Patient and Physician Perspectives of Systemic Lupus Erythematosus Flare: A Qualitative Study.

OBJECTIVE: Systemic lupus erythematosus (SLE) flares are associated with increased damage and decreased health-related quality of life. We hypothesized that there is discordance between physicians' and patients' views of SLE flare. In this study, we aimed to explore patient and physician descriptions of SLE flares. METHODS: We conducted a qualitative descriptive study using in-depth interviews with a purposeful sample of patients with SLE (who met 1997 American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria) and practicing rheumatologists. Interviews were audio-recorded, transcribed, and analyzed using applied thematic analysis. RESULTS: Forty-two patient participants with SLE, representing a range of SLE activity, completed interviews. The majority described flare symptoms as joint pain, fatigue, and skin issues lasting several days. Few included objective signs or laboratory measures, when available, as features of flare. We interviewed 13 rheumatologists from 10 academic and 3 community settings. The majority defined flare as increased or worsening SLE disease activity, with slightly more than half requiring objective findings. Around half of the rheumatologists included fatigue, pain, or other patient-reported symptoms. CONCLUSION: Patients and physicians described flare differently. Participants with SLE perceived flares as several days of fatigue, pain, and skin issues. Providers defined flares as periods of increased clinical SLE activity. Our findings suggest the current definition of flare may be insufficient to integrate both perceptions. Further study is needed to understand the pathophysiology of patient flares and the best way to incorporate patients' perspectives into clinical assessments.

The Type 1 & 2 systemic lupus erythematosus model: Perspectives of people living with systemic lupus erythematosus.

OBJECTIVE: In the new Type 1 & 2 model for systemic lupus erythematosus (SLE), Type 1 SLE represents classic inflammatory manifestations, such as arthritis, while Type 2 SLE encompasses symptoms such as pain and fatigue where the relationship to inflammation is less clear. The objective of this study was to interview individuals living with SLE to determine the content and face validity of the Type 1 & 2 SLE model. METHODS: We conducted a qualitative study using semi-structured interviews with a purposeful sample of participants who met classification criteria for SLE. Participants were asked to describe their experiences with Type 1 & 2 SLE symptoms and treatments, and they indicated if and how their personal experiences aligned with the Type 1 & 2 SLE model. All interviews were audio-recorded and transcribed; applied thematic analysis identified the most frequent and salient themes. RESULTS: We interviewed 42 participants with SLE. Type 2 SLE symptoms, such as pain and fatigue, were very common, with almost all participants experiencing some Type 2 symptoms at some point during their disease course. Participants described Type 1 SLE symptoms as being acute flares and life-threatening and Type 2 SLE symptoms as "everyday lupus" that affected their daily lives and were a dominant part of their SLE disease experience. Most participants stated they want their rheumatologists to discuss Type 2 symptoms during clinical appointments in order to address their full symptom experience. CONCLUSION: We demonstrated content and face validity of the Type 1 & 2 SLE model with people living with SLE. Participants in our study largely understood the model and felt it accurately reflected their experience living with SLE. Type 2 SLE symptoms are very common in individuals with SLE and impact patients' quality of life. Using the model to address Type 2 SLE symptoms allows the rheumatologist to incorporate the patient's perspective and provide patient-centered care.

Sustaining a therapeutic environment within mental health in-patient settings during COVID-19. Results of a Delphi study.

AIM: Develop a strengths-based, person-centred, trauma-informed and recovery-oriented framework to mitigate any potential increase in conflict resulting from the implementation of C19 restrictions. BACKGROUND: Guidance addressing the unique challenges posed by Covid-19 within mental health in-patient settings, including how to support those whose distress may present as behaviour that challenges including violence and self-harm, remains urgently needed. METHODOLOGY/APPROACH: A Delphi design involving four iterative stages was adopted. Stage 1 involved a review and synthesis of COVID-19-related public health and ethical guidance and a narrative literature review. A formative operational framework was then developed. Stage 2 sought to establish the face validity of the framework through engagement with frontline and senior staff in mental health services in Ireland, Denmark and Netherlands. Stage 3 investigated the content validity of the final framework through a plenary presentation and discussion of the framework at a scientific symposium of the European Violence in Psychiatric Research Group (EViPRG, 2020). Stage 4 sought expert appraisal of the framework using a structured evaluation completed by a panel of eighteen multidisciplinary experts from nine countries, including four academics, six clinicians and eight holding dual clinical/academic appointments to assess content validity. RESULTS: The guidance adopts the widely advocated approach to support those whose distress may present as behaviour services find challenging in identifying the need for primary, secondary, tertiary and recovery measures. It emphasizes person-centred care while integrating specific Covid-19 public health requirements into service planning. It also aligns with contemporary best practice in in-patient mental health care, incorporating the principles of Safewards, the core values of trauma-informed care, and an explicit on recovery. CONCLUSION: The guidance developed has face and content validity.

