Technology use to support employment-related outcomes for people with intellectual and developmental disability: an updated meta-analysis.

OBJECTIVES: The aim of this study is to update and extend an original meta-analysis which included papers published up to and including 2003 and investigated the impact of technology use on employment-related outcomes for people with intellectual and developmental disability. METHODS: Following on from the original meta-analysis, this study is a meta-analysis of pertinent single-subject experimental design studies conducted from 2004 to 2016 and employs the same metric methods as the original contribution. RESULTS: The results are generally consistent with those of the original meta-analysis, namely, applied cognitive technology effectively supports employment-related outcomes for people with intellectual and developmental disability. Nevertheless, significant differences in the intervention effects were found (a) between groups of individuals with varying levels of disability, and (b) between interventions utilizing technology with and without universal design features. CONCLUSIONS: In line with the original contribution, applied cognitive technology seems to support people with intellectual and developmental disabilities to better achieve employment-related outcomes. More research is needed though to explore the impact of different types of technology on employment-related outcomes.

Triangulated Proxy Reporting: a technique for improving how communication partners come to know people with severe cognitive impairment.

PURPOSE: This paper explains and demonstrates the pilot application of Triangulated Proxy Reporting (TPR); a practical technique for enhancing communication around people who have severe cognitive impairment (SCI). METHODS AND RESULTS: An introduction explains SCI and how this impacts on communication; and consequently on quality of care and quality of life. This is followed by an explanation of TPR and its origins in triangulation research techniques. An illustrative vignette explicates its utility and value in a group home for a resident with profound multiple disabilities. The Discussion and Conclusion sections propose the wider application of TPR for different cohorts of people with SCIs, their communication partners and service providers. CONCLUSIONS: TPR presents as a practical technique for enhancing communication interactions with people who have SCI. The paper demonstrates the potential of the technique for improving engagement amongst those with profound multiple disabilities, severe acquired brain injury and advanced dementia and their partners in and across different care settings. Implications for Rehabilitation Triangulated Proxy Reporting (TPR) shows potential to improve communications between people with severe cognitive impairments and their communication partners. TPR can lead to improved quality of care and quality of life for people with profound multiple disabilities, very advanced dementia and severe acquired brain injury, who otherwise are very difficult to support. TPR is a relatively simple and inexpensive technique that service providers can incorporate into practice to improving communications between clients with severe cognitive impairments, their carers and other support professionals.

The half-life of infusion fluids: An educational review.

An understanding of the half-life (T1/2) of infused fluids can help prevent iatrogenic problems such as volume overload and postoperative interstitial oedema. Simulations show that a prolongation of the T1/2 for crystalloid fluid increases the plasma volume and promotes accumulation of fluid in the interstitial fluid space. The T1/2 for crystalloids is usually 20 to 40 min in conscious humans but might extend to 80 min or longer in the presence of preoperative stress, dehydration, blood loss of <1 l or pregnancy.The longest T1/2 measured amounts to between 3 and 8 h and occurs during surgery and general anaesthesia with mechanical ventilation. This situation lasts as long as the anaesthesia. The mechanisms for the long T1/2 are only partly understood, but involve adrenergic receptors and increased renin and aldosterone release. In contrast, the T1/2 during the postoperative period is usually short, about 15 to 20 min, at least in response to new fluid.The commonly used colloid fluids have an intravascular persistence T1/2 of 2 to 3 h, which is shortened by inflammation. The fact that the elimination T1/2 of the infused macromolecules is 2 to 6 times longer shows that they also reside outside the bloodstream. With a colloid, fluid volume is eliminated in line with its intravascular persistence, but there is insufficient data to know if this is the same in the clinical setting.

Deep Assessment: A Novel Framework for Improving the Care of People with Very Advanced Alzheimer's Disease.

Best practice in understanding and caring for people with advanced Alzheimer's disease presents extraordinary challenges. Their severe and deteriorating cognitive impairments are such that carers find progressive difficulty in authentically ascertaining and responding to interests, preferences, and needs. Deep assessment, a novel multifaceted framework drawn from research into the experiences of others with severe cognitive impairments, has potential to empower carers and other support professionals to develop an enhanced understanding of people with advanced Alzheimer's disease and so deliver better calibrated care in attempts to maximize quality of life. Deep assessment uses a combination of techniques, namely, Behaviour State Observation, Triangulated Proxy Reporting, and Startle Reflex Modulation Measurement, to deliver a comprehensive and deep assessment of the inner states (awareness, preferences, likes, and dislikes) of people who cannot reliably self-report. This paper explains deep assessment and its current applications. It then suggests how it can be applied to people with advanced Alzheimer's disease to develop others' understanding of their inner states and to help improve their quality of life. An illustrative hypothetical vignette is used to amplify this framework. We discuss the potential utility and efficacy of this technique for this population and we also propose other human conditions that may benefit from research using a deep assessment approach.

