Journal of Clinical Monitoring and Computing 2018-2019 end of year summary: respiration.

This paper reviews 28 papers or commentaries published in Journal of Clinical Monitoring and Computing in 2018 and 2019, within the field of respiration. Papers were published covering endotracheal tube cuff pressure monitoring, ventilation and respiratory rate monitoring, lung mechanics monitoring, gas exchange monitoring, CO2 monitoring, lung imaging, and technologies and strategies for ventilation management.

Doctors' decisions when disclosing their mental ill-health.

BACKGROUND: Understanding of what prevents doctors from seeking help for mental ill-health has improved. However, less is known about what promotes timely disclosure and the nature of doctors' decision making. AIMS: This study aimed to define how doctors make decisions about their own mental ill-health, and what facilitates disclosure. It explored the disclosure experiences of doctors and medical students; their attitudes to their decisions, and how they evaluate potential outcomes. METHODS: Qualitative, semi-structured interviews with UK doctors and medical students with personal experience of mental ill-health. Participants were recruited through relevant organizations, utilizing regular communications such as newsletters, e-mails and social media. Data were subject to a thematic analysis. RESULTS: Forty-six interviews were conducted. All participants had disclosed their mental ill-health to someone; not all to their workplace. Decision making was complex, with many participants facing multiple decisions throughout their careers. Disclosures were made despite the many obstacles identified in the literature; participants described enablers to and benefits of disclosing. The importance of appropriate responses to first disclosures was highlighted. CONCLUSIONS: Motivations to disclose mental ill-health are complex and multifactorial. An obstacle for one was an enabler for another. Understanding this and the importance of the first disclosure has important implications for how best to support doctors and medical students in need.

Feasibility of measuring psychological resilience in hospitalized patients with acute illness: The Resilience After the Trauma of Acute Illness (RAFT) study.

Resilience is the 'ability to bounce back'. We want to investigate whether measurement of resilience during an acute hospital admission is feasible. We conducted a feasibility study. Resilience was measured using the Brief Resilience Scale. Results were contextualized by measuring chronic disease burden, anxiety, depression, coping strategies and personality traits. 56 or 103 patients approached took part in the study. A group of 12 patients undergoing pulmonary rehabilitation served as a control group. We found evidence of low resilience in 4/44 (9%) patients admitted as medical emergencies. Low resilience was statistically related to the Hospital Anxiety and Depression Scale and a number of coping strategies and personality traits. We found no relation between measures of resilience and previous admissions to hospital. The concept of resilience might be applicable to unscheduled admissions to hospital. Larger studies are required to establish whether low resilience is common and amenable to intervention. REC number 17/WA/0024.

A qualitative exploration of the meaning of the term "survivor" to young women living with a history of breast cancer.

There has been a recent increase in research considering the perceptions of the term "cancer survivor" held by individuals who have or have had cancer. This article explores the meaning of the term to young women living with a history of breast cancer. Twenty women participated in semi-structured interviews about their experience of breast cancer. The methodology was informed by social constructionist grounded theory. Three of the women interviewed said they would use the term survivor to describe themselves, but most of the women felt it did not fit with their experiences. The accounts of those who accepted and rejected the survivor identity are explored, and subthemes in the latter are "survivor as somebody else" and "cancer's ongoing presence." This article calls into question the basing of intervention strategies on the notion of the "cancer survivor," and the assumption that younger women favour the survivor identity. Participants struggled with the demand to live up to the ideal of the survivor, which implied a high degree of agency where in reality, cancer was a disempowering experience. Being labelled a survivor obscured ongoing impacts of cancer on the young women's lives.

Journal of Clinical Monitoring and Computing 2017 end of year summary: respiration.

This paper reviews 32 papers or commentaries published in Journal of Clinical Monitoring and Computing in 2016, within the field of respiration. Papers were published covering airway management, ventilation and respiratory rate monitoring, lung mechanics and gas exchange monitoring, in vitro monitoring of lung mechanics, CO2 monitoring, and respiratory and metabolic monitoring techniques.

