Using mixed methods to explore diabetes care in a medium-secure setting in England: A case study.

BACKGROUND AND AIMS: Diabetes is highly prevalent among individuals with serious mental illness. Managing diabetes in forensic mental health settings presents unique challenges which are under-reported and poorly understood. This study aimed to explore diabetes care in a medium-secure setting and identify key areas for improvement. METHODS: A single case study design used a retrospective chart review. Qualitative interviews and a focus group were analyzed using thematic analysis. RESULTS: Prevalence of diabetes was over twice that of the general population and highest in female service users. Evidence suggests limited understanding and lack of diabetes education for staff and service users, and difficulties in accessing external diabetes recourses. CONCLUSION: Constraints inherent to forensic mental health settings contribute to difficulties in accessing external resources and adequate diabetes education. Secure mental health services should adopt a collaborative approach to diabetes care and provide appropriate specialist training to both staff and service users.

The health economic benefits of perioperative patient warming for prevention of blood loss and transfusion requirements as a consequence of inadvertent perioperative hypothermia.

Active warming of patients is recommended by The National Institute for Health and Care Excellence (NICE) to prevent inadvertent perioperative hypothermia (IPH). This paper examines the cost effectiveness of one consequence of IPH, an increase in blood loss and the resulting transfusion risk. We quantified the risk and modelled two patient pathways, one with and one without warming, across two different surgery types. We were able to demonstrate the cost effectiveness of active warming based on one consequence even allowing for uncertainties in the model.

Melanoma immunotherapy using mature DCs expressing the constitutive proteasome.

BACKGROUND: Many cancers, including melanoma, exclusively express constitutive proteasomes (cPs) and are unable to express immunoproteasomes (iPs). In contrast, mature DCs used for immunotherapy exclusively express iPs. Since proteasomes generate peptides presented by HLA class I molecules, we hypothesized that mature melanoma antigen-loaded DCs engineered to process antigens through cPs would be superior inducers of antimelanoma immunity in vivo. METHODS: Subjects with metastatic melanoma were vaccinated with mature DCs transfected with RNAs encoding melanoma antigens MART1, MAGE-3, gp100, and tyrosinase. These DCs were derived from monocytes that were untransfected (Arm A; n = 4), transfected with control siRNA (Arm B; n = 3), or transfected with siRNAs targeting the 3 inducible iP subunits (Arm C; n = 5). RESULTS: Vaccination stimulated antigen-specific T cell responses in all subjects, which peaked after 3-4 vaccinations, but remained elevated in Arm C subjects. Also in Arm C, circulating melanoma cell levels (as detected by quantitative PCR) fell, and T cell lytic activity against autologous melanoma was induced. In HLA-A2⁺ subjects, CD8⁺ T cells that bound tetramers loaded with cP-derived melanoma antigenic peptides were found in the peripheral blood only in Arm C subjects. Of 2 subjects with active disease (both in Arm C), one had a partial clinical response, while the other, who exhibited diffuse dermal and soft tissue metastases, had a complete response. CONCLUSION: These results suggest that the efficacy of melanoma DC-based immunotherapy is enhanced when tumor antigen-loaded DCs used for vaccination express cPs. TRIAL REGISTRATION: Clinicaltrials.gov NCT00672542. FUNDING: Duke Clinical Research Institute/Duke Translational Medicine Institute, Duke Melanoma Consortium, and Duke University Department of Surgery.

A novel "four-rod technique" for lumbo-pelvic reconstruction: theory and technical considerations.

