Trans-radial cerebral angiography for stereotactic radiosurgery treatment of arteriovenous malformations

OBJECTIVES

The popularity of trans-radial access (TRA) for cerebral angiography is growing. Potential benefits of TRA over traditional trans-femoral access (TFA) are multitude. This study aimed to evaluate discharge outcomes and patient opinion of TRA compared to TFA in patients undergoing cerebral angiography prior to stereotactic radiosurgery (SRS) treatment for cerebral arteriovenous malformations.

METHODS

Consecutive patients treated at the National Centre for Stereotactic Radiosurgery (Sheffield, United Kingdom) over a 22-month period were included. All patients underwent cerebral angiography with either TRA or TFA as part of treatment planning prior to SRS. TRA patients who had previously undergone TFA in other centres were surveyed for their experience of cerebral angiography using a questionnaire. SRS staff at our centre was approached for their opinion.

RESULTS

492 patients were included (median age = 43 years, 57.5% male, median lesions treated = 1). More patients underwent angiography with TFA (75.2%) than TRA (24.8%). No difference was found in accumulated dose for angiography between the groups (p>0.05). There was 17.6% reduction in overnight stay between TRA and TRF, the proportion of patients requiring overnight admission was higher for the TFA (35.2%) than TRA (17.6%, p<0.05). 101 patients were surveyed, with a response rate of 47%. Most respondents (79%) indicated preference for TRA over TFA.

CONCLUSIONS

Use of TRA in pre-SRS cerebral angiography is feasible and improves both patient and staff experience. The adoption of TRA could have important implications for department resources and costs by reducing the proportion of overnight admissions.

Personal protective equipment training & lived experience for healthcare staff during COVID-19

Objectives

To describe the lived experience of healthcare staff during the Coronavirus Disease 2019 (COVID-19) pandemic relating to the use of personal protective equipment (PPE) and investigate risks associated with PPE use, error mitigation and acceptability of mindfulness incorporation into PPE practice.

Methods

A qualitative human factors' study at two Irish hospitals occurred in late 2020. Data was collected by semi-structured interview and included role description, pre-COVID-19 PPE experience, the impact of COVID-19 on lived experience, risks associated with PPE use, contributory factors to errors, error mitigation strategies and acceptability of incorporating mindfulness into PPE practice.

Results

Of 45 participants, 23 of whom were nursing staff (51%), 34 (76%) had previously worn PPE and 25 (56%) used a buddy system. COVID-19 lived experience impacted most on social life/home-work interface (n=36, 80%). Nineteen staff (42%) described mental health impacts. The most cited risk concerned 'knowledge of procedures' (n=18, 40%). Contributory factors to PPE errors included time (n=15, 43%) and staffing pressures (n=10, 29%). Mitigation interventions included training/education (n=12, 40%). The majority (n=35, 78%) supported mindfulness integration into PPE practice.

Conclusions

PPE training should address healthcare staff lived experiences and consider incorporation of mindfulness and key organisational factors contributing to safety.

CTIM-01. PHASE II TRIAL OF PEMBROLIZUMAB AND LENVATINIB FOR LEPTOMENINGEAL METASTASES

Leptomeningeal metastasis (LMD) is a late complication of cancer with poor prognosis and median survival of approximately 4-6 weeks without treatment. Whole brain radiation remains the mainstay of treatment, however it can cause significant neurocognitive sequelae and has not been shown to prolong overall survival. Thus, new treatment strategies are urgently needed to improve outcomes in patients with LMD. Results from recent Phase 2 studies of immune checkpoint inhibitors in LMD shows promising improvement in overall survival. Combining anti-VEGF therapy and immunotherapy may control symptoms due to inflammation and tumor-induced irritation, minimize steroid use, and promote improved efficacy of immunotherapy through modulation of the tumor immune microenvironment. We designed a multi-institutional, single-arm Phase 2 study of pembrolizumab in combination with lenvatinib in patients with LMD from any solid tumor. The primary objective is to estimate the overall survival rate at 6 months (OS6). A Simon two-stage design with a total sample size of 19 evaluable patients will be used to compare a null hypothesis of OS6 of 25% against an alternative hypothesis of 55%. Secondary objectives include assessing safety of pembrolizumab and lenvatinib in this patient population, systemic response rate, intracranial/intraspinal response rate, and progression-free survival. We will also explore clinician-reported neurologic outcomes and patient-reported quality of life and symptom burden. Blood, cerebrospinal fluid, and tissue biomarkers will be analyzed to determine predictors of response. Patients must be on minimal doses of steroids prior to study enrollment and cannot have received prior immune checkpoint inhibitor or anti-VEGF therapy. Response to treatment will be determined using RANO-BM for intracranial disease and RECIST 1.1 for systemic disease. Study accrual is anticipated over 12-24 months with anticipated total study duration of 30 months.

