Examining the knowledge work of person-centred care: Towards epistemic reciprocity.

OBJECTIVE: It is increasingly recognised that when healthcare staff fails to give adequate credence to patients' illness-related knowledge work, this epistemic injustice undermines person-centred care. Therefore, we set out to examine the experiences of people with long-term conditions with knowledge work in healthcare settings to identify changes needed to strengthen person-centred primary care. METHODS: We designed a qualitative study and recruited people with long-term conditions in the UK. We conducted individual interviews (analysed using interpretive phenomenological analysis) and focus groups (analysed using thematic analysis), then integrated findings from both methods through an approach focused on their complementarity. RESULTS: Participants described how successful person-centred consultations were characterised by a negotiation between patient and doctor and moments of broad exploration, reflexive listening, and reciprocal enquiry, which allowed for epistemic reciprocity. CONCLUSIONS: Epistemic reciprocity is a core component of person-centred clinical consultations, fostering the co-creation of new knowledge of patient experience and need through the interactive knowledge work of patient and doctor. PRACTICE IMPLICATIONS: Medical education could benefit from initiatives that develop knowledge use and integration skills across primary care professionals. Accommodating for patient's and doctor's knowledge work during clinical practice requires redesigning the consultation process, including timing, headspace, pre-consultation, and post-consultation work.

The Southern Ocean Exchange: porous boundaries between humpback whale breeding populations in southern polar waters.

Humpback whales (Megaptera novaeangliae) are a cosmopolitan species and perform long annual migrations between low-latitude breeding areas and high-latitude feeding areas. Their breeding populations appear to be spatially and genetically segregated due to long-term, maternally inherited fidelity to natal breeding areas. In the Southern Hemisphere, some humpback whale breeding populations mix in Southern Ocean waters in summer, but very little movement between Pacific and Atlantic waters has been identified to date, suggesting these waters constituted an oceanic boundary between genetically distinct populations. Here, we present new evidence of summer co-occurrence in the West Antarctic Peninsula feeding area of two recovering humpback whale breeding populations from the Atlantic (Brazil) and Pacific (Central and South America). As humpback whale populations recover, observations like this point to the need to revise our perceptions of boundaries between stocks, particularly on high latitude feeding grounds. We suggest that this "Southern Ocean Exchange" may become more frequent as populations recover from commercial whaling and climate change modifies environmental dynamics and humpback whale prey availability.

Management of unruptured brain aneurysms: retrospective analysis of a single centre experience.

Embolization is very effective in preventing bleeding of unruptured aneurysms with lower rates of mortality and morbidity than surgical treatment. Neurosurgery remains, however, a good alternative. This retrospective analysis examined data stored the digital database of Bellaria Hospital Radiology Department, evaluating patients, treatments and devices used as well as outcomes and complications. Therapy should be tailored to each individual case to offer each patient the best treatment. Out of 265 unruptured intracranial aneurysms detected, 182 were treated by embolization. 16 cases presented complications (12 only radiologically found); severe clinical consequences occurred in 3%: one ischaemia and five haemorrhages. Conservative treatment was adopted in 21 patients. Long-term follow-up is mandatory as aneurysms could increase their size and develop an irregular morphology in ten years' time. Endovascular embolization is a very effective treatment with positive outcomes in the majority of cases and a percentage of retreatments of 8%. In order to increase the number of successful cases, a multidisciplinary cooperation with neurosurgeons is strongly recommended.

Revascularized giant aneurysm of the anterior communicating artery after surgery and embolization, occluded by placement of a Leo+Baby intracranial stent. A case report.

Balt (Montmorency, France) recently manufactured the Leo+Baby dedicated intracranial stent for arteries with a calibre between 1.5 and 3.10 mm. We describe a patient with a partially thrombosed giant sacciform aneurysm of the anterior communicating artery treated without success by surgery and coil embolization subsequently occluded by placement of a Leo+Baby stent (Balt, Montmorency, France). A 56-year-old man presented with a giant aneurysm in the anterior communicating artery region. Following successive surgical intervention and embolization procedures the patient was referred to us with a revascularized aneurysm measuring 15×9×8 cm. To stabilize the endovascular occlusion a combined treatment was scheduled with coil embolization and stent deployment after dual antiplatelet therapy started five days before the interventional procedure. Treatment was undertaken two weeks later under general anaesthesia and total heparinization. A microcatheter was inserted into the aneurysmal sac and four metal coils were released for a total of 61cm obtaining almost complete occlusion of the aneurysm from the circulation. A Leo+Baby stent (2.5×18 mm) was subsequently deployed across the aneurysm neck. At follow-up angiography two months later the aneurysm appeared substantially excluded from the arterial circulation except for a small portion in the neck. Six months later, four months after suspending antiplatelet therapy, follow-up angiography disclosed the complete exclusion of the aneurysm from the circulation. Deployment of the new ministent through the same microcatheter used to release the coils made the interventional procedure simpler and faster.

