Evaluating inhaler technique, patient preferences and opportunities for improvement in hospitals in the UK.

Inhalers are a key aspect of managing airways disease. With effective use, they can reduce symptoms, reduce the frequency of exacerbations and thus reduce usage of healthcare services. Inhalers are associated with a significant carbon footprint, accounting for 3% of NHS' carbon emissions. We aimed to audit inhaler technique, patient preferences and inhaler prescribing and disposal to identify areas for improving the sustainability of respiratory care. An audit tool was created, and patient interviews conducted across eight different sites. Our data demonstrate that inhaler users, while self-reporting high levels of confidence in their inhaler technique, frequently make errors in inhaler technique. Additionally, the majority of patients considered the carbon footprint of their inhalers important and would consider changing to a lower carbon alternative. The majority of patients surveyed were not disposing of their inhalers correctly. This short audit has identified key areas for improvement in the quality and sustainability of respiratory care.

Improving Antimicrobial Use to Protect the Environment: What Is the Role of Infection Specialists?

Anthropogenic environmental changes are causing severe damage to the natural and social systems on which human health depends. The environmental impacts of the manufacture, use, and disposal of antimicrobials cannot be underestimated. This article explores the meaning of environmental sustainability and four sustainability principles (prevention, patient engagement, lean service delivery, and low carbon alternatives) that infection specialists can apply to support environmental sustainability in health systems. To prevent inappropriate use of antimicrobials and consequent antimicrobial resistance (AMR) requires international, national, and local surveillance plans and action supporting antimicrobial stewardship (AMS). Engaging patients in addressing environmental sustainability, for example through public awareness campaigns about the appropriate disposal of unused and expired antimicrobials, could drive environmentally sustainable changes. Streamlining service delivery may include using innovative methods such as C-reactive protein (CRP), procalcitonin (PCT), or genotype-guided point of care testing (POCT) to reduce unnecessary antimicrobial prescribing and risk of adverse effects. Infection specialists can assess and advise on lower carbon alternatives such as choosing oral (PO) over intravenous (IV) antimicrobials where clinically appropriate. By applying sustainability principles, infection specialists can promote the effective use of healthcare resources, improve care quality, protect the environment, and prevent harm to current and future generations.

COVID-19 presenting as severe, persistent abdominal pain and causing late respiratory compromise in a 33-year-old man.

A 33-year-old man presented repeatedly with severe abdominal pain and diarrhoea. Renal colic was suspected, and he was admitted for pain management. Questioning elicited an additional history of sore throat and mild, dry cough. Inflammatory markers were mildly raised (C reactive protein (CRP) 40 mg/L). Initial nasopharyngeal swabs were negative for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by PCR. CT of the kidneys, ureters and bladder (CT KUB) was normal; however, CT of the thorax showed multifocal bilateral peripheral areas of consolidation consistent with COVID-19 infection. He developed respiratory compromise and was transferred to the intensive care unit (ICU). Sputum was positive for SARS-CoV-2 by PCR, and culture grew Yersinia enterocolitica He recovered following supportive management and treatment with piperacillin-tazobactam.

Including papers in languages other than English in systematic reviews: important, feasible, yet often omitted.

A truly international and systematic review (SR) identifies and synthesizes relevant evidence regardless of the geographical provenance or language of publication. Despite recommendations, international SRs continue to exclude papers in languages other than English (LOE) at searching, screening, and analysis phases either explicitly in their protocols or by omitting to attend to LOE. Although guidelines on including LOE publications in SRs are lacking, a small body of literature provides strategies for screening LOE titles and abstracts. Drawing on experience from published SRs, this commentary summarizes the existing literature and highlights further strategies that can be used. Online translation tools and language skills of colleagues can often be used during searching and screening at no financial cost. When LOE papers meet inclusion criteria, a member of the SR team with relevant language skills, if available, or an external translator will ideally be involved multiple times during the review process. Weighing up the novelty and import of insights from a paper against translation costs can inform decisions about whether LOE papers should be included and the frequency with which a translator should be involved. Removing language restrictions requires attention at all stages of an SR. A plan for addressing LOE papers at each stage should be documented at the outset of the review and may need to be revised depending on the number of papers identified. Reporting of the approach used is important for transparency and confirmability.

Building an environmentally accountable medical curriculum through international collaboration.

BACKGROUND: Global environmental change is associated with significant health threats. The medical profession can address this challenge through advocacy, health system adaptation and workforce preparedness. Stewardship of health systems with attention to their environmental impacts can contribute to mitigation of and adaptation to negative health impacts of environmental change. Medical schools have an integral role in training doctors who understand the interdependence of ecosystems and human health. Yet integrating environmental perspectives into busy medical curricula is not a simple task. CONTENT: At the 2016 Association for Medical Education in Europe conference, medical educators, students and clinicians from six continents discussed these challenges in a participatory workshop. Here we reflect on emerging themes from the workshop and how to plan for curricular change. Firstly, we outline recent developments in environmental health and associated medical education. Secondly, we reflect on our process and outcomes during this innovative approach to international collaboration. Thirdly, we present learning objectives which cover core content for environmentally accountable medical curricula, developed through a reflective process of international collaboration integrating current literature and the workshop outcomes. CONCLUSIONS: International collaboration can bring together diverse perspectives and provide critical insights for the inclusion of environmental health into basic education for medical practitioners.