Kidney Exchange to Overcome Financial Barriers to Kidney Transplantation.

Organ shortage is the major limitation to kidney transplantation in the developed world. Conversely, millions of patients in the developing world with end-stage renal disease die because they cannot afford renal replacement therapy-even when willing living kidney donors exist. This juxtaposition between countries with funds but no available kidneys and those with available kidneys but no funds prompts us to propose an exchange program using each nation's unique assets. Our proposal leverages the cost savings achieved through earlier transplantation over dialysis to fund the cost of kidney exchange between developed-world patient-donor pairs with immunological barriers and developing-world patient-donor pairs with financial barriers. By making developed-world health care available to impoverished patients in the developing world, we replace unethical transplant tourism with global kidney exchange-a modality equally benefitting rich and poor. We report the 1-year experience of an initial Filipino pair, whose recipient was transplanted in the United states with an American donor's kidney at no cost to him. The Filipino donor donated to an American in the United States through a kidney exchange chain. Follow-up care and medications in the Philippines were supported by funds from the United States. We show that the logistical obstacles in this approach, although considerable, are surmountable.

Symptoms of post-traumatic stress disorder, severe psychological distress, explosive anger and grief amongst partners of survivors of high levels of trauma in post-conflict Timor-Leste.

BACKGROUND: Little is known about the mental health of partners of survivors of high levels of trauma in post-conflict countries. METHOD: We studied 677 spouse dyads (n = 1354) drawn from a community survey (response 82.4%) in post-conflict Timor-Leste. We used culturally adapted measures of post-traumatic stress disorder (PTSD), psychological distress, explosive anger and grief. RESULTS: Latent class analysis identified three classes of couples: class 1, comprising women with higher trauma events (TEs), men with intermediate TEs (19%); class 2, including men with higher TEs, women with lower TEs (23%); and class 3, comprising couples in which men and women had lower TE exposure (58%) (the reference group). Men and women partners of survivors of higher TE exposure (classes 1 and 2) had increased symptoms of explosive anger and grief compared with the reference class (class 3). Women partners of survivors of higher TE exposure (class 2) had a 20-fold increased rate of PTSD symptoms compared with the reference class, a pattern that was not evident for men living with women exposed to higher levels of trauma (class 1). CONCLUSIONS: Men and women living with survivors of higher levels of trauma showed an increase in symptoms of grief and explosive anger. The manifold higher rate of PTSD symptoms amongst women living with men exposed to high levels of trauma requires replication. It is important to assess the mental health of partners when treating survivors of high levels of trauma in post-conflict settings.

Journal of Clinical Monitoring and Computing 2016 end of year summary: respiration.

This paper reviews 16 papers or commentaries published in Journal of Clinical Monitoring and Computing in 2016, within the field of respiration. Papers were published covering peri- and post-operative monitoring of respiratory rate, perioperative monitoring of CO2, modeling of oxygen gas exchange, and techniques for respiratory monitoring.

Typical patterns of expiratory flow and carbon dioxide in mechanically ventilated patients with spontaneous breathing.

Incomplete expiration of tidal volume can lead to dynamic hyperinflation and auto-PEEP. Methods are available for assessing these, but are not appropriate for patients with respiratory muscle activity, as occurs in pressure support. Information may exist in expiratory flow and carbon dioxide measurements, which, when taken together, may help characterize dynamic hyperinflation. This paper postulates such patterns and investigates whether these can be seen systematically in data. Two variables are proposed summarizing the number of incomplete expirations quantified as a lack of return to zero flow in expiration (IncExp), and the end tidal CO2 variability (varETCO2), over 20 breaths. Using these variables, three patterns of ventilation are postulated: (a) few incomplete expirations (IncExp < 2) and small varETCO2; (b) a variable number of incomplete expirations (2 ≤ IncExp ≤ 18) and large varETCO2; and (c) a large number of incomplete expirations (IncExp > 18) and small varETCO2. IncExp and varETCO2 were calculated from data describing respiratory flow and CO2 signals in 11 patients mechanically ventilated at 5 levels of pressure support. Data analysis showed that the three patterns presented systematically in the data, with periods of IncExp < 2 or IncExp > 18 having significantly lower variability in end-tidal CO2 than periods with 2 ≤ IncExp ≤ 18 (p < 0.05). It was also shown that sudden change in IncExp from either IncExp < 2 or IncExp > 18 to 2 ≤ IncExp ≤ 18 results in significant, rapid, change in the variability of end-tidal CO2 p < 0.05. This study illustrates that systematic patterns of expiratory flow and end-tidal CO2 are present in patients in supported mechanical ventilation, and that changes between these patterns can be identified. Further studies are required to see if these patterns characterize dynamic hyperinflation. If so, then their combination may provide a useful addition to understanding the patient at the bedside.