Complications in the treatment of intracranial aneurysms with silk stents: an analysis of 30 consecutive patients.

Flow-diverting stents (Silk and PED) have radically changed the approach to intracranial aneurysm treatment from the use of endosaccular materials to use of an extraaneurysmal endoluminal device. However, much debate surrounds the most appropriate indications for the use of FD stents and the problems raised by several possible complications.We analysed our technical difficulties and the early (less than ten days after treatment) and late complications encountered in 30 aneurysms treated comprising 13 giant lesions, 12 large, five with maximum diameters <10 mm and one blister-like aneurysm. In our experience the primary indications for the use of FD stents can be the symptomatic intracavernous giant aneurysms. Although the extracavernous carotid siphon aneurysms have major risk of bleeding, FD stents are indicated clearly explaining the risks to the patient in case of severe mass effect. There is a very complex assessment for aneurysms of the vertebrobasilar circulation.

A minimally invasive treatment for lumbar disc herniation: DiscoGel® chemonucleolysis in patients unresponsive to chemonucleolysis with oxygen-ozone.

A multitude of therapies is available to treat disc herniation, ranging from conservative methods (medication and physical therapy) to minimally invasive (percutaneous) treatments and surgery. O2-O3 chemonucleolysis (O2-O3 therapy) is one of the minimally invasive treatments with the best cost/benefit ratio and lowest complication rate. Another substance recently made available exploiting the chemical properties of pure ethanol is DiscoGel®, a radiopaque gelified ethanol more viscous than absolute alcohol 8,9. The present study aimed to assess the therapeutic outcome of DiscoGel® chemonucleolysis in patients with lumbar disc herniation unresponsive to O2-O3 therapy. Thirty-two patients aged between 20 and 79 years were treated by DiscoGel® chemonucleolysis between December 2008 and January 2010. The treatment was successful (improvement in pain) in 24 out of 32 patients. DiscoGel® is safe and easy to handle and there were no complications related to product diffusivity outside the treatment site. The therapeutic success rate of DiscoGel® chemonucleolysis in patients unresponsive to O2-O3 therapy was satisfactory. Among other methods used to treat lumbar disc herniation, DiscoGel® chemonucleolysis can be deemed an intermediate procedure bridging conservative medical treatments and surgery.

Treatment of intracranial aneurysms using flow-diverting silk stents (BALT): a single centre experience.

The Silk stent (Balt, Montmorency, France) is a retractable device designed to achieve curative reconstruction of the parent artery associated with an intracranial aneurysm. We present our initial experience with the Silk flow-diverting stent in the management and follow-up of 25 patients presenting with intracranial aneurysms.Twenty-five patients (age range, 34-81 years; 24 female) were treated with the Silk flow-diverting device. Aneurysms ranged in size from small (5), large (10) and giant (10) and included wide-necked aneurysms, multiple, nonsaccular, and recurrent intracranial aneurysms. Nine aneurysms were treated for headache, 14 for mass effect. None presented with haemorrhage. All patients were pretreated with dual antiplatelet medications for at least 72 hours before surgery and continued taking both agents for at least three months after treatment. A total of 25 Silk stents were used. Control MR angiography and/or CT angiography was typically performed prior to discharge and at one, three, six and 12 months post treatment. A follow-up digital subtraction angiogram was performed between six and 19 months post treatment.Complete angiographic occlusion or subtotal occlusion was achieved in 15 patients in a time frame from three days to 12 months. Three deaths and one major complication were encountered during the study period. Two patients, all with cavernous giant aneurysms, experienced transient exacerbations of preexisting cranial neuropathies and headache after the Silk treatment. Both were treated with corticosteroids, and symptoms resolved completely within a month.In our experience the Silk stent has proven to be a valuable tool in the endovascular treatment of intracranial giant partially thrombosed aneurysms and aneurysms of the internal carotid artery cavernous segment presenting with mass effect. The time of complete occlusion of the aneurysms and the risk of the bleeding is currently not predictable.

Staged treatment of a blood blister-like aneurysm with stent-assisted coiling followed by flow diverter in-stent insertion. A case report.

