Protracted fibrinolysis resistance following cardiac surgery with cardiopulmonary bypass: A prospective observational study of clinical associations and patient outcomes.

BACKGROUND: Surgery on cardiopulmonary bypass (CPB) elicits a pleiomorphic systemic host response which, when severe, requires prolonged intensive care support. Given the substantial cross-talk between inflammation, coagulation, and fibrinolysis, the aim of this hypothesis-generating observational study was to document the kinetics of fibrinolysis recovery post-CPB using ClotPro® point-of-care viscoelastometry. Tissue plasminogen activator-induced clot lysis time (TPA LT, s) was correlated with surgical risk, disease severity, organ dysfunction and intensive care length of stay (ICU LOS). RESULTS: In 52 patients following CPB, TPA LT measured on the first post-operative day (D1) correlated with surgical risk (EuroScore II, Spearman's rho .39, p < .01), time on CPB (rho = .35, p = .04), disease severity (APACHE II, rho = .52, p < .001) and organ dysfunction (SOFA, rho = .51, p < .001) scores, duration of invasive ventilation (rho = .46, p < .01), and renal function (eGFR, rho = -.65, p < .001). In a generalized linear regression model containing TPA LT, CPB run time and markers of organ function, only TPA LT was independently associated with the ICU LOS (odds ratio 1.03 [95% CI 1.01-1.05], p = .01). In a latent variables analysis, the association between TPA LT and the ICU LOS was not mediated by renal function and thus, by inference, variation in the clearance of intraoperative tranexamic acid. CONCLUSIONS: This observational hypothesis-generating study in patients undergoing cardiac surgery with cardiopulmonary bypass demonstrated an association between the severity of fibrinolysis resistance, measured on the first post-operative day, and the need for extended postoperative ICU level support. Further examination of the role of persistent fibrinolysis resistance on the clinical outcomes in this patient cohort is warranted through large-scale, well-designed clinical studies.

Capnodynamic monitoring of lung volume and blood flow in response to increased positive end-expiratory pressure in moderate to severe COVID-19 pneumonia: an observational study.

BACKGROUND: The optimal level of positive end-expiratory pressure (PEEP) during mechanical ventilation for COVID-19 pneumonia remains debated and should ideally be guided by responses in both lung volume and perfusion. Capnodynamic monitoring allows both end-expiratory lung volume ([Formula: see text]) and effective pulmonary blood flow (EPBF) to be determined at the bedside with ongoing ventilation. METHODS: Patients with COVID-19-related moderate to severe respiratory failure underwent capnodynamic monitoring of [Formula: see text] and EPBF during a step increase in PEEP by 50% above the baseline (PEEPlow to PEEPhigh). The primary outcome was a > 20 mm Hg increase in arterial oxygen tension to inspired fraction of oxygen (P/F) ratio to define responders versus non-responders. Secondary outcomes included changes in physiological dead space and correlations with independently determined recruited lung volume and the recruitment-to-inflation ratio at an instantaneous, single breath decrease in PEEP. Mixed factor ANOVA for group mean differences and correlations by Pearson's correlation coefficient are reported including their 95% confidence intervals. RESULTS: Of 27 patients studied, 15 responders increased the P/F ratio by 55 [24-86] mm Hg compared to 12 non-responders (p < 0.01) as PEEPlow (11 ± 2.7 cm H2O) was increased to PEEPhigh (18 ± 3.0 cm H2O). The [Formula: see text] was 461 [82-839] ml less in responders at PEEPlow (p = 0.02) but not statistically different between groups at PEEPhigh. Responders increased both [Formula: see text] and EPBF at PEEPhigh (r = 0.56 [0.18-0.83], p = 0.03). In contrast, non-responders demonstrated a negative correlation (r = - 0.65 [- 0.12 to - 0.89], p = 0.02) with increased lung volume associated with decreased pulmonary perfusion. Decreased (- 0.06 [- 0.02 to - 0.09] %, p < 0.01) dead space was observed in responders. The change in [Formula: see text] correlated with both the recruited lung volume (r = 0.85 [0.69-0.93], p < 0.01) and the recruitment-to-inflation ratio (r = 0.87 [0.74-0.94], p < 0.01). CONCLUSIONS: In mechanically ventilated patients with moderate to severe COVID-19 respiratory failure, improved oxygenation in response to increased PEEP was associated with increased end-expiratory lung volume and pulmonary perfusion. The change in end-expiratory lung volume was positively correlated with the lung volume recruited and the recruitment-to-inflation ratio. This study demonstrates the feasibility of capnodynamic monitoring to assess physiological responses to PEEP at the bedside to facilitate an individualised setting of PEEP. TRIAL REGISTRATION: NCT05082168 (18th October 2021).

