Tropical parasitic itch in returned travellers and immigrants from endemic areas.

Itch is the most common skin symptom among tropical parasitic diseases (TPD), but there are limited data about its characteristics in these conditions. In dermatology practices and travellers' health clinics in the developed world, itch is a common complaint among travellers returning from endemic areas, as well among migrants arriving from endemic areas, where they may have been exposed to TPD. Studying aspects of pruritus among TPD may lead to improvements in prompt, accurate diagnosis and management of these conditions. This review examines the major itch-inducing TPDs, including schistosomiasis, echinococcosis, onchocerciasis, scabies, cutaneous larva migrans, larva currens, African trypanosomiasis, dracunculiasis and other causes of travel associated pruritus. We focus on the link between pruritus and other symptoms, aetiology, clinical staging and therapeutic options for these parasitic illnesses. Because some tropical parasitic diseases can present with significant pruritus, we attempt to identify aspects of the pruritus that are characteristic of-or unique to-specific conditions. These diagnostic insights may help clinicians create a rational and focused differential diagnosis and help determine optimal disease management pathways. In this sense, management involves treating the individual, seeking epidemiologically linked cases, preventing recurrences or relapses, and reducing spread of the disease.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy.

BACKGROUND: Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy. METHODS: A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months. DISCUSSION: If successful, GEMS would be an option for a standardized APP-led survivorship care intervention. TRIAL REGISTRATION: ClinicalTrials.govNCT05006482, registered on August 9, 2021.

Family caregiver descriptions of stopping chemotherapy and end-of-life transitions.

PURPOSE: The purpose of this study was to describe family caregivers' perspectives of the final month of life of patients with advanced cancer, particularly whether and how chemotherapy was discontinued and the effect of clinical decision-making on family caregivers' perceptions of the patient's experience of care at the end of life (EOL). METHODS: Qualitative descriptive design using semi-structured interviews collected from 92 family caregivers of patients with end-stage cancer enrolled in a randomized clinical trial. We used a phased approach to data analysis including open coding, focused coding, and within and across analyses. RESULTS: We identified three patterns of transitions characterizing the shift away from active cancer treatment: (1) "We Pretty Much Knew," characterized by explicit discussions about EOL care, seemingly shared understanding about prognosis and seamless transitions from disease-oriented treatment to comfort-oriented care, (2) "Beating the Odds," characterized by explicit discussions about disease-directed treatment and EOL care options, but no shared understanding about prognosis and often chaotic transitions to EOL care, and (3) "Left to Die," characterized by no recall of EOL discussions with transitions to EOL occurring in crisis. CONCLUSIONS: As communication and palliative care interventions continue to develop to improve care for patients with advanced cancer, it is imperative that we take into account the different patterns of transition and their unique patient and caregiver needs near the end of life. Our findings reveal considerable, and potentially unwarranted, variation in transitions from active treatment to death.

Modeling salinization and recovery of road salt-impacted lakes in temperate regions based on long-term monitoring of Lake George, New York (USA) and its drainage basin.

Road salt mitigates winter highway icing but accumulates in watershed soils and receiving waters, affecting soil chemistry and physical, biological, and ecological processes. Despite efforts to reduce salt loading in watersheds, accumulated cations and Cl- continue to impact tributaries and lakes, and the recovery process is not well understood. Lake George, New York (USA) is typical of many temperate lakes at risk for elevated Cl- concentrations from winter deicing; the lake salt concentration increased by ~3.4% year-1 since 1980. Here, we evaluated the ionic composition in Finkle Brook, a major watershed draining to Lake George, studied intermittently since 1970 and typical of other salt-impacted Lake George tributaries. Salt loading in the Lake George basin since the 1940s displaced cations from exchange sites in basin soils; these desorbed cations follow a simple ion-exchange model, with lower sodium and higher calcium, magnesium and potassium fluxes in runoff. Reduced salt application in the Finkle Brook watershed during the low-snow winter of 2015-2016 led to a 30-40% decline of Cl- and base cations in the tributary, implying a Cl- soil half-life of 1-2 years. We developed a conceptual model that describes cation behavior in runoff from a watershed that received road salt loading over a long period of time, and then recovery following reduced salt loading. Next, we developed a dynamic model estimating time to steady-state for Cl- in Lake George with road salt loading starting in 1940, calibrating the model with tributary runoff and lake chemistry data from 1970 and 1980, respectively, and forecasting Cl- concentrations in Lake George based on various scenarios of salt loading and soil retention of Cl-. Our Lake George models are readily adaptable to other temperate lakes with drainage basins where road salt is applied during freezing conditions and paved roads cover a portion of the watershed.