Blood blister-like aneurysms (BBLA) are rare lesions sometimes difficult to recognize and in most cases associated with diffuse subarachnoid haemorrhage and severe clinical conditions. BBLA are life-threatening because they tend to enlarge rapidly and to rebleed, and no consensus has so far been reached on the best management strategy. We describe a patient with a BBLA in the right ICA treated successful by a two-stage embolization procedure first with coils and an open cell stent (Neuroform 3) and later by further coil placement and insertion of a flow-diverting stent (Silk).

Combination treatment of flag with non-pegylated liposomal doxorubicin (MYOCET(TM)) in elderly patients with acute myeloid leukemia: a single center experience.

The incidence of acute myeloid leukemia (AML) increases with age, but results of intensive chemotherapy in elderly patients are disappointing. Non-pegylated liposomal formulations of doxorubicin (Myocet™) have been developed with the aim of reducing systemic and cardiac toxicity especially in the elderly. We evaluated the efficacy and toxicity profiles of fludarabine, cytarabine and granulocyte colony-stimulating factor (FLAG) regimen given in association with Myocet™ in 35 patients with AML, median age 69 years (range 61-83 years). Nineteen (54.3%) had newly-diagnosed AML, twelve (34.3%) patients had secondary AML (ten with Myelodisplastic Syndrome, two with Primary Myelofibrosis) and 4 (11.4%) patients had had a late relapse (>12 months) of AML. Complete remission (CR) and partial remission (PR) were obtained in twenty-two (63%) and 3 (8.5%) patients, respectively. Seven (20%) patients showed a resistant disease. There were 3 early deaths (8.5%). Six patients (17%) experienced severe cardiovascular toxicity. The median overall survival (OS) was 12 months (range 1-52 months) with a median disease-free survival (DFS) of 20 months (range 1-48 months). One-year and two-year DFS were 78.9% and 26.7%, respectively. This study demonstrates that in elderly patients with AML, FLAG-Myocet combination shows promising efficacy response with acceptable toxicity, enabling most patients to receive further treatments, including transplantation procedures.

The use of flow-diverting stents in the treatment of giant cerebral aneurysms: preliminary results.

The treatment of giant cerebral aneurysms has always been a challenge for neurosurgeons and neuroradiologists. Flow-diverting stents (Silk; Pipeline Embolization Device) are new endovascular devices introduced for the treatment of intracranial aneurysms without release of intrasaccular coils. They are tubular bimetallic endoluminal devices with low porosity. We have employed these stents in the Neuroradiology Unit of Bellaria Hospital (Bologna, Italy) since the end of 2008, treating nine patients with giant carotid cerebral aneurysms using nine Silk stents as soon as the device obtained the CE mark. All patients were pretreated with dual antiplatelet medications before surgery. The Silk stents were deployed through a 4F Balt introducer, which ensured an uneventful and very quick procedure. Control CT angiography or MR angiography was typically performed at discharge and one, three, six and 12 months after treatment. Post-treatment results were: four complete occlusions, three near complete occlusions (residual neck flow) with reduced volume of the aneurysm and two more than 50% reduction of intra-aneurysmal flow. A fatal hemorrhagic complication occurred in one patient, probably due to the antiplatelet treatment. The Silk stent seems a very interesting curative device to treat giant aneurysms with preservation of the parent artery and small adjacent branches. Technical improvements will certainly reduce the thrombogenic effect with the related risks.

Ruptured "occult" aneurysm disclosed by three-dimensional angiographic reconstructions.

Rotational angiographic sequences and their three-dimensional reconstructions have led to major improvements in angiographic diagnostics, especially in the study of brain aneurysms. Reconstructions accurately depict the morphology of the aneurysm, namely any wall irregularities and the possible origin of arterial branches from the aneurysmal sac, and display the aneurysm on multiple spatial planes, measuring its different diameters and ratios (particularly the dome to neck ratio). Lastly, three-dimensional angiographic reconstructions will sometimes disclose ruptured or intact aneurysms not depicted by digital subtraction angiography. A 43-year-old woman was admitted to the emergency room of Maggiore Hospital, Bologna Local Health Trust, presenting severe headache, confusion and nuchal rigidity. Emergency CT scan disclosed cisternal subarachnoid haemorrhage. Subsequent 3D sequences revealed an aneurysm of the left carotid artery siphon. This occult aneurysm found in our patient had been masked by the overlying infundibular origin of the posterior communicating artery. This prevented detection of the lesion not only in standard oblique anteroposterior, craniocaudal and lateral sequences but also in the rotational sequence. Identification of the aneurysm in our patient was the result of the diagnostic strategy adopted. When cisternal subarachnoid haemorrhage is detected, our protocol routinely includes a rotational angiographic sequence centred on the anterior circulation and on the posterior circulation when the standard examination fails to depict the course of all the vessels or when the features of subarachnoid haemorrhage strongly suggest aneurysm rupture in that anatomical location. Three-dimensional angiographic reconstructions are extremely useful not only to characterize brain aneurysms, but also to disclose ruptured occult aneurysms and additional zero grade lesions.