IMMU-08. PHASE II TRIAL OF PEMBROLIZUMAB AND LENVATINIB FOR LEPTOMENINGEAL METASTASES

Leptomeningeal metastasis (LMD) is a late complication of cancer with poor prognosis and median survival of approximately 4-6 weeks without treatment. Whole brain radiation remains the mainstay of treatment, however it can cause significant neurocognitive sequelae and has not been shown to prolong overall survival. Thus, new treatment strategies are urgently needed to improve outcomes in patients with LMD. Results from recent Phase 2 studies of immune checkpoint inhibitors in LMD shows promising improvement in overall survival. Combining anti-VEGF therapy and immunotherapy may control symptoms due to inflammation and tumor-induced irritation, minimize steroid use, and promote improved efficacy of immunotherapy through modulation of the tumor immune microenvironment. We designed a multi-institutional, single-arm Phase 2 study of pembrolizumab in combination with lenvatinib in patients with LMD from any solid tumor. The primary objective is to estimate the overall survival rate at 6 months (OS6). A Simon two-stage design with a total sample size of 19 evaluable patients will be used to compare a null hypothesis of OS6 of 25% against an alternative hypothesis of 55%. Secondary objectives include assessing safety of pembrolizumab and lenvatinib in this patient population, systemic response rate, intracranial/intraspinal response rate, and progression-free survival. We will also explore clinician-reported neurologic outcomes and patient-reported quality of life and symptom burden. Blood, cerebrospinal fluid, and tissue biomarkers will be analyzed to determine predictors of response. Patients must be on minimal doses of steroids prior to study enrollment and cannot have received prior immune checkpoint inhibitor or anti-VEGF therapy. Response to treatment will be determined using RANO-BM for intracranial disease and RECIST 1.1 for systemic disease. Study accrual is anticipated over 12-24 months with anticipated total study duration of 30 months.

Research and innovation as a catalyst for food system transformation

BACKGROUND

Food systems are associated with severe and persistent problems worldwide. Governance approaches aiming to foster sustainable transformation of food systems face several challenges due to the complex nature of food systems.

SCOPE AND APPROACH

In this commentary we argue that addressing these governance challenges requires the development and adoption of novel research and innovation (R&I) approaches that will provide evidence to inform food system transformation and will serve as catalysts for change. We first elaborate on the complexity of food systems (transformation) and stress the need to move beyond traditional linear R&I approaches to be able to respond to persistent problems that affect food systems. Though integrated transdisciplinary approaches are promising, current R&I systems do not sufficiently support such endeavors. As such, we argue, we need strategies that trigger a double transformation - of food systems and of their R&I systems.

KEY FINDINGS AND CONCLUSIONS

Seizing the opportunities to transform R&I systems has implications for how research is done - pointing to the need for competence development among researchers, policy makers and society in general - and requires specific governance interventions that stimulate a systemic approach. Such interventions should foster transdisciplinary and transformative research agendas that stimulate portfolios of projects that will reinforce one another, and stimulate innovative experiments to shape conditions for systemic change. In short, a thorough rethinking of the role of R&I as well as how it is funded is a crucial step towards the development of the integrative policies that are necessary to engender systemic change - in the food system and beyond.

Nudging Discharge Readiness With a Poster: A Sequential, Exploratory Mixed Methods Pilot Study of Patient Caregivers

Many hospitals face a common challenge: limited space for a high number of patients. This has led to quick patient throughput, which can impact patient perception of discharge readiness. This study examined whether a poster highlighting tasks to complete as part of the discharge process improved caregiver perception of readiness to transition home. Using a sequential, exploratory mixed methods design, focus groups were convened to explore clinical staff perspective on the discharge process on 3 pediatric inpatient units at a large, urban, pediatric academic medical center in the United States. Analysis of this content informed the design of a poster intervention to “nudge” caregivers (eg, parents, legal guardians) toward readiness and self-efficacy that was then tested in a randomized, controlled experiment. The poster focused on practical knowledge for specific areas of transition adjustment, such as medication and care recipient recovery behaviors, barriers, and enablers. Caregivers (n = 135) completed surveys at discharge indicating their perceived readiness to transition home with their child. Analysis of covariance was used to test the effect of the poster condition (poster vs no poster) on caregiver readiness, preparedness, and confidence for discharge while controlling for previous admission history. Significant effects for poster presence were found on caregivers’ perceived readiness for discharge, F_1,125 = 7.75, P = .006, Cohen’s d = 0.44; and caregivers’ perceived preparedness for the transition home, F_1,121 =7.24, P = .008, Cohen’s d = 0.44. Only a marginal effect was found for poster condition on caregivers’ confidence ratings, F_1,125 = 2.93, P = .090, Cohen’s d = 0.29. The results suggest that simple nudges in the patient care environment may yield measurable improvements in caregiver outcomes.

