Protocol for a randomised controlled trial for Reducing Arthritis Fatigue by clinical Teams (RAFT) using cognitive-behavioural approaches.

INTRODUCTION: Rheumatoid arthritis (RA) fatigue is distressing, leading to unmanageable physical and cognitive exhaustion impacting on health, leisure and work. Group cognitive-behavioural (CB) therapy delivered by a clinical psychologist demonstrated large improvements in fatigue impact. However, few rheumatology teams include a clinical psychologist, therefore, this study aims to examine whether conventional rheumatology teams can reproduce similar results, potentially widening intervention availability. METHODS AND ANALYSIS: This is a multicentre, randomised, controlled trial of a group CB intervention for RA fatigue self-management, delivered by local rheumatology clinical teams. 7 centres will each recruit 4 consecutive cohorts of 10-16 patients with RA (fatigue severity ≥ 6/10). After consenting, patients will have baseline assessments, then usual care (fatigue self-management booklet, discussed for 5-6 min), then be randomised into control (no action) or intervention arms. The intervention, Reducing Arthritis Fatigue by clinical Teams (RAFT) will be cofacilitated by two local rheumatology clinicians (eg, nurse/occupational therapist), who will have had brief training in CB approaches, a RAFT manual and materials, and delivered an observed practice course. Groups of 5-8 patients will attend 6 × 2 h sessions (weeks 1-6) and a 1 hr consolidation session (week 14) addressing different self-management topics and behaviours. The primary outcome is fatigue impact (26 weeks); secondary outcomes are fatigue severity, coping and multidimensional impact, quality of life, clinical and mood status (to week 104). Statistical and health economic analyses will follow a predetermined plan to establish whether the intervention is clinically and cost-effective. Effects of teaching CB skills to clinicians will be evaluated qualitatively. ETHICS AND DISSEMINATION: Approval was given by an NHS Research Ethics Committee, and participants will provide written informed consent. The copyrighted RAFT package will be freely available. Findings will be submitted to the National Institute for Health and Care Excellence, Clinical Commissioning Groups and all UK rheumatology departments. ISRCTN: 52709998; Protocol v3 09.02.2015.

Are spinal precautions necessary in all seizure patients?

The purpose of this retrospective chart review study was to evaluate the necessity of spinal precautions in uncomplicated seizure patients. The population was all patients from the Emergency Department with a primary diagnosis of seizure over a 10.5-year period. The setting was a university-affiliated county teaching hospital with an annual patient volume of over 58,000. The key outcome measure was an association of spinal injuries to uncomplicated seizures. A total of 1,656 cases were reviewed. No spinal injuries were found. Three nonspinal fractures were associated with seizure activity. Transportation costs increased approximately 113% and nursing costs increased approximately 57% for patients with seizure placed in spinal precautions. Quality Assurance and Risk Management files showed no complaints or litigation secondary to missed spinal injuries. This retrospective chart review study seriously questions routine use of spinal precautions in uncomplicated seizure cases. If spinal precautions were not used in this group, there would be a significant potential cost savings without increased morbidity. A prospective study is needed to confirm these findings.

Objectives to direct the training of emergency medicine residents on off-service rotation in cardiology, Part 2.

This article is the second of two parts outlining the objectives for a resident rotation in cardiology. Cardiology is offered as an off service rotation or an elective at some emergency medicine residency training programs. An organized core curriculum may provide a structured learning environment to help ensure that certain principles and objectives important to the practice of emergency medicine are learned. We have developed a written core curriculum containing a subject content list, learning objectives, and references for emergency medicine residents on cardiology services. This is a continuation of a series of objectives for off-service rotations for emergency medicine residents.

Development and initial application of a real time thermal control system for laser tissue welding.

The ability to sense and control continuously surface temperatures of a tissue being exposed to laser radiation could standardize parameters and eliminate subjective interpretation of results during laser tissue repair. We describe the development and testing of a control system that enables the operator to maintain relatively specific tissue temperatures for the purpose of laser welding. After initial development, the infrared thermal control system combined with an argon laser was used to repair urethral defects in 45 adult male rats. Repairs were completed using various predetermined temperatures of 50, 60, 70, 80 or 90C. The integrity of each weld was quantitatively determined by measuring intraluminal bursting pressure immediately after repair. In all temperature groups bursting pressures were in excess of 85 mm. Hg. Those performed at 80C produced the strongest weld (analysis of variance p = 0.0001). However, welding temperatures above 70C sacrificed the integrity of the underlying urothelium producing obvious damage when viewed microscopically. We were able to demonstrate that temperature is an objective parameter of tissue welding that can be continuously assessed and controlled during the laser repair of tissue defects to produce effective, predictable welds.

Objectives to direct the training of emergency medicine residents on off-service rotation in cardiology, Part 1.

This article is the first of a two-part series outlining the objectives for emergency medicine residents on a cardiology rotation. Cardiology is offered as an off service rotation or an elective at some emergency medicine residency training programs. An organized core curriculum may provide a structured learning environment to help ensure that certain principles and objectives important to the practice of emergency medicine are learned. We have developed a written core curriculum containing a subject content list, learning objectives, and references for emergency medicine residents on cardiology services. This is the 28th in a series of objectives for off-service rotations for emergency medicine residents.

CO2 laser welding versus conventional microsuture repair in patch-graft urethroplasty.

This study evaluates the repair of urethral tissue using microsurgery and a combination of laser welding techniques. Using the rat as a model, a patch-graft urethroplasty was performed with either conventional microsuture repair, laser-assisted microsuture repair, or laser-assisted microsuture with protein solder. Repairs were assessed at various time periods (days 0, 1, 7, and 21). Analysis of success rate, bursting strength, histology, and operative time were completed. The laser with protein solder had the highest success rate at each time period and demonstrated advanced healing with the least amount of inflammation. Operative time was decreased by 30 percent using the laser. In conclusion, the laser solder repair was significantly better than either laser alone or conventional microsutures.

Preparation of human albumin solder for laser tissue welding.

Previous studies have demonstrated that the addition of a protein solder to augment the laser tissue weld significantly improves postoperative results. Herein we describe a method for the preparation of human albumin for use as a laser tissue solder. We also review the brief history of laser tissue solders and discuss recent advances using this technology.

Optimal parameters for CO2 laser reconstruction of urethral tissue using a protein solder.

This study was designed to determine the optimal laser parameters for welding urethral tissue and to develop further understanding of the welding process. A partial transection of the pendulous rat urethra was repaired using laser powers of 80, 120, and 160 milliwatts with shutter speeds of 50 milliseconds, 100 milliseconds, and in a continuous wave mode. Repairs were made using the laser alone and the laser plus a protein solder. Measurements of intraluminal bursting strength, percentage stricture and histology were performed. The highest bursting strength with the least amount of tissue damage was achieved using a power of 120 milliwatts with 100 milliseconds pulses and the addition of a protein solder. The average percentage stricture was lowest with the laser plus solder repair (4.2%) when compared to laser only repair (14%). Intraluminal bursting strength was similar in both types of repairs. Histology demonstrated marked changes in collagen organization after laser application in all models.