Effect of positive end-expiratory pressure on pulmonary shunt and dynamic compliance during abdominal surgery.

BACKGROUND: General anaesthesia decreases pulmonary compliance and increases pulmonary shunt due to the development of atelectasis. The presence of capnoperitoneum during laparoscopic surgery may further decrease functional residual capacity, promoting an increased amount of atelectasis compared with laparotomy. The aim of this study was to evaluate the effects of different levels of positive end-expiratory pressure (PEEP) in both types of surgery and to investigate whether higher levels of PEEP should be used during laparoscopic surgery. METHODS: This prospective observational study included 52 patients undergoing either laparotomy or laparoscopic surgery. Three levels of PEEP were applied in random order: (1) zero (ZEEP), (2) 5 cmH2O and (3) 10 cmH2O. Pulmonary shunt and ventilation/perfusion mismatch were assessed by the automatic lung parameter estimator system. RESULTS: Pulmonary shunt was similar in both groups. However, in laparotomy, a PEEP of 5 cmH2O significantly decreased shunt when compared with ZEEP (12 vs 6%; P=0.001), with additional PEEP having no further effect. In laparoscopic surgery, a significant reduction in shunt (13 vs 6%; P=0.001) was obtained only at a PEEP of 10 cmH2O. Although laparoscopic surgery was associated with a lower pulmonary compliance, increasing levels of PEEP were able to ameliorate it in both groups. CONCLUSION: Both surgeries have similar negative effects on pulmonary shunt, while the presence of capnoperitoneum reduced only the pulmonary compliance. It appears that a more aggressive PEEP level is required to reduce shunt and to maximize compliance in case of laparoscopic surgery.

Journal of Clinical Monitoring and Computing 2015 end of year summary: respiration.

This paper reviews 17 papers or commentaries published in Journal of Clinical Monitoring and Computing in 2015, within the field of respiration. Papers were published covering monitoring and training of breathing, monitoring of gas exchange, hypoxemia and acid-base, and CO2 monitoring.

Historical Matching Strategies in Kidney Paired Donation: The 7-Year Evolution of a Web-Based Virtual Matching System.

Failure to convert computer-identified possible kidney paired donation (KPD) exchanges into transplants has prohibited KPD from reaching its full potential. This study analyzes the progress of exchanges in moving from "offers" to completed transplants. Offers were divided into individual segments called 1-way transplants in order to calculate success rates. From 2007 to 2014, the Alliance for Paired Donation performed 243 transplants, 31 in collaboration with other KPD registries and 194 independently. Sixty-one of 194 independent transplants (31.4%) occurred via cycles, while the remaining 133 (68.6%) resulted from nonsimultaneous extended altruistic donor (NEAD) chains. Thirteen of 35 (37.1%) NEAD chains with at least three NEAD segments accounted for 68% of chain transplants (8.6 tx/chain). The "offer" and 1-way success rates were 21.9 and 15.5%, respectively. Three reasons for failure were found that could be prospectively prevented by changes in protocol or software: positive laboratory crossmatch (28%), transplant center declined donor (17%) and pair transplanted outside APD (14%). Performing a root cause analysis on failures in moving from offer to transplant has allowed the APD to improve protocols and software. These changes have improved the success rate and the number of transplants performed per year.