3T MRI in the Evaluation of Brain Aneurysms Treated with Flow-Diverting Stents: Preliminary Experience.

Deployment of stents across the neck of intracranial aneurysms to isolate the lesion from the circulation is a recently introduced endovascular treatment. These devices are known as flow-diverting stents because the stent mesh design drastically slows the blood flow within the aneurysm sac, thereby stimulating thrombus formation. Treated aneurysms require close follow-up monitoring using an effective minimally invasive method. We devised a dedicated follow-up protocol using a high field strength magnetic resonance system (MR) with gadolinium administration to monitor 11 patients treated by insertion of flow-diverting stents. Findings were compared with the results of a reference imaging procedure (CT angiography). MR accurately demonstrated patency of the stent lumen and monitored the evolution of the aneurysmal sac in all patients. Gadolinium administration proved essential in two patients to depict the complete exclusion of the flow within the aneurysmal sac.

Primary diffuse large B-cell lymphoma of the breast: prognostic factors and outcomes of a study by the International Extranodal Lymphoma Study Group.

BACKGROUND: Primary diffuse large B-cell lymphoma (DLBCL) of breast is rare. We aimed to define clinical features, prognostic factors, patterns of failure, and treatment outcomes. PATIENTS AND METHODS: A retrospective international study of 204 eligible patients presenting to the International Extranodal Lymphoma Study Group-affiliated institutions from 1980 to 2003. RESULTS: Median age was 64 years, with 95% of patients presenting with unilateral disease. Median overall survival (OS) was 8.0 years, and median progression-free survival 5.5 years. In multifactor analysis, favourable International Prognostic Index score, anthracycline-containing chemotherapy, and radiotherapy (RT) were significantly associated with longer OS (each P < or = 0.03). There was no benefit from mastectomy, as opposed to biopsy or lumpectomy only. At a median follow-up time of 5.5 years, 37% of patients had progressed--16% in the same or contralateral breast, 5% in the central nervous system, and 14% in other extranodal sites. CONCLUSIONS: The combination of limited surgery, anthracycline-containing chemotherapy, and involved-field RT produced the best outcome in the pre-rituximab era. A prospective trial on the basis of these results should be pursued to confirm these observations and to determine whether the impact of rituximab on the patterns of relapse and outcome parallels that of DLBCL presenting at other sites.

Preliminary experience of cerecyte coils in the treatment of intracranial aneurysms.

SUMMARY: Coil embolization of intracranial aneurysms is the first choice treatment in many centres worldwide. The ISAT study reported in favour of endovascular treatment even though coil embolization carries a higher risk of revascularization than surgical clipping. Bioactive coils boosting fibrosis within the aneurysm and neointimal production could counteract the tendency of embolized aneurysms to re-open. We reviewed our cohort in a retrospective study based on the following inclusion criteria: 1) Cerecyte coils (Micrus Endovascular, San Jose, Calif) were the only bioactive coils deployed. 2) Cerecyte coils were used in the first embolization procedure. Between July 2005 and December 2007 39 patients matched these inclusion criteria, 15 men and 24 women (average age 63.5 years) with 44 aneurysms. Treatment outcomes were: 30 aneurysms completed excluded from the circulation, 13 aneurysms almost completed excluded from the circulation, one incomplete aneurysm occlusion. Two aneurysms out of 44 recurred during follow-up (4.54%) and were re-embolized. The radio-opacity and conformational memory of the Cerecyte coils were satisfactory and they were easy to manoeuvre and detach.

Treatment of carotid siphon aneurysms with a microcell stent. A case report.

SUMMARY: The treatment of giant, large, multiple or wide-necked carotid siphon aneurysms has always represented a challenge for neurosurgeons and neuroradiologists. Very recently the use of stents with tiny holes has been proposed by two companies: Balt Silk Stent in Europe and Pipeline in America. We have used the Silk stent on a few patients and describe our first case who now has an eleven month follow-up. The carotid siphon presented three converging aneurysms sharing a very large common neck. The Silk stent (Balt Extrusion, Montmorency, France) was deployed through a 4F Balt introducer. The procedure was uneventful and very quick. As soon as the stent was positioned contrast medium stagnation was displayed within the aneurysm. The patient's post-operative course was normal and she was discharged three days later in good health.

