"Always opening and never closing": How dialogical therapists understand and create reflective conversations in network meetings.

Tom Andersen's reflecting team process, which allowed families to witness and respond to the talk of professionals during therapy sessions, has been described as revolutionary in the field of family therapy. Reflecting teams are prominent in a number of family therapy approaches, more recently in narrative and dialogical therapies. This way of working is considered more a philosophy than a technique, and has been received positively by both therapists and service users. This paper describes how dialogical therapists conceptualise the reflective process, how they work to engage families in reflective dialogues and how this supports change. We conducted semi-structured, reflective interviews with 12 dialogical therapists with between 2 and 20 years of experience. Interpretative Phenomenological analysis of transcribed interviews identified varying conceptualisations of the reflecting process and descriptions of therapist actions that support reflective talk among network members. We adopted a dialogical approach to interpretation of this data. In this sense, we did not aim to condense accounts into consensus but instead to describe variations and new ways of understanding dialogical reflecting team practices. Four themes were identified: Lived experience as expertise; Listening to the self and hearing others; Relational responsiveness and fostering connection; and Opening space for something new. We applied these themes to psychotherapy process literature both within family therapy literature and more broadly to understand more about how reflecting teams promote helpful and healing conversations in practice.

Is conservative management of the indeterminate thyroid nodule [Thy3f or Bethesda category IV] safe?

PURPOSE: The histological diagnosis after diagnostic thyroidectomy for indeterminate thyroid nodules is often non-malignant and some cancers detected are considered 'indolent'. The safety and effectiveness of conservative management in these patients are unclear. The aim of this study was to determine the safety of conservative management of indeterminate thyroid nodules and to explore association between clinical features and pathology in patients undergoing surgery. METHODS: This is a retrospective cohort study of patients presenting to a single centre over a 4-year period (2013-2016) with thyroid nodules that were considered indeterminate (thy3f in the UK RCPath classification) on cytology. Demographic data, ultrasound features, follow-up details (in those undergoing conservative management) and histology details (in those undergoing surgery) were collected. RESULTS: Of 164 patients that had Thy3f cytology, 34 were initially managed conservatively; however, 4 of these eventually had surgery (due to patient preference). No patient on conservative management had significant disease progression on ultrasound at a median (interquartile range) of 27 (16-40) months. Of the 134 patients that underwent surgery, 26 had thyroid malignancy. The BTA 'U' classification, gender and age (> 55) were not associated with malignancy in these nodules, but larger nodules (> 40 mm) were more likely to be malignant (p = 0.042). CONCLUSIONS: Conservative management of indeterminate (Thy3f or Bethesda stage IV) thyroid nodules is safe in the short term and may be indicated in selected cases after appropriate discussion of risks and benefits of surgery.

Immunoglobulin G4-related disease in a dog.

Immunoglobulin G4-related disease (IgG4-RD), which affects many organ systems, has been recognized as a distinct clinical entity in human medicine for just over a decade but has not been previously identified in dogs. In humans, IgG4-RD is characterized by diffuse IgG4-positive lymphoplasmacytic infiltrates that commonly lead to increased serum concentrations of IgG4 and IgE, peripheral eosinophilia, tumorous swellings that often include the parotid salivary glands, obliterative phlebitis, and extensive fibrosis. Herein we describe the diagnosis, clinical progression, and successful treatment of IgG4-RD in an 8-year-old female spayed Husky mixed breed dog. Immunoglobulin G4-related disease should be considered as a differential diagnosis for dogs with vague clinical signs, lymphoplasmacytic swellings, restricted polyclonal gammopathy, eosinophilia or some combination of these findings.

Smoking Predicting Physical Activity in an Aging America.

