Segmental spinal root avulsion in the adult rat: a model to study avulsion injury pain.

Road traffic accidents are the most common cause of avulsion injury, in which spinal roots are torn from the spinal cord. Patients suffer from a loss of sensorimotor function, intractable spontaneous pain, and border-zone hypersensitivity. The neuropathic pains are particularly difficult to treat because the lack of a well-established animal model of avulsion injury prevents identifying the underlying mechanisms and hinders the development of efficacious drugs. This article describes a hindlimb model of avulsion injury in adult rats where the L5 dorsal and ventral spinal root are unilaterally avulsed (spinal root avulsion [SRA]), leaving the adjacent L4 spinal root intact. SRA produced a significant ipsilateral hypersensitivity to mechanical and thermal stimulation by 5 days compared with sham-operated or naïve rats. This hypersensitivity is maintained for up to 60 days. No autotomy was observed and locomotor deficits were minimal. The hypersensitivity to peripheral stimuli could be temporarily ameliorated by administration of amitriptyline and carbamazepine, drugs that are currently prescribed to avulsion patients. Histological assessment of the L4 ganglion cells revealed no significant alterations in calcitonin gene-related peptide (CGRP), IB4, transient receptor potential cation channel subfamily V member 1 (TrpV1), or N52 staining across groups. Immunohistochemistry of the spinal cord revealed a localized glial response, phagocyte infiltration, and neuronal loss within the ipsilateral avulsed segment. A comparable response from glia and phagocytes was also found in the intact L4 spinal cord, supporting the role for central mechanisms within the L4-5 spinal cord in contributing to the generation of the pain-related behavior. The SRA model provides a platform to investigate possible new pharmacological treatments for avulsion injuries.

Applying lean: implementation of a rapid triage and treatment system.

OBJECTIVE: Emergency department (ED) crowding creates issues with patient satisfaction, long wait times and leaving the ED without being seen by a doctor (LWBS). Our objective was to evaluate how applying Lean principles to develop a Rapid Triage and Treatment (RTT) system affected ED metrics in our community hospital. METHODS: Using Lean principles, we made ED process improvements that led to the RTT system. Using this system, patients undergo a rapid triage with low-acuity patients seen and treated by a physician in the triage area. No changes in staffing, physical space or hospital resources occurred during the study period. We then performed a retrospective, observational study comparing hospital electronic medical record data six months before and six months after implementation of the RTT system. RESULTS: ED census was 30,981 in the six months prior to RTT and 33,926 after. Ambulance arrivals, ED patient acuity and hospital admission rates were unchanged throughout the study periods. Mean ED length of stay was longer in the period before RTT (4.2 hours, 95% confidence interval [CI] = 4.2-4.3; standard deviation [SD] = 3.9) than after (3.6 hours, 95% CI = 3.6-3.7; SD = 3.7). Mean ED arrival to physician start time was 62.2 minutes (95% CI = 61.5-63.0; SD = 58.9) prior to RTT and 41.9 minutes (95% CI = 41.5-42.4; SD = 30.9) after. The LWBS rate for the six months prior to RTT was 4.5% (95% CI = 3.1-5.5) and 1.5% (95% CI = 0.6-1.8) after RTT initiation. CONCLUSION: Our experience shows that changes in ED processes using Lean thinking and available resources can improve efficiency. In this community hospital ED, use of an RTT system decreased patient wait times and LWBS rates.

Simulation has a key role in the educational environment.

Further to ' Supporting the lecturer to deliver high-fidelity simulation ' (art & science August 10), the shortage of student placements should not be the main reason for increasing the use of simulation.

A comprehensive systematic review of the use of simulation in the continuing education and training of qualified medical, nursing and midwifery staff.

BACKGROUND: Simulation can be defined as a person, device or set of conditions made to resemble a real life situation. It is used in many high-risk industries particularly when reality is dangerous, critical events are rare and errors are costly in human and/or financial terms. The use of simulation in the UK is now considered an essential component of education programmes designed for healthcare practitioners. However the use of simulation in undergraduate education has been studied in depth but little is known about its use in postgraduate education. OBJECTIVE: The aim of this systematic review was to establish: where and in which context is simulation an effective educational medium in post qualifying/continuing education; what is the benefit to learners of using simulation in respect of their knowledge, skills and confidence and what are the implications for future research in this area? INCLUSION CRITERIA: This review looked for both quantitative and qualitative evidence in the form of primary research.The review focused on post qualification medical, nursing and midwifery staff undertaking educational development programmes utilising simulation. Types of interventions: the intervention explored in this review is simulation in the form of the re-creation of a patient centred scenario / event in a realistic context. The review explicitly excluded simulation designed to specifically to improve motor skills in isolation from context, such as part task trainers. TYPES OF OUTCOME MEASURES: The outcome measures to be explored in this review were: demonstration of the application of knowledge to the simulated clinical situation; demonstrable improvement in knowledge of the environment and equipment; demonstration of risk assessment; safe working practice in relation to the clinical environment; recognition of own limitations and knowing when to call for help; effective communication; team working and leadership skills; evidence from learners in relation to the educational experience; evidence of increased learner confidence following simulated practice; evidence of improved patient outcome being assessed in relation to training SEARCH STRATEGY: The search strategy aimed to find both published and unpublished English language studies from 1998-2009. Databases systematically searched included: Medline, CINAHL, EMBASE, ERIC and the Dissertation Abstracts International Proceedings. METHODOLOGICAL QUALITY: Papers were assessed for methodological quality independently by two of the review team. Critical appraisal of methodological quality of papers was undertaken using the Joanna Briggs Institute modules, Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) and Qualitative Assessment and Review Instrument (JBI-QARI). Differences in judgment were resolved through discussion between the two reviewers of their differences and through the inclusion of a third reviewer if necessary in order to reach consensus. A fifth member of the team independently reviewed all included and excluded studies as a quality control mechanism. DATA COLLECTION: The process of data extraction was undertaken independently by two reviewers using the JBI data extraction tools. DATA SYNTHESIS: A statistical meta-analysis of the data was not possible due to the variation in outcome measures used in the papers. The findings are therefore presented descriptively using the specified outcome measures as a reporting framework. RESULTS: The initial search identified 1522 papers. Thirty eight papers were considered to have met the inclusion criteria and were subsequently critically appraised for methodological quality. Thirty papers were considered to be of appropriate quality for inclusion in the review. These were predominantly experimental pre post test studies but they covered a wide range of healthcare workers and situations. CONCLUSION: There is considerable evidence that suggests that simulation based educational programmes are consistently effective in improving the performance of doctors, nurses and midwives in educational contexts particularly in teamwork and communication. There is also evidence that practitioners value simulation as a learning and teaching strategy. There is however very little evidence to support the assumption that improvements in performance are translated into "real life" clinical settings and ultimately outcomes for service users. IMPLICATIONS FOR PRACTICE: Although the evidence base provided by this review is relatively weak in terms of educational practice it would seem to have high face validity. The evidence has added coherence when seen in the context of educational theory and those planning educational programmes for healthcare practitioners should be cognizant of the potential benefits offered by simulation as part of a blended approach to learning. IMPLICATIONS FOR RESEARCH: This review has identified a clear need to establish causative links between simulation based educational programmes and improvements in healthcare practice, by using experimental designs where simulation is compared with other educational interventions.