Changing climate and sea level alter Hg mobility at Lake Tulane, Florida, U.S.

Between 45,000 cal years BP and the beginning of the Holocene, the accumulation rate for Hg in sediments of Lake Tulane, Florida ranged from ≈2 to 10 µg m(-2) yr(-1), compared with 53 µg Hg m(-2) yr(-1) in the 1985-1990 period of anthropogenic input. The locality experienced regional draw-down of the water table during the Wisconsinan glaciation, which lowered global sea level by nearly 130 m. Natural atmospheric deposition of Hg to the surrounding area resulted in long-term (ca. 100,000 years) sequestration of this atmospheric flux of Hg, primarily by adsorption in the oxic Al- and Fe-hydroxide-rich sandy subsoil. Global sea level rise during deglaciation led to a rising regional water table, flooding the oxidized soils surrounding Tulane. Iron and adsorbed Hg were mobilized by reductive dissolution and transported by groundwater flow to Lake Tulane and ultimately to the accumulating sediment. The accumulation rate of Hg (and Fe) increased rapidly about 16,000 cal years BP, peaked at nearly 60 µg Hg m(-2) yr(-1) ca. 13,000-14,000 cal years BP, declined sharply during the Younger Dryas, and then increased sharply to a second 60 µg Hg m(-2) yr(-1) peak about 5000 cal years BP. Thereafter, it declined nearly to background by 900 cal years BP. In similar geologic situations, rapid modern sea level rise will initiate this process globally, and may mobilize large accumulations of Hg and lesser amounts of As, and other redox sensitive metals to groundwater and surface water.

Shared medical appointments for bariatric surgery follow-up: a patient satisfaction questionnaire.

BACKGROUND: Shared medical appointments (SMAs) are group clinics where practitioners see several patients, with common health needs, at once. There is a great financial strain on the National Health Service (NHS) to provide bariatric surgery. The aim of this study was to review patient satisfaction with the SMA that is the default means of following up patients after bariatric surgery at one particular NHS trust. METHODS: A patient-validated questionnaire was designed and handed out at the end of the SMAs. Patients who attended an SMA earlier in 2011 were also retrospectively sent questionnaires via post. RESULTS: A total of 47 patients completed the questionnaire from seven different SMAs covering the period from January to July 2011. All patients underwent laparoscopic adjustable gastric banding. After attending an SMA, patients gave an overall mean satisfaction rating of 4.13 ± 0.163 (on a scale of 1 to 5, 1 = very poor and 5 = excellent) which represented an increase (p < 0.01) compared to preconceptions before the clinic (3.59 ± 0.175). A cost analysis estimated a yearly saving of £4,617 or 65.1% made by the SMAs compared to 1:1 appointments. CONCLUSIONS: The bariatric surgery SMA demonstrates high levels of patient satisfaction and is cost-effective.

The evolution of the science of Bear Brook Watershed in Maine, USA.

