Educational Project: Learning From The Patient

Introduction

Learning from the patient presents a pedagogical experience where patients expert in mental health participate as teachers in the teaching-learning processes.

This training activity is a pilot aimed to assess the impact and integration in the study plan of the students following the training course in auxiliary nursing care, Barcelona.

Objectives

To offer a global vision on mental health problems in order to break the stigma, being the persons affected the main actors.

Stress the value of the patient voice and its particular way of living and suffering the illness in order to offer a suitable attention.

Promote the integration of expert patients as teachers in the education programs.

Methodology

The training activity starts with the evaluation of the previous mental health knowledge and believes of the students.

Round table with the participation of:

– 2 expert patients explain their history of life and how the illness affects their day-to-day life;

– 2 mental health professionals explain how they help patients to recover and empower them.

Four groups about the impact of illness on a personal, educational, working and social level.

Results

The expert patients were very optimistic and reinforced their own self-esteem. The students show a more positive attitude towards mental illness and express that patients’ are first PEOPLE, then patients’

Conclusions

The expert patients collaborating with professionals are ready to become teachers in the health care academic programs and, specifically, in mental health.

Taking into account the patient voice and vision improves the technical, personal and social competences of professionals.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Balancing Success and Risk in Orthopedic Trauma Surgery: The Ridge-Walking between Sound Accepting "Good" and Risky Striving for "Better"

Immediate post-operative rating of surgical performance can be a valuable source of learning when trying to analyze the reasons for the difference between "work as planned" and "work as done". There are many reasons for the difference, but they can only be found if complete documentation of the surgical steps allows retrospective scrutiny. Documentation like ICUC1 provides this opportunity for scrutiny and may allow better understanding of some unexpected post-operative evolutions.

[Carbamazepine and psychotropic treatment interaction: Two case studies of carbamazepine overdosage]

Drug interaction is a frequent situation in pediatrics and child psychiatry. Carbamazepine (CBZ) is an antiepileptic drug used as a mood stabilizer in child psychiatry. CBZ is known to be a potent inducer of various CYP isoenzymes of cytochrome P450, which might result in a decrease in the plasma concentration of associated treatments. We describe two cases of CBZ overdosage in adolescent inpatients (14 and 16 years). The patients were treated with risperidone associated with fluoxetine in one and with loxapine in the other case, and CBZ was introduced as a mood stabilizer. Patients presented typical clinical symptoms (fatigue, dizziness, gastrointestinal signs, blurred vision). Overdosage was confirmed by an elevated CBZ plasma concentration (17 and 15.5 mg/L, therapeutic range 4-12 mg/L). We recommend introducing CBZ very progressively in patients treated with psychotropics, particularly when it is associated to several treatments. An intensification of clinical and biological follow-up with early plasma concentration testing should allow for better treatment adjustment.

Incidence and initial disease course of inflammatory bowel diseases in 2011 in Europe and Australia: results of the 2011 ECCO-EpiCom inception cohort

BACKGROUND AND AIMS

The aim of the present study was to validate the IBD (inflammatory bowel diseases) incidence reported in the 2010 ECCO-EpiCom (European Crohn's and Colitis Organization-Epidemiological Committee) inception cohort by including a second independent inception cohort from participating centers in 2011 and an Australian center to investigate whether there is a difference in the incidence of IBD between Eastern and Western European countries and Australia.

METHODS

Fourteen centers from 5 Eastern and 9 Western European countries and one center from Australia participated in the ECCO-EpiCom 2011 inception cohort. Patients' data regarding disease type, socio-demographic factors, extraintestinal manifestations and therapy were entered into the Web-based EpiCom database, www.ecco-epicom.eu.

RESULTS

A total of 711 adult patients were diagnosed during the inclusion year 2011, 178 (25%) from Eastern, 461 (65%) from Western Europe and 72 (10%) from Australia; 259 (37%) patients were diagnosed with Crohn's disease, 380 (53%) with ulcerative colitis and 72 (10%) with IBD unclassified. The mean annual incidence rate for IBD was 11.3/100,000 in Eastern Europe, 14.0/100,000 in Western Europe and 30.3/100,000 in Australia. Significantly more patients were diagnosed with complicated disease at diagnosis in Eastern Europe compared to Western Europe (43% vs. 27%, p=0.02).

CONCLUSION

Incidence rates, disease phenotype and initial treatment characteristics in the 2011 ECCO-EpiCom cohort were not significantly different from that reported in the 2010 cohort.

