COPD Self-Management: A Patient-Physician Perspective.

This article is co-authored by five patients living with chronic obstructive pulmonary disease (COPD), and a primary care physician who has over 30 years of clinical experience and is involved in educating healthcare professionals. The first section of this article is authored by the patients, who describe their experiences of living with COPD. The section that follows is authored by the physician, who discusses the management of COPD in the context of the patients' experiences.

Assessment of renal oxygenation during partial nephrectomy using hyperspectral imaging.

PURPOSE: DLP® hyperspectral imaging is a technology that can be used to construct a highly sensitive, noninvasive, real-time tissue hemoglobin saturation map. This almost video rate technology may be a tool to monitor renal perfusion/oxygenation during hilar occlusion and kidney recovery. We describe our initial experience using hyperspectral imaging to assess renal hemoglobin saturation parameters during open partial nephrectomy for renal cortical tumors in humans. MATERIALS AND METHODS: Hyperspectral images were collected intraoperatively during open partial nephrectomy. The kidney was actively illuminated using a hyperspectral imaging camera with visible light consisting of a chemometrically predetermined spectrum (520 to 645 nm) for hemoglobin. Spectroscopic reflectance images were captured by a focal plane array, which were digitally processed to visualize the percent of oxyhemoglobin at each image pixel. RESULTS: Hyperspectral imaging was done in 21 patients with a mean age of 56 years who were undergoing partial nephrectomy. Mean clamp time was 37.0 minutes. Median baseline percent of oxyhemoglobin in all patients was 74.6%. Hyperspectral imaging revealed a median 20.0% decrease from normalized pre-occlusion baseline at a median 10.3 minutes of hilar occlusion, where it plateaued for the duration of kidney ischemia. Upon reperfusion the percent of oxyhemoglobin returned to baseline at a median of 5.8 minutes. CONCLUSIONS: Hyperspectral imaging is a real-time noninvasive method to assess renal oxyhemoglobin saturation intraoperatively throughout the kidney. A nadir percent of oxyhemoglobin is attained within 10 minutes of hilar occlusion. This knowledge may allow future surgical or pharmacological interventions that titrate or minimize ischemic injury in real time.

Trauma history in a high secure male forensic inpatient population.

There is an increasing focus on trauma within forensic services. This study aimed to investigate exposure to trauma among a high secure male forensic population. Based on the Childhood Trauma Questionnaire (CTQ) and the Trauma History Questionnaire (THQ) data capture sheets were developed. Patients' own offending behaviour was included as a source of potential trauma. Records for all patients placed within the hospital (n = 194) were reviewed. All patients had been exposed to a traumatic event over the lifespan, with 75% having been exposed to trauma during childhood. Sixty-five percent of patients had experienced more than one type of trauma during childhood; the mean number of trauma types experienced during this period being 2.31. In adulthood 63% had been exposed to one trauma type while 29% had been exposed to two or more trauma types. No significant difference was found between those with and those without childhood trauma histories on hospital variables including admission length, seclusion and incidents. The implications of these results in the context of adopting a trauma informed care approach to treatment in forensic settings are discussed, and recommendations for future clinical and research directions are made.

Understanding Ultraviolet Radiation Dorsal Foot Injury at the Beach.

BACKGROUND: Efforts made to protect the dorsal aspect of the foot are currently unknown. We sought to determine whether beachgoers protect the dorsal aspect of their feet as frequently as other anatomic sites. METHODS: A convenience sample of Galveston, Texas, beachgoers completed anonymous surveys to assess whether the dorsal foot was at risk for ultraviolet radiation (UV-R) injury. Additional information collected included demographics and general knowledge about skin cancer to determine if these variables were significantly correlated with dorsal foot protection from UV-R injury. RESULTS: Of 216 respondents, only 103 used a topical UV-R barrier on their dorsal feet, while 183 applied sunscreen to the body and 133 applied sunscreen to the legs. Eighty-seven of 113 nonusers explained, "I did not think about it." The average number of applications of sunscreen per person to the dorsal feet was less than other anatomical body sites (1.19 body applications, 0.86 leg applications, and 0.58 dorsal feet applications per person; P < .001). 58.0% of females applied sunscreen to the dorsal feet compared with only 36.5% of males (P = .001). Self-identifying Fitzpatrick skin type 5 or 6 individuals did not apply sunscreen to the dorsal foot as regularly as individuals with types 1 to 4 (84.6% versus 47.6%; P = .0001). CONCLUSIONS: Current skin cancer epidemiology pairs the feet and the legs together as "lower extremity." For epidemiologic purposes, however, feet and legs should be considered distinct areas in UV-R research because they may use different photoprotection strategies.