Comparing the Performance Status Scale and MD Anderson Dysphagia Inventory as swallowing outcome measures in head and neck cancer: a prospective cohort study.

OBJECTIVES: To examine the relationship between the two disease-specific measures currently in use to assess swallowing outcomes following treatment in patients with head and neck cancer: the Performance Status Scale (PSS) and MD Anderson Dysphagia Inventory (MDADI). DESIGN: A prospective cohort study. SETTING: Four head and neck cancer multidisciplinary clinics in the North of England Cancer Network. PARTICIPANTS: 114 patients with cancers of the upper aerodigestive tract. MAIN OUTCOME MEASURE: Measures of swallowing function administered prospectively across 4 timepoints RESULTS: Spearman's correlation coefficients were used to measure the relationship between the two scales. There was statistically significant correlation between the two tools at pre-treatment (rs = 0.428, P < 0.000), 3 months post-treatment (rs = 0.454, P < 0.002), 6 months post-treatment (rs = 0.551, P < 0.000) and 12 months post-treatment (rs = 0.680, P < 0.000). CONCLUSION: This is the first prospective study comparing the MDADI and PSS questionnaires at multiple time points. Our study shows that these different instruments have a good relationship in measuring swallowing function in patients with head and neck cancer in short and medium term after treatment.

Nutrient additions to seagrass seed planting improve seedling emergence and growth.

To maximize the opportunities of seagrass as a nature-based solution requires restoration to occur on a large scale. New methods and knowledge are required that can solve ecological bottlenecks, improving its reliability and effectiveness. Although there is increasing interest in the use of seeds for seagrass restoration there exists a limited understanding of how best to plant them with the most knowledge on germination and seedling emergence coming from laboratory studies. Here we present the results of a novel field study on the emergence success of seeds of the seagrass Zostera marina when subjected to varied planting treatments. Seeds were planted into hessian bags according to a factorial design of three treatments (sediment type, detritus addition, and nutrient addition). By adding nutrients to natural sediment, the present study provides some evidence of seagrass shoot emergence and maximum shoot length doubling. The present study provides evidence that even in heavily nutrient-rich environments, seagrass sediments may require additional nutrients to improve seedling emergence and growth. It also highlights the highly variable nature of planting seagrass seeds in shallow coastal environments. Critically this study provides increasing levels of evidence that small subtleties in the method can have large consequences for seagrass restoration and that for restoration to scale to levels that are relevant for nature-based solutions there remain many unknowns that require consideration.

Replication of 13 genome-wide association (GWA)-validated risk variants for type 2 diabetes in Pakistani populations.

AIMS/HYPOTHESIS: Recent genome-wide association (GWA) studies and subsequent replication studies have greatly increased the number of validated type 2 diabetes susceptibility variants, but most of these have been conducted in European populations. Despite the high prevalence of the disease in South Asians, studies investigating GWA-validated type 2 diabetes risk variants in this ethnic group are limited. We investigated 30 single nucleotide polymorphisms (SNPs), predominantly derived from recent GWA studies, to determine if and to what extent these variants affect type 2 diabetes risk in two Punjabi populations, originating predominantly from the District of Mirpur, Pakistan. METHODS: Thirty SNPs were genotyped in 1,678 participants with type 2 diabetes and 1,584 normoglycaemic control participants from two populations; one resident in the UK and one indigenous to the District of Mirpur. RESULTS: SNPs in or near PPARG, TCF7L2, FTO, CDKN2A/2B, HHEX/IDE, IGF2BP2, SLC30A8, KCNQ1, JAZF1, IRS1, KLF14, CHCHD9 and DUSP9 displayed significant (p < 0.05) associations with type 2 diabetes, with similar effect sizes to those seen in European populations. A constructed genetic risk score was associated with type 2 diabetes (p = 5.46 × 10(-12)), BMI (p = 2.25 × 10(-4)) and age at onset of diabetes (p = 0.002). CONCLUSIONS/INTERPRETATION: We have demonstrated that 13 variants confer an increased risk of type 2 diabetes in our Pakistani populations; to our knowledge this is the first time that SNPs in or near KCNQ1, JAZF1, IRS1, KLF14, CHCHD9 and DUSP9 have been significantly associated with the disease in South Asians. Large-scale studies and meta-analyses of South Asian populations are needed to further confirm the effect of these variants in this ethnic group.