B-22 Non-Convulsive Seizure and Post-Ictal Psychosis Presenting as Foreign Language in a Monolingual Patient: A Case Report

Objective

This paper seeks to advance the discussion of foreign language automatisms and clinical consequences of Non-Convulsive Status Epilepticus (NCSE) such as post-ictal psychosis. We present the first case of a monolingual English speaker communicating solely in Spanish, a non-native language during an epileptic episode.

Method

A 70-year old man with no history of seizures, epilepsy, or psychiatric illness presented to his primary care provider with episodes of confusion and "speaking Spanish." Prolonged video EEG performed after admission demonstrated a disorganized background with a mixture of generalized theta and delta activity with frequent focal and generalized ictal and epileptiform activity occurring predominantly out of the right hemisphere.

Results

Laboratory evaluation punctures were unrevealing. MRI of the brain with and without contrast were both normal. Keppra and Depakote were continued during the admission. His psychosis and cognitive impairment improved slowly over several days though he did not return back to his neurological baseline. He returned to speaking only English after several days of treatment. He continued to have frontal lobe dysfunction with psychotic features. A diagnosis of rapidly progressive dementia of unclear etiology was given.

Conclusion

Though foreign language automatisms are a rare consequence of NCSE, the combination of psychotic symptoms and confusion presented in this case creates an interesting connection between psychosis, dementia syndromes, and epilepsy, all involving aberrant activity or deficits in similar brain regions. The generation of foreign language automatisms may indicate a form of psychotic symptomology manifesting as a language anomaly as opposed to visual hallucinations, delusions, or formal thought disorder.

Genomic and Biochemical Characterization of Acinetobacter Podophage Petty Reveals a Novel Lysis Mechanism and Tail-Associated Depolymerase Activity

The increased prevalence of drug-resistant, nosocomial Acinetobacter infections, particularly from pathogenic members of the Acinetobacter calcoaceticus-baumannii complex, necessitates the exploration of novel treatments such as phage therapy. In the present study, we characterized phage Petty, a novel podophage that infects multidrug-resistant Acinetobacter nosocomialis and Acinetobacter baumannii Genome analysis reveals that phage Petty is a 40,431-bp ϕKMV-like phage, with a coding density of 92.2% and a G+C content of 42.3%. Interestingly, the lysis cassette encodes a class I holin and a single-subunit endolysin, but it lacks canonical spanins to disrupt the outer membrane. Analysis of other ϕKMV-like genomes revealed that spaninless lysis cassettes are a feature of phages infecting Acinetobacter within this subfamily of bacteriophages. The observed halo surrounding Petty's large clear plaques indicated the presence of a phage-encoded depolymerase capable of degrading capsular exopolysaccharides (EPS). The product of gene 39, a putative tail fiber, was hypothesized to possess depolymerase activity based on weak homology to previously reported phage tail fibers. The 101.4-kDa protein gene product 39 (gp39) was cloned and expressed, and its activity against Acinetobacter EPS in solution was determined. The enzyme degraded purified EPS from its host strain A. nosocomialis AU0783, reducing its viscosity, and generated reducing ends in solution, indicative of hydrolase activity. Given that the accessibility to cells within a biofilm is enhanced by degradation of EPS, phages with depolymerases may have enhanced diagnostic and therapeutic potential against drug-resistant Acinetobacter strains.IMPORTANCE Bacteriophage therapy is being revisited as a treatment for difficult-to-treat infections. This is especially true for Acinetobacter infections, which are notorious for being resistant to antimicrobials. Thus, sufficient data need to be generated with regard to phages with therapeutic potential, if they are to be successfully employed clinically. In this report, we describe the isolation and characterization of phage Petty, a novel lytic podophage, and its depolymerase. To our knowledge, it is the first phage reported to be able to infect both A. baumannii and A. nosocomialis The lytic phage has potential as an alternative therapeutic agent, and the depolymerase could be used for modulating EPS both during infections and in biofilms on medical equipment, as well as for capsular typing. We also highlight the lack of predicted canonical spanins in the phage genome and confirm that, unlike the rounding of lambda lysogens lacking functional spanin genes, A. nosocomialis cells infected with phage Petty lyse by bursting. This suggests that phages like Petty employ a different mechanism to disrupt the outer membrane of Acinetobacter hosts during lysis.