What Is the Trigger for Sexual Climax?

A model is proposed to consider sexual climax in men, women, and animals as a unitary phenomenon. Sexual climax is a stereotyped rhythmic pattern of spinally generated neural activity in the autonomic and somatic nerves innervating pelvic organs. A column of neurons in the spinal cord of the male rat is strongly activated by ejaculation (sexual climax in the male). These neurons project to the thalamus and are therefore called lumbar spinothalamic cells (LSt cells). Comprehensive studies have demonstrated that the LSt cells constitute a central pattern generator of ejaculation. These findings have been extended to female animals. Further studies identified LSt cells in the lumbar spinal cord of men and women. Strong evidence indicates that the LSt cells mediate ejaculation in men. The climax model generalizes and extends these studies. It postulates that LSt cells in the lumbar spinal cord of humans and animals of both sexes generate climax. The LSt cells generate the neural activity driving the pelvic contractions and other responses of climax. The activity is transmitted to supraspinal sites to activate orgasm. The LSt cells receive excitatory and inhibitory projections from supraspinal sites. The descending projections reflect subjective arousal and inhibitions. Spinal sensory neurons from the genitals provide excitatory and inhibitory innervation to the LSt cells. These represent pleasurable and noxious sensations. The supraspinal and spinal excitatory and inhibitory inputs are integrated by the LSt. When the sum of the excitatory inputs, minus the sum of the inhibitory inputs reaches a threshold, the LSt cells generate sexual climax.

Users of cannabis-only are less likely to accept brief interventions than other substance use profiles in a sample of people living with HIV/AIDS.

BACKGROUND AND OBJECTIVES: Research has shown that people living with HIV/AIDS (PLWHA) engage in increased rates of substance use, which has a number of potential negative health outcomes. Increased legalization of cannabis is likely to further increase the availability and use of cannabis in this population. Efforts have been made to integrate screening and intervention resources as part of an individual's routine healthcare visits. Though brief approaches such as Screening and Brief Intervention (SBIRT) have shown promise in addressing alcohol use, results are mixed in addressing cannabis use. The present study investigated how individuals reporting cannabis use responded to an invitation to engage in a brief negotiated intervention (BNI). METHODS: PLWHA participated in a self-administered tablet computer-based version of SBIRT. Patients screened as having at-risk, high-risk, or dependent substance use (N = 331) were eligible to receive the BNI. Of these patients, 101 reported cannabis-only use, with or without alcohol. RESULTS: Binary logistic regressions controlling for Alcohol Use Disorders Identification Test and Drug Abuse Screening Test score and demographics, found that cannabis-only use was significantly related to declining the BNI. DISCUSSION AND CONCLUSIONS: Cannabis-only engagement predicts lower BNI acceptance rates than other substance use profiles; inappropriate screening tools may be one reason for this discrepancy. Implications and directions for future research are discussed. SCIENTIFIC SIGNIFICANCE: Findings are relevant in modifying SBIRT for cannabis use. To our knowledge, this is the first work to evaluate acceptance of brief interventions for cannabis as compared to other substances and brief intervention acceptance in a sample of PLWHA.

Family Caregiver and Provider Perspectives on Inclusive Care: Aligning Needs and Expectations.

BACKGROUND: Home-based and community-based health care for individuals with complex medical conditions is often provided by family caregivers. Yet caregivers often are not meaningfully included in interactions with clinical health care teams. Inclusive care means inviting the caregiver to participate in shared decision-making and treatment planning. For aging or medically vulnerable adults, caregiver inclusion is an important facet of patient-centered care. METHODS: We apply a mixed-methods approach using a survey (n=50) and semistructured interview data (n=13) from a national sample of caregivers of veterans and semistructured interview data from (n=24) providers from 3 Veterans Affairs regional networks. We elicited data from caregivers about their experiences with inclusive care and how providers communicate with them and assess their capacity. We juxtaposed these data with provider perspectives to see where there was alignment. FINDINGS: We determined that caregivers play important roles in trust-building, communications management, implementation of care plans at home or in the community, and improving the care of care recipients-while maintaining a balance between competing tensions. CONCLUSIONS: Our findings suggest that expanding inclusive care could improve care quality and health outcomes of individuals with complex health care needs. Further, our findings bolster recent policy efforts at the federal and state levels to increase recognition of caregivers as key members of the health care team.