Exploring pregnant women's experiences of stopping smoking with an incentive scheme with 'enhanced' support: a qualitative study.

AIM: This study aims to understand pregnant women's experiences of smoking cessation with an incentive scheme in a deprived UK city. This is important because smoking cessation with pregnant women is one of the most crucial public health initiatives to promote, and is particularly challenging in deprived areas. While financial incentive schemes are controversial, there is a need to better understand pregnant women's experiences. The scheme combined quasi-financial incentives (shopping vouchers) for validated quits (carbon monoxide (CO) validated at < 10 ppm), enhanced support from smoking cessation advisors, the opportunity to identify a 'Significant Other Supporter' and nicotine replacement therapy. METHODS: With the focus on understanding pregnant women's experiences, a qualitative design was adopted. Semi-structured interviews were completed with 12 pregnant women from the scheme, and the three advisors. All interviews were transcribed, and thematic analysis conducted. RESULTS: Pregnant women reported various challenges to quitting, including long-established routines, and stress. Participants were aware of stigma around incentives but were all very positive about the scheme. The relationship with advisors was described as fundamental. The women valued their advice and support, while uptake of the 'Significant Other Supporter' appeared low. Participants viewed the CO monitoring as 'an incentive', while the vouchers were framed as a 'bonus'. Advisors perceived the vouchers as helping engage pregnant women and maintain quit status, and women appreciated the vouchers both as financial assistance and recognition of their accomplishments. CONCLUSION: This study highlights the great value women placed on the support, advice and monitoring from specialist advisors. The distinction between vouchers as a welcomed bonus, rather than 'the incentive' to engage, is important. How smoking cessation and schemes to promote this are communicated to pregnant women and health professionals is important, particularly given the stigma and controversy involved.

Occupational health risks of pathologists--results from a nationwide online questionnaire in Switzerland.

BACKGROUND: Pathologists are highly trained medical professionals who play an essential part in the diagnosis and therapy planning of malignancies and inflammatory diseases. Their work is associated with potential health hazards including injuries involving infectious human tissue, chemicals which are assumed to be carcinogenic or long periods of microscope and computer work. This study aimed to provide the first comprehensive assessment of the health situation of pathologists in Switzerland. METHODS: Pathologists in Switzerland were contacted via the Swiss Society of Pathologists and asked to answer an ethically approved, online anonymous questionnaire comprising 48 questions on occupational health problems, workplace characteristics and health behaviour. RESULTS: 163 pathologists participated in the study. Forty percent of pathologists reported musculoskeletal problems in the previous month. The overall prevalence was 76%. Almost 90% of pathologists had visual refraction errors, mainly myopia. 83% of pathologists had experienced occupational injuries, mostly cutting injuries, in their professional career; more than one fifth of participants reported cutting injuries in the last year. However, long lasting injuries and infectious diseases were rare. Depression and burnout affected every eighth pathologist. The prevalence of smoking was substantially below that of the general Swiss population. CONCLUSIONS: The results of this study suggest that more care should be taken in technical and personal protective measures, ergonomic workplace optimisation and reduction of work overload and work inefficiencies. Despite the described health risks, Swiss pathologists were optimistic about their future and their working situation. The high rate of ametropia and psychological problems warrants further study.

A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing.

AIMS: This qualitative literature review aims to critically assess and analyse published literature to determine drivers influencing over-prescribing by general practitioners (GPs) in primary care, exploring their views and opinions, and also to determine how antibiotic prescribing can be improved and unnecessary prescribing reduced, thus reducing the threat to public health from antibiotic resistance. It is intended to develop new thinking in this area and add to existing knowledge concerning GPs' antibiotic prescribing behaviour. METHODS: Thematic analysis following Braun and Clarke's 2006 framework was used to analyse 17 qualitative studies chosen from EBSCOhost databases, focusing on GPs' views of antibiotic prescribing in primary care, with specific search strategies and inclusion criteria to ensure study quality and trustworthiness. RESULTS: Three main themes and nine sub-themes were generated from the studies. The first main theme discussed GP factors related to over-prescribing, the main drivers being GP attitudes and feelings and anxiety/fear concerning prescribing. The second theme highlighted external factors, with pressures from time and financial issues as the main drivers within this theme. The final theme marked patient pressure, demand and expectation with lack of patient education as the major drivers affecting GP over-prescribing. CONCLUSION: The findings of this research show GPs' antibiotic prescribing in primary care is complex, being influenced by many internal and external factors. A multifaceted approach to interventions targeting the drivers identified could significantly reduce the level of antibiotic prescribing thus minimising the impact of antibiotic resistance and promoting a more efficient working environment for GPs and patients alike.