Immediate hypersensitivity to chlorhexidine

Chlorhexidine is a widely used and effective antiseptic agent. Although skin contact is usually well tolerated, it may cause both immediate and delayed hypersensitivity reactions. We report a case of immediate hypersensitivity to chlorhexidine causing both skin and respiratory symptoms following occupational exposure to chlorhexidine in a health-care worker.

A Cooking Intervention to Increase Vegetable Consumption by Parents With Children Enrolled in an Early Head Start Home Visiting Program: A Pilot Study in Portland, Oregon, 2013-2014

Introduction

Cooking interventions may improve diet quality. Most cooking interventions are delivered in group settings. Home visiting programs may be an appropriate mechanism for delivering such interventions to low-income families with young children. We conducted a pilot study to test the feasibility of using a cooking intervention delivered by home visitors to improve attitudes and behaviors related to vegetable consumption by low-income parents with children enrolled in a home visiting program.

Methods

We invited 121 parents with children enrolled in an Early Head Start Home Visiting program in Portland, Oregon, to participate. During 2013–2014, each month for 8 months, home visitors (n = 14) implemented 1 cooking activity plus 1 complementary activity focused on 12 vegetables. We collected pre- and post-intervention data on participants’ cooking confidence and whether they tried and liked the selected vegetables. We also measured fidelity to protocol and home visitors’ perception of intervention usability.

Results

Of 104 participants, 58 provided pre- and post-intervention data. We observed a significant increase in confidence in baking, roasting or grilling vegetables; cooking 6 of 10 vegetables; and trying 7 of 12 vegetables. Nearly all respondents participated in the monthly cooking activity (96%) and complementary activity (94%). Twelve of 14 home visitors reported that the intervention was acceptable, feasible, and easy to understand, and needed systems supports to implement.

Conclusion

Cooking interventions may be a feasible approach to improving attitudes and behaviors related to vegetable consumption by low-income families with young children. Additional research is needed to assess the impact of such interventions on vegetable consumption.

Adolescent Reasoning about Drug Use

In this study, adolescents' reasoning about drug use was investigated from a social-cognitive perspective. In an interview and classification task, adolescents were asked to (a) evaluate drug use in comparison to other social and moral transgressions; (b) distinguish between soft and hard legal and illegal drugs; (c) conceptualize drug use in relation to acts of self-harm, such as suicide; (d) weigh legal, societal, physical, and psychological consequences of drug use; and (e) evaluate authorities' jurisdictions to prohibit drug use. Sixty adolescents, evenly divided between males and females, in Grades 10, 11, and 12 participated. Age and gender differences emerged regarding adolescents' judgments about drug use and whether individuals have the right to harm themselves. The findings have implications for research on adolescent social reasoning and for drug education programs.

Spontaneous cutaneous endometriosis of the umbilicus

Cutaneous endometriosis that arises de novo, without a prior history of surgery, is a rare phenomenon. The clinical diagnosis of cutaneous endometriosis remains challenging due to the variable clinical appearance and symptoms of the condition, and therefore must be considered in the differential diagnosis of any umbilical lesion. We report a 31-year-old woman who presented with spontaneous cutaneous endometriosis of the umbilicus.

What do patients find helpful in psychotherapy? Implications for the therapeutic relationship in mental health nursing

This study examined client perception of the therapeutic impact of two models of therapy delivered by mental health nurses and clinical psychologists respectively - psychodynamic interpersonal therapy (PIT) and cognitive behavioural therapy (CBT). A non-equivalent groups design was used in order to benchmark results against Llewelyn et al.: one group received PIT and the other received CBT. This design was utilized principally because the research was conducted across two practice settings where randomization was not feasible. We used two intact groups in practice research settings that received the therapies as reported in Llewelyn et al. Sixty-one clients receiving CBT or PIT in practice research settings completed a Helpful Aspects of Therapy form after each session in order to measure client perceptions of helpful and hindering events in therapy. Only two out of the 13 impacts were rated as significantly different. PIT clients reported higher levels of 'awareness' than CBT clients, whereas CBT clients reported higher levels of problem solution than PIT clients. The results replicate Llewelyn et al.'s findings in that clients experienced theoretically different models of therapy as broadly similar in their therapeutic impact. We argue that this provides some support for the influence of 'common' rather than 'specific' factors in psychotherapy effectiveness in mental health nursing.

