2†Pathways to detection of non-infectious childhood uveitis in the UK: findings from the UNICORN cohort study.

INTRODUCTION: Prompt detection of childhood uveitis is key to minimising negative impact. From an internationally unique inception cohort, we report pathways to disease detection.UNICORNS is a national childhood non-infectious uveitis study with longitudinal collection of a standardised clinical dataset and patient reported outcomes. Descriptive analysis of baseline characteristics are reported.Amongst 150 recruited children (51% female, 31% non-white ethnicity) age at detection ranged from 2-18yrs (median 10). In 69%, uveitis was diagnosed following onset of symptoms: time from first symptoms to uveitis detection ranged from 0-739days (median 7days), with longer time to detection for those presenting initially to their general practitioner. Non symptomatic children were detected through JIA/other disease surveillance (16%), routine optometry review (5%) or child visual health screening (1%). Commonest underlying diagnoses at uveitis detection were JIA (17%), TINU (9%, higher than pre-pandemic reported UK disease frequency) and sarcoid (1%). 60% had no known systemic disease at uveitis detection. At disease detection, in at least one eye: 34% had structural complications (associated with greater time to detection - 17 days versus 4 days for uncomplicated presentation).The larger relative proportions of children with non-JIA uveitis reported here increase the importance of improving awareness of childhood uveitis amongst the wider clinical communities. There is scope for improvement of pathways to detection. Forthcoming analysis on the full cohort (251 recruited to date across 33 hospitals and 4 nations) will provide nationally representative data on management and the determinants of visual and broader developmental/well-being outcomes.

Locoregional management of in-transit metastasis in melanoma: an Ontario Health (Cancer Care Ontario) clinical practice guideline.

Objective: The purpose of this guideline is to provide guidance on appropriate management of satellite and in-transit metastasis (itm) from melanoma. Methods: The guideline was developed by the Program in Evidence-Based Care (pebc) of Ontario Health (Cancer Care Ontario) and the Melanoma Disease Site Group. Recommendations were drafted by a Working Group based on a systematic review of publications in the medline and embase databases. The document underwent patient- and caregiver-specific consultation and was circulated to the Melanoma Disease Site Group and the pebc Report Approval Panel for internal review; the revised document underwent external review. Recommendations: "Minimal itm" is defined as lesions in a location with limited spread (generally 1-4 lesions); the lesions are generally superficial, often clustered together, and surgically resectable. "Moderate itm" is defined as more than 5 lesions covering a wider area, or the rapid development (within weeks) of new in-transit lesions. "Maximal itm" is defined as large-volume disease with multiple (>15-20) 2-3 cm nodules or subcutaneous or deeper lesions over a wide area.■ In patients presenting with minimal itm, complete surgical excision with negative pathologic margins is recommended. In addition to complete surgical resection, adjuvant treatment may be considered.■ In patients presenting with moderate unresectable itm, consider using this approach for localized treatment: intralesional interleukin 2 or talimogene laherparepvec as 1st choice, topical diphenylcyclopropenone as 2nd choice, or radiation therapy as 3rd choice. Evidence is insufficient to recommend intralesional bacille Calmette- Guérin or CO2 laser ablation outside of a research setting.■ In patients presenting with maximal itm confined to an extremity, isolated limb perfusion, isolated limb infusion, or systemic therapy may be considered. In extremely select cases, amputation could be considered as a final option in patients without systemic disease after discussion at a multidisciplinary case conference.■ In cases in which local, regional, or surgical treatments for itm might be ineffective or unable to be performed, or if a patient has systemic metastases at the same time, systemic therapy may be considered.

The application of a haemorrhage assessment tool in evaluating control of bleeding in a pilot trauma haemorrhage trial.

OBJECTIVES: To determine whether it was feasible to use a haemorrhage assessment tool (HAT) within a trauma trial and whether the data obtained could differentiate patients who had achieved haemostasis. BACKGROUND: Major haemorrhage is one of the leading causes of death worldwide, affecting 40% of trauma patients. Clinical trials evaluating haemostatic interventions often use transfusion outcomes as a primary endpoint. Transfusion is highly dependent on local practice, limiting its reliability as a robust, transferable endpoint. METHODS: A five-point HAT questionnaire was applied to participants enrolled into the EFIT-1 trial. This RCT evaluated the feasibility of administering a 6 g fibrinogen concentrate to patients with severe trauma haemorrhage. RESULTS: Of participants, 98% completed a HAT; 75% participants had 'achieved haemostasis' at the time of tool completion, as determined by clinical acumen alone. HAT scores were able to differentiate which participants required transfusion after 3 h. Of participants, 56% were transfused red blood cells when they scored 0-2, compared to 17% with HAT scores between 3 and 5. CONCLUSION: This study has confirmed the feasibility of using a HAT during the emergency care of patients suffering trauma haemorrhage, and future studies should be conducted to determine its value as an endpoint in haemostasis studies.

Primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in cutaneous melanoma: a clinical practice guideline.

Background: For patients who are diagnosed with early-stage cutaneous melanoma, the principal therapy is wide surgical excision of the primary tumour and assessment of lymph nodes. The purpose of the present guideline was to update the 2010 Cancer Care Ontario guideline on wide local excision margins and sentinel lymph node biopsy (slnb), including treatment of the positive sentinel node, for melanomas of the trunk, extremities, and head and neck. Methods: Using Ovid, the medline and embase electronic databases were systematically searched for systematic reviews and primary literature evaluating narrow compared with wide excision margins and the use of slnb for melanoma of the truck and extremities and of the head and neck. Search timelines ran from 2010 through week 25 of 2017. Results: Four systematic reviews were chosen for inclusion in the evidence base. Where systematic reviews were available, the search of the primary literature was conducted starting from the end date of the search in the reviews. Where systematic reviews were absent, the search for primary literature ran from 2010 forward. Of 1213 primary studies identified, 8 met the inclusion criteria. Two randomized controlled trials were used to inform the recommendation on completion lymph node dissection.Key updated recommendations include:■ Wide local excision margins should be 2 cm for melanomas of the trunk, extremities, and head and neck that exceed 2 mm in depth.■ slnb should be offered to patients with melanomas of the trunk, extremities, and head and neck that exceed 0.8 mm in depth.■ Patients with sentinel node metastasis should be considered for nodal observation with ultrasonography rather than for completion lymph node dissection. Conclusions: Recommendations for primary excision margins, sentinel lymph node biopsy, and completion lymph node dissection in patients with cutaneous melanoma have been updated based on the current literature.

Team consultancy using cognitive analytic therapy: a controlled study in assertive outreach.

The objective of this study was to evaluate the clinical and organizational efficacy of formulation-based consultancy to clinical teams using a randomized control trial methodology. Patients in an Assertive Outreach Team (AOT) were randomized into cognitive analytic consultancy (CAC; n = 10) or treatment as usual (TAU; n = 10). CAC consisted of three consultancy sessions with individual team members to formulate and map the dysfunctional roles and procedures adopted by both patient and team. Subsequent changes to practice were then supported via team supervision. Measures of patient and team functioning were taken across four discrete study phases; (1) baseline team training, (2) case consultation, (3) team supervision and (4) 3-month follow-up. Team members were additionally interviewed before and following the trial. No differences were evident between CAC and TAU in terms of patient outcomes. However, the climate of the AOT significantly improved longitudinally over the course of the trial, with CAC facilitating enhanced clinical and team practices. The results are discussed in terms of methodological limitations, the advantages/disadvantages of team consultation and the potential for the further development of the CAC model.

A prospective study of the responsiveness of depression and suicidal ideation in acne patients to different phases of isotretinoin therapy.

The degree and manner to which isotretinoin affects the mental health of acne patients has not been extensively researched, despite reports of possible associations between isotretinoin and depression. In this study, 33 patients with acne were prescribed a standard 16-week treatment regime with isotretinoin. At the initiation of isotretinoin treatment, week 8 review and termination of treatment, patients completed validated measures of depression, hopelessness and self-rated dermatological severity and were also assessed dermatologically using an acne grading protocol. When the first phase of isotretinoin treatment (week 1 to week 8) was compared to the second phase (week 9 to week 16), patients reported significant improvements in the cognitive-affective features of depression during the first phase of treatment, but not during the second phase. Corresponding improvements in the somatic symptoms of depression and hopelessness were not found. The implications of the research are discussed in relation to methodological design issues in this area.

From research and development to practice-based evidence: clinical governance initiatives in a service for adults with mild intellectual disability and mental health needs.

BACKGROUND: Practice-based evidence represents the contribution of practitioners who utilize research methodologies to examine the quality of their clinical practice and service provision. METHODS: The present paper describes the evolution of a routine practice-based evidence system (PBES) via four phases of research and development. The four phases are described, as is their relevance to assessment and intervention with regard to the mental health problems of people with mild intellectual disability. Phase four describes the development of a routine PBES. RESULTS: The PBES is capable of profiling the individual mental health needs of service users and examining service effectiveness and quality at an organizational level. CONCLUSIONS: The PBES is discussed according to its current utility and possible directions for future development. The system is presented as an example of clinical governance that could be utilized by multidisciplinary teams to develop and maintain an organizational culture of quality.

