Peri-operative care of elective adult surgical patients with a learning disability.

People with a learning disability can experience significant problems in accessing healthcare and this may be partly reflected in worse health outcomes compared with the general population, including a shorter life expectancy. The Equality Act (2010) requires that organisations and individuals make changes to the way services are provided for all disabled people to mitigate, as far as possible, any disadvantage they may face in accessing these services. These changes are termed 'reasonable adjustments'. This article describes the reasonable adjustments that can be made to facilitate the admission of an adult surgical patient with a learning disability, and therefore reduce health inequality. Each stage of a patient's journey through the hospital needs to be anticipated and planned for. Many of these changes are not only applicable to the wider care of people with a learning disability, but also to any person who lacks capacity and who is struggling to access healthcare. Key recommendations include the development of assessment tools, pathways and policies specific to the learning disabled patient; identification of key personnel including a learning disability lead, an acute liaison learning disability nurse, pre-assessment and operating theatre personnel and ward learning disability champions; regular multidisciplinary team meetings for planning and best interest assessments; and establishing an electronic alert on the patient administration system to identify learning disabled patients. The anaesthetist, operating theatre and learning disability teams play a pivotal role in ensuring individualised admission plans are made for patients with a learning disability to reduce these healthcare inequalities and improve peri-operative care.

RECK controls breast cancer metastasis by modulating a convergent, STAT3-dependent neoangiogenic switch.

Metastasis is the primary cause of cancer-related death in oncology patients. A comprehensive understanding of the molecular mechanisms that cancer cells usurp to promote metastatic dissemination is critical for the development and implementation of novel diagnostic and treatment strategies. Here we show that the membrane protein RECK (Reversion-inducing cysteine-rich protein with kazal motifs) controls breast cancer metastasis by modulating a novel, non-canonical and convergent signal transducer and activator of transcription factor 3 (STAT3)-dependent angiogenic program. Neoangiogenesis and STAT3 hyperactivation are known to be fundamentally important for metastasis, but the root molecular initiators of these phenotypes are poorly understood. Our study identifies loss of RECK as a critical and previously unknown trigger for these hallmarks of metastasis. Using multiple xenograft mouse models, we comprehensively show that RECK inhibits metastasis, concomitant with a suppression of neoangiogenesis at secondary sites, while leaving primary tumor growth unaffected. Further, with functional genomics and biochemical dissection we demonstrate that RECK controls this angiogenic rheostat through a novel complex with cell surface receptors to regulate STAT3 activation, cytokine signaling, and the induction of both vascular endothelial growth factor and urokinase plasminogen activator. In accordance with these findings, inhibition of STAT3 can rescue this phenotype both in vitro and in vivo. Taken together, our study uncovers, for the first time, that RECK is a novel regulator of multiple well-established and robust mediators of metastasis; thus, RECK is a keystone protein that may be exploited in a clinical setting to target metastatic disease from multiple angles.

Long term Gyrodactylus lomi infection on isolated juvenile chub (Leuciscus cephalus).

Previous studies on long term gyrodactylid infections on isolated fish have shown that for the majority of Gyrodactylus-fish interactions, infections peak at a maximum level and then decline as the host mounts an effective immune response. In the current study, juvenile chub collected from the wild still harboured Gyrodactylus lomi infections after 6 - 10 months in the laboratory despite being individually maintained at 12 C.

Vasodilator iontophoresis a possible new therapy for digital ischaemia in systemic sclerosis?

OBJECTIVE: This study investigated whether whole finger vasodilator iontophoresis increases digital blood flow in patients with systemic sclerosis (SSc): If so, this might indicate a novel approach to therapy. METHODS: Eight patients and 8 healthy controls underwent whole finger iontophoresis using a specially designed chamber. Treatment was with 0.5% sodium nitroprusside (NaNP) or 1% acetylcholine chloride (ACh), and the procedure then repeated with the other vasodilator (randomly assigned order). Three treatments were carried out for each chemical; 2 min treatments were carried out bilaterally at 200 microA, a third was then carried out for 5 min on one digit only (randomly assigned to left or right). Blood flow increases were monitored with laser Doppler imaging (LDI). Maximum perfusion increase from baseline (MAX) and the area under the time perfusion curve (AUC), normalized for baseline, were calculated. Data were compared with a three-way analysis of variance test. RESULTS: Perfusion increased in both patients and controls, but significantly more so in controls (P(MAX) = 0.001, P(AUC) = 0.005, respectively). Values were significantly higher for the 5 min treatment compared with the 2 min treatment (P(MAX) = 0.011 and P(AUC) = 0.008 for both groups). No significant differences were found between the use of NaNP and ACh. CONCLUSIONS: The increased perfusion with both ACh and NaNP in the patient group (albeit to a lesser degree than in the control group) indicates that this local approach to vasodilation is effective. Increasing iontophoresis time causes more sustained vasodilation. Further studies are indicated to investigate a possible therapeutic effect in patients with severe digital ischaemia.

