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Many inhaler devices are currently used in clinical practice to deliver medication, with each inhaler device offering different benefits to overcome technique issues. Inhaler technique remains poor, contributing to reduced airway drug deposition and consequently poor disease control. Scoring inhaler technique has been used within research as an outcome measure of inhaler technique assessment, and this systematic review collates and evaluates these scoring methods. The review protocol was prospectively registered in PROSPERO (CRD42020218869). A total of 172 articles were screened with 77 included, and the results presented using narrative synthesis due to the heterogeneity of the study design and data. The most frequently used scoring method awarded one point per step in the inhaler technique checklist and was included in 59/77 (77%) of articles; however limited and varied guidance was provided for score interpretation. Other inhaler technique scoring methods included grading the final inhaler technique score, expressing the total score as a percentage/ratio, deducting points from the final score when errors were made, and weighting steps within the checklist depending on how crucial the step was. Vast heterogeneity in the number of steps and content in the inhaler technique checklists was observed across all device types (range 5-19 steps). Only 4/77 (5%) of the inhaler technique measures had undertaken fundamental steps required in the scale development process for use in real world practice. This review demonstrates the demand for a tool that measures inhaler technique and highlights the current unmet need for one that has undergone validation., Competing Interests: Declaration of competing interest There is no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

COVID-19 is frequently accompanied by a hypercoagulable inflammatory state with microangiopathic pulmonary changes that can precede the diffuse alveolar damage characteristic of typical acute respiratory distress syndrome (ARDS) seen in other severe pathogenic infections. Parallels with systemic inflammatory disorders such as atypical hemolytic uremic syndrome (aHUS) have implicated the complement pathway in the pathogenesis of COVID-19, and particularly the anaphylatoxins C3a and C5a released from cleavage of C3 and C5, respectively. C5a is a potent cell signalling protein that activates a cytokine storm-a hyper-inflammatory phenomenon-within hours of infection and the innate immune response. However, excess C5a can result in a pro-inflammatory environment orchestrated through a plethora of mechanisms that propagate lung injury, lymphocyte exhaustion, and an immune paresis. Furthermore, disruption of the homeostatic interactions between complement and extrinsic and intrinsic coagulation pathways contributes to a net pro-coagulant state in the microvasculature of critical organs. Fatal COVID-19 has been associated with a systemic inflammatory response accompanied by a pro-coagulant state and organ damage, particularly microvascular thrombi in the lungs and kidneys. Pathologic studies report strong evidence of complement activation. C5 blockade reduces inflammatory cytokines and their manifestations in animal studies, and has shown benefits in patients with aHUS, prompting investigation of this approach in the treatment of COVID-19. This review describes the role of the complement pathway and particularly C5a and its aberrations in highly pathogenic virus infections, and therefore its potential as a therapeutic target in COVID-19., (© 2020 The Authors. Journal of Thrombosis and Haemostasis published by Wiley Periodicals LLC on behalf of International Society on Thrombosis and Haemostasis.)

Refractory ceramic fibres (RCF) and alkaline earth silicate (AES) wools are types of man-made vitreous fibre (MMVF) that are used in demanding high-temperature industrial applications, generally above 900 °C and up to 1400 °C. When exposed to prolonged high temperatures, MMVF can devitrify with the formation of cristobalite and other crystalline silica species, which is of potential concern because crystalline silica (CS) is classified as carcinogenic. This article reviews the chemico-physical processes and morphological consequences of fibre devitrification, the forms and micro-location of CS produced, and the toxicity of devitrified fibres and the CS species formed in this way. It also examines scenarios for worker exposure to the products of fibre devitrification in industries using RCF and/or AES wools. We identify gaps in knowledge and make recommendations for future research., (Copyright © 2013 Elsevier Inc. All rights reserved.)