OBJECTIVES: Tobacco smoking and physical inactivity are among leading behavioral risk factors for ill health in older adults. This study considers how smoking is associated with physical activity. DESIGN: Using a Life-Course model, data are analyzed regarding this relationship, controlling for, and interacted with, life-course and other factors. Daily smokers and sometimes smokers were hypothesized to engage in less leisure-time physical activity than those who never smoked, while those who stopped smoking were expected to do more than never smokers. Analyses were performed using SAS-Callable SUDAAN. SETTING AND PARTICIPANTS: Secondary data from ten years of a national sample of adults aged 18 and over of the National Health Interview Survey, 2001-2010, are used (N = 264,945, missing data excluded, of 282,313 total cases). MEASUREMENTS: Daily smokers, occasional smokers, and smoking quitters are compared to never smokers with regard to requisite physical activity (150 minutes per week of moderate, 100 of vigorous, and/or 50 of strengthening activity). Life-course measures include birth cohorts, age, and year of survey, as well as gender, race/ethnicity, and education. RESULTS: Overall, hypotheses are supported regarding daily smokers and quitters; but the hypothesis is strongly rejected among sometimes smokers, who are much more likely to do requisite physical activity. Findings differ by age, sometimes smokers age 65 and over being less likely to do physical activity. Findings among all men are similar to the overall findings, while those among all women are similar to those for older respondents. Associations of smoking status with physical activity vary greatly by race/ethnicity. CONCLUSIONS: Daily smokers may be most in need of both smoking cessation and leisure-time physical activity interventions. Smoking-cessation efforts may pay greater physical activity benefits among women and the aged, while smoking-reduction efforts may provide better outcomes among men. Smoking reduction efforts may pay more exercise benefits among African-Americans and Hispanics.

Atypical Morphology and Disparate Speciation in a Case of Feline Cryptococcosis.

A 6-year-old, spayed female cat was presented with acute respiratory signs and pleural effusion. Computed tomography scan revealed a large, lobulated mass effect in the ventral right hemithorax with concurrent sternal lymphadenopathy. A cytologic sample of the mass contained pyogranulomatous inflammation, necrotic material, and abundant yeast structures that lacked a distinct capsule and demonstrated rare pseudohyphal forms. Fungal culture and biochemical testing identified the yeast as Cryptococcus albidus, with susceptibility to all antifungal agents tested. However, subsequent 18S PCR identified 99% homology with a strain of Cryptococcus neoformans and only 92% homology with C. albidus. The patient responded well to fluconazole therapy unlike the only known previous report of C. albidus in a cat. The unusual cytologic morphology in this case underscores the need for ancillary testing apart from microscopy for fungal identification. Though C. albidus should be considered as a potential feline pathogen, confirmation with PCR is recommended when such rare non-neoformans species are encountered.

Cat scratch disease: U.S. clinicians' experience and knowledge.

Cat scratch disease (CSD) is a zoonotic infection caused primarily by the bacterium Bartonella henselae. An estimated 12,000 outpatients and 500 inpatients are diagnosed with CSD annually, yet little is known regarding clinician experience with and treatment of CSD in the United States. Questions assessing clinical burden, treatment and prevention of CSD were posed to 3,011 primary care providers (family practitioners, internists, paediatricians and nurse practitioners) during 2014-2015 as part of the annual nationwide DocStyles survey. Among the clinicians surveyed, 37.2% indicated that they had diagnosed at least one patient with CSD in the prior year. Clinicians in the Pacific and Southern regions were more likely to have diagnosed CSD, as were clinicians who saw paediatric patients, regardless of specialty. When presented with a question regarding treatment of uncomplicated CSD, only 12.5% of clinicians chose the recommended treatment option of analgesics and monitoring, while 71.4% selected antibiotics and 13.4% selected lymph node aspiration. In a scenario concerning CSD prevention in immunosuppressed patients, 80.6% of clinicians chose some form of precaution, but less than one-third chose the recommended option of counseling patients to treat their cats for fleas and avoid rough play with their cats. Results from this study indicate that a substantial proportion of U.S. clinicians have diagnosed CSD within the past year. Although published guidelines exist for treatment and prevention of CSD, these findings suggest that knowledge gaps remain. Therefore, targeted educational efforts about CSD may benefit primary care providers.

Evaluation of the biological differences of canine and human factor VIII in gene delivery: implications in human hemophilia treatment.

The canine is the most important large animal model for testing novel hemophilia A (HA) treatment. It is often necessary to use canine factor VIII (cFIII) gene or protein for the evaluation of HA treatment in the canine model. However, different biological properties between cFVIII and human FVIII (hFVIII) indicated that the development of novel HA treatment may require careful characterization of non-human FVIII. To investigate whether the data obtained using cFVIII can translate to HA treatment in human, we analyzed the differential biological properties of canine heavy chain (cHC) and light chain (cLC) by comparing with human heavy chain (hHC) and light chain (hLC). The secretion of cHC was 5-30-fold higher than hHC, with or without light chains (LCs). cHC+hLC group exhibited ~18-fold increase in coagulation activity compared with hHC+hLC delivery by recombinant adeno-associated viral vectors. Unlike hHC, the secretion of cHC was independent of LCs. cLC improves the specific activity of FVIII by two- to threefold compared with hLC. Moreover, the cLC, but not cHC, contributes to the higher stability of cFVIII. Our results suggested that the cFVIII expression results in the canine model should be interpreted with caution as the cHC secreted more efficiently than hHC and cLC exhibited a more active and stable phenotype than hLC.

