Seafloor macrolitter as a settling platform for non-native species: A case study from UK waters.

Marine litter is increasingly recognised as a vector for the spread of non-native species (NNS). However, our understanding of its role in the propagation of NNS in UK waters remains limited. As part of the Clean Seas Environmental Monitoring Programme, we opportunistically analysed seafloor macrolitter items trawled from various locations around the coast of England and Wales and examined each for the presence of NNS. Of the 41 litter items analysed, we identified a total of 133 taxa, including two non-native and four cryptogenic species. This confirms that NNS are settling on seafloor macrolitter in UK waters and that these can be detected using morphological taxonomic analysis. Furthermore, we propose a methodology to classify litter based on size, rugosity and polymer/material type to explore whether there were detectable patterns governing community composition and litter characteristics. This exploratory investigation provides evidence to inform future risk assessments of NNS vectors and pathways.

Modelling of marine debris pathways into UK waters: Example of non-native crustaceans transported across the Atlantic Ocean on floating marine debris.

The long-distance transfer of non-native, potentially invasive species via floating marine debris is an increasing threat to biodiversity and conservation efforts. To address the lack of understanding around mechanisms and pathways of species transfer via marine debris, a novel modelling approach was applied to recreate the likely trajectory and source of a large piece of debris fouled by non-native species collected from UK marine waters. This approach applied the Oil Spill Contingency and Response (OSCAR) simulation tool, an adapted oil spill modelling programme, which was informed by a combination of biological trait information for the foulant species, marine debris characteristics and hydrodynamic data. The modelling output suggested an origin in the Western Atlantic, a scenario concurrent with the known distribution of the foulant species. This modelling approach represents a valuable tool with which to determine the origin and trajectory of invasive species transferred via marine debris.

Management of superior mesenteric venous thrombus in cystic fibrosis related liver disease.

Abdominal pain is a common feature in patients with cystic fibrosis (CF) and CF related liver disease (CFLD). Superior mesenteric venous (SMV) thrombosis is an uncommon but important cause of abdominal pain. Management strategies are complicated by an underlying prothrombotic state and increased risk of bleeding from complications of CF and CFLD. This review addresses clinical presentation, detection and management options of an acute SMV thrombus in the context of CF.

Outcomes Following Bronchial Artery Embolisation for Haemoptysis in Cystic Fibrosis.

BACKGROUND: Bronchial artery embolisation (BAE) is recommended for the treatment of massive haemoptysis in cystic fibrosis (CF), but there are no randomised controlled trials of this therapy and its role in sub-massive haemoptysis is unclear. This study aimed to determine the outcomes and safety of BAE in adults with CF. MATERIALS AND METHODS: All patients with CF undergoing BAE at our centre between March 2011 and January 2015 were identified at the time of the procedure. Patient records were reviewed at hospital discharge, death or one month post-procedure (whichever was soonest). Follow-up continued to January 2016. Severity of haemoptysis was classified as: massive (>240 ml/24 h or >100 ml/day for ≥2 days), moderate-severe (>20 ml/24 h) or mild (<20 ml/24 h). RESULTS: Twenty-seven patients underwent 51 BAE procedures over a median follow-up period of 26 months (range 1-54). Ten patients (37%) required more than one BAE during the study. BAE was performed for massive haemoptysis in 18 cases (35%). Haemoptysis recurred after 31 (61%) of BAE procedures with no difference in recurrence rates between massive and sub-massive haemoptysis. Side effects were reported after 61% of procedures with chest pain the most common adverse event . Mortality after first BAE in the study was 3.9% at 30 days and 14.8% at 12 months. No significant predictors of mortality were identified. CONCLUSIONS: BAE is often effective in controlling haemoptysis but is associated with considerable morbidity and high recurrence rates.

Dental treatment for people with cystic fibrosis.