HLA-C*06:02 genotype is a predictive biomarker of biologic treatment response in psoriasis.

BACKGROUND: Biologic therapies can be highly effective for the treatment of severe psoriasis, but response for individual patients can vary according to drug. Predictive biomarkers to guide treatment selection could improve patient outcomes and treatment cost-effectiveness. OBJECTIVE: We sought to test whether HLA-C*06:02, the primary genetic susceptibility allele for psoriasis, predisposes patients to respond differently to the 2 most commonly prescribed biologics for psoriasis: adalimumab (anti-TNF-α) and ustekinumab (anti-IL-12/23). METHODS: This study uses a national psoriasis registry that includes longitudinal treatment and response observations and detailed clinical data. HLA alleles were imputed from genome-wide genotype data for 1326 patients for whom 90% reduction in Psoriasis Area and Severity Index score (PASI90) response status was observed after 3, 6, or 12 months of treatment. We developed regression models of PASI90 response, examining the interaction between HLA-C*06:02 and drug type (adalimumab or ustekinumab) while accounting for potentially confounding clinical variables. RESULTS: HLA-C*06:02-negative patients were significantly more likely to respond to adalimumab than ustekinumab at all time points (most strongly at 6 months: odds ratio [OR], 2.95; P = 5.85 × 10-7), and the difference was greater in HLA-C*06:02-negative patients with psoriatic arthritis (OR, 5.98; P = 6.89 × 10-5). Biologic-naive patients who were HLA-C*06:02 positive and psoriatic arthritis negative demonstrated significantly poorer response to adalimumab at 12 months (OR, 0.31; P = 3.42 × 10-4). Results from HLA-wide analyses were consistent with HLA-C*06:02 itself being the primary effect allele. We found no evidence for genetic interaction between HLA-C*06:02 and ERAP1. CONCLUSION: This large observational study suggests that reference to HLA-C*06:02 status could offer substantial clinical benefit when selecting treatments for severe psoriasis.

Leveraging institutional support for family caregivers to meet the health and vocational needs of persons with disabilities.

BACKGROUND: Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance). PURPOSE: To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services. METHODS: Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26). FINDINGS: Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity. DISCUSSION: Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role.

Location of Power within Psychiatry: A Fifty-Year Journey as Represented in Film.

Over the last half of the twentieth century, many advances in the field of psychiatry and mental health have occurred and continue today. Among these developments are the increasing recognition of patient rights and the expanding role of psychiatric nurses. This paper presents a view of how these changes have been reflected in film over a period of fifty years in both documentary and Hollywood movies. Discussion of advances in psychiatry, as identified in the selected films, is presented against the background of social change that was occurring in the United States and Western Europe during this period.

Use of Magnetic Induction to Activate a "Touchless" Shape Memory Alloy Implantable Penile Prosthesis.

INTRODUCTION: We describe a novel physiologic penile prosthesis that uses shape memory alloy properties to mimic the transition between a flaccid and erect penis using magnetic induction instead of hydraulic pressure. AIM: To evaluate the parameters of magnetic induction to activate a shape memory alloy implantable penile prosthesis. METHODS: We prototyped an implantable penile prosthesis cylinder using temperature-tuned nickel titanium alloy tubes laser cut to specifications. The device was then tested implanted in an animal tissue model and in cadaveric tissue. Testing consisted of placing the device deactivated in its more malleable and compressed state, then activating it using an external inducer wand while measuring temperature changes that occur on the surface of the device, within the tissue, and at the skin surface. MAIN OUTCOME MEASURES: Our main outcome measures were the efficiency of activation and thermal safety of this approach. RESULTS: Using a handheld magnetic inductor, we were able to successfully activate the SMA penile prosthesis with no direct contact under 45 seconds. This handheld wand produced a magnetic field that penetrated tissue and caused the appropriate phase change within the prosthesis. Tissue temperature (middle and surface probes) in the animal tissue model increased only a few degrees Celsius during the activation process, and never exceeded 28 degrees Celsius from a baseline at room temperature ∼ 25 degrees Celsius. We encountered similar results without a notable change in tissue temperature in the cadaveric tests. The fully activated device resisted buckling forces of 2.66 kgf ± 0.045. CLINICAL IMPLICATIONS: This non-hydraulic shape memory prosthesis obviates the needs for reservoirs and pumps, and the wand-based interaction with the device may be easier to use. STRENGTH & LIMITATIONS: This technology represents a fundamental departure from the hydraulic-based penile prosthesis and has comparable mechanical properties as current-marked devices. It appears to show thermal safety in controlled environments, however real-world use would need further studies. Further optimization of prototypes needs to be done prior to human clinical trials. CONCLUSION: A shape memory penile prosthesis is a promising alternative to hydraulic-based penile prostheses and can be activated safely and efficiently using magnetic induction in our models of the human penis. Le BV, McVary KT, McKenna K, et al. Use of Magnetic Induction to Activate a "Touchless" Shape Memory Alloy Implantable Penile Prosthesis. J Sex Med 2019;16:596-601.