The impact of abdominal aortic aneurysm surgery on intensive care unit resources in an Irish tertiary centre

BACKGROUND

The potential impact of surgical service reconfiguration on intensive care unit (ICU) resources needs to be assessed.

AIMS

To determine the resources required to provide post-operative ICU care to patients undergoing open abdominal aortic aneurysm (AAA) repair or endovascular aneurysm repair (EVAR) at a specialist centre in the HSE South area

METHODS

For 198 patients, we calculated: (1) ICU bed-days; (2) organ support required; and (3) monetary cost of ICU care.

RESULTS

In total, 82.8% (101/122) of patients undergoing open AAA repair required post-operative ICU care (52 emergency and 49 elective). Emergency cases required more ICU bed-days (median 4.2 vs. 1.9, p<0.0005) and were more likely to require ventilation (odds ratio, OR 11.7, p<0.0001), inotropes (OR 3.1, p=0.01) or enteral nutrition (OR 23.3, p<0.0001). Mean cost per patient was €3,956 for elective cases and €16,419 for emergency cases. No patient required ICU admission after EVAR (n=76).

CONCLUSIONS

Open AAA surgery places significant demands on ICU resources. The planned reconfiguration of surgical services in Ireland must provide for parallel investment in ICU facilities and expertise.

Guided entropy mode Rayleigh scattering in optical fibers

Rayleigh scattering in optical fibers has the potential to degrade the performance of low-noise opto-electronic systems. In this Letter, we measure the Rayleigh gain spectrum of optical fibers. Our data show the gain bandwidth and the offset frequency of the Rayleigh gain peak. Both the gain bandwidth and the peak frequency are 3 orders of magnitude lower than the corresponding values for bulk silica. Our data suggest that the narrower gain bandwidth and frequency shift that we observe are due to guided entropy modes in the fiber. This effect is fundamental and will be present in any medium in which light is guided so that transverse intensity gradients exist.

A comparison of cryotherapy and imiquimod for treatment of actinic keratoses: lesion clearance, safety, and skin quality outcomes

BACKGROUND

There is limited direct comparative data on imiquimod versus cryotherapy to treat actinic keratoses.

OBJECTIVE

Compare lesion response through 12 months post-initial treatment.

METHODS

Patients with ≥ 10 lesions on the face or scalp were randomized to cryotherapy (up to 10 lesions per session, up to 4 sessions, every 3 months) or imiquimod (3-times-per-week for 3-4 weeks, up to 2 courses) with repeat treatment depending on response.

RESULTS

In 36 patients assigned to cryotherapy and 35 to imiquimod, lesion complete response rates were 85.0 percent (306/360) and 66.9 percent (234/350) for cryotherapy and imiquimod, respectively (P<0.0002). For completely cleared lesions, global skin quality was excellent in 82 percent (250/306) versus 100 percent (234/234) for cryotherapy and imiquimod, respectively (P<0.0001). More cryotherapy than imiquimod patients had hypopigmentation (54.8% versus 24.0%, P=0.0197), as well as blister formation, redness/erythema, flaking/scaling/dryness, and scabbing/crusting (P<0.05).

CONCLUSION

12-month lesion complete clearance rate was higher with repeated cryotherapy, but cosmetic outcome was better with imiquimod.

Antimicrobial usage in an intensive care unit: a prospective analysis

Antimicrobial therapies in the Intensive Care Unit (ICU) need to be appropriate in both their antimicrobial cover and duration. We performed a prospective observational study of admissions to our semi-closed ICU over a three-month period and recorded the indications for antimicrobial therapy, agents used, duration of use, changes in therapy and reasons for changes in therapy. A change in therapy was defined as the initiation or discontinuation of an antimicrobial agent. There were 51 patients admitted during the three-month study period and all received antimicrobial therapy. There were 135 changes in antimicrobial therapy. 89 (66%) were made by the ICU team and 32 (24%) were made by the primary team. Changes were made due to a deterioration or lack of clinical response in 41 (30%) cases, due to the completion of prescribed course in 36 (27%) cases, and in response to a sensitivity result in 25 (19%) cases. Prophylactic antibiotic courses (n=24) were of a duration greater than 24 hours in 15 (63%) instances. In conclusion, the majority of changes in antimicrobial therapy were not culture-based and the duration of surgical prophylaxis was in excess of current recommended guidelines.