AIM: To describe the nature and consequences of the multi-system genetic condition cystic fibrosis with a view to ensuring optimal dental treatment planning for these patients. METHODS: A literature search was conducted to identify the key medical and dental manifestations of cystic fibrosis. These findings are discussed and utilised to create recommendations for treatment planning in patients with cystic fibrosis for the practising dental practitioner. RESULTS: Cystic fibrosis is a complex, lethal, multisystem autosomal recessive disorder resulting from mutations on chromosome 7 which result in dysfunction of an ion channel that sits on epithelial surfaces. Respiratory disease remains the leading cause of mortality. Survival has greatly increased in recent decades secondary to improved treatment and specialist care. Specific dental manifestations of the disease may result from the condition itself or complications of treatment. Modification of patient management may be necessary to provide optimum patient care. CONCLUSION: The pathophysiology and clinical manifestations are relevant to practicing dental practitioners and inform recommendations to be utilised to ensure optimal treatment planning for these patients.

Costo-iliac distance: a physical sign of understated importance.

INTRODUCTION: Osteoporosis is a common condition, especially affecting the older female population. The ability to predict loss of lumbar height using simple anatomical measurements would be a useful tool. METHODS: Forty subjects were recruited. Mean age was 72 years. Arm span (AS) and the costo-iliac distance (CID) were measured. The CID/AS ratio was calculated. The L(1)-L(4) vertebral height of each patient was obtained from dual-energy X-ray absorptiometry (DEXA). RESULTS: There was a statistically significant correlation between the lumbar height and CID/AS ratio (R (2) = 0.79, p < 0.001). CONCLUSION: The CID/AS ratio may be a useful bedside test in identifying loss of lumbar vertebral height.

Does perfusion computed tomography facilitate clinical decision making for thrombolysis in unselected acute patients with suspected ischaemic stroke?

BACKGROUND: Despite use in clinical practice and major positive trials of thrombolysis, non-contrast computed tomography (NCCT) is not sensitive for identifying penumbral tissue in acute stroke. This study evaluated how physiological imaging using CT perfusion (CTP) could add to the diagnostic utility of an NCCT and inform clinical decisions regarding thrombolysis. METHODS: Forty imaging datasets containing NCCT and CTP were retrospectively identified from a cohort of consecutive acute stroke patients. Two sets of observers (n = 6) and a neuroradiologist evaluated the images without knowledge of clinical symptoms. Inter-observer agreement was calculated using the κ statistic for identifying acute ischaemic change on NCCT: perfusion abnormalities (namely cerebral blood volume, cerebral blood flow and time to peak), and penumbral tissue on perfusion maps obtained by two image processing algorithms. RESULTS: Inter-rater agreement was moderate (κ = 0.54) for early ischaemic change on NCCT. Perfusion maps improved this to substantial for cerebral blood volume (κ = 0.67) and to almost perfect for time to peak (κ = 0.87) and cerebral blood flow (κ = 0.87). The agreement for qualitative assessment of penumbral tissue was substantial to perfect for images obtained using the two different perfusion algorithms. Overall, there was a high rate of decision to thrombolyse based on NCCT (81.25%). CTP strengthened the decision to thrombolyse based on NCCT in 38.3% of cases. It negatively influenced the decision in 14.6% of cases, this being significantly more common in experienced observers (p = 0.02). CONCLUSIONS: We demonstrate that the qualitative evaluation of CTP produces near perfect inter-observer agreement, regardless of the post-processing method used. CTP is a reliable, accessible and practical imaging modality that improves confidence in reaching the appropriate diagnosis. It is particularly useful for less experienced clinicians, to arrive at a physiologically informed treatment decision.

Comparison of arterial and venous blood gases and the effects of analysis delay and air contamination on arterial samples in patients with chronic obstructive pulmonary disease and healthy controls.

BACKGROUND: Arterial blood gases (ABGs) are often sampled incorrectly, leading to a 'mixed' or venous sample. Delays in analysis and air contamination are common. OBJECTIVES: We measured the effects of these errors in patients with chronic obstructive pulmonary disease (COPD) exacerbations and controls. METHODS: Arterial and venous samples were analyzed from 30 patients with COPD exacerbation and 30 controls. Venous samples were analysed immediately and arterial samples separated into non-air-contaminated and air-contaminated specimens and analysed at 0, 30, 60, 90 and 180 min. RESULTS: Mean venous pH was 7.371 and arterial pH was 7.407 (p < 0.0001). There was a correlation between venous and arterial pH (r = 0.5347, p < 0.0001). The regression equation to predict arterial pH was: arterial pH = 4.2289 + 0.43113 · venous pH. There were no clinically significant differences in arterial PO2 associated with analysis delay. A statistically significant decline in pH was detected at 30 min in patients with COPD exacerbation (p = 0.0042) and 90 min in controls (p < 0.0001). A clinically significant decline in pH emerged at 73 min in patients with COPD exacerbation and 87 min in controls. Air contamination was associated with a clinically significant increase in PO2 in all samples, including those that were immediately analyzed. CONCLUSIONS: Arterial and venous pH differ significantly. Venous pH cannot accurately replace arterial pH. Temporal delays in ABG analysis result in a significant decline in measured pH. ABGs should be analysed within 30 min. Air contamination leads to an immediate increase in measured PO2, indicating that air-contaminated ABGs should be discarded.