Health-related quality of life improves during one year of medical and surgical treatment in a European population-based inception cohort of patients with inflammatory bowel disease--an ECCO-EpiCom study

BACKGROUND & AIMS

Health-related quality of life (HRQoL) is impaired in patients with Inflammatory Bowel Disease (IBD). The aim was prospectively to assess and validate the pattern of HRQoL in an unselected, population-based inception cohort of IBD patients from Eastern and Western Europe.

METHODS

The EpiCom inception cohort consists of 1560 IBD patients from 31 European centres covering a background population of approximately 10.1 million. Patients answered the disease specific Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and generic Short Form 12 (SF-12) questionnaire at diagnosis and after one year of follow-up.

RESULTS

In total, 1079 patients were included in this study. Crohn's disease (CD) patients mean SIBDQ scores improved from 45.3 to 55.3 in Eastern Europe and from 44.9 to 53.6 in Western Europe. SIBDQ scores for ulcerative colitis (UC) patients improved from 44.9 to 57.4 and from 48.8 to 55.7, respectively. UC patients needing surgery or biologicals had lower SIBDQ scores before and after compared to the rest, while biological therapy improved SIBDQ scores in CD. CD and UC patients in both regions improved all SF-12 scores. Only Eastern European UC patients achieved SF-12 summary scores equal to or above the normal population.

CONCLUSION

Medical and surgical treatment improved HRQoL during the first year of disease. The majority of IBD patients in both Eastern and Western Europe reported a positive perception of disease-specific but not generic HRQoL. Biological therapy improved HRQoL in CD patients, while UC patients in need of surgery or biological therapy experienced lower perceptions of HRQoL than the rest.

MEG spectral analysis in subtypes of mild cognitive impairment

Mild cognitive impairment (MCI) has been described as an intermediate stage between normal aging and dementia. Previous studies characterized the alterations of brain oscillatory activity at this stage, but little is known about the differences between single and multidomain amnestic MCI patients. In order to study the patterns of oscillatory magnetic activity in amnestic MCI subtypes, a total of 105 subjects underwent an eyes-closed resting-state magnetoencephalographic recording: 36 healthy controls, 33 amnestic single domain MCIs (a-sd-MCI), and 36 amnestic multidomain MCIs (a-md-MCI). Relative power values were calculated and compared among groups. Subsequently, relative power values were correlated with neuropsychological tests scores and hippocampal volumes. Both MCI groups showed an increase in relative power in lower frequency bands (delta and theta frequency ranges) and a decrease in power values in higher frequency bands (alpha and beta frequency ranges), as compared with the control group. More importantly, clear differences emerged from the comparison between the two amnestic MCI subtypes. The a-md-MCI group showed a significant power increase within delta and theta ranges and reduced relative power within alpha and beta ranges. Such pattern correlated with the neuropsychological performance, indicating that the a-md-MCI subtype is associated not only with a "slowing" of the spectrum but also with a poorer cognitive status. These results suggest that a-md-MCI patients are characterized by a brain activity profile that is closer to that observed in Alzheimer disease. Therefore, it might be hypothesized that the likelihood of conversion to dementia would be higher within this subtype.

A form of apolipoprotein a-I is found specifically in relapses of focal segmental glomerulosclerosis following transplantation

Recurrence of idiopathic focal segmental glomerulosclerosis (FSGS) following kidney transplantation occurs in a large percentage of patients. Accurate prediction of recurrence and elucidation of its pathogenesis are major therapeutic goals. To detect differential proteins related to FSGS recurrence, proteomic analysis was performed on plasma and urine samples from 35 transplanted idiopathic FSGS patients, divided into relapsing and nonrelapsing. Several proteins were detected increased in urine of relapsing FSGS patients, including a high molecular weight form of apolipoprotein A-I, named ApoA-Ib, found exclusively in relapsing patients. This finding was verified by Western blot individually in the 35 patients and validated in an independent group of 40 patients with relapsing or nonrelapsing FSGS, plus two additional groups: FSGS-unrelated patients showing different proteinuria levels (n = 30), and familial FSGS transplanted patients (n = 14). In the total of 119 patients studied, the ApoA-Ib form was detected in 13 of the 14 relapsing FSGS patients, and in one of the 61 nonrelapsing patients. Only one of the 30 patients with FSGS-unrelated proteinuria tested positive for ApoA-Ib, and was not detected in familial patients. Urinary ApoA-Ib is associated with relapses in idiopathic FSGS and warrants additional investigation to determine its usefulness as biomarker of relapse following transplantation.