Towards improved ways of knowing children with profound multiple disabilities: introducing startle reflex modulation.

OBJECTIVE: To propose startle reflex modulation (SRM) as an objective measure of emotions of children with profound multiple disabilities (PMD). Knowledge about emotion states of children with PMD is crucial to their individualised care and support. Proxy reporting, observational and physiological measures of emotion are reported in the literature. Despite advances in this science, the rigour of the findings and methods are contested. In this article, we introduce SRM; a neurophysiological measure untried with children with PMD, despite its well-known sensitivity to even subtle changes in affective processing without depending on explicit responses. RESULTS: We propose a research agenda that aims to deliver a more comprehensive and accurate profile of the inner states of these children, based upon previous research undertaken using SRM. CONCLUSION: It is suggested that this objective measure has potential to provide useful information about the inner emotional states of children with PMD.

Failure to predict difficult tracheal intubation for emergency caesarean section.

BACKGROUND AND AIM: Difficult tracheal intubation following induction of general anaesthesia for caesarean section is a cause of morbidity and mortality. Our aim was to evaluate five bedside predictors that might identify women with potential intubation difficulty immediately prior to emergency caesarean section. PATIENTS AND METHODS: Women requiring emergency caesarean section with general anaesthesia and tracheal intubation who had been assessed by the same experienced anaesthesiologist preoperatively were included in this study. Mallampati score, sternomental distance, thyromental distance, interincisor gap and atlantooccipital extension were all measured. The same anaesthesiologist performed laryngoscopy and graded the laryngeal view according to Cormack and Lehane. Exact logistic regression was used to identify significant independent predictors for difficult intubation (Cormack and Lehane grades ≥ 3) with two-sided P value less than 0.05 considered as significant. RESULTS: In 3 years, 239 women were recruited. Cormack and Lehane grades of 2 or less (easy) were found in 225 and grade of at least 3 (difficult) in 14 women. Patients' characteristics (age, height, weight, BMI or weight gain) were not significantly associated with difficulty of intubation. The incidence of difficult intubation was 1/17 women [95% confidence interval (CI) from 1/31 to 1/10]. A positive result from any of the five predictors combined had a sensitivity of 0.21 (95%CI 0.05-0.51), a specificity of 0.92 (95%CI 0.88-0.96), a positive predictive value of 0.15 (95%CI 0.032-0.38) and a negative predictive value of 0.95 (95%CI 0.91-0.97) for a Cormack and Lehane grade of at least 3 at laryngoscopy. CONCLUSION: Airway assessment using these tests cannot be relied upon to predict a difficult intubation at emergency caesarean section as the low sensitivity means that 79% (95%CI 49-95) of difficult intubations will be missed.

International consensus report on the investigation and management of primary immune thrombocytopenia.

Previously published guidelines for the diagnosis and management of primary immune thrombocytopenia (ITP) require updating largely due to the introduction of new classes of therapeutic agents, and a greater understanding of the disease pathophysiology. However, treatment-related decisions still remain principally dependent on clinical expertise or patient preference rather than high-quality clinical trial evidence. This consensus document aims to report on new data and provide consensus-based recommendations relating to diagnosis and treatment of ITP in adults, in children, and during pregnancy. The inclusion of summary tables within this document, supported by information tables in the online appendices, is intended to aid in clinical decision making.

Intraoperative awareness during general anesthesia for cesarean delivery.