A case of multiple cardiac calcified amorphous tumours.

Cardiac calcified amorphous tumours of the heart are rare non-neoplastic cardiac masses that can present like a malignant mass or an intra-cardiac thrombus. We report an extremely unusual case of a 73year old man who presented to hospital with dyspnoea and subsequent investigations revealed multiple cardiac CATs.

What do tomorrow's doctors need to learn about ecosystems? - A BEME Systematic Review: BEME Guide No. 36.

BACKGROUND: Human health is fundamentally determined by the health of ecosystems. Guidance is lacking about how to address the topic of ecosystems within medical education. AIMS: To determine the nature of discussions around ecosystems in the educational, medical and medical education literature. To identify learning needs of tomorrow's doctors. METHODS: A narrative synthesis approach was used. Systematic searches were completed in 14 databases. Two independent reviewers screened results. Preliminary synthesis included textual descriptions and quality appraisal. Data were analysed using the Education for Sustainable Healthcare framework and thematic analysis. Relationships between studies were explored. Best evidence synthesis, contacting authors of primary studies and critical reflection reinforced robustness. RESULTS: Six thousand seven hundred and fifty-three abstracts and 123 full texts were screened. Twenty-seven studies were included. Many studies lacked clear reporting. Medical students and doctors displayed knowledge about ecosystems, but lacked confidence to enact sustainable practices. Education about causes and consequences of environmental change is required. Few studies proposed specific learning objectives. CONCLUSIONS: To prepare for roles as health care workers and leaders, medical students must learn about relationships between ecosystems, health and health care. The Education for Sustainable Healthcare framework outlines essential knowledge and attitudes but requires addition of practical competencies. Further research should explore the framework's relevance in different contexts, in order to structure training accordingly.

Interventions for treating depression in Muslim Patients: a systematic review.

BACKGROUND: Religious belief is an important determinant of mental health, depression is the mental illness responsible for the largest disease burden globally, and Islam is the fastest growing world religion. Here we systematically review the literature on the engagement of Muslim patients in the treatment of depression. METHOD: A search of electronic databases, including non-traditional sources, was conducted and content experts were contacted in order to identify qualitative studies, quantitative studies and opinion pieces. A standardised data extraction pro forma and thematic analysis were applied to included studies. RESULTS: 25 studies met the inclusion criteria. Muslims hold many beliefs about depression relevant to its treatment. Advice about how to identify and respond to such beliefs was contradictory and rarely based upon research evidence. The literature is generally of poor quality and rarely distinguishes between religion and culture. LIMITATIONS: Many studies do not distinguish between beliefs and values that are religious and those that are cultural. The majority of papers identified are English language, suggesting that literature from predominantly Muslim countries is underrepresented, despite our strategy of searching for literature from all relevant countries. CONCLUSION: Much of the evidence identified by this review is methodologically weak or includes assertions made without qualification. This evidence provides important perspectives, but should be interpreted with caution. High-quality research is needed to improve our understanding of the treatment of depression in Muslim clients, to determine how existing therapies can be modified to meet the needs of Muslim clients, and to evaluate the effectiveness of such modified therapies.

The weight of nations: an estimation of adult human biomass.

BACKGROUND: The energy requirement of species at each trophic level in an ecological pyramid is a function of the number of organisms and their average mass. Regarding human populations, although considerable attention is given to estimating the number of people, much less is given to estimating average mass, despite evidence that average body mass is increasing. We estimate global human biomass, its distribution by region and the proportion of biomass due to overweight and obesity. METHODS: For each country we used data on body mass index (BMI) and height distribution to estimate average adult body mass. We calculated total biomass as the product of population size and average body mass. We estimated the percentage of the population that is overweight (BMI > 25) and obese (BMI > 30) and the biomass due to overweight and obesity. RESULTS: In 2005, global adult human biomass was approximately 287 million tonnes, of which 15 million tonnes were due to overweight (BMI > 25), a mass equivalent to that of 242 million people of average body mass (5% of global human biomass). Biomass due to obesity was 3.5 million tonnes, the mass equivalent of 56 million people of average body mass (1.2% of human biomass). North America has 6% of the world population but 34% of biomass due to obesity. Asia has 61% of the world population but 13% of biomass due to obesity. One tonne of human biomass corresponds to approximately 12 adults in North America and 17 adults in Asia. If all countries had the BMI distribution of the USA, the increase in human biomass of 58 million tonnes would be equivalent in mass to an extra 935 million people of average body mass, and have energy requirements equivalent to that of 473 million adults. CONCLUSIONS: Increasing population fatness could have the same implications for world food energy demands as an extra half a billion people living on the earth.