Qualitative research as evidence: criteria for rigour and relevance

This paper is about the nature and construct of evidence and its relation to qualitative research. Using a post-modern lens, we begin by defining evidence, signifying the importance of context, and use discourse as a vehicle for looking at the ways in which qualitative research evidence struggles to achieve the equivalent standing of its quantitative counterpart. In outlining the role of discourse in the creation of research paradigms, we offer a conceptual map that enables a repositioning of qualitative research in the evidence-based genre. In order to best illustrate our standpoint, we then provide two examples of qualitative, transformational research approaches and relate these to the criteria of rigour and relevance, criteria which we would argue when met are examples of high-quality evidence. Having used the examples of discourse analysis and auto-ethnography, we then conclude by exposing and decentralising the myth that surrounds the discourse of evidence-based practice, which continues, albeit unintentionally, to discredit any evidence that falls outside of its parameters.

The advancement of a new human factors report--'The Unique Report'--facilitating flight crew auditing of performance/operations as part of an airline's safety management system

This paper presents the findings of research relating to the specification of a new human factors report, conducted as part of the work requirements for the Human Integration into the Lifecycle of Aviation Systems project, sponsored by the European Commission. Specifically, it describes the proposed concept for a unique report, which will form the basis for all operational and safety reports completed by flight crew. This includes all mandatory and optional reports. Critically, this form is central to the advancement of improved processes and technology tools, supporting airline performance management, safety management, organisational learning and knowledge integration/information-sharing activities. Specifically, this paper describes the background to the development of this reporting form, the logic and contents of this form and how reporting data will be made use of by airline personnel. This includes a description of the proposed intelligent planning process and the associated intelligent flight plan concept, which makes use of airline operational and safety analyses information. Primarily, this new reporting form has been developed in collaboration with a major Spanish airline. In addition, it has involved research with five other airlines. Overall, this has involved extensive field research, collaborative prototyping and evaluation of new reports/flight plan concepts and a number of evaluation activities. Participants have included both operational and management personnel, across different airline flight operations processes. Statement of Relevance: This paper presents the development of a reporting concept outlined through field research and collaborative prototyping within an airline. The resulting reporting function, embedded in the journey log compiled at the end of each flight, aims at enabling employees to audit the operations of the company they work for.

A review and critical appraisal of measures of therapist-patient interactions in mental health settings

OBJECTIVES

To assemble and to appraise critically the current literature on tests and measures of therapist-patient interactions in order to make recommendations for practice, training and research, and to establish benchmarks for standardisation, acceptability and routine use of such measures.

DATA SOURCES

Major electronic databases (including PsycINFO) were searched from inception to 2002.

REVIEW METHODS

A comprehensive conceptual map of the subject area of therapist-patient interactions was developed through data extraction from, and analysis of, studies selected from the literature searches. The results of these searches were assessed and appraised to produce a set of possible therapist-patient measures. These measures were then evaluated.

RESULTS

The contextual map included the various concepts and domains that had been used in the context of the literature on therapist-patient interactions, and was used to guide the successive stages of the review. Three developmental processes were identified as necessary for the provision of an effective therapeutic relationship: 'establishing a relationship', 'developing a relationship' and 'maintaining a relationship'. Eighty-three therapist-patient measures having basic information on reliability and validity were identified for critical appraisal. The areas of the conceptual map that received most coverage (i.e. over 50% measures associated with them) were framework, therapist and patient engagement, roles, therapeutic techniques and threats to the relationship. These areas relate to the three key developmental processes outlined above. Of the 83 measures matching the content domain, 43 met the minimum standard. A total of 30 measures displayed adequate responsiveness or precision. None of the 43 measures that met the minimum standard was fully addressed in terms of acceptability and feasibility evidence. The majority of these measures had three or fewer components described. Therefore, out of a total of 83 measures matching the content domain, no measure could be said to have met an industry standard.

CONCLUSIONS

The findings indicate that the therapist-patient interaction can be measured using a wide range of instruments of varying value. However, due care should be taken in ensuring that the measure is suitable for the context in which it is to be used. Following on from this work, it is suggested that specific research networks for the development of therapist-patient measures should be established, that research activity should prioritise investment in increasing the evidence base of existing measures rather than attempting to develop new ones, and that research activity should focus on improving these existing measures in terms of acceptability and feasibility issues.