Intraoperative awareness is defined as the spontaneous recall of an event occurring during general anesthesia. A move away from rigid anesthetic protocols, which were designed to limit drug transmission across the placenta, has reduced the incidence of awareness during cesarean delivery to approximately 0.26%. Nevertheless, it remains an undesirable complication with potential for the development of posttraumatic stress disorder. Assessing depth of anesthesia remains a challenge for the anesthesia provider as clinical signs are unreliable and there is no sensitive and specific monitor. Bispectral Index monitoring with the goal of scores <60 has been recommended to prevent awareness. Induction drugs vary in their ability to produce amnesia and the period of hypnotic effect is affected by the rate at which they are redistributed. After initiation of anesthesia, volatile anesthetics should be administered to a target of 0.7 minimum alveolar anesthetic concentration, which has been shown to consistently achieve mean Bispectral Index scores <60. Because of its rapid uptake, nitrous oxide remains an important adjunct to reduce the risk of awareness during emergency cesarean delivery. In the absence of fetal compromise, there is no rationale for an inspired oxygen concentration above 0.33. Deeper levels of anesthesia reduce the incidence of awareness; current evidence does not suggest an increased risk of tocolysis or fetal morbidity.

A comparison of minimum local anesthetic volumes and doses of epidural bupivacaine (0.125% w/v and 0.25% w/v) for analgesia in labor.

BACKGROUND: In this study we sought to determine and compare the minimum local anesthetic volumes (MLAV) and doses (MLAD) of two concentrations of bupivacaine for epidural pain relief in labor, and to quantify the effect on dose. METHODS: Eighty women were randomized in a double-blind manner to receive a first bolus of either plain bupivacaine 0.125% (w/v) or 0.25% (w/v). The arbitrary starting volume was 15 mL. Subsequent volumes were decided by sequential allocation according to analgesic efficacy. A visual analog pain score < or =10 (0-100) within 30 min, indicated effective analgesia. The next woman received a decrement of 2 mL. A failure of the visual analog pain score to reach < or =10 was followed by a 2 mL increment for the next woman. RESULTS: Using the formula of Dixon and Massey, MLAV and MLAD, with 95% confidence intervals (CI) were calculated for each concentration. MLAV was 13.6 mL (95% CI 12.4-14.8), with bupivacaine 0.125% (w/v), and 9.2 mL (95% CI 6.9-11.5) with bupivacaine 0.25% (w/v). The difference was highly significant (P = 0.002). MLAD for these volumes were 17.0 mg (95% CI 15.5-18.5), and 23.1 mg (17.2-28.9), respectively (P = 0.045). CONCLUSIONS: Bupivacaine 0.125% (w/v) when compared with 0.25% (w/v) produced equivalent analgesia with a 50% increase in volume, but with a 25% reduction in dose. Any reduction in dose, without loss of efficacy, reduces risk of toxicity and improves safety.

The relative motor blocking potencies of intrathecal ropivacaine: effects of concentration.

UNLABELLED: This study established the median effective dose (ED(50)) for motor block of intrathecal 1% and 0.1% ropivacaine and determined the effects of the concentration of the solution injected on the motor block obtained. We enrolled into this prospective, randomized, double-blind, sequential allocation study 54 parturients undergoing elective Cesarean delivery under combined spinal-epidural technique. Parturients were randomized to receive intrathecal ropivacaine either 1% or 0.1%. The initial dose was chosen to be 4 mg, with subsequent doses being determined by the response of the previous patient (testing interval, 1 mg). The occurrence of any motor block in either lower limb within 5 min from the intrathecal injection of the study solution was considered effective. The motor block at 5 min was 6.1 mg for 1% ropivacaine (95% confidence interval [CI], 5.1-7.1) and was 9.1 mg (95% CI, 7.8-10.3) for 0.1% ropivacaine (P = 0.0013; 95% CI difference, 1.3-4.7). The relative efficacy ratio of the 2 concentrations was 1.5 (95% CI difference, 1.2-1.9) in favor of the larger concentration. The ED(50) of spinal ropivacaine to produce motor block in pregnant patients was significantly influenced by the concentration of the local anesthetic, with dose requirements being increased by 50% for the smaller concentration. IMPLICATIONS: The minimum local anesthetic dose for motor block with 0.1% ropivacaine is 50% larger than the 1% concentration with a relative efficacy ratio of 1.5. Our findings suggest that more diluted local anesthetic solutions determine less motor block, and this may be considered in ambulant laboring parturients.

Can anesthesia improve the outcome in high risk obstertric patients?

Obstetric anesthetists should have an infrastructure that allows for referral and assessment of high risk patients. Management plans should be agreed well before delivery. This information must be available to other members of the team. Protocol for common high risk problems should be agreed and introduced. Promoting regional blockade for Cesarean section will reduce maternal anesthetic mortality. Epidural anesthesia preserves fetal biochemistry better than other forms of anesthesia.