START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients.

BACKGROUND: Inappropriate prescribing encompasses acts of commission i.e. giving drugs that are contraindicated or unsuitable, and acts of omission i.e. failure to prescribe drugs when indicated due to ignorance of evidence base or other irrational basis e.g. ageism. There are considerable published data on the prevalence of inappropriate prescribing; however, there are no recent published data on the prevalence of acts of omission. The aim of this study was to calculate the prevalence of acts of prescribing omission in a population of consecutively hospitalised elderly people. METHODS: A screening tool (screening tool to alert doctors to the right treatment acronym, START), devised from evidence-based prescribing indicators and arranged according to physiological systems was prepared and validated for identifying prescribing omissions in older adults. Data on active medical problems and prescribed medicines were collected in 600 consecutive elderly patients admitted from the community with acute illness to a teaching hospital. On identification of an omitted medication, the patient's medical records were studied to look for a valid reason for the prescribing omission. RESULTS: Using the START list, we found one or more prescribing omissions in 57.9% of patients. In order of prevalence, the most common prescribing omissions were: statins in atherosclerotic disease (26%), warfarin in chronic atrial fibrillation (9.5%), anti-platelet therapy in arterial disease (7.3%) and calcium/vitamin D supplementation in symptomatic osteoporosis (6%). CONCLUSION: Failure to prescribe appropriate medicines is a highly prevalent problem among older people presenting to hospital with acute illness. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice.

Novel agents in the management of Mycobacterium tuberculosis disease.

The goals of tuberculosis control are to cure active disease, prevent relapse, reduce transmission and avert the emergence of drug resistance. However, since the 1960s, there have been few developments in available therapies. Currently available agents are complicated by numerous side-effects, drug interactions and the need for a long duration of therapy. Rifampicin-containing regimes lead to hepatic enzyme induction which can complicate or preclude the use of protease inhibitors and non-nucleoside reverse transcriptase inhibitors in patients infected with the human immunodeficiency virus. Furthermore, emerging drug resistance has complicated management for many patients and clinicians. Therefore, new chemotherapeutic agents are urgently needed. Existing antimicrobials are emerging as potent antituberculous agents. Recent studies have demonstrated the antituberculous activity of newer fluoroquinolones including levofloxacin, moxifloxacin, and gatifloxacin. Their use as first line antituberculous agents is currently under investigation. Furthermore, the oxazolidinones linezolid and PNU-100480 have been shown to have antituberculous activity in addition to their antibacterial effects. Several other agents are currently being developed for the treatment of tuberculosis. These agents include diarylquinolones (R207910), nitroimidazopyrans (PA-824, OPC-67683), ethambutol analogues (SQ109), cerulenin, trans-cinnamic acid, macrolides, pyrroles (LL3858), long-acting rifamycins and inhaled interferon-gamma. Furthermore, vaccines are being explored for pre-exposure and post-exposure use. This review will describe therapeutic developments in the management of tuberculosis, highlighting mechanisms of action of new pharmacological agents and their potential for clinical use.

Inappropriate prescribing in the elderly: a comparison of the Beers criteria and the improved prescribing in the elderly tool (IPET) in acutely ill elderly hospitalized patients.