Experimental infections of the monogenean Gyrodactylus turnbulli indicate that it is not a strict specialist.

Parasites represent a threat to endangered fish species, particularly when the parasite can host switch and the new host is vulnerable. If the parasite is highly host specific then successful host switching should be a rare occurrence; however, the host range of many parasites which are assumed to be specialists has never been tested. This includes the monogenean Gyrodactylus turnbulli, a well-studied ectoparasite found caudally on its known host, the guppy, Poecilia reticulata. In this study, we monitored parasite establishment and reproduction on a range of poeciliids and more distantly related fish. Individually maintained fish were experimentally infected with a single parasite and monitored daily to establish whether G. turnbulli could survive and reproduce on other fish species. Gyrodactylus turnbulli can infect a wider range of hosts than previously considered, highlighting the fact that host specificity can never be assumed unless experimentally tested. Our findings also have significant implications for parasite transmission to novel hosts and provide further insight into the evolutionary origins of this ubiquitous group of fish pathogens. Previous molecular evidence indicates that host switching is the key mechanism for speciation within the genus Gyrodactylus. Until recently, most Gyrodactylus spp. were assumed to be narrowly host specific. However, our findings suggest that even so-called specialist species, such as G. turnbulli, may represent a threat to vulnerable fish stocks. In view of the potential importance of host switching under artificial conditions, we propose to describe this as 'artificial ecological transfer' as opposed to 'natural ecological transfer', host switching under natural conditions.

Abnormal microvascular response is localized to the digits in patients with systemic sclerosis.

OBJECTIVE: To investigate the hypothesis that cutaneous microvascular perfusion of the dorsum of the hand (in response to local heating) and distal phalanx (in response to occlusion) is impaired in patients with systemic sclerosis (SSc) compared with healthy controls. METHODS: Twenty-nine patients with SSc and 29 control subjects were recruited. Perfusion was monitored using novel dual-wavelength laser Doppler imaging, allowing measurement of both smaller (capillaries) and larger (thermoregulatory) vessels. Postacclimatization, a baseline dorsum scan (red or green wavelength) was performed. A heating pad was placed on the dorsum (total stimulus time 6 minutes at 34-40 degrees C), and following removal of the pad, baseline wavelength scans were performed until perfusion returned to baseline values. This was then repeated for the second wavelength. The maximum perfusion increase due to heating (PEAK1) and area under the perfusion-time curve (AUC) were determined. In addition, scans (both wavelengths) of the index finger were performed prior to and during 2 minutes of suprasystolic occlusion, and the response upon occlusion release was monitored with single-point laser Doppler. The decrease in perfusion due to occlusion (from preocclusion baseline values) (%DECREASE) and the maximum increase (from baseline perfusion values under occlusion) in hyperemic perfusion upon removal of occlusion (PEAK/OCC) were calculated. RESULTS: PEAK1 and AUC values were not significantly different between patients and controls, as assessed with either wavelength. A significant difference between groups was found in the %DECREASE values with the green, but not the red, wavelength. A significant between-group difference was also found in PEAK/OCC values, using both wavelengths. CONCLUSION: This study suggests that SSc has no effect on microvascular perfusion in the dorsum of the hand, and that the abnormal microvascular response is localized to the digits, affecting both smaller and larger vessels.

Dual wavelength (532 and 633 nm) laser Doppler imaging of plaque psoriasis.