Reduction in HbA1c using professional flash glucose monitoring in insulin-treated type 2 diabetes patients managed in primary and secondary care settings: A pilot, multicentre, randomised controlled trial.

AIM: Analyse the effects of professional flash glucose monitoring system (FreeStyle Libre Pro™) on glycaemic control in insulin-treated type 2 diabetes. METHODS: Primary (n = 17) and secondary care centres (n = 5) randomised 148 type 2 diabetes patients into three groups: (A) self-monitoring of blood glucose (n = 52), (B) self-monitoring of blood glucose and two Libre Pro sensor wears (n = 46) or (C) self-monitoring of blood glucose and four sensor wears (n = 50). Primary endpoint was time in range (glucose 3.9-10 mmol/L) within group C comparing baseline with days 172-187. Predefined secondary endpoints included HbA1c, hypoglycaemia and quality of life measures analysed within and between groups (clinicaltrials.gov, NCT02434315). RESULTS: In group C, time in range in the first 14 days (baseline) and days 172-187 was similar at 15.0 ± 5.0 and 14.1 ± 4.7 h/day (mean ± SD), respectively, (p = 0.1589). In contrast, HbA1c reduced from baseline to study end within group C by 4.9 ± 8.8 mmol/mol (0.44% ± 0.81%; p = 0.0003). HbA1c was also lower in group C compared with A at study end by 5.4 ± 1.79 mmol/mol (0.48% ± 0.16%; p = 0.0041, adjusted mean ± SE), without increased time in hypoglycaemia (p = 0.1795). Treatment satisfaction scores improved in group C compared with A (p = 0.0225) and no device-related serious adverse events were reported. CONCLUSIONS: Libre Pro can improve HbA1c and treatment satisfaction without increasing hypoglycaemic exposure in insulin-treated type 2 diabetes individuals managed in primary/secondary care centres.

First do no harm... Terminal restlessness or drug-induced delirium.

Terminal restlessness is a term frequently used to refer to a clinical spectrum of unsettled behaviors in the last few days of life. Because there are many similarities between the clinical pictures observed in terminal restlessness and delirium, we postulate that at times what is referred to as terminal restlessness may actually be an acute delirium sometimes caused by medication used for symptom control. It is important therefore to consider the causes for this distressing clinical entity, treat it appropriately, and ensure the treatment provided does not increase its severity. This brief review aims to consider the medications that are commonly used toward the end of life that may result in a picture of delirium (or terminal restlessness). These include opioids, antisecretory agents, anxiolytics, antidepressants, antipsychotics, antiepileptics, steroids and nonsteroidal anti-inflammatory drugs (NSAIDs). This review also aims to raise awareness regarding the recognition and diagnosis of delirium and to highlight the fact that delirium may be reversible in up to half of all cases. Good management of delirium has the potential to significantly improve patient care at the end of life.

How is risk defined in high-risk surgical patient management?

The definition of risk in surgical patients is a complex and controversial area. Generally risk is poorly understood and depends on past individual and professional perception, and societal norms. In medical use the situation is further complicated by practical considerations of the ease with which risk can be measured; and this seems to have driven much risk assessment work, with a focus on objective measurements of cardiac function. The usefulness of risk assessment and the definition of risk is however in doubt because there are very few studies that have materially altered patient outcome based on information gained by risk assessment. This paper discusses these issues, highlights areas where more research could usefully be performed, and by defining limits for high surgical risk, suggests a practical approach to the assessment of risk using risk assessment tools.

Key issues in the quality assurance of the One Number Census.

As part of the 2001 Census, the One Number Census project estimated and adjusted the Census database for underenumeration. As a result of the highly innovative One Number Census and the Quality Assurance process it encompassed, it was also ensured that robust results could be obtained for each local authority area. This article examines some of the issues and analyses that were undertaken as part of that assessment of the 2001 Census population counts for England and Wales. The article firstly highlights the key issues surrounding the implementation of the 2001 Census fieldwork. The article then explores the 2001 Census results through a series of demographic analyses to illustrate the sorts of issues investigated during the One Number Census Quality Assurance process itself. These analyses look at the patterns contained within the results, and comparisons with key alternative sources of population counts. Overall, these in-depth analyses and investigations provide further credence to the plausibility of the One Number Census results.

Older men with unexplained hepatitis.