What is the normal small bowel length in humans? first donor-based cohort analysis

Normal small bowel length (SBL) has been reported within a wide range, but never studied in a cohort of either pediatric or adult deceased donors. Between 5/2006 and 2/2011, SBL was measured in all grafts procured for intestinal transplantation at a single center and used for either isolated intestinal transplant (15) or multiorgan transplants (5) employing a standardized method. SBL was the only not significantly different variable among pediatric and adult donors divided by age 16. Furthermore, donors were classified in 3 groups: group 1: Height < 70 cm, group 2: 71-150 cm and group 3: ≥ 151 cm. Mean age was: 0.58, 5.6, 22.01 years, respectively. Mean height and weight were 65.8, 123.2, 166.1 cm (p = 0.001) and 6.9, 23.8, 65.2 kg (p = 0.001), for each group. The SBL by group was: 283.0, 324.7, 356.0 cm, remaining as the only nonsignificant variable (p = 0.06), in contrast to BMI, BSA (p = 0.001). The SBL/height ratio: 4.24, 2.7, 2.12 (p = 0.001; rho: -0.623) or SBL/BSA ratio was 8.36, 3.7, and 2.03, respectively (p : 0.0001; rho: -0.9). SBL does not increase with growth like other anthropometric variables. The SBL/height ratio significantly decreases with growth; however, bowel diameter increases, which needs further evaluation.

Concepts of diabetes self-management in Mexican American and African American low-income patients with diabetes

The goal of the study was to explore low-income minority patients' concepts of diabetes self-management and assess the extent to which patient beliefs correspond to evidence-based recommendations. African American and Mexican American patients with type 2 diabetes were recruited from safety net clinics that serve the uninsured and under-insured in Chicago and San Francisco to participate in focus group discussions. Grounded theory was used to identify themes related to diabetes self-management. Strategies participants mentioned for diabetes self-care were medication use, diet, weight loss and exercise. Eating more fruit and vegetables and consuming smaller portions were the most commonly mentioned dietary behaviors to control diabetes. African Americans expressed skepticism about taking medications. Mexican Americans discussed barriers to acquiring medications and use of herbal remedies. Mexican Americans frequently mentioned intentional exercise of long duration as a management strategy, whereas African Americans more frequently described exercise as regular activities of daily living. Blood glucose self-monitoring and reducing risks of diabetes complications were rarely mentioned as diabetes self-management behaviors. African American and Mexican American patients have different concepts of diabetes self-management, especially with regard to medication use and physical activity. Consideration of these differences may facilitate design of effective self-management interventions for these high-risk populations.

Deadly diving? Physiological and behavioural management of decompression stress in diving mammals

Decompression sickness (DCS; 'the bends') is a disease associated with gas uptake at pressure. The basic pathology and cause are relatively well known to human divers. Breath-hold diving marine mammals were thought to be relatively immune to DCS owing to multiple anatomical, physiological and behavioural adaptations that reduce nitrogen gas (N(2)) loading during dives. However, recent observations have shown that gas bubbles may form and tissue injury may occur in marine mammals under certain circumstances. Gas kinetic models based on measured time-depth profiles further suggest the potential occurrence of high blood and tissue N(2) tensions. We review evidence for gas-bubble incidence in marine mammal tissues and discuss the theory behind gas loading and bubble formation. We suggest that diving mammals vary their physiological responses according to multiple stressors, and that the perspective on marine mammal diving physiology should change from simply minimizing N(2) loading to management of the N(2) load. This suggests several avenues for further study, ranging from the effects of gas bubbles at molecular, cellular and organ function levels, to comparative studies relating the presence/absence of gas bubbles to diving behaviour. Technological advances in imaging and remote instrumentation are likely to advance this field in coming years.

Cerebral infarction secondary to vasospasm after perimesencephalic subarachnoid hemorrhage

Perimesencephalic subarachnoid hemorrhage (pSAH) has been described as a distinct form of subarachnoid hemorrhage (SAH) associated with good outcomes. We report a 48-year-old female who developed cerebral infarction due to severe diffuse vasospasm following pSAH. The patient presented with non-aneurysmal pSAH and was discharged home on day 5. However, one week later she developed an acute onset of right hemiparesis. A brain MRI showed acute infarctions on diffusion weighted imaging and her cerebral angiogram showed diffuse vasospasm. The patient received intra-arterial diltiazem and hypervolemic-hypertensive-hemodilution therapy with resulting resolution of the vasospasm and hemiparesis. While not as common as in SAH, there is a potential for the occurrence of cerebral infarction due to vasospasm after pSAH.