Awake videolaryngoscopy-assisted tracheal intubation of the morbidly obese.

Awake videolaryngoscopy may be useful for the tracheal intubation of the morbidly obese. This prospective, observational study enrolled 50 patients undergoing bariatric surgery. After sedation and topical anaesthesia of the airway, awake tracheal intubation was attempted, assisted by videolaryngoscopy, and terminated if there was severe gagging, coughing, or inadequate laryngeal view. After three attempts the procedure was considered a failure. Twenty-seven intubations were successful on the first attempt, fifteen on the second, six on the third and two were not successful, giving a success rate of 96% (95% CI 86-100%). In one failure, inserting the tracheal tube caused severe gagging in spite of an adequate view of the larynx, and the trachea was intubated with the videolaryngoscope after induction of anaesthesia. The second failure was due to gagging, with subsequent tracheal intubation successful using fibreoptic bronchoscopy. When managing the morbidly obese airway, awake tracheal intubation using videolaryngoscopy may be considered.

High density micromass cultures of a human chondrocyte cell line: a reliable assay system to reveal the modulatory functions of pharmacological agents.

Osteoarthritis is a highly prevalent and disabling disease for which we do not have a cure. The identification of suitable molecular targets is hindered by the lack of standardized, reproducible and convenient screening assays. Following extensive comparisons of a number of chondrocytic cell lines, culture conditions, and readouts, we have optimized an assay utilizing C-28/I2, a chondrocytic cell line cultured in high-density micromasses. Utilizing molecules with known effects on cartilage (e.g. IL-1ß, TGFß1, BMP-2), we have exploited this improved protocol to (i) evoke responses characteristic of primary chondrocytes; (ii) assess the pharmacodynamics of gene over-expression using non-viral expression vectors; (iii) establish the response profiles of known pharmacological treatments; and (iv) investigate their mechanisms of action. These data indicate that we have established a medium-throughput methodology for studying chondrocyte-specific cellular and molecular responses (from gene expression to rapid quantitative measurement of sulfated glycosaminoglycans by Alcian blue staining) that may enable the discovery of novel therapeutics for pharmacological modulation of chondrocyte activation in osteoarthritis.

Unintentional subdural catheter placement during labor analgesia shows typical radiological pattern but atypical response to the Tsui test.

Subdural injection may be associated with abnormally extensive or limited spread of local anesthetics during neuraxial anesthesia. This complication is difficult to diagnose clinically. Radiological imaging is the gold standard for confirming the location of subdural catheter, but electrical stimulation of the catheter has also been described as a useful diagnostic tool. We present the case of an obstetric patient with unintentional subdural catheter placement that presented as a failed epidural block associated with severe upper back and scapular pain on catheter injection. Electrical stimulation of the catheter did not elicit muscle contractions until a current of 4 mAmp was attained, which is the response pattern of epidural placement. Subdural location of the catheter was subsequently confirmed by contrast radiography. This case adds to the evidence that subdural catheters are difficult to identify clinically, and that electrical stimulation may not differentiate them from epidural catheters.

Accuracy and reproducibility of conformal radiotherapy using data from a randomised controlled trial of conformal radiotherapy in prostate cancer (MRC RT01, ISRCTN47772397).

AIMS: The MRC RT01 trial used conformal radiotherapy to the prostate, a method that reduces the volume of normal tissue treated by 40-50%. Because of the risk of geographical miss, the trial used portal imaging to examine whether treatment delivery was within the required accuracy. MATERIAL AND METHODS: In total, 843 patients were randomly assigned to receive 64 Gy in 32 fractions over 6.5 weeks or 74 Gy in 37 fractions over 7.5 weeks. Field displacements and corrections were recorded for all imaged fractions. Displacement trends and their association with time, disease and treatment set-up characteristics were examined using univariate and multivariate analyses. A Radiographer Trial Implementation Group (RTIG) was set up to inform the quality assurance process and to promote the development of best practice. RESULTS: Treatment isocentre positioning was within 5 mm in every direction on 6238 (83%) of the 7535 fractions imaged. In total, 532 (81%) of 695 included patients had at least one > or = 3 mm displacement and 415 (63%) had at least one > or = 5 mm displacement. Univariate, multivariate and stepwise models of > or =5 mm displacements showed an increased likelihood of displacement in weeks 1 and 2 with low melting point alloy (LMPA) blocks compared with multileaf collimators, film verification compared with electronic portal imaging (EPI) and increased number of fractions imaged. Except for LMPA, this was also seen for > or = 5 mm displacements in weeks 3-6. CONCLUSIONS: Accurate conformal treatment was delivered. The use of EPI was associated with increased reported accuracy. The RTIG was a crucial part of the quality assurance process.

