Gazing Into the Crystal Ball: Calciphylaxis Causing Striking Retinal Vascular Calcification, Ocular Ischemic Syndrome, Crystalline Retinopathy, and Ischemic Optic Neuropathy.

ABSTRACT: A 72-year-old woman with membranous glomerulonephritis and failed renal transplant on peritoneal dialysis presented with bilateral vision loss. She reported several months of diminishing right eye vision that worsened after cataract extraction. On presentation, visual acuity was hand motion in the right and 20/100 in the left eye with a right afferent pupillary defect. Confrontation visual fields were constricted bilaterally. Intraocular pressure was 23 in the right eye, and there was diffuse right eye central corneal opacity with iris neovascularization. Fundus examination revealed bilateral pale optic nerves with cotton wool spot inferior to the left optic disc and diffuse arteriolar whitening with crystalline deposits in the left macula. Given fundus appearance, concurrent ischemic optic neuropathy, and ocular ischemic syndrome, ocular calciphylaxis was suspected. The patient reported development of painful gluteal nodules a month prior, and biopsy revealed calcinosis cutis, a dermatopathologic finding on the spectrum of calcific vasculitides. Her vision continued to decline in both eyes with left eye vision of 20/400. Intravenous sodium thiosulfate through hemodialysis was started with initial improvement in left eye vision to 20/125, but subsequently declined despite treatment. Pathogenesis of systemic calciphylaxis is poorly understood but believed to result from upregulation of osteogenesis and decreased inhibition of vascular calcification in parathyroid axis dyscrasias due to end-stage renal disease. Excess serum calcium-phosphate deposits in blood vessels causing tissue infarction, most commonly in the skin. Prior case reports have described ischemic optic neuropathy mimicking giant cell arteritis and crystalline retinopathy with ocular ischemic syndrome separately. Treatment with empiric intravenous sodium thiosulfate and calcium chelation may preserve vision in some patients.

Assessing patient preferences for the delivery of different community-based models of care using a discrete choice experiment.

OBJECTIVES: To assess patient preferences for different models of care defined by location of care, frequency of care and principal carer within community-based health-care services for older people. DESIGN: Discrete choice experiment administered within a face-to-face interview. SETTING: An intermediate care service in a large city within the United Kingdom. PARTICIPANTS: The projected sample size was calculated to be 200; however, 77 patients were recruited to the study. The subjects had recently been discharged from hospital and were living at home and were receiving short-term care by a publicly funded intermediate care service. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The degree of preference, measured using single utility score, for individual service characteristics presented within a series of potential care packages. RESULTS: Location of care was the dominant service characteristics with care at home being the strongly stated preference when compared with outpatient care (0.003), hospital care (<0.001) and nursing home care (<0.001) relative to home care, although this was less pronounced among less sick patients. Additionally, the respondents indicated a dislike for very frequent care contacts. No particular type of professional carer background was universally preferred but, unsurprisingly, there was evidence that sick patients showed a preference for nurse-led care. CONCLUSIONS: Patients have clear preferences for the location for their care and were able to state preferences between different care packages when their ideal service was not available. Service providers can use this information to assess which models of care are most preferred within resource constraints.

Supervision, support and mentoring interventions for health practitioners in rural and remote contexts: an integrative review and thematic synthesis of the literature to identify mechanisms for successful outcomes.

OBJECTIVE: To identify mechanisms for the successful implementation of support strategies for health-care practitioners in rural and remote contexts. DESIGN: This is an integrative review and thematic synthesis of the empirical literature that examines support interventions for health-care practitioners in rural and remote contexts. RESULTS: This review includes 43 papers that evaluated support strategies for the rural and remote health workforce. Interventions were predominantly training and education programmes with limited evaluations of supervision and mentoring interventions. The mechanisms associated with successful outcomes included: access to appropriate and adequate training, skills and knowledge for the support intervention; accessible and adequate resources; active involvement of stakeholders in programme design, implementation and evaluation; a needs analysis prior to the intervention; external support, organisation, facilitation and/or coordination of the programme; marketing of the programme; organisational commitment; appropriate mode of delivery; leadership; and regular feedback and evaluation of the programme. CONCLUSION: Through a synthesis of the literature, this research has identified a number of mechanisms that are associated with successful support interventions for health-care practitioners in rural and remote contexts. This research utilised a methodology developed for studying complex interventions in response to the perceived limitations of traditional systematic reviews. This synthesis of the evidence will provide decision-makers at all levels with a collection of mechanisms that can assist the development and implementation of support strategies for staff in rural and remote contexts.

Preparing a 21st century workforce: is it time to consider clinically based, competency-based training of health practitioners?