Management of Large Cecal Polyps: When Can the Ileocecal Valve Be Spared?

BACKGROUND: Endoscopic mucosal resection comprises the first-line treatment for large cecal polyps. With up to 14% of unresectable colonic polyps harboring malignancy, the management of endoscopically unresectable cecal polyps remains an oncologic right hemicolectomy, which can be associated with substantial postoperative morbidity. OBJECTIVE: This study compares the outcomes of patients with cecal polyps who underwent either endoscopic mucosal resection, a cecectomy, or a right hemicolectomy. DATA SOURCES: Patients undergoing either endoscopic mucosal resection, partial cecectomy, or right hemicolectomy from 2008 to 2017 at a single tertiary care institution were selected. STUDY SELECTION: This was a retrospective cohort study. MAIN OUTCOME MEASURES: The primary outcomes measured were the rate of malignancy, complication rate, estimated blood loss, and hospital length of stay between surgical cohorts. RESULTS: One hundred twenty-nine patients with cecal polyps were identified, of which 52 were referred for surgery. Nineteen underwent partial cecectomy and 33 (27.3%) underwent right hemicolectomy. Two patients undergoing cecectomy required conversion to hemicolectomy because the resected specimen did not contain the polyp. The 2 surgical cohorts did not differ significantly regarding age, sex, or ASA classification. Procedural complication rates were higher among those undergoing hemicolectomy compared with those undergoing cecectomy (37.1% versus 5.9%, p = 0.02). Estimated blood loss (50 vs 10 mL, p = 0.02), operative duration (98 vs 76 minutes, p = 0.009), and length of stay (4 vs 2 days, p < 0.001) were higher in patients undergoing hemicolectomy than in those undergoing cecectomy. No invasive malignancies were identified on final pathology within the cecectomy cohort. LIMITATIONS: Single-institution data and retrospective design were limitations of this study. CONCLUSIONS: In tertiary centers, the majority of large cecal polyps are benign and can be addressed by using endoscopic mucosal resection. When involvement of the appendiceal orifice or ileocecal valve precludes endoscopic treatment, surgical resection is the standard of care. In the subset of cases not involving the ileocecal valve and without preoperative evidence of malignancy, partial cecectomy spares the ileocecal valve and can offer reduced postoperative morbidity compared with a formal right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/A674.

Aplasia Cutis Congenita with Ischemic Cortical Change and Normal Array Cytogenetic Analysis with a Fetus Papyraceus Twin.

BACKGROUND: Aplasia cutis congenita (ACC) is a heterogeneous condition that can be associated with fetus papyraceus. Few reports exist documenting genetic investigations in ACC or determining the etiology and recurrence risks. OBJECTIVE: We present a Frieden group 5 ACC with fetus papyraceus along with molecular studies. RESULTS: The newborn had multifocal aplasia cutis congenita involving the head, trunk, and limbs with cerebral ischemic changes demonstrated by imaging. The newborn had a monochorionic twin fetus papyraceus. The array cytogenetic analysis was normal. CONCLUSION: Supported by the ischemic cerebral damage, a monochorionic twin fetus papyraceus (monochorionic twins often have vascular anastomoses), and a normal cytogenetic array, this ACC with Frieden group 5 may have resulted from rapid but non-fatal exsanguination of the surviving twin into the dead twin. This type of ACC may have a low recurrence risk.