BACKGROUND: Increased blood flow occurs in plaques of psoriasis, and an increase in blood flow has been shown to occur in uninvolved skin adjacent to the active edge. OBJECTIVES: In order to gain more insight into the pathophysiology of the active edges of plaques of psoriasis, we investigated different components of the microcirculation in the lesional and nonlesional skin of patients with psoriasis, using dual wavelength laser Doppler imaging (LDI). METHODS: The cutaneous blood flow in 23 plaques on the forearms of 20 patients with chronic plaque psoriasis was recorded using dual wavelength LDI. Perfusion was determined within the plaque (P), in uninvolved skin adjacent to the plaque (A) and in nonadjacent skin (U). RESULTS: Perfusion in plaques was increased as imaged by either 633 nm (red wavelength) or 532 nm (green wavelength) compared with both adjacent and nonadjacent uninvolved skin: median (interquartile range) P/A(RED) = 3.7 (2.5-4.9), P/A(GREEN) = 1.3 (1.2-1.6), P/U(RED) = 4.2 (2.7-6.1), P/U(GREEN) = 1.5 (1.3-1.9). CONCLUSIONS: Vascular perfusion is increased within plaques of psoriasis compared with adjacent and nonadjacent uninvolved skin. The results suggest an area of increased perfusion in skin adjacent to plaques, when compared with nonadjacent skin, for both deeper (large) and superficial (small) vessels (imaged by 633 and 532 nm, respectively). We believe that this dual wavelength tool may be a suitable and useful way of assessing pathophysiology and treatment response in psoriasis.

Thermal effects of the Er:YAG laser on a simulated dental pulp: a quantitative evaluation of the effects of a water spray.

OBJECTIVES: To quantify the temperature increments in a simulated dental pulp following irradiation with an Er:YAG laser, and to compare those increments when the laser is applied with and without water spray. METHODS: Two cavities were prepared on either the buccal or lingual aspect of sound extracted teeth using the laser. One cavity was prepared with water spray, the other without and the order of preparation randomised. Identical preparation parameters were used for both cavities. Temperature increments were measured in the pulp chamber using a calibrated thermocouple and a novel pulp simulant. RESULTS: Maximum increments were 4.0 degrees C (water) and 24.7 degrees C (no water). Water was shown to be highly significant in reducing the overall temperature increments in all cases (p<0.001; paired t-test). None of the samples prepared up to a maximum of 135 J cumulative energy prepared with water spray exceeded that threshold at which pulpal damage can be considered to occur. Only 25% of those prepared without water spray remained below this threshold. DISCUSSION: Extrapolation of the figures suggests probably tolerable limits of continuous laser irradiation with water in excess to 160 J. With the incorporation of small breaks in the continuity of laser irradiation that occur in the in vivo situation, the cumulative energy dose tolerated by the pulp should far exceed these figures. CONCLUSIONS: The Er:YAG laser must be used in conjunction with water during cavity preparation. As such it should be considered as an effective tool for clinical use based on predicted pulpal responses to thermal stimuli.

Soft and hard tissue ablation with short-pulse high peak power and continuous thulium-silica fibre lasers.

Thulium lasers operating near approximately 2 microm are the subject of interest for various medical applications. The newly developed Tm3+ silica fibre laser in Q-switched and CW operation was investigated to determine its efficiency in the interaction with soft and hard tissues. The interaction was investigated using a free-running continuous (CW) Tm(3+)-doped fibre laser (wavelength 1.99 microm, with self-pulsation ranging over 1 to few tens of microseconds) and for novel Q-switched operation of the same fibre laser (pulse durations from 150 to 900 ns and pulse repetition rates from 100 Hz to 17 kHz). Residual damage and affected zones using the Q-switched laser were nearly six times smaller than using the CW fibre laser for about 50 s of exposure time, and increased with pulse repetition rate. The energy required to ablate tissue with the Q-switched fibre laser ranged from 0.2 to 0.6 kJ/cm3 and was significantly smaller than that for the CW fibre laser of 153 to 334 kJ/cm3. Under both high-resolution reflected optical microscopy and histological examination, tissue crater depths were observed as cleanly cut with smooth walls and minimal charring in the case of Q-switched operation of the fibre laser. This study is the first direct comparison of tissue interaction of short-pulse (Q-switched) and CW Tm(3+)-doped silica fibre lasers on crater depth, heat of ablation and collateral damage. The Q-switched Tm(3+)-doped silica fibre laser effectively ablates tissue with little secondary damage.