A 59-year-old Caucasian man presented with painless jaundice for 6 weeks. He drank 70 units of alcohol per week. Examination revealed jaundice, spider angiomata and a 3 cm firm hepatomegaly. Initial bloods: bilirubin 152 µmol/L, alanine aminotransferase 1484 IU/L, alkaline phosphatase 130 IU/L, γ-glutamyl-transpeptidase 1224 IU/L and International Normalised Ratio 1.1. A standard liver screen was normal, and an abdominal ultrasound/CT scan suggested cirrhosis, confirmed by liver biopsy on day 5. Hepatitis E virus (HEV) serology on day 6 indicated acute infection. He developed severe hepatic decompensation characterised by worsening jaundice, ascites and variceal bleeding. On day 33 ribavirin 600 mg was initiated though discontinued after 2 weeks on receipt of a negative HEV RNA. At the last follow-up he had recovered, and remains abstinent from alcohol. We describe a case of autochthonously (locally) acquired HEV infection with life-threatening hepatic decompensation in the presence of undiagnosed alcohol-related cirrhosis.

Renal oxygenation measurement during partial nephrectomy using hyperspectral imaging may predict acute postoperative renal function.

BACKGROUND AND PURPOSE: Digital Light Processing hyperspectral imaging (HsI) produces a highly sensitive, real-time tissue oxygenation map to monitor renal perfusion/oxygenation during partial nephrectomy (PN). Our initial experience with HsI revealed considerable variation in the baseline renal oxygenation, and we sought to correlate these differences with postoperative renal function. PATIENTS AND METHODS: Hyperspectral images were collected intraoperatively in patients undergoing PN for cortical tumors. The kidney was illuminated with visible light (520-645 nm), the spectrum corresponding to that of oxyhemoglobin. Reflectance images were captured and digitally processed to determine the percentage of oxyhemoglobin (HbO2) at each image pixel. Images were taken before hilar occlusion; these %HbO2 values were used to categorize patients as high (>75% HbO2) or low (<75% HbO2) oxygenation, and postoperative eGFR was assessed. RESULTS: There were 26 patients who underwent PN with ice cooling and HsI imaging. Nineteen patients had a "low" preclamp oxygenation (mean 69%) while the other 7 had a "high" HbO2 (mean 77%). There was no difference in tumor size, hematocrit value, clamp time, or preoperative eGFR between the two groups. Patients with a higher baseline %HbO2 had no significant postoperative change in their eGFR (mean 0 mL/min/1.73 m(2), +4%), while those with the lower baseline %HbO2 had a significant acute decline (mean 15 mL/min/1.73 m(2), -20%, P=0.02, 0.006). CONCLUSIONS: Baseline renal oxygenation, as measured with HsI, may help predict risk of postoperative renal insufficiency and may distinguish between patients with otherwise similar baseline characteristics, such as eGFR. HsI may provide individualized assessment of renal function to influence intraoperative decision-making to help preserve renal function.

Renal oxygenation during partial nephrectomy: a comparison between artery-only occlusion versus artery and vein occlusion.

BACKGROUND AND PURPOSE: During partial nephrectomy (PN), artery-only (AO) occlusion may mitigate ischemia/reperfusion injury because of retrograde venous flow. Using digital light processing-hyperspectral imaging (DLP(®)-HSI), we compared renal oxygenation during AO vs artery and vein (AV) occlusion in patients undergoing PN. PATIENTS AND METHODS: Thirty-seven patients who were undergoing complex open PN (median R.E.N.A.L. nephrometry of 8) at our institution underwent renal oxygenation assessment using DLP-HSI. Percent renal parenchymal oxyhemoglobin (%HbO2) during AO vs AV occlusion was recorded and its correlation with postoperative estimated glomerular filtration rate (eGFR) was investigated using Pearson correlation. AO and AV occlusion was performed in 12 and 25 patients, respectively. RESULTS: Comparing AO vs AV, mean ischemia time was 41 vs 35 minutes (P=0.02). The %HbO2 at baseline was 73.6% vs 71% (P=0.23). After hilar occlusion, %HbO2 quickly reached an "ischemic plateau" in both groups, with mean ischemic %HbO2 measures of 59.7% vs 62.2% (P=0.19). In the AV group, a lower mean ischemic %HbO2 was associated with lower eGFR at the most recent follow-up (r=0.46, P=0.02) and remained significant on multivariable analysis (odds ratio 2.31; 95% confidence interval 0.29-4.32; P=0.03). CONCLUSIONS: In this pilot clinical study, renal oxygenation profiles during PN as assessed by DLP-HSI were similar for AO vs AV occlusion. Significant retrograde venous oxygen delivery using an AO occlusion technique could not be demonstrated. There was also no renal functional advantage for AO occlusion in this population of difficult PN where prolonged ischemia times may have mitigated any advantage. Further study in cases with shorter ischemia times is warranted.