Health workforce training in the 21st century is still based largely on 20th century healthcare paradigms that emphasise professionalisation at the expense of patient-focussed care. This is illustrated by the paradox of increased training times for health workers that have corresponded with workforce shortages, the limited career options and pathways for paraprofessional workers, and inefficient clinical training models that detract from, rather than add to, service capacity. We propose instead that a 21st century health workforce training model should be: situated in the clinical setting and supported by outsourced university training (not the other way around); based on the achievement of specific milestones rather than being time-defined; and incorporate para-professional career pathways that allow trainees to 'step-off' with a useable qualification following the achievement of specific competencies. Such a model could be facilitated by existing technology and clinical training infrastructure, with enormous potential for economies of scale in the provision of formal training. The benefits of a clinically based, competency-based model include an increase in clinical service capacity, and clinical training resources become a resource for the delivery of healthcare, not just education. Existing training models are unsustainable, and are not preparing a workforce with the flexibility the 21st century demands.

Implementing large-scale workforce change: learning from 55 pilot sites of allied health workforce redesign in Queensland, Australia.

BACKGROUND: Increasingly, health workforces are undergoing high-level 're-engineering' to help them better meet the needs of the population, workforce and service delivery. Queensland Health implemented a large scale 5-year workforce redesign program across more than 13 health-care disciplines. This study synthesized the findings from this program to identify and codify mechanisms associated with successful workforce redesign to help inform other large workforce projects. METHODS: This study used Inductive Logic Reasoning (ILR), a process that uses logic models as the primary functional tool to develop theories of change, which are subsequently validated through proposition testing. Initial theories of change were developed from a systematic review of the literature and synthesized using a logic model. These theories of change were then developed into propositions and subsequently tested empirically against documentary, interview, and survey data from 55 projects in the workforce redesign program. RESULTS: Three overarching principles were identified that optimized successful workforce redesign: (1) drivers for change need to be close to practice; (2) contexts need to be supportive both at the local levels and legislatively; and (3) mechanisms should include appropriate engagement, resources to facilitate change management, governance, and support structures. Attendance to these factors was uniformly associated with success of individual projects. CONCLUSIONS: ILR is a transparent and reproducible method for developing and testing theories of workforce change. Despite the heterogeneity of projects, professions, and approaches used, a consistent set of overarching principles underpinned success of workforce change interventions. These concepts have been operationalized into a workforce change checklist.

Traumatic arteriovenous fistula of the superficial temporal artery: a histopathologic report.

Traumatic aneurysms, pseudoaneurysms, and arteriovenous (AV) fistulas of the superficial temporal artery (STA) are uncommon, accounting for only 0.5% to 2.0% of all aneurysms subjected to surgery. In the literature that relates to the STA, the general term "aneurysm following traumatic injury" often includes a wide array of pathologic entities, including proper aneurysms, pseudoaneurysms, and AV fistulas. In 75% of cases, such aneurysms are due to blunt trauma. Within this group, STA AV fistulas constitute an exceedingly rare subset. The case presents the occurrence of a traumatic AV fistula of the STA following blunt trauma (karate kick) and provides the first description of the histologic appearance of this lesion.

Diffuse alveolar hemorrhage and Libman-Sacks endocarditis as a manifestation of possible primary antiphospholipid syndrome.

Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of circulating autoantibodies against phospholipid-binding plasma proteins, leading to an increased risk of thrombosis and pregnancy loss. The most common manifestation of lung disease in APS is pulmonary embolism, which may often be the presenting symptom. We present a 30-year-old man with probable primary APS (with no history of thromboses) presenting with diffuse alveolar hemorrhage, an uncommon presentation. He was also found to have severe mitral valve regurgitation and during valve replacement surgery had cardiac vegetations compatible with a presentation of Libman-Sacks endocarditis. There are only 21 other reported cases of diffuse alveolar hemorrhage occurring as a result of APS. This is the first case of Libman-Sacks endocarditis in the setting of probable APS and alveolar hemorrhage.Diffuse alveolar hemorrhage should be considered as a nonthrombotic manifestation of APS, even in the absence of known thromboses, and may be the presenting symptom.

Peripheral intrapulmonary lipoma in a 26-year-old woman - a case report.

Rare in occurrence, the following case of intrapulmonary lipoma is only the fifth known case in a female patient reported in the literature. Importantly, the incorporation of this lesion into the differential diagnosis during frozen section of a predominantly adipocytic lesion limited the extent of surgical intervention and provided the patient with an optimal standard of care.

70-year-old female presenting with rectosigmoid (colonic) xanthoma and multiple benign polyps - case report.

Xanthomas are benign lesions frequently described in the upper gastrointestinal tract, most commonly in the stomach. In the stomach, these lesions are usually associated with chronic gastritis, intestinal metaplasia, H. pylori infection and duodenogastric reflux following gastric surgery, but are otherwise indolent. Xanthomas in the upper gastrointestinal tract occur in a broad age range, 45-82 years (mean: 65 years). Rare cases have also been described in the esophagus, duodenum, small intestine, colon and rectum. Rectosigmoid location of xanthomas have been described in rare cases. We present a case of polypoid xanthoma in the rectosigmoid colon occurring in a 70-year-old female with a history of hyperplastic polyps.