Digital vascular response to topical glyceryl trinitrate, as measured by laser Doppler imaging, in primary Raynaud's phenomenon and systemic sclerosis.

OBJECTIVE: To investigate digital microvascular responses to topical glyceryl trinitrate (GTN) in patients with primary Raynaud's phenomenon (PRP), limited cutaneous systemic sclerosis (LCSSc) and healthy control subjects, using laser Doppler imaging. METHODS: Ten patients with PRP, 13 with LCSSc and 10 control subjects were studied. Baseline skin microvascular blood flow of the dorsum of the index, middle and ring fingers of the non-dominant hand was measured using scanning laser Doppler imaging. After the initial image, 2% GTN ointment was rubbed on the dorsum of one finger for 1 min; placebo ointment was rubbed on the dorsum of a second finger for 1 min, and the third finger remained untreated. Further laser Doppler scanning of these three fingers was conducted immediately, 10 and 20 min after ointment application. RESULTS: There was increased blood flow response to placebo compared with no treatment (P<0.001) and to GTN compared with placebo (P=0.004). The change in blood flow over time differed significantly between placebo and GTN (P<0.001), but not between placebo and no ointment application: blood flow increased with GTN and decreased with placebo/no treatment at 10 and 20 min. There were no differences in initial baseline blood flow or response between the subject groups. CONCLUSIONS: An exogenous supply of nitric oxide by topical GTN ointment causes local endothelial-independent vasodilatory responses in PRP, LCSSc patients and control subjects. As well as demonstrating the effectiveness of topical GTN in patients with PRP and LCSSc, this study illustrates the ability of laser Doppler imaging to quantify local vasodilatory effects.

A mass on breast imaging predicts coexisting invasive carcinoma in patients with a core biopsy diagnosis of ductal carcinoma in situ.

An image-guided core-needle breast biopsy (IGCNBB) diagnosis of ductal carcinoma in situ (DCIS) is often upgraded to invasive carcinoma (IC) after complete excision. When IC is identified after excision patients must be returned to the operating room for evaluation of their axillary nodes. We performed this study to identify histologic or mammographic features that would predict the presence of invasion when DCIS is documented by IGCNBB. Patients with an IGCNBB diagnosis of DCIS were identified from a prospective database. Imaging abnormalities were classified as either calcification only or mass with or without calcifications. IGCNBB specimens were reviewed to document nuclear grade and the presence of comedo-type necrosis, periductal fibrosis, and periductal inflammation. Patients were divided into two groups, DCIS and IC, on the basis of the final diagnosis after complete excision. From July 1993 through May 2000, 148 of 2995 (4.9%) IGCNBBs demonstrated DCIS; eight were excluded after pathologic review. Of the remaining 140 patients 36 (26%) demonstrated IC after complete excision. The presence of a mass on breast imaging was the only significant predictor of IC (P = 0.04). On the basis of the results of this study we now perform sentinel lymph node mapping and biopsy at the initial surgical procedure for patients with an IGCNBB diagnosis of DCIS and an associated mass on breast imaging.

Image-guided breast biopsy.

Image-guided breast biopsy has become an attractive alternative to wire-localized excisional biopsy to evaluate women with nonpalpable abnormalities detected by breast imaging. We have organized a database from our institution that includes over 3,500 procedures. We have reviewed our institutional results and the literature pertaining to image-guided breast biopsy. Discussed in this review are the indications and contraindications for image-guided biopsy, common techniques employed, accuracy based on pathology, reimbursement issues, and the multidisciplinary approach used at our institution. The results of our review affirm our position that image-guided breast biopsy is the preferred technique to evaluate women with nonpalpable breast imaging abnormalities.

Biopsy technique has no impact on local recurrence after breast-conserving therapy.