Acne: a biopsychosocial and evolutionary perspective with a focus on shame.

PURPOSE: Hypotheses regarding the psychological factors implicated in the development and maintenance of acne first emerged in the middle of the eighteenth century. However, the psychodermatological literature from this date relating to acne has variously been described as confusing, overly prone to conjecture and, in particular, atheoretical. The current paper has two key objectives; first, to present a biopsychosocial model of acne development and maintenance and, secondly, to understand the psychosocial strain imposed by acne from an evolutionary perspective with a particular emphasis on body shame reactions. METHODS: The psychodermatological literature relating to acne is reviewed with the data analysed for potential biopsychosocial interactions and shame eliciting responses. RESULTS: The review indicates that acne can be reconceptualized as a biopsychosocial phenomena which, in turn, provides the field with innovative hypotheses for empirical inquiry and the potential for expanding and evaluating treatment options. The evolutionary analysis illustrates that acne provides the potential for distressing body shame reactions due to the skin disease's potential for damaging self-other evaluations of attractiveness. CONCLUSIONS: Acne has tended to be viewed as a minor dermatological complaint which imposes minimal psychological distress upon sufferers. The paper concludes that acne has the ability to elicit in some sufferers significant mental health concerns due to a heightened sense of shame relating to appearance.

The psychological and emotional impact of acne and the effect of treatment with isotretinoin.

Although knowledge concerning the dermatological treatment of chronic acne has grown considerably in recent years, relatively few studies have assessed the impact of effective physical intervention upon the psychoemotional functioning of patients. Hypotheses regarding the psychological impact of acne were developed using concepts drawn from evolutionary psychology. A sample of 34 patients (19 men and 15 women) with chronic acne were assessed for psychological, emotional and dermatological symptomatology using a variety of self-report questionnaires over four time-points during 16 weeks treatment with isotretinoin. Thirty-four patients completed the first assessment, 21 the second, 20 the third and 15 the fourth and final assessment. At the first assessment, prior to isotretinoin treatment, 15 patients (44%) reported clinically significant levels of anxiety, while six patients (18%) reported clinically significant depression. Women with acne were significantly more embarrassed than their male counterparts about their skin disease. Treatment with isotretinoin produced significant improvements across a wide variety of psychological functions, although the emotional status of patients appeared to be more resistant to change. Acne appears to be a condition which has the potential to damage, perhaps even in the long term, the emotional functioning of some patients.

Current perspectives on nonarteritic anterior ischemic optic neuropathy.

BACKGROUND: The traditional view of nonarteritic anterior ischemic optic neuropathy (NAION) has been challenged. Progressive forms of the disease and spontaneous improvements in vision have been reported with increasing frequency. The pathogenesis of the disease has been refined. Treatment in the form of optic nerve sheath decompression has been advocated and dismissed by a major study. METHODS: The pathogenesis, presentation, risk factors, and associated conditions, differential diagnosis, and management of NAION are reviewed. RESULTS: NAION is currently considered an untreatable, ischemic disorder of the optic nerve head. In most cases, it results from a drop in optic nerve head perfusion pressure, below a critical level. No treatment is available to restore perfusion before loss of vision and visual field takes place. CONCLUSIONS: Despite changes in the reported natural history and pathogenesis of NAION, there is still no available treatment. Management involves reduction of risk factors to prevent development of the disease and differentiating it from the arteritic type.

The treatment of chronic post-traumatic nightmares using psychodynamic-interpersonal psychotherapy: a single-case study.

This article presents a single-case experimental study of a woman suffering a traumatized reaction to a road traffic accident (RTA). In addition to meeting the DSM-IV (APA, 1994) criteria for the diagnosis of PTSD, the client suffered recurrent bizarre nightmares. The client reported at assessment, that each night her dreams were dominated by a terrifying hooded cloaked faceless figure. The central aim of the study therefore was to assess the efficacy of a psychodynamic-interpersonal (PI) style psychotherapy in the context of an unusual PTSD reaction. The methodology employed an A/B multiple baseline time series design, with six month follow-up. A and B represent a series of dream diary observations under two conditions: assessment/baseline (A) and treatment/intervention (B). Treatment consisted of a manualized psychodynamic-interpersonal (PI) psychotherapy to facilitate insight into the content and meaning of the nightmares. The intervention reduced the frequency and associated distress of the nightmares to zero. Follow-up at six months noted the long-term efficacy of the psychotherapy. The study is discussed with reference to the assimilation model of psychotherapeutic change.