STUDY DESIGN: Surgical technique with case example. OBJECTIVE: To report on a novel technique that allows for the placement of 4 separate longitudinal rods across the lumbo-pelvic junction. SUMMARY OF BACKGROUND DATA: Despite advances in surgical techniques and instrumentation, lumbo-pelvic fixation remains a significant challenge. Fusions to the pelvis create long lever arms and generate high forces across the lumbosacral junction, resulting in high rates of screw pullout and implant fracture. In the attempt to achieve better bony fixation, techniques described include the use of bone cement, hydroxyapatite, and expandable screws. Although this process has decreased the incidence of screw pullout, it has not addressed the problem of rod fracture at the lumbo-pelvic junction. METHOD: There are 4 separate longitudinal rods placed across the lumbo-pelvic junction that couples proximal lumbar screw anchors to 4 separate pelvic fixation points. Proximal lumbar fixation anchors are based on alternating Roy-Camille "straight ahead" screws and Magerl "lateral to medial converging" pedicle screws. There are 4 distal pelvic fixation anchors used based on 1 pair of Galveston-like screws and 1 pair of proximal iliac wing screws. RESULTS: Early results of both ex vivo and in vivo reconstruction show that careful insertion of the lumbar and pelvic screws allows for divergent placement of the pedicle screw heads in a manner that 2 longitudinal rods can be placed per side, resulting in a total of 4 longitudinal rods across the lumbo-pelvic junction. Selection of cross-links in various combinations allows for additional axial and torsional stability, depending on the desired reconstruction. CONCLUSION: Longer follow-up is necessary, and biomechanical and finite element studies are needed to show long-term efficacy of this technique, however, early results indicate that such a construct is feasible. Furthermore, depending on the general medical condition of the patient, immediate postoperative weight bearing is possible and reasonable.

Parental knowledge and children's use of bicycle helmets.

Helmet use protects against head injury. Our objective was to assess whether parental knowledge of helmet safety is associated with helmet use in children, and whether a relationship exists between helmet ownership and other safety behaviors. Three hundred forty-one surveys were distributed to parents of third through fifth graders; 97% of parents believed that a helmet confers protection; 49% of parents reported that their child owns a helmet. Of the helmet owners, 27% reported that the child wears it more than 75% of the time. Seat belt usage was associated with helmet ownership (p=0.02) and frequency of wearing a helmet (p=0.04). Although parents are aware of the benefits, a barrier between helmet ownership and usage exists.

Uptake rates of thorium progeny in a semiarid environment.

The release rates and transformation processes that influence the mobility, biological uptake, and transfer of radionuclides are essential to the assessment of the health effects in the food chain and ecosystem. This study examined concentrations of 222Th in both soil and vegetation at a closed military training site, Kirtland Air Force Base (KAFB), New Mexico. Brazilian sludge was intentionally introduced into the topsoil in the early 1960s to simulate nuclear weapon accidents. Soil (60) and vegetation (120) samples were collected from 1996 to 2000 and analyzed for radionuclides and progeny. High-resolution gamma-ray spectroscopy was used to determine radionuclide activities. The results indicate that the thorium progeny were the predominant contaminant in soil and vegetation. Concentration ratios (CRs) were calculated based on actinium levels.

Coronary revascularization: a procedure in transition from on-pump to off-pump? The role of glucose-insulin-potassium revisited in a randomized, placebo-controlled study.

OBJECTIVE: To investigate an optimized glucose-insulin-potassium (GIK) solution regimen as an alternate myocardial protective strategy in off-pump coronary artery bypass graft (OP-CAB) surgery and as a supplement to conventional coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB). DESIGN: Prospective, randomized, placebo-controlled. SETTING: Single institution, cardiothoracic specialty hospital. PARTICIPANTS: Forty-four patients scheduled for elective multivessel coronary artery surgery using either conventional CPB (n = 22) or OP-CAB techniques (n = 22). INTERVENTIONS: Preischemic, ischemic, and postischemic administration of GIK solution was carried out, optimally dosed to ensure nonesterified fatty acid (NEFA) suppression, and supplemented with magnesium, a glycolytic enzymatic cofactor. MEASUREMENTS AND MAIN RESULTS: GIK solution therapy reduced plasma NEFA levels (p < 0.001) in OP-CAB surgery and CPB groups but failed to affect the incidence of non-Q wave perioperative myocardial infarction, incidence of postoperative atrial fibrillation, incidence of postoperative infection, reduction in creatinine clearance, or duration of postoperative intensive care unit or hospital length of stay. After adjusting for GIK solution therapy, OP-CAB surgery resulted in significantly less ischemic injury (troponin I >15 microg/L, 19.0% v 91.3%; p = 0.0001) and reduced postoperative infections (14.3% v 43.5%; p = 0.049). CONCLUSION: GIK solution therapy achieved NEFA suppression and an insignificant trend toward reduced biochemical parameters of ischemic injury in OP-CAB surgery and CPB groups, but no major clinical benefit (perioperative myocardial infarction, intensive care unit length of stay, or hospital length of stay) was shown after elective CABG surgery in low-risk patients. Compared with CPB, OP-CAB surgery significantly reduced ischemic injury and postoperative infections.