Developing ethical strategies to assist oncologists in seeking informed consent to cancer clinical trials.

Randomised clinical trials have come to be regarded as the gold standard in treatment evaluation. However, many doctors see the discussion of a clinical trial as an intrusion into the doctor-patient relationship and find these discussions difficult to initiate. Detailed informed consent is now a requirement of patient participation in trials; however, it is known that patients commonly fail to understand and recall the information conveyed. These difficulties for doctors and patients raise questions about the ethical integrity of the informed consent process. In this study, we have developed a set of communication strategies underpinned by ethical, linguistic and psychological theory, designed to assist doctors in this difficult task. Initially, audiotape transcripts of 26 consultations in which 10 medical oncologists invited patients to participate in clinical trials were analysed by expert ethicists, linguists, oncologists and psychologists, using rigorous qualitative methodology. A subset of seven of these was subjected to detailed linguistic analysis. A strategies document was developed to address themes which emerged from these analyses. This document was presented to relevant expert stakeholders. Their feedback was incorporated into the final document. Four themes emerged from the analysis; (a) shared decision-making, (b) the sequence of moves in the consultation, (c) the type and clarity of the information provided and (d) disclosure of controversial information and coercion. Detailed strategies were developed to assist doctors to communicate in these areas. We have developed a set of ethical strategies which may assist health professionals in this difficult area. A training package based on these strategies is currently being evaluated in a multi-centre randomised controlled trial.

Problems with HIV/AIDS prevention, care and treatment in Togo, West Africa: professional caregivers' perspectives.

This paper used accounts of professional caregivers to HIV/AIDS patients in Lomé, Togo, West Africa to explore the impacts of cultural, institutional and socio-economic factors in the fight against HIV/AIDS. Thirteen health professionals and 17 non-health professionals who work with people living with HIV/AIDS were interviewed in June and July 2002 in Lomé, Togo. The study found that, in Togo there are some cultural, socio-economic and institutional practices that put Togolese at risk of contracting HIV and complicate the care of those who become infected. People with HIV/AIDS face socio-economic, emotional and psychological battles as they attempt to deal with their physical health and the social reactions to such a stigmatizing disease. Thus, in order to contain the spread of HIV/AIDS, people living with HIV/AIDS, family caregivers, traditional healers as well as the public must be educated about the importance of preventing the disease and how each group can help achieve success in its control. Interventions in prevention and care should be designed with an awareness of these structural factors that contribute to the spread of AIDS and compromise the quality of care given to those who become infected.

Characterization of attenuated Renibacterium salmoninarum strains and their use as live vaccines.

Two nutritionally mutant strains of Renibacterium salmoninarum (Rs) were isolated that grew on tryticase soy agar (Rs TSA1) or brain heart infusion agar (Rs BHI1). These 2 strains could be continuously cultured on these media, whereas typical R. salmoninarum would only grow on KDM-2 agar. We determined no other phenotypic difference that could be used to distinguish them from wild-type R. salmoninarum. Both strains were found to be avirulent when 5 x 10(6) bacteria were intraperitoneally (i.p.) injected into Atlantic salmon. Rs TSA1, Rs BHI1, and Rs MT-239 (a R. salmoninarum strain previously shown to be attenuated) were tested as live vaccines in 2 separate trials. The best protection was seen with Rs TSA1. Vaccinated Atlantic salmon had relative percent survival (RPS) of 50 at 74 d post-challenge in Trial 1 and 76 at 60 d post-challenge in Trial 2. In both trials, 100% of the control salmon died from bacterial kidney disease (BKD) (within 40 d for Trial 1 and 50 d for Trial 2) after i.p. challenge with 5 x 10(6) live cells of the virulent isolate Rs Margaree.

Host cell invasion and intracellular residence by Aeromonas salmonicida: role of the S-layer.