Renal oxygenation during robot-assisted laparoscopic partial nephrectomy: characterization using laparoscopic digital light processing hyperspectral imaging.

UNLABELLED: Abstract Background and Purpose: Digital light processing-based hyperspectral imaging (DLP(®)-HSI) was adapted for use during laparoscopic surgery by coupling the spectral illumination source with a conventional laparoscopic light guide and incorporating a customized digital charge-coupled device camera for image acquisition. The system was used to characterize renal oxygenation during robot-assisted laparoscopic partial nephrectomy (RALPN) in humans. PATIENTS AND METHODS: After Institutional Review Board approval, laparoscopic DLP-HSI was performed in consecutive patients undergoing RALPN at our institution. Time trends in relative tissue oxygen saturation (%HbO2) were descriptively analyzed. Associations between %HbO2 and patient age, comorbidities, and estimated glomerular filtration rate (eGFR) were investigated using the Kendall tau test. RESULTS: Laparoscopic DLP-HSI was performed in 18 patients between May 2011 and February 2012. Median (interquartile range; IQR) age was 55.9 (49-67.5) years. Of the patients, 10/18 (56%) were men and 12/18 (66.7%) had a history of hypertension, diabetes, and/or tobacco use. Median (IQR) %HbO2 before, during, and after ischemia was 60.8% (57.9-68.2%), 53.6% (46.8-55.1%), and 61.5% (54.9-67.6%), respectively. Baseline %HbO2 was inversely associated with preoperative eGFR (τ=-0.38; P=0.036), and eGFR at most recent follow-up (τ=-0.38; P=0.036). Baseline or ischemic %HbO2 did not correlate with hypertension, diabetes, and/or tobacco history. Younger patients (<56 years) had a lower median baseline %HbO2 (P=0.07) and a higher median preoperative eGFR (P=0.038), than their older counterparts. CONCLUSION: The laparoscopic HSI system successfully characterized dynamic changes in renal oxygenation during RALPN. Intraoperative laparoscopic HSI outcomes have the potential to predict postoperative individual kidney function.

RNF212 is a dosage-sensitive regulator of crossing-over during mammalian meiosis.

Crossing-over ensures accurate chromosome segregation during meiosis, and every pair of chromosomes obtains at least one crossover, even though the majority of recombination sites yield non-crossovers. A putative regulator of crossing-over is RNF212, which is associated with variation in crossover rates in humans. We show that mouse RNF212 is essential for crossing-over, functioning to couple chromosome synapsis to the formation of crossover-specific recombination complexes. Selective localization of RNF212 to a subset of recombination sites is shown to be a key early step in the crossover designation process. RNF212 acts at these sites to stabilize meiosis-specific recombination factors, including the MutSγ complex (MSH4-MSH5). We infer that selective stabilization of key recombination proteins is a fundamental feature of meiotic crossover control. Haploinsufficiency indicates that RNF212 is a limiting factor for crossover control and raises the possibility that human alleles may alter the amount or stability of RNF212 and be risk factors for aneuploid conditions.

Minimal arterial in-flow protects renal oxygenation and function during porcine partial nephrectomy: confirmation by hyperspectral imaging.

OBJECTIVES: To examine the potential for renal protection through incomplete renal artery (RA) occlusion with both assessments of creatinine changes and the use of hyperspectral imaging to monitor tissue oxygenation. Renal ischemia during partial nephrectomy can have adverse consequences on renal function. METHODS: Fourteen pigs with a solitary kidney underwent open partial nephrectomy with warm ischemia. The RA flow was measured and reduced to 25%, 10%, and 0% of baseline for 60 minutes. Hyperspectral imaging was used to assess the percentage of oxyhemoglobin (%HbO(2)) at baseline, during ischemia, and during reperfusion. The %HbO(2) and change in the serum creatinine level from baseline were compared. RESULTS: The baseline RA flow and %HbO(2) were similar in all groups, and, as expected, RA occlusion resulted in decreasing %HbO(2). The reduction of RA flow to 25% and 10% improved the nadir tissue oxygenation compared with 0% flow (P = .01 and P = .04, respectively) and 25% flow also appeared to prolong the interval to reach the nadir %HbO(2). Reperfusion resulted in a swift return to the baseline %HbO(2) in all 3 groups. The change in the serum creatinine from baseline to postoperative day 7 showed significantly improved renal preservation in the 25% RA flow group. CONCLUSIONS: Incomplete RA occlusion during porcine partial nephrectomy resulted in favorable renal oxygenation profiles with as little as 10% blood flow and appeared to be renoprotective when 25% of the baseline RA flow is preserved. Hyperspectral imaging is a sensitive, noninvasive tool for real-time monitoring of renal oxygenation and, thereby, blood flow, which could facilitate intraoperative decision-making to protect kidney function.