Carotid Stenting without Angioplasty and without Protection: The Advantages of a Less Invasive Procedure.

SUMMARY: Endovascular stenting is a consolidated alternative to thrombendarterectomy in the treatment of extracranial carotid artery atheromasic stenosis. The most common complication of stenting is a distal embolism causing clinically silent orsymptomatic cerebral ischaemia. To prevent this complication distal embolism protection devices are often used but their effectiveness remains unsettled. In addition, there is some evidence that distal embolism may actually be triggered by the protection systems due to clot formationat their distal surface or in the intimal lesions these systems cause. Another rarer complicationis hyperperfusion syndrome arising during both stenting and thrombendarterectomy but more common in endovascular procedures. To avoid these complications the Neuroradiology Service at Bellaria Hospital (Bologna Local Health Trust) has devised a mini-invasive carotid stenting technique that does not require either distal embolism protection or angioplasty. The technique uses only the radial force exerted by the self-expanding stent to widen the atherosclerotic stenosis slowly and gradually. The goal of treatment has also changed from a prompt restoration of the atheromasic vessel's original calibre to slow transformation of the hemodynamic significance of the stenosis. The technique's success lies mainly in selecting the stenosis to treat using CT angiography to analyse plaque morphology and structure.We used the technique to treat 83 stenotic lesions in 75 patients. The study aims to describe and discussour experience.

Intracranial stenting in the treatment of wide-necked aneurysms.

SUMMARY: We positioned the following self-expanding stents certified for intracranial application: 16 Neuroform (Boston Scientific), three INX (Medtronic), one Leo (Balt). 6F calibre femoral introducers and guiding catheters were used for stent placement changing to 5F calibre introducers and guiding catheters (Envoy, Cordis) for the Neuroform 2 and 3 stents. All procedures were carried out under general anaesthesia and heparinization. Our pharmacological protocol consisted of adjunctive treatment with anti-aggregants during the interventional procedure and for the following six months, without premedication. From November 2000 to August 2006 we treated 28 patients (27 F/1M) with giant wide-necked aneurysms and one dissecting basilar artery aneurysm requiring the placement of 29 stents. We successfully positioned 20 stents: 11 stents combined with coils (8 immediate; 3 late) with complete exclusion of the aneurysm from the circulation in seven cases and subtotal exclusion in four; nine stents not followed by embolization with complete exclusion of the aneurysm from the circulation in six cases and subtotal exclusion in three. Stenting was not possible in nine cases due to extreme vessel tortuosity and the poor flexibility of release systems for the first stents. No late stent occlusion or subarachnoid haemorrhage were encountered after treatment.

Stenting and coil embolization of a surgically treated residual aneurysm of the middle cerebral artery bifurcation associated with coil embolization of a communicating artery aneurysm. A case report.

We describe the case of a 76-year-old man admitted to our hospital for mild subarachnoid haemorrhage detected by CT scan in an aneurysm of the left middle cerebral artery bifurcation treated surgically 29 years earlier and not completely occluded. Angiography disclosed a further aneurysm in the anterior communicating artery. During the same procedure we treated the residual aneurysm in the left middle cerebral artery bifurcation positioning a Neuroform3 stent (Boston) and embolization deploying two biologically active Cerecyte coils (Balt) for a total of 10 cm and excluding the communicating artery aneurysm from the circulation releasing two active Cerecyte coils for a total length of 30.9 cm. The procedure was well tolerated by the patient and did not give rise to neurological deficits.

[Integration of biological and workplace monitoring as an efficient control of chemical exposure]. / Integrazione dei piani di monitoraggio degli indicatori biologici di esposizione e dei piani di monitoraggio ambientale/espositivo.

Evaluation of professional exposure by means of biological monitoring is nowadays a consolidated method in the practice of Occupational Health. Generally biological monitoring is used simultaneously to ambient monitoring as a complementary method to obtain a mutual validation of exposure assessment. Experience gathered in the last years allowed us to verify that at low exposure levels, the values of biological indicators of dose are always markedly below their limits. Consequently, under standard conditions, it appears useful to alternate the two different exposure assessments (either biological or ambient monitoring), in order to obtain an efficient control of chemical exposure. Moreover, this methodological approach allows a better integration of all the professionals, who manage directly or indirectly the activities concerning Occupational Health and Industrial Hygiene, having as their first goal the health protection of employees and job environment.