BackgroundWithin an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver “optimal analgesia,” which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects.MethodsWith input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients.DiscussionAs a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.
This paper reports on two studies which show that cognitive therapy effects as much individual change when presented in small group format, as when presented in individual format to community-based populations suffering depression. In Study 1, referrals from an inner-city general practice health centre were assigned to group or individual cognitive therapy; or to waiting list control, while also receiving their usual treatment from their GP. Cognitive therapy was superior to the waiting list condition and group presentation was as effective as individual presentation. Large effect sizes, reliable change and maintenance of treatment gains at 3, 6 and 12 months are reported. In Study 2 referrals primarily from the occupational health services of large local employers were assigned to group or individual cognitive therapy. Group presentation was again as effective as individual presentation, and large effect sizes, reliable change and maintenance of treatment gains at 1, 2, 3 and 6 months are demonstrated.
Is propositional religious faith constituted by belief? Recent debate has focussed on whether faith may be constituted by a positive non-doxastic cognitive state, which can stand in place of belief. This paper sets out and defends the doxastic theory. We consider and reject three arguments commonly used in favour of non-doxastic theories of faith: (1) the argument from religious doubt; (2) the use of 'faith' in linguistic utterances; and (3) the possibility of pragmatic faith. We argue that belief is required to maintain a distinction between genuine faith, pretend faith, and fictionalist faith.
The hepatitis C virus (HCV) NS5A inhibitor ABT-267 (ombitasvir, OBV), the HCV NS4/4A protease inhibitor ABT-450 (paritaprevir, PTV), the CYP3A inhibitor ritonavir (r) and the non-nucleoside NS5B polymerase inhibitor ABT-333 (dasabuvir, DSV) (OBV/PTV/r + DSV) with or without ribavirin (RBV) is a direct-acting antiviral regimen approved in the United States and other major countries for the treatment of HCV in genotype 1 (GT1) infected patients. Patients with HCV who are considered “hard-to-cure” have generally been excluded from registration trials due to rigorous study inclusion criteria, presence of comorbidities and previous treatment failures.
To investigate the efficacy of this regimen in HCV G1-infected patients historically excluded from clinical trials.
Patients were ≥ 18 years old and chronically infected with HCV GT1 (GT1a, GT1b or GT1a/1b). Patients were treatment-naïve or previously failed a regimen including pegylated interferon/RBV +/- telaprevir, boceprevir, or simeprevir. One hundred patients were treated with the study drug regimen, which was administered for 12 or 24 wk +/- RBV according to GT1 subtype and presence/absence of cirrhosis. Patients were evaluated every 4 wk from treatment day 1 and at 4 and 12 wk after end-of-treatment.
Many of the patients studied had comorbidities (44.2% hypertensive, 33.7% obese, 20.2% cirrhotic) and 16% previously failed HCV treatment. Ninety-six patients completed study follow-up and 99% achieved 12-wk sustained virologic response. The majority (88.4%) of patients had undetectable HCV RNA by week 4. The most common adverse events were fatigue (12%), headache (10%), insomnia (9%) and diarrhea (8%); none led to treatment discontinuation. Physical and mental patient reported outcomes scores significantly improved after treatment. Almost all (98%) patients were treatment compliant.
In an all-comers HCV GT1 population, 12 or 24-wk of OBV/PTV/r + DSV +/- RBV is highly effective and tolerable and results in better mental and physical health following treatment.
Cognitive behaviour therapy (CBT) treatments have been developed and validated with respect to specific diagnoses. In routine clinical practice diagnostic accuracy is poor, making for poorly targeted treatment. The problems posed by lack of diagnostic rigour, including non-detection of co-morbidity, are rarely the subject of supervision sessions and treatment failures may be inappropriately attributed to other factors such as lack of therapeutic skill or an unmotivated client. It is argued that a false dichotomy exists between diagnosis and case formulation fuelled by professional territorial disputes. We suggest that diagnosis acts as a lens, focusing attention on the range of cognitions salient to a case formulation and also highlights psychosocial and environmental factors that may affect treatment outcome. It is recommended that practitioners enhance their effectiveness by using structured interviews routinely as a part of their ongoing assessment of clients.
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