Investing in learning and training refugee doctors.

BACKGROUND: Medically qualified refugees seek to build a new life and return to clinical medicine. The National Health Service (NHS) in the UK needs to develop a workforce to meet the needs of the communities it serves, and refugee doctors have the potential to contribute to the NHS, using their experience and skills to benefit patients. METHODS: Fifty-four per cent of refugee doctors in the UK live in London, so in response, the London Deanery (Postgraduate Department of Medical and Dental Education, London University) has undertaken a series of initiatives over the past 8 years assisting refugee doctors back into medical employment. Clinical attachments, supernumerary 6-month posts and general practitioner (GP) training rotations have been offered. The projects, doctors involved, educational provision and outcomes are reported. The obstacles and barriers to returning to substantive posts in medicine are also discussed. RESULTS: Fifty-six per cent of the refugee doctors were known to be working after the schemes, 52 per cent gained substantive posts and 39 per cent entered training grades. DISCUSSION: Investing in innovative and creative work-based training programmes for refugee doctors is worthwhile, but needs to be adequately resourced if refugee doctors are to bring ultimate benefit to the NHS.

The case report and palliative management of a patient with carcinoid syndrome and crises.

The case report of a patient who suffered from severe carcinoid syndrome and frequent carcinoid crises. The discussion highlights key points in the palliative management of this rare, complex condition.

Reduced meiotic crossovers and delayed prophase I progression in AtMLH3-deficient Arabidopsis.

Characterization of AtMLH3, the Arabidopsis homologue of the prokaryotic MutL mismatch repair gene, reveals that it is expressed in reproductive tissue where it is required for normal levels of meiotic crossovers (COs). Immunocytological studies in an Atmlh3 mutant indicate that chromosome pairing and synapsis proceed with normal distribution of the early recombination pathway proteins. Localization of the MutS homologue AtMSH4 occurs, suggesting that double Holliday junctions (dHjs) are formed, but the MutL homologue AtMLH1, which forms a heterocomplex with AtMLH3, fails to localize normally. Loss of AtMLH3 results in an approximately 60% reduction in COs and is accompanied by a substantial delay of approximately 25 h in prophase I progression. Analysis of the chiasma distribution in Atmlh3 suggests that dHj resolution can occur, but in contrast to wild type where most or all dHjs are directed to form COs the outcome is biased in favour of a non-CO outcome by a ratio of around 2 to 1. The data are compatible with a model whereby the MutL complex imposes a dHj conformation that ensures CO formation.

Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse.

OBJECTIVE: Our purpose was to estimate the percentage of women with symptomatic pelvic organ prolapse who had a successful pessary fitting trial, to identify pelvic examination parameters that are associated with an unsuccessful pessary fitting trial, and to identify the most commonly used pessary for each stage of prolapse. STUDY DESIGN: In a prospective, observational study, 100 consecutive women with symptomatic pelvic organ prolapse were examined, staged, and fitted with either a ring or Gellhorn pessary. A successful pessary fitting trial occurred if a woman continued to use a pessary 1 week after being fitted. Women were then divided into two groups on the basis of whether they had a successful pessary fitting trial: group 1 was successful, and group 2 was unsuccessful. Pelvic examination parameters were evaluated as risk factors for an unsuccessful pessary fitting trial. RESULTS: Group 1 had 73 women, and group 2 had 27 women. A short vaginal length (< or =6 cm) and a wide vaginal introitus (4 fingerbreadths accommodated) were associated with group 2 (11% vs 0%, P=.02, and 22% vs 7%, P=.04, respectively). Ring pessaries were used more with stage II and III prolapse (100% and 71%, respectively), whereas Gellhorn pessaries were used more with stage IV prolapse (64%, P<.001). CONCLUSION: Seventy-three women (73%) with symptomatic pelvic organ prolapse had a successful pessary fitting trial. A short vaginal length and a wide vaginal introitus were risk factors for an unsuccessful pessary fitting trial. Gellhorn pessaries are more often needed with stage IV prolapse.