The Bear Brook Watershed in Maine (BBWM), USA is a paired watershed study with chemical manipulation of one watershed (West Bear = WB) while the other watershed (East Bear = EB) serves as a reference. Characterization of hydrology and chemical fluxes occurred in 1987-1989 and demonstrated the similarity of the ca. 10 ha adjacent forested watersheds. From 1989-2010, we have added 1,800 eq (NH(4))(2)SO(4) ha(-1) y(-1) to WB. EB runoff has slowly acidified even as atmospheric deposition of SO4(-2) has declined. EB acidification included decreasing pH, base cation concentrations, and alkalinity, and increasing inorganic Al concentration, as SO4(-2) declined. Organic Al increased. WB has acidified more rapidly, including a 6-year period of increasing leaching of base cations, followed by a long-term decline of base cations, although still elevated over pretreatment values, as base saturation declined in the soils. Sulfate in WB has not increased to a new steady state because of increased anion adsorption accompanying soil acidification. Dissolved Al has increased dramatically in WB; increased export of particulate Al and P has accompanied the acidification in both watersheds, WB more than EB. Nitrogen retention in EB increased after 3 years of study, as did many watersheds in the northeastern USA. Nitrogen retention in WB still remains at over 80%, in spite of 20+ years of N addition. The 20-year chemical treatment with continuous measurements of critical variables in both watersheds has enabled the identification of decadal-scale processes, including ecosystem response to declining SO4(-2) in ambient precipitation in EB and evolving mechanisms of treatment response in WB. The study has demonstrated soil mechanisms buffering pH, declines in soil base saturation, altered P biogeochemistry, unexpected mechanisms of storage of S, and continuous high retention of treatment N.

Complications of bariatric surgery: presentation and emergency management--a review.

INTRODUCTION: The prevalence of obesity surgery is increasing rapidly in the UK as demand rises. Consequently, general surgeons on-call may be faced with the complications of such surgery and need to have an understanding about how to manage them, at least initially. Obesity surgery is mainly offered in tertiary centres but patients may present with problems to their local district hospital. This review summarises the main complications that may be encountered. MATERIALS AND METHODS: A full literature search was carried out looking at articles published in the last 10 years. Keywords for search purposes included bariatric, surgery, complications, emergency and management. CONCLUSIONS: Complications of bariatric surgery have been extensively written about but never in a format that is designed to aid the on-call surgeon. The intricate details and rare complications have been excluded to concentrate on those symptoms and signs that are likely to be encountered by the emergency team.

An overview of the management of morbid obesity.

Obesity is a modern-day epidemic with serious physical, psychological and economic implications for the patients. Tackling obesity is now a priority for most healthcare providers. Managing such patients can be complex, emotional, time consuming and often frustrating. Obesity surgery, in its various forms, has revolutionised this struggle. With appropriate selection of patients, adequate resources and a multidisciplinary team involvement, obesity can now effectively be "cured". It is vital that those who deal with obese patients know how to access these services and understand the processes involved in the journey from initial assessment to postoperative follow-up. Obesity surgery has a major impact in reducing obesity-related comorbidities such as diabetes and hypertension and contributes to society by returning patients to work. Prevention must be at the heart of any strategy to manage obesity, but, for established cases, surgery is taking centre stage and will continue to flourish as new techniques and procedures are developed.

Controls on mercury and methylmercury deposition for two watersheds in Acadia National Park, Maine.

Throughfall and bulk precipitation samples were collected for two watersheds at Acadia National Park, Maine, from 3 May to 16 November 2000, to determine which landscape factors affected mercury (Hg) deposition. One of these watersheds, Cadillac Brook, burned in 1947, providing a natural experimental design to study the effects of forest type on deposition to forested watersheds. Sites that face southwest received the highest Hg deposition, which may be due to the interception of cross-continental movement of contaminated air masses. Sites covered with softwood vegetation also received higher Hg deposition than other vegetation types because of the higher scavenging efficiency of the canopy structure. Methyl mercury (MeHg) deposition was not affected by these factors. Hg deposition, as bulk precipitation and throughfall was lower in Cadillac Brook watershed (burned) than in Hadlock Brook watershed (unburned) because of vegetation type and watershed aspect. Hg and MeHg inputs were weighted by season and vegetation type because these two factors had the most influence on deposition. Hg volatilization was not determined. The total Hg deposition via throughfall and bulk precipitation was 9.4 microg/m(2)/year in Cadillac Brook watershed and 10.2 microg/m(2)/year in Hadlock Brook watershed. The total MeHg deposition via throughfall and bulk precipitation was 0.05 microg/m(2)/year in Cadillac Brook watershed and 0.10 microg/m(2)/year in Hadlock Brook watershed.