Virulent strains of the fish pathogen Aeromonas salmonicida, which have surface S-layers (S+), efficiently adhere to, enter, and survive within macrophages. Here we report that S+ bacteria were 10- to 20-fold more adherent to non-phagocytic fish cell lines than S-layer-negative (S-) mutants. When reconstituted with exogenous S-layers, these S- mutants regained adherence. As well, latex beads coated with purified S-layers were more adherent to fish cell lines than uncoated beads, or beads coated with disorganized S-layers, suggesting that purified S-layers were sufficient to mediate high levels of adherence, and that this process relied on S-layer structure. Gentamicin protection assays and electron microscopy indicated that both S+ and S- A. salmonicida invaded non-phagocytic fish cells. In addition, these fish cells were unable to internalize S-layer-coated beads, clearly suggesting that the S-layer is not an invasion factor. Lipopolysaccharide (which is partially exposed in S+ bacteria) appeared to mediate invasion. Surprisingly, A. salmonicida did not show net growth inside fish cells cultured in the presence of gentamicin, as determined by viable bacterial cell counts. On the contrary, bacterial viability sharply decreased after cell infection. We thus concluded that the S-layer is an adhesin that promotes but does not mediate invasion of non-phagocytic fish cell lines. These cell lines should prove useful in studies aimed at characterizing the invasion mechanisms of A. salmonicida, but of limited value in studying the intracellular residence and replication of this invasive bacterium in vitro.

Co-culture of Aeromonas salmonicida and host cells in intraperitoneal implants is associated with enhanced bacterial survival.

An experimental procedure that we named "in vivo co-culture technology" allowed us to study the interactions between Aeromonas salmonicida and host cells, inside semipermeable chambers implanted in the peritoneal cavity of Atlantic salmon. Intraperitoneal implants containing bacteria and host cells, or bacteria and lysed cells, consistently yielded higher numbers of viable bacteria than implants containing bacteria only. Electron microscopy confirmed that 30 min after chamber inoculation, numerous bacteria were already internalized by exudate cells, and that at 3 h, destruction of these cells was evident. Thus, the rapid invasion and (or) the A. salmonicida-mediated lysis of host cells may constitute a survival strategy in vivo. The co-culture of bacteria with exudate peritoneal cells may be applicable to the in vivo study of other pathogens.

Heme oxygenase isoform expression in cellular and antibody-mediated models of acute inflammation in the rat.

Heme oxygenase (HO) is the rate-limiting enzyme in the catabolism of heme to biliverdin, carbon monoxide (CO), and free iron. The enzyme exists as a constitutive isoform (HO-2) and an inducible isoform (HO-1), which is also a stress protein (HSP32). HO-1 has previously been shown to be associated with the resolution phase of a non-immune model of acute inflammation. In addition, elevation of the enzyme was markedly anti-inflammatory. In the present study, these observations have been extended to two pleural models of immune-driven inflammation in the rat, an immediate type III hypersensitivity (Arthus) reaction and a delayed type IV hypersensitivity reaction. Whilst these models have differing inflammatory mechanisms and time courses, they both showed HO activity to be maximal during the resolution phase. This activity was associated with increases in exudate bilirubin (a breakdown product of biliverdin) and increased expression of HO-1. Immunocytochemical analysis of inflammatory cell smears from the two models showed that HO-1 and HO-2 expression was restricted to mononuclear cells in the type IV hypersensitivity reaction, but included the polymorphonuclear cell population in the type III hypersensitivity reaction. Thus, irrespective of the pathogenesis of the lesion, evidence is accumulating to suggest that HO-1 has a universal role in the resolution of inflammation.

COX-1, COX-2, and COX-3 and the future treatment of chronic inflammatory disease.

A new generation of non-steroidal anti-inflammatory drugs has been described that selectively targets the inducible isoform of cyclo-oxygenase, cyclo-oxygenase 2 (COX-2). This isoform is expressed at sites of inflammation, which has led to the speculation that its inhibition could provide all the benefits of current nonsteroidal anti-inflammatory drugs, but without their major side-effects on the gastrointestinal system (which are due to inhibition of COX-1). We have shown that COX-2 (identified by use of specific antibodies) is induced during the resolution of an inflammatory response, inhibition of COX-2 resulting in persistence of the inflammation due to the prevention of the synthesis of a range of anti-inflammatory prostanoids. We propose that there is a third isoform of this enzyme family, COX-3, a proposal that will have implication for the prescription of both existing and new generation anti-inflammatory drugs, and might represent a new therapeutic target.