It is taught that full thickness skin grafts contract minimally in humans. We aimed to examine this assumption. In a prospective study, a scale photograph of each of 54 human full thickness skin grafts was taken at operation once the graft had been inset, but before the application of any tie-over or other dressing. For 50 grafts, a subsequent scale photograph was taken at follow-up (mean 111 days post-operation). The photographs were digitised and the areas of the grafts recorded. Significant area reduction in human full thickness skin grafts was found (P< 0.01, mean area change -38%). Greater contraction was associated with infection than without (P = 0.02, mean area change with infection -48%, without infection -33%). Full thickness skin grafts applied to the peri-orbital area and nose contracted more than those applied to the scalp and temples (P = 0.002). No differences in contraction were found between donor sites, between methods of fixation, between males and females or between those taking no medication and those taking steroids or non-steroidal anti-inflammatory medication. Area change did not correlate with initial graft area, patient age or time to second photograph., (Copyright 2000)

A series of reproducible measurements have been developed with reference to a single midline datum that describe the position of key landmarks on the female breast. Measurements were made on a 'normal' population of 60 subjects content with their breast shape in order to (1) produce 'normal' reference data for breast shape in a population of varying weight and height; and (2) to evaluate factors which may influence the measurements. The findings show that the vertical positions of the measurements migrate inferiorly with increasing age. With increasing weight, the landmarks (except the medial end of the inframammary crease) migrate inferolaterally. Areolar diameter decreases with increasing age and increases with increasing weight. Only one of the 12 bilateral breast measurement parameters shows a significant mean difference between the right and left breast. However, in a proportion of subjects, individual measurements show fluctuating asymmetry. Subsequently, measurements were made of the breasts of women attending with requests for either reduction (n = 25) or augmentation (n = 6) mammaplasty. Compared with the 'normal' population, the group requesting reduction mammaplasty differed significantly in the majority of measurements. The group of patients requesting breast augmentation showed fewer differences compared with the 'normal' population. The average BMI of women requesting augmentation mammaplasty was significantly less and that of women requesting reduction mammaplasty significantly greater than the normal population. In conclusion, a simple and reproducible method of morphometric measurement of the female breast is described. Application of this method suggests that patients requesting reduction or augmentation mammaplasty on the NHS represent a significant deviation from 'normal' morphometry and do not simply have a subjective distortion of their own body image.

Procedures designed to limit spread of methicillin-resistant Staphylococcus aureus (MRSA) in burns units demand time and resources. To assess the significance of MRSA in burns patients we performed a retrospective review of MRSA colonization in in-patients over a 41-month period at the North Trent Sub-regional Burns Unit. Patients were compared with MRSA free controls, matched for age and percentage body surface area (BSA) burn and admitted during the same time period. Length of stay, number of operations and deaths were outcome indicators. All patients managed non-operatively were excluded, leaving 40 MRSA patients and 46 controls. There was no statistical difference between the two groups with regard to number of operations (p= 0.07), duration of admission (p = 0.12) or mortality (p = 0.09). Of the control group, 83% had wound swabs positive for methicillin-sensitive Staphylococcus aureus (MSSA). there was no statistical difference in any outcome variables between this sub-group of controls and MRSA patients. Colonization with S. aureus (both MRSA and MSSA) was associated with larger burns (p<0.05), twice as many operative procedures (p<0.05) and prolonged admissions (p<0.01). Mortality was unaltered by staphylococcal colonization (p = 0.8). Although our study lacks power, we would suggest that methicillin resistance per se is not associated with increased morbidity or mortality in burns patients.

Leukaemia in an 11-year-old bitch was characterized by the presence in the peripheral blood and bone marrow of cells with lobulated nuclei and numerous metachromatic cytoplasmic granules. The results of cytochemical stains for peroxidase and naphthol AS-D chloracetate esterase activity were negative. Ultrastructurally, the cytoplasmic granules were finely granular with no membranous coils or crystalline lattice structures. Based on these findings, the neoplastic cells were classified as basophils.