GPs' opinions of discharge summaries generated by advanced nurse practitioners in emergency care settings.

AIM: Clinical handover at the point of discharge is critically important. It generally occurs through a written document, usually in the form of a discharge summary. Hospital discharge summaries contribute to continuity of care for patients who leave hospital and who may require care in the community provided by their GP. They must be accurate, valid, reliable, timely, legible and complete. The aim of this study was to investigate GPs' perceptions of the content of discharge summaries generated by emergency advanced nurse practitioners (EANPs). METHOD: A cross-sectional descriptive survey design was used and a questionnaire was distributed to 120 GPs. Raw statistical data were analysed using SPSS v22 while the qualitative data from the open-ended questions were manually analysed. FINDINGS: Most GPs were satisfied with the EANPs' discharge summary letters. However, this study supports previous papers that identified deficits in communication between secondary care and GPs. CONCLUSION: There is a need to refine discharge summaries to create an enhanced structured discharge summary template that can be used by all disciplines.

Role of PAR2 in the Development of Lower Urinary Tract Dysfunction.

PURPOSE: Lower urinary tract symptoms are a common finding in patients with chronic prostatitis/chronic pelvic pain syndrome. We previously reported that the mast cell-tryptase-PAR2 (protease activated receptor 2) axis has a critical role in the development of chronic pain in experimental autoimmune prostatitis, a mouse model of chronic prostatitis/chronic pelvic pain syndrome. Therefore, we examined whether PAR2 activation mediates lower urinary tract dysfunction. MATERIALS AND METHODS: Functional cystometry was done in male B6 mice along with immunoblotting and immunohistochemistry for the expression of COL1A1 (collagen type I α I) and α-SMA (α-smooth muscle actin). Flow cytometry analysis was performed on single cell suspensions of the prostate, bladder, lymph nodes and spleen. RESULTS: Experimental autoimmune prostatitis resulted in increased urinary voiding frequency and decreased bladder capacity 30 days after initiation. Concurrently, there was increased expression of COL1A1 and α-SMA in the prostates and bladders. In contrast, induction of experimental autoimmune prostatitis in PAR2 knockout mice did not result in altered urodynamics or increased markers of fibrosis in the prostate or the bladder. Single cell suspensions of the prostate, bladder, lymph nodes and spleen demonstrated that in the absence of PAR2 cellular inflammatory mechanisms were still initiated in experimental autoimmune prostatitis but PAR2 expression may be required to maintain chronic inflammation. Finally, antibody mediated PAR2 neutralization normalized urinary voiding frequency and bladder capacity, and attenuated chronic pelvic pain. CONCLUSIONS: PAR2 activation in the prostate may contribute to the development of lower urinary tract dysfunction through proinflammatory as well as profibrotic pathways.

Comparing the efficacy of photodynamic and sonodynamic therapy in non-melanoma and melanoma skin cancer.

Sonodynamic therapy (SDT) involves the activation of a non-toxic sensitiser drug using low-intensity ultrasound to produce cytotoxic reactive oxygen species (ROS). Given the low tissue attenuation of ultrasound, SDT provides a significant benefit over the more established photodynamic therapy (PDT) as it enables activation of sensitisers at a greater depth within human tissue. In this manuscript, we compare the efficacy of aminolevulinic acid (ALA) mediated PDT and SDT in a squamous cell carcinoma (A431) cell line as well as the ability of these treatments to reduce the size of A431 ectopic tumours in mice. Similarly, the relative cytotoxic ability of Rose Bengal mediated PDT and SDT was investigated in a B16-melanoma cell line and also in a B16 ectopic tumour model. The results reveal no statistically significant difference in efficacy between ALA mediated PDT or SDT in the non-melanoma model while Rose Bengal mediated SDT was significantly more efficacious than PDT in the melanoma model. This difference in efficacy was, at least in part, attributed to the dark pigmentation of the melanoma cells that effectively filtered the excitation light preventing it from activating the sensitiser while the use of ultrasound circumvented this problem. These results suggest SDT may provide a better outcome than PDT when treating highly pigmented cancerous skin lesions.

Bullous Pemphigoid Arising in Lower Leg Vein Graft Incision Site.

Bullous pemphigoid is a blistering disorder which can be idiopathic or arise secondary to drugs or trauma; however, blistering arising within surgical scars is rare. We present a patient with no prior skin history who developed blistering in his left calf vein harvesting scar soon after coronary artery bypass surgery.