Histopathologic findings and diagnostic difficulties posed with use of escharotic agents for treatment of skin lesions: a case report and review of the literature.

Escharotic agents have been used as alternative therapy for treatment of skin cancer and skin problems for centuries. Internet web sites such as online health product stores and eBay have made them widely available to the general public. The use of these agents carries risk of incomplete removal of tumor, damage of surrounding healthy tissues and marked scarring with poor cosmetic outcome. We report the case of a 27-year-old man who presented with history of moles and self-treatment with an escharotic agent containing bloodroot in order to document the histopathologic findings of topical bloodroot treatment and to show the clinical consequences that may occur in the unsuspecting public. To the best of our knowledge, the histological features following use of bloodroot (Sanguinaria canadensis) have not yet been documented.

Localized chronic fibrosing vasculitis causing a rhinophymatous eruption.

We describe a patient with localized chronic fibrosing vasculitis who presented with a rhinophymalike eruption of the nose. To our knowledge, the manifestation of this condition on the nose has not been previously reported. The differential diagnosis also is examined.

Assisting role redesign: a qualitative evaluation of the implementation of a podiatry assistant role to a community health setting utilising a traineeship approach.

BACKGROUND: Increasing demands for podiatry combined with workforce shortages due to attrition, part-time working practices and rural healthcare shortages means that in some geographic areas in Australia there are insufficient professionals to meet service demand. Although podiatry assistants have been introduced to help relieve workforce shortages there has been little evaluation of their impact on patient, staff and/or service outcomes. This research explores the processes and outcomes of a 'trainee' approach to introducing a podiatry assistant (PA) role to a community setting in the Australian Capital Territory (ACT) Government Health Service Directorate. METHOD: A qualitative methodology was employed involving interviews and focus groups with service managers, qualified practitioners, the assistant, service users and consumer representatives. Perspectives of the implementation process; the traineeship approach; the underlying mechanisms that help or hinder the implementation process; and the perceived impact of the role were explored. Data were analysed using the Richie and Spencer Framework approach. RESULTS: Although the impact of the PA role had not been measured at the time of the evaluation, the implementation of the PA traineeship was considered a success in terms of enabling the transfer of a basic foot-care service from nursing back to podiatry; releasing Enrolled Nurses (ENs) from foot-care duties; an increase in the number of treatments delivered by the podiatry service; and high levels of stakeholder satisfaction with the role. It was perceived that the transfer of the basic foot-care role from nursing to podiatry through the use of a PA impacted on communication and feedback loops between the PA and the podiatry service; the nursing-podiatry relationship; clinical governance around the foot-care service; and continuity of care for clients through the podiatry service. The traineeship was considered successful in terms of producing a PA whose skills were shaped by and directly met the needs of the practitioners with whom they worked. However, the resource intensiveness of the traineeship model was acknowledged by most who participated in the programme. CONCLUSIONS: This research has demonstrated that the implementation of a PA using a traineeship approach requires good coordination and communication with a number of agencies and staff and substantial resources to support training and supervision. There are added benefits of the new role to the podiatry service in terms of regaining control over podiatric services which was perceived to improve clinical governance and patient pathways.

Understanding service context: development of a service pro forma to describe and measure elderly peoples' community and intermediate care services.

The purpose of this paper was to develop a pro forma which classifies the components of service delivery and organization which may impact on the outcomes of elderly peoples' community and intermediate care services. The resulting analytic template provides a basis for comparison between services and may help guide service commissioning and development. A qualitative approach was used in which key evaluations and reports were selected on the basis that they described elderly peoples' community and intermediate care services. These were analysed systematically using a qualitative (template) approach to draw out the key themes used to describe services. Themes were then structured hierarchically into an analytic template. Seventeen key documents were analysed. The initial coding framework classified 334 themes describing intermediate care services. These items were then clustered into 78 categories, which were reduced to 17 subcategories, then six overall groupings to describe the services, namely; (1) context; (2) reason for the service; (3) service-users; (4) access to the service; (5) service structure; and (6) the organization of care. The resulting analytic template has been developed into a 'service pro forma' which can be used as a basis to describe and compare a range of services. We propose that all service evaluations should describe, in detail, their context in a comparable way, so that other services can learn from and/or apply the findings from these studies.

Two unstable beta chain variants associated with beta-thalassemia: Hb Miami [beta116(G18)his-->Pro], and Hb Hershey [beta70(E14)Ala-->Gly], and a second unstable Hb variant at 170: Hb Abington [beta70(E14)Ala-->Pro].

We report on three previously undescribed unstable hemoglobin (Hb) variants: Hb Miami, Hb Hershey and Hb Abington. Hb Miami was associated with a beta(+)-thalassemia (thal) mutation [IVS-I-110 (G-->A)], whereas Hb Hershey was associated with a B0-thal mutation [IVS-I-1 (G-->A)]. Hb Hershey also has decreased oxygen affinity. These three Hb variants illustrate the range of clinical severity that can be seen with unstable Hb variants, particularly when combined with a thalassemic mutation.