. Pre-discharge oxygen requirements were set on clinical grounds. Before discharge, oxygen saturations were recorded blind using a data-logger. Infant's oxygen requirements, hospital attendances, and details of ALTEs were recorded over the subsequent year. RESULTS: Sixteen infants were studied. Median (range): birth-weight 938 grams (448 - 1,638); gestational age 28 weeks (24 - 32); discharge oxygen requirement 0.20 litres/minute (0.05 - 0.50). Eight infants subsequently had one or more ALTEs. Discharge oxygen saturation profiles were significantly lower in these infant when compared to those not having ALTEs (p < 0.05), despite receiving supplementary oxygen. CONCLUSIONS: Before discharge home, formal oxygen saturation studies should be performed in infants receiving supplementary oxygen to ensure optimum oxygen delivery.

Twelve-month prospective study of oxygen saturation measurements among term and preterm infants.

BACKGROUND: Optimising home oxygen delivery in infants has important logistical and safety implications. This can be aided by having a suitable reference range of normal values for arterial oxygen saturation using pulse oximetry (SpO(2)). OBJECTIVES: To describe oxygenation profiles in healthy preterm and term infants in relation to gestational and postnatal age, to extend reference values to guide home oxygen therapy. STUDY DESIGN: Prospective monitoring of SpO(2) for 4 hours at 3 monthly intervals of 34 term, and 53 preterm healthy infants, took place over a 12-month period using an Ohmeda Biox 3700e pulse oximeter and data logger. RESULTS: Group mean and 5th percentiles were used to construct cumulative frequency curves at each time interval, representing the normal reference range of SpO(2) profiles for term and preterm infants over time. CONCLUSIONS: These data may be used to test the benefits in the home or hospital of having a reference range of normal values for cumulative SpO(2).

Living and managing with the long-term implications of neonatal chronic lung disease: The experiences and perspectives of children and their parents.

OBJECTIVE: The purpose of the study was to investigate children's perspectives of living with chronic lung disease (CLD) and their parents' long-term experiences of caring for them. BACKGROUND: CLD caused by prematurity of birth is associated with continuing respiratory, neuro-developmental and psychosocial issues. METHODS: 10 children (6-15 years old) with CLD and 12 parents were involved in semi-structured qualitative interviews. Data were analyzed using thematic analysis. RESULTS: CLD was described as 'getting easier over time' and that you 'learnt to live with it.' Expertise was acquired in controlling symptoms and recognizing the onset of illness, despite expressed uncertainty of the nature of the condition. Children experienced difficulties engaging in peer activities and encountered cases of teasing and isolation at school. CONCLUSION: CLD was reported as becoming easier over time to live with. Despite this, children experienced challenges engaging in peer activities and families described difficulties interacting with health and education services.

Two-year outcomes for infants with low cord pH at birth.

OBJECTIVE: To determine the long-term outcome of infants born with cord pH ≤ 7.0 and no clinical evidence of asphyxia at birth. SETTING: Tertiary Referral Centre. A prospective matched cohort study was conducted. 51 term infants were recruited following singleton birth with venous cord pH ≤ 7.0. For each recruited baby a healthy baby with normal cord pH ≥ 7.20 was recruited matched for gestation, gender and mode of delivery. Ages and Stages Questionnaires (ASQ)(TM) and Health Screening Questionnaires (HSQ) were sent out at 24 months of age. Two independent assessors, blinded to the case assignment, reviewed intrapartum and neonatal events to look for clinical evidence of birth asphyxia among the cases. RESULT: From 102 infants recruited, 62 questionnaires (24 cases, 38 controls) were returned. 20 matched pairs with no clinical evidence of birth asphyxia were available for analysis. The groups were similar except in terms of birth weight; the pH ≥ 7.0 group had mean birth weight 584 g lower than controls (p = 0.005). The ASQ motor scores were lower in children born with low cord pH (p = 0.019); however, once adjusted for birth weight, the difference was not significant (p = 0.289). CONCLUSION: It is unlikely that abnormal cord pH in otherwise healthy neonates leads to a substantially increased risk of abnormal neurodevelopmental outcome or severe health problems by 2 years of age.

The first five years: a mixed methods study investigating reflections on working as a hospital consultant.

OBJECTIVES: This paper revisits the same cohort of hospital consultants approximately five years after they were first appointed to investigate their reflections on establishing themselves in their role. DESIGN: Mixed methods using a short survey and in-depth semistructured interviews. SETTING: The study was conducted within one Deanery in the North of England. PARTICIPANTS: The same 45 hospital consultants who were invited to participate in the study in 2007 were asked to take part in the second stage of the project in February 2011. These 45 consultants started their appointments no earlier than May 2006 within 12 National Health Service (NHS) Trusts in one Deanery. A total of 16 consultants participated. Six consultants who took part in semistructured interviews in 2007-2008 were invited to be interviewed again. Four consented and participated in a further interview in 2011. MAIN OUTCOME MEASURES: Do consultants feel they have completed their transition into their senior clinical posts? Yes, although the ever changing nature of the consultant role means new challenges are always having to be being addressed. What support mechanisms are valued by consultants? Informal support mechanisms are greatly valued by consultants and these are built up over time. Are consultants satisfied that they made the correct specialty choice? Yes, all respondents reported satisfaction in their specialty choice. RESULTS: After reflecting on five years in post, all agreed that Specialist training prepared them well for the clinical aspects of their role. Ten (62%) felt they were not prepared for dealing with Trust Management issues and 13 (81%) felt unprepared for financial management. CONCLUSIONS: consultants learn on the job and eventually fulfil their potential in the role over time. However, the role is regularly changing so informal support mechanisms are valued to help deal with a highly complex role.

The training needs and career intentions of staff grade and associate specialist doctors.

This article outlines the results of a study which used an online survey to explore the career intentions of staff grade and associate specialist doctors in one region and their training needs to inform those managing the continued professional development of staff grade and associate specialist doctors.