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The article discusses metformin therapy for the management of infertility in women with polycystic ovary syndrome (PCOS). Topics discussed include contribution of high levels of circulating insulin to excess androgen production and to anovulation; study comparing metformin with placebo in 320 women with PCOS and recommendation for the use of other insulin sensitisers such as thiazolidinediones.

LINKED CONTENT: This article is linked to Yoon et al paper. To view this article, visit https://doi.org/10.1111/apt.17909 [ABSTRACT FROM AUTHOR]

Background: As part of a multifaceted approach to patient and public involvement and engagement (PPIE), alongside traditional methods, a closed Facebook group was established to facilitate PPIE feedback on various aspects of a project that used video‐recording to examine risk communication in NHS Health Checks between June 2017 and July 2019. Objective: To explore the process and impact of conducting PPIE through a closed Facebook group and to identify the associated benefits and challenges. Methods: Supported by reflections and information from project meetings used to document how this engagement informed