BACKGROUND: In appropriate prescribing is a significant and persistent problem in elderly people, both in hospital and the community and has been described in several countries in Europe and also the USA. The problem of inappropriate prescribing has not been quantified in the Republic of Ireland. The most commonly used criteria for the identification of inappropriate prescribing are the Beers' criteria [both independent of diagnosis (ID) and considering diagnosis (CD) - 2003 version]. The Beers' criteria ID includes 48 different categories of either single medications or multiple medications of a similar class identified as inappropriate prescriptions and the Beers' criteria CD contains 19 different categories containing possible drug-disease interactions. A second tool, the improved prescribing in the elderly tool (IPET) has also been validated and used in hospital and community studies and has 14 categories of either explicitly contraindicated medications or possible drug-disease interactions. OBJECTIVES: The primary aim of the study is to measure the incidence of inappropriate prescribing among older community-dwelling individuals presenting to an acute hospital in the Republic of Ireland. A secondary aim of this study was also therefore to compare the efficacy of the above two tools in identifying inappropriate prescribing. METHODS: A prospective, consecutive observational cohort study was carried out over a 4-month period. The setting was an urban-based university hospital acute geriatric medicine assessment unit. Subjects in this study (n = 350) were consecutively screened on admission to hospital (mean age = 80.3 +/- 6.1 years) and all patients had both Beers' criteria ID and CD and IPET applied to their list of prescription drugs on admission, cross-referenced with their list of current active medical diagnosis. RESULTS: The results of the study identified a high rate of inappropriate prescribing among this population of community-dwelling subjects. The total number of inappropriate prescriptions identified using the Beers' criteria (ID) was 148 affecting 121 patients. The Beers' criteria (CD) identified 69 inappropriate prescriptions in 60 patients and the IPET identified 112 inappropriate prescriptions in 78 patients. The Beers criteria (ID and CD combined) identified at least one inappropriate prescription in 34% of subjects and the IPET identified one in at least 22% of subjects. CONCLUSIONS: This study identifies high rates of use of inappropriate medications in community-dwelling elderly presenting with acute illness to hospital. These are comparable with inappropriate prescribing rates identified in previous studies. The revised Beers' criteria (2003) identified more inappropriate prescriptions than the IPET in this population of elders.

Alternative medicine use by homeless youth.

BACKGROUND: Mainstream health care for homeless youth is often fragmented or unavailable. OBJECTIVE: To evaluate the use of complementary and alternative medicine (CAM) by homeless youth who use our free clinic. DESIGN: Self-administered cross-sectional survey. SUBJECTS AND METHODS: Subjects included homeless youth between the ages of 14 and 21 years receiving care at the 45th Street Clinic Youth Program in Seattle, Wash, between January 29,1998, and March 5, 1998. The self-administered survey included items on demographics, health issues, use frequency of different therapists or therapies, referral sources, and perceived effectiveness of treatment. RESULTS: The response rate by patients was 96.3% (157/163) with an average respondent age of 18.5 years (range, 14-21 years). Complementary and alternative medicine was used by 70.1% of the subjects. Referrals most often came from friends (52.7%). The most common reason for using CAM was because it was "natural" (43.9%). Most of those who used alternative therapies (87.3%) believed they had been helped "some" or "a lot." Given a choice of providers to visit when they were ill, 51.7% would seek care from a physician, 36.9% from a CAM provider, and 11.4% would treat themselves. CONCLUSIONS: Care with CAM is frequently used and accepted by homeless youth. Cost-effectiveness and contributions to overall health care require additional evaluation. Integrating CAM into allopathic health centers may serve as an incentive to entice youth into mainstream health care.

Reparative epiretinal fibrosis after diabetic vitrectomy.

Closed microsurgery for the haemorrhagic and tractional sequelae of proliferative diabetic retinopathy is frequently successful in restoring and maintaining useful vision. Severe complications may arise, however, including the reproliferation of cellular membranes on the retinal surface with subsequent retinal distortion or redetachment. The clinical and histopathological features of such reparative epiretinal fibrosis are presented and methods of prevention are discussed.

Prevention of blindness in diabetic retinopathy.

Diabetic retinopathy, hitherto the most common cause of blindness in those between 30-64 years of age has become treatable. Both diabetic maculopathy and proliferative retinopathy can be treated effectively by photocoagulation. The treatment is most successful if given early, before visual loss becomes irreversible. Recently, vitrectomy with additional microsurgical techniques has been developed and shown to be effective in restoring vision to many patients blind from the complications of proliferative retinopathy.