Use of Br and Se in peat to reconstruct the natural and anthropogenic fluxes of atmospheric Hg: A 10000-year record from Caribou Bog, Maine.

Using Br and Se as reference elements, the natural and anthropogenic fluxes of atmospheric Hg were reconstructed for the past 10,000 years using peat cores from Caribou Bog, ME. In the ombrotrophic peat layers, the average background Hg accumulation rate (AR) was 1.7 +/- 1.3 microg m(-2) year(-1) which is comparable with the natural rate of atmospheric Hg accumulation reported in other retrospective studies. The average Hg AR determined using all peat samples dating from preindustrial times, including minerotrophic peat, was slightly greater (3.1 +/- 2.3 microg m(-2) year(-1)) which may reflect differences in canopy interception due to the changes in plant communities, aquatic inputs, or possibly climatic factors. The maximum Hg AR (32 microg m(-2) year(-1)) occurred ca. 1961 A.D. In samples predating the settlement by Europeans, there is a linear correlation between the AR of Hg and those of Br and Se; this relationship allows both Br and Se to be used to calculate the natural AR of Hg (Hgnat). The difference between Hg AR and Hg(nat) is the Hg AR in excess of background (Hg(ex)). Because Hg(ex) was positive only after ca. 1840 A.D., it is assumed to represent the anthropogenic Hg component. By the late 19th century, Hg(ex) deposition was equal to the natural flux. At the peak in Hg deposition in 1961 A.D., Hgex made up >90% of total atmospheric Hg deposition. The AR in the uppermost peat decreased to 25% of peak values by 2000 A.D.

Does changing the configuration of a motor racing circuit make it safer?

OBJECTIVES: To assess the pattern of injuries presenting to a racing circuit medical centre in two three-year periods before and after two chicanes were built into the track. METHODS: Medical centre records were used to identify all patients assessed during the two time periods. Those referred to hospital were categorised by injury severity into three groups. RESULTS: The proportions of those attending the medical centre that were referred and admitted to hospital were the same in both periods (12-13% and 3% respectively). During the two study periods, the risk of a severe injury for a car driver decreased from 0.1% to 0.03% (p<0.05). For a motorcyclist, similar values were 0% and 0.2% (not significant). CONCLUSIONS: Chicanes have improved the safety of the racing circuit for car drivers, reducing the risk of injury.

Development and experience with an algorithm to evaluate suspected smallpox cases in the United States, 2002-2004.

Concerns that smallpox, an eradicated disease, might reappear because of a bioterror attack and limited experience with smallpox diagnosis in the United States prompted us to design a clinical algorithm. We used clinical features of classic smallpox to classify persons presenting with suspected smallpox rashes into 3 categories: those with high, those with moderate, and those with low risk of having smallpox. The classification guides subsequent diagnostic strategies, limiting smallpox laboratory testing to high-risk persons to minimize the number of false-positive test results. From January 2002 through June 2004, the Centers for Disease Control and Prevention (CDC) received 43 consultations regarding suspected smallpox cases. No patient was at high risk for having smallpox. One patient was tested for the presence of variola virus. Varicella was the diagnosis for 23 cases (53%). The algorithm worked well to guide clinical and public health responses to suspected smallpox cases. The poster is available from CDC, and an interactive version and laboratory protocol are available at http://www.bt.cdc.gov/agent/smallpox/diagnosis/riskalgorithm/index.asp. We recommend use of the algorithm in the United States and elsewhere.