An imperial laboratory: the investigation and treatment of treponematoses in occupied Haiti, 1915-1934.

This article examines anti-treponematoses work as part of US occupation public health policy in Haiti, a unique event in the history of international health. Yaws was highly prevalent in Haiti, but occupation doctors initially ignored it because of its close association with syphilis and stigmas attached to sexually transmitted disease. This changed when C.S. Butler asserted that yaws was "innocent" and that the two diseases should therefore be considered as one. Treatment increased as an anti-treponematoses campaign was now believed to hold great benefits for the occupation's paternalist and strategic aims, even though it ultimately failed. This work reflected Haiti's status as a public health "laboratory" which affected Haitian medicine for years to come and significantly influenced future campaigns aimed at disease eradication.

Emotional Freedom Techniques to Treat Posttraumatic Stress Disorder in Veterans: Review of the Evidence, Survey of Practitioners, and Proposed Clinical Guidelines.

BACKGROUND: High prevalence rates of posttraumatic stress disorder (PTSD) in active military and veterans present a treatment challenge. Many PTSD studies have demonstrated the efficacy and safety of Emotional Freedom Techniques (EFT). OBJECTIVES: To develop clinical best practice guidelines for the use of EFT to treat PTSD, on the basis of the published literature, practitioner experience, and typical case histories. METHODS: We surveyed 448 EFT practitioners to gather information on their experiences with PTSD treatment. This included their demographic profiles, prior training, professional settings, use of assessments, and PTSD treatment practices. We used their responses, with the research evidence base, to formulate clinical guidelines applying the "stepped care" treatment model used by the United Kingdom's National Institute for Health and Clinical Excellence. RESULTS: Most practitioners (63%) reported that even complex PTSD can be remediated in 10 or fewer EFT sessions. Some 65% of practitioners found that more than 60% of PTSD clients are fully rehabilitated, and 89% stated that less than 10% of clients make little or no progress. Practitioners combined EFT with a wide variety of other approaches, especially cognitive therapy. Practitioner responses, evidence from the literature, and the results of a meta-analysis were aggregated into a proposed clinical guideline. CONCLUSION: We recommend a stepped care model, with 5 EFT therapy sessions for subclinical PTSD and 10 sessions for clinical PTSD, in addition to group therapy, online self-help resources, and social support. Clients who fail to respond should be referred for appropriate further care.

Can physician assistants be effective in the UK?

The National Health Sevice (NHS) faces a serious shortage of medical staff. One solution is to introduce US-style physician assistants (PAs) who train for around two years following previous clinical work or a first degree, and perform duties similar to junior doctors. This paper reviews the history and role of PAs, the quality of their work and their likely impact in the UK. A variety of sources were searched to identify suitable studies. The use of PAs in the UK appears to be an acceptable model that could eventually reduce the current skill shortage and provide high quality patient care. Twelve US-sourced PAs currently work in Sandwell, West Midlands. A recent report suggests they have made a substantial contribution to primary care and have improved patient access. For PAs to be successful in the UK, they must be highly regarded practitioners. High quality educational courses must be established to ensure their credibility.

Medical care practitioners: introducing a new profession into the UK.

The NHS is suffering from a serious shortage of qualified medical staff. One possible solution is to introduce medical care practitioners (MCPs) (USA-style physician assistants) into the healthcare team. This article examines the history and role of PAs, as well as some of the issues concerning the role, and how other health professionals might perceive it. The article also describes one MCP programme that has already started in Britain at Wolverhampton University. The use of MCPs in the UK appears to offer a potential solution to reduce the current skill shortage in this country.

The epidemiology of preterm birth.

Preterm birth is a major clinical problem, accounting for 47% of all neonatal deaths. The preterm delivery rate in UK is approximately 7%, and rates of preterm birth are steadily increasing. The diagnosis of preterm labour is difficult and most interventions to halt labour are unsuccessful. Despite this, the lack of good data hinders high quality research. The West Midlands has the highest perinatal mortality in the UK and a Perinatal Institute was set up in 2000 to address this, and aid improvements in care. Survival rates amongst preterm infants have changed dramatically over the last decade, with 88% survival for 2728 weeks, and 21% for > or =24 weeks (depending on birth weight). Risk factors include lower social class, less education, single marital status, low income, younger maternal age, low body weight, ethnicity, smoking, poor housing along with medical factors such as induction, premature rupture of membranes, infection, multiple pregnancy intrauterine death, fetal and uterine abnormalities and chorioamnionitis. Data from further detailed, robust studies are required to facilitate a comprehensive understanding of risk factors and their relationship with each other. Only then will it be possible to influence the adverse outcomes described.