Image-guided core needle breast biopsy (IGCNBB) is an incisional biopsy technique that has been associated with tumor cell displacement. Theoretically tumor cell displacement may affect local recurrence rates in patients treated with breast-conserving therapy (BCT). We performed a study to determine if the biopsy method impacted local control rates following BCT. Patients with nonpalpable breast cancer (invasive and intraductal) diagnosed at our institution and treated with BCT between July 1993 and July 1996 were selected to provide a follow-up period in which the majority of local recurrences should be detected. Patients were divided into two groups based on their method of diagnosis. Group I patients were diagnosed by IGCNBB and group II patients were diagnosed by wire localized excisional breast biopsy (WLEBB). Factors potentially affecting local recurrence rates were retrospectively reviewed. Two hundred eleven patients were treated with BCT, 132 were diagnosed by IGCNBB and 79 by WLEBB. The two patient groups were similar when compared for prognostic factors and treatment. All patients' BCT included histologically negative margins. There were 4 (3.0%) local recurrences in Group I at a median follow-up of 44.4 months and 2 (2.5%) local recurrences in group II at a median follow-up of 50.1 months. This difference was not significant. Breast cancer patients diagnosed by IGCNBB can be treated by BCT with acceptable local control rates. Additional surveillance of our institutional experience and others' is mandatory to validate IGCNBB as the preferred biopsy method for nonpalpable mammographic abnormalities.

Developing an infection control for anaesthetic equipment.

Hospital risk management demands the development of broad and inclusive infection control policies. This is particularly true for anaesthetic equipment where appropriate recommendations on decontamination measures remains a difficult subject for infection control teams since there are no national guidelines. It is a topic which has perhaps been neglected in hospital infection control policies despite the widespread use of anaesthetic equipment in many clinical areas outside the theatre complex. This article offers practical guidance when preparing an infection control policy for anaesthetic equipment. The cost effectiveness of single patient use items versus reprocessing equipment is discussed. The importance of a multi-disciplinary approach, especially where the evidence base is weak, is highlighted.

Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T(is,1,2) breast cancer.

BACKGROUND: We hypothesized that wide-field brachytherapy (BRT) after margin negative excision would result in complication rates, local recurrence rates, and cosmesis scores equivalent to external beam radiotherapy (ERT). METHODS: Patients with T(is,1,2) tumors less than or equal to 4 cm, 0 to 3 positive axillary nodes, and negative inked surgical margins were entered prospectively into BRT phase I/II trial. Patients who met the eligibility criteria for BRT but were treated with ERT during the same time period were retrospectively identified as controls. A blinded panel of healthcare professionals graded cosmetic outcome. RESULTS: Fifty patients with 51 breast cancers received BRT from January 1992 to October 1993. We identified 94 patients eligible for BRT but concurrently treated with ERT. At a median follow-up of 75 months, the two groups were similar for grade III treatment toxicities, local/regional recurrence rates, and cosmesis scores. CONCLUSIONS: For selected breast cancer patients undergoing breast-conserving therapy, BRT is an attractive alternative to ERT.

Laser-tissue interaction with a continuous wave 3-mcm fibre laser: preliminary studies with soft tissue.

BACKGROUND AND OBJECTIVE: Lasers operating at wavelengths in the mid-infrared region have become increasingly popular for applications in areas of surgery and medicine. Advances in fibre laser technology have introduced a highly efficient, compact, diode-pumped source operating at around the 3-mcm wavelength. This study examines the effects of this recently developed laser on soft biological tissue. STUDY DESIGN/MATERIALS AND METHODS: Chicken breast and liver tissue samples were exposed to 800 mW continuous wave laser power, at a wavelength of 2.71 mcm, with incident spot sizes of around 150 mcm. Samples were inspected grossly immediately after laser irradiation and also prepared for histologic processing. RESULTS: After irradiation, visual assessment of changes at sample surfaces indicated a region of thermally affected tissue surrounding the ablation crater. This region was observed to grow in size to around 1.0 mm in diameter after 3 seconds of laser exposure at 800 mW. An ablation velocity of 0.80 mm.s(-1) was determined in chicken breast for the same incident laser parameters. Analysis of samples irradiated at 800 mW and processed for histology revealed minimal damage at hole boundaries and no signs of char formation, providing incident exposure times were restricted to below around 0. 5 seconds. CONCLUSION: This fibre laser source has demonstrated its potential to fulfil medical applications, enabling accurate, precise tissue removal to proceed at a rapid ablation rate. The efficiency and small size of the laser are attractive features.