Introduction of a child and adolescent mental health link worker: education and health staff focus group findings

Policy guidance suggests that outcomes for adolescents with mental health problems can be improved by secondary education services (SES) and child and adolescent mental health services (CAMHS) working more closely. This study reports on staff experiences of the introduction of a mental health link worker (MHLW). The findings of two focus groups are presented, conducted with staff from CAMHS and SES. These focus groups formed part of the overall wider evaluation of the MHLW role. The groups explored staff perceptions and experiences following the introduction of the MHLW, and elicited their views on the effectiveness of this innovative role. Qualitative methods were employed, and analysis was conducted using the principles of grounded theory and the constant comparative method. The findings revealed that the MHLW was well received by both groups, despite the identification of potential barriers. A number of key themes emerged, which included the ability of the link worker to improve communication and to encourage mutual understanding between services. The issues raised by these themes are discussed and recommendations are made for future practice and research.

Inhibition of c-Jun N-terminal kinase pathway attenuates cerebral vasospasm after experimental subarachnoid hemorrhage through the suppression of apoptosis

BACKGROUND

Recent studies have demonstrated that apoptosis in cerebral arteries could play an essential role in cerebral vasospasm after subarachnoid hemorrhage (SAH) and that SP600125, an inhibitor of c-Jun N-terminal kinase (JNK) could suppress apoptosis. The present study examined whether SP600125 could reduce cerebral vasospasm through the suppression of apoptosis.

METHOD

Fifteen dogs were assigned to 3 groups: control, SAH, and SAH + SP600125 (30 micromol/l). SAH was induced by the injection of autologous blood into the cisterna magna on day 0 and day 2. Angiograms were evaluated on day 0 and day 7. The activation of the JNK pathway and caspase-3 were also evaluated using Western blot. To determine the distribution, TUNEL staining and immunohistochemistry for phosphorylated c-jun and cleaved caspase-3 were performed.

FINDINGS

Severe vasospasm was observed in the basilar artery of the SAH dogs. SP600125 reduced angiographic and morphological vasospasm and reduced the expression of cleaved caspase-3, thereby suppressing apoptosis.

CONCLUSIONS

These results demonstrate that SP600125 attenuates cerebral vasospasm through the suppression of apoptosis, which may provide a novel therapeutic target for cerebral vasospasm.

Occupational contact dermatitis in Australia: diagnostic and management practices, and severity of worker impairment

The aims of this study were to compare treatment and referral practices between general practitioners (GPs) and dermatologists and to evaluate predictors for occupational contact dermatitis (OCD) disease severity measured in terms of worker impairment. Data were collected from 181 patients recruited for a larger study of OCD. Information about treatment recommendations and usual referral practices are reported for 123 patients. Data from patients, diagnosed with work-related skin disease, were modelled for severity of worker impairment. GPs were more likely to treat a patient independently, referring if the patient did not improve, whereas dermatologists were more likely to refer for patch testing on initial presentation. Dermatologists were more likely to recommend gloves and GPs were more likely to recommend soap avoidance/substitution. 2 GPs and no dermatologists reported recommending the best practice combination of moisturizers, topical corticosteroids and soap substitutes. When adjusted for all variables including age, sex, duration and diagnostic subgroup, workers with atopy as a cofactor had the most severe impairment. This study suggests that in Australia, patients with suspected OCD are initially managed within general practice, few clinicians recommend best practice treatments for OCD, and that atopy is associated with severity. These findings have implications for health resource allocation, clinician education, and the pre-employment counselling of atopic patients.

Occupational autoeczematization or atopic eczema precipitated by occupational contact dermatitis?

Autoeczematization is characterized by the sudden dissemination of a previously localised form of eczema. While widely described, most cases reported have followed chronic, localized stasis dermatitis. In this study, we describe the clinical scenario of occupational contact dermatitis (OCD) triggering endogenous-like eczema in atopic individuals, who often have not had eczema since childhood, if at all. These cases appear similar to previously described cases of autoeczematization. To show this clinical scenario, a series of 6 patients is presented from the Occupational Dermatology Clinic in Melbourne, Australia. These workers initially developed OCD, usually affecting the hands, which then precipitated a flare of more generalized eczema. This appeared clinically consistent with atopic eczema (AE), and often became recurrent, and sometimes persistent. OCD can precipitate a flare of more generalized eczema, in a pattern consistent with AE, which may then persist. The clinical scenario is similar to that described for autoeczematization. It is possible that the pathophysiology, when clarified, will prove to be similar. Workers' compensation issues may become complicated for these patients, as the relationship between their generalized eczema and their occupational exposures may not be readily apparent. As a result, the work relatedness of their condition may not be recognized.