Abstract P1-01-26: Clinical Implications of pN0 mol+ in Breast Cancer Patients

Introduction: Axillary lymph node involvement is the most significant prognostic factor in breast cancer patients. The real-time PCR (RT-PCR) appeared to be a sensitive method to diagnose the lymph node axillary stage, but the clinical relevance of pN0 (mol+) has not yet been established. We present the clinical characteristics of the subgroup of patients diagnosed as pN0 (mol+) and their clinical outcome after a mean follow-up of 72 months.

Material & Methods: Between June 2000 and November 2006, 674 patients with T1-T3 primary invasive breast cancer and low probability of axillary lymph node involvement, were included in a prospective study of the molecular analyses of the sentinel lymph node (SLN) biopsy. Each SLN was bi-dissected; one half was snap frozen for subsequent molecular analysis, on the other half, routine pathological analyses was performed, including immunoassaying for cam 5.2 antibody. The molecular analyses was performed by RT-PCR using the gene marker KRT 19. Adjuvant treatment and clinical outcome has been recorded after a mean follow-up of 72 months.

Results: 135 cases were staged as pN0 (mol+). Most of them corresponded to infiltrating ductal carcinoma (95%), 2.2% lobular, 1.5% colloid and 1.5% medullar. Nuclear grade: I in 5% of cases, II in 35% and III in 34% of them. By tumour stage, 1.5% were pT1a; 24% pT1b: 58% pT1c; 15% pT2 and 1.5% pT3. According to molecular subtypes, 73% of cases were luminal, 18.5% triple negative ones and 8.5% HER2 positive. All the patients except 5 ones received adjuvant systemic treatment: 41.5% hormonal therapy for at least 5 years; 32% chemotherapy followed by hormonotherapy and 18.5% chemotherapy, of those two patients received trastuzumab for 1 year. At the time of the analysis, there have been 4 local recurrences, 3 metastasic recurrences and 2 contra lateral ones. For survival analyses, 2 cases were excluded for presenting a previous breast cancer history, and one patient died after the last CMF from a septic shock. Of the 132 resting patients, 122 are free of relapse at the time of this analysis, the 3 patients with distant metastasis are on treatment for metastatic disease, 2 patients were death by other neoplastic diseases and 5 cases were death by other medical causes (4 cardiac and 1 respiratory failure). Survival rate for N0 mol+ was 94%, no specific breast cancer death have occurred at the present survival analyses.

Conclusions: Tumours diagnosed as pN0 (mol+) presented clinical and molecular characteristics of worse prognosis than pN0 (mol-) and this is translated in a higher proportion of patients staged N0 (mol+) treated with chemotherapy than pN0 (mol-). Survival in this subgroup of patients is high in relation to the adjuvant treatment delivered.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-26.

Pheochromocytoma in Eisenmenger's syndrome: a therapeutic challenge

Surgical treatment of pheochromocytoma is associated with high hemodynamic risk, which is even higher in patients with complex congenital heart disease. Nowadays, patients with cyanotic congenital heart disease are living longer and an increased incidence of pheochromocytoma has been reported in this population. We demonstrate the feasibility and importance of minimally invasive surgery in the management of pheochromocytoma in a 45-year-old woman with complex congenital heart disease and Eisenmenger's syndrome. A successful laparoscopic resection of the tumor was performed in association with multidisciplinary management during hospitalization.

Data Quality Assessment for In Silico Methods: A Survey of Approaches and Needs

As indicated in Chapter 3, there are a large number of potential sources of data now available for modelling purposes. These range from historical literature references for a few compounds to highly curated databases of hundreds of thousands of compounds, available via the internet. Before including any data in an in silico model, the question of data quality must be addressed. Although it is difficult to define the quality of data in absolute terms, it is possible to assess the suitability of data for a given purpose. There are many reasons for variability within data and the degree of error that is acceptable for one model may not be the same as for another. For example generating a global model intended to pre-screen large numbers of compounds does not require the same degree of accuracy as performing an individual risk assessment for a chemical of interest. In this chapter, sources of data variability and error will be discussed and formal methods to score data quality, such as use of the Klimisch criteria, will be described. Examples of data quality issues will be given for specific endpoints relating to both environmental and human health effects. Mathematical approaches (Dempster-Schafer theory and Bayesian networks) demonstrating how this information relating to confidence in the data can be incorporated into in silico models is also discussed.