Public health action and mass chemoprophylaxis in response to a small meningococcal infection outbreak at a nursery in the West Midlands, England.

BACKGROUND: Meningococcal infection is fatal in 10% of cases, and age-specific attack rates are highest in infancy. A nursery outbreak was declared just before a bank holiday weekend in August 2010, when two children attending the same nursery were confirmed to have meningococcal infection. Although such outbreaks are rare, they generate considerable public alarm and are challenging to manage and control. This report describes the investigation and public health response to the outbreak. RESULTS: Both cases had relatively mild disease and were confirmed as having serogroup B infection. Chemoprophylaxis and advice were given to most of the 146 children and 30 staff at the nursery. Within 28 hours of declaring the outbreak, over 95% of parents received information, advice and prescriptions for their children. GPs were also given information and the after-hours service provided continuity over the weekend. No further cases were identified and the outbreak was closed four weeks after being declared. CONCLUSIONS: Considerable logistical challenges were involved in providing timely advice and chemoprophylaxis to the entire nursery and staff one day before a bank holiday weekend. The speed of the public health response and implementation of preventive measures was crucial in providing assurance to parents and staff, and reducing their anxiety. The decision to provide on-site prescribing at the nursery (coupled with information sessions and individual counselling) proved to be a key implementation-success factor. Effective coordination and management by the outbreak control team was able to rapidly provide leadership, delegate tasks, identify gaps, allocate resources and ensure a proactive media response. A number of useful lessons were learnt and recommendations were made for future local practice.

An imperial laboratory: the investigation and treatment of treponematoses in occupied Haiti, 1915-1934 / Um laboratório imperial: investigação e tratamento da treponematose no Haiti ocupado, 1915-1934

This article examines anti-treponematoses work as part of US occupation public health policy in Haiti, a unique event in the history of international health. Yaws was highly prevalent in Haiti, but occupation doctors initially ignored it because of its close association with syphilis and stigmas attached to sexually transmitted disease. This changed when C.S. Butler asserted that yaws was "innocent" and that the two diseases should therefore be considered as one. Treatment increased as an anti-treponematoses campaign was now believed to hold great benefits for the occupation's paternalist and strategic aims, even though it ultimately failed. This work reflected Haiti's status as a public health "laboratory" which affected Haitian medicine for years to come and significantly influenced future campaigns aimed at disease eradication.

Este artigo investiga o trabalho anti-treponêmico como parte da política norte-americana de saúde pública na ocupação do Haiti, evento inédito na história da saúde internacional. Era alta a incidência da bouba no Haiti, mas médicos da ocupação a ignoravam por ser parecida com a sífilis e pelos estigmas da doença sexualmente transmitida. A situação mudou quando C.S. Butler afirmou que a bouba era "inocente" e que as duas doenças deveriam ser consideradas uma. Surgiram mais tratamentos com uma campanha anti-treponêmica que trazia benefícios aos objetivos paternalistas e estratégicos da ocupação, apesar do seu fracasso final. Esse trabalho ilustra o Haiti como "laboratório" de saúde pública, o que afetou a medicina haitiana por anos e influenciou campanhas futuras para erradicar a doença.

Mobile telecommunications and health: report of an investigation into an alleged cancer cluster in Sandwell, West Midlands.

AIMS: Residents of one street expressed concern about the number of incident cancers, following the installation of a nearby mobile phone base station. The investigation explored whether the base station could be responsible for the cancers. METHODS: Data were collected from residents' medical records. GPs and oncologists provided further information. RESULTS: Ward-level cancer incidence and mortality data were also obtained, over four three-year time periods. A total of 19 residents had developed cancer. The collection of cancers did not fulfil the criteria for a cancer cluster. Standardized mortality ratios (SMRs) for all malignant neoplasms (excluding non-melanoma skin cancers) in females (1.38 (95% CI, 1.08-1.74)) and all persons (1.27 (CI, 1.06-1.51)) were significantly higher than in the West Midlands during 2001-3. There were no significant differences for colorectal, female breast and prostate cancers, for any time period. Standardized incidence ratios (SIRs) for non-melanoma skin cancers in males and all persons was significantly lower than in the West Midlands during 1999-2001, and significantly lower in males, females and all persons during 2002-4. CONCLUSIONS: We cannot conclude that the base station was responsible for the cancers. It is unlikely that information around a single base station can either demonstrate or exclude causality.