Elevated BNP with normal systolic function in asymptomatic individuals at-risk for heart failure: a marker of diastolic dysfunction and clinical risk

BACKGROUND

B-type natriuretic peptide (BNP) is widely accepted in the evaluation of left ventricular systolic dysfunction and heart failure. However, little is known of the implications of elevated BNP levels in individuals with preserved systolic function (PSF).

AIMS

To investigate the drivers and clinical implications of elevated BNP levels in asymptomatic individuals with established PSF.

METHODS

We enrolled 154 individuals who all underwent physical examination, BNP evaluation and Doppler-echocardiographic studies. They were divided into those above and below the median BNP level (50 pg/ml).

RESULTS

Independent predictors of higher BNP were older age, more severe left ventricular hypertrophy (LVH), reduced E/A ratio and ischaemic heart disease. Survival and multivariable analysis demonstrated more death and/or admission in those above the median BNP (HR: 4.79, p=0.007).

CONCLUSIONS

Elevated BNP is the strongest, independent predictor of serious adverse cardiovascular outcomes in this population and requires closer clinical follow-up.

Allergic contact dermatitis to quaternium 15 in a moisturizing lotion

A 56-year-old nurse from a rural area presented with a 12-month history of hand dermatitis. She had previously been patch tested by a local medical practitioner with the thin-layer rapid-use epicutaneous test, which had shown allergies to quaternium 15 and formaldehyde. After testing, she was prescribed methylprednisolone aceponate 1 mg/g cream by the medical practitioner, but was not informed that quaternium 15 is contained in the Microshield moisturizing lotion she was using at work. When her dermatitis persisted, she saw a dermatologist, who advised her to avoid the Microshield moisturizing lotion, and use a waterless hand cleanser on return to work. The diagnoses were firstly allergic contact dermatitis from quaternium 15 in the moisturizing lotion, and secondly irritant contact dermatitis from nursing work. This case highlights both the presence of quaternium 15 in a product commonly used in health-care settings in Australia, and the importance of offering informed, appropriate advice to patients following patch testing.

Allergic contact dermatitis to thiourea in a neoprene knee brace

SUMMARY An elderly woman developed an itchy, weeping, erythematous, papular eruption, confined to the skin under her neoprene knee brace. Allergic contact dermatitis to diethylthiourea and to her neoprene knee brace were diagnosed by positive patch test reactions. Allergic contact dermatitis from thioureas may be underdiagnosed, as they are not tested as part of the standard patch test series. Clinicians are encouraged to consider this diagnosis in patients with reactions to synthetic rubber, especially neoprene.

Incidence and prevalence rates for occupational contact dermatitis in an Australian suburban area

Occupational contact dermatitis (OCD) regularly causes high levels of worker morbidity; however, this is often not reflected in available statistics. This study aimed to collect and verify OCD reports/referrals and generate disease estimates for a defined geographical area in Melbourne, Australia. Two methods of data collection were used. In the first method, 30 general practitioners (GPs), 2 dermatologists and 1 dermatology outpatient clinic within a defined area reported each worker with suspected OCD seen as part of routine practice. With the second method, workers living in the area who were referred to a tertiary referral OCD clinic were included in the study. An occupational dermatologist used a gold standard process that included diagnostic patch testing to verify suspected cases. The incidence rate for confirmed cases was 20.5 per 100,000 workers [95% confidence interval (CI): 13-32.1]. The 1-year-period prevalence rate was 34.5 per 100,000 (95% CI: 24.4-48.7). The positive predictive value (PPV) was highest for the occupational dermatology clinic referrals [63% (95% CI: 49-76%)] compared with reports from the dermatologists/dermatology outpatient clinic [55% (95% CI: 36-74%)] and from GPs [43% (95% CI: 29-59%)]. This study utilizes reports from GPs and dermatologists to provide OCD disease estimates and validation data for an OCD disease register.

Occupational allergic contact dermatitis to bisphenol F epoxy resin

A 30-year-old man presented with eyelid dermatitis and was diagnosed with occupational allergic contact dermatitis to an epoxy resin based on the monomer diglycidyl ether of bisphenol F. He did not react to the standard epoxy resin based on bisphenol A, but reacted to a diluted sample of epoxy resin taken from his workplace, an adhesives manufacturing plant. The diagnosis would not have been made had he not brought samples from work, which were patch tested after appropriate dilution. The material safety data sheet provided additional evidence that the epoxy was not based on bisphenol A. The patient's symptoms subsided after avoidance of the identified product.