An FTO variant is associated with Type 2 diabetes in South Asian populations after accounting for body mass index and waist circumference.

AIMS: A common variant, rs9939609, in the FTO (fat mass and obesity) gene is associated with adiposity in Europeans, explaining its relationship with diabetes. However, data are inconsistent in South Asians. Our aim was to investigate the association of the FTO rs9939609 variant with obesity, obesity-related traits and Type 2 diabetes in South Asian individuals, and to use meta-analyses to attempt to clarify to what extent BMI influences the association of FTO variants with diabetes in South Asians. METHODS: We analysed rs9939609 in two studies of Pakistani individuals: 1666 adults aged ≥40 years from the Karachi population-based Control of Blood Pressure and Risk Attenuation (COBRA) study and 2745 individuals of Punjabi ancestry who were part of a Type 2 diabetes case-control study (UK Asian Diabetes Study/Diabetes Genetics in Pakistan; UKADS/DGP). The main outcomes were BMI, waist circumference and diabetes. Regression analyses were performed to determine associations between FTO alleles and outcomes. Summary estimates were combined in a meta-analysis of 8091 South Asian individuals (3919 patients with Type 2 diabetes and 4172 control subjects), including those from two previous studies. RESULTS: In the 4411 Pakistani individuals from this study, the age-, sex- and diabetes-adjusted association of FTO variant rs9939609 with BMI was 0.45 (95%CI 0.24-0.67) kg/m(2) per A-allele (P=3.0 × 10(-5) ) and with waist circumference was 0.88 (95% CI 0.36-1.41) cm per A-allele (P=0.001). The A-allele (30% frequency) was also significantly associated with Type 2 diabetes [per A-allele odds ratio (95%CI) 1.18 (1.07-1.30); P=0.0009]. A meta-analysis of four South Asian studies with 8091 subjects showed that the FTO A-allele predisposes to Type 2 diabetes [1.22 (95%CI 1.14-1.31); P=1.07 × 10(-8) ] even after adjusting for BMI [1.18 (95%CI 1.10-1.27); P=1.02 × 10(-5) ] or waist circumference [1.18 (95%CI 1.10-1.27); P=3.97 × 10(-5) ]. CONCLUSIONS: The strong association between FTO genotype and BMI and waist circumference in South Asians is similar to that observed in Europeans. In contrast, the strong association of FTO genotype with diabetes is only partly accounted for by BMI.

Acid-base chemistry of plasma: consolidation of the traditional and modern approaches from a mathematical and clinical perspective.

OBJECTIVE: Debate still exists as to whether the Stewart (modern) or traditional model of acid-base chemistry is best in assessing the acid-base status of critically ill patients. Recent studies have compared various parameters from the modern and traditional approaches, assessing the clinical usefulness of parameters such as base excess, anion gap, corrected anion gap, strong ion difference and strong ion gap. To compare the clinical usefulness of these parameters, and hence the different approaches, requires a clear understanding of their meaning; a task only possible through understanding the mathematical basis of the approaches. The objective of this paper is to provide this understanding, limiting the mathematics to a necessary minimum. METHOD: The first part of this paper compares the mathematics of these approaches, with the second part illustrating the clinical usefulness of the approaches using a patient example. RESULTS: This analysis illustrates the almost interchangeable nature of the equations and that the same clinical conclusions can be drawn regardless of the approach adopted. CONCLUSIONS: Although different in their concepts, the traditional and modern approaches based on mathematical models can be seen as complementary giving, in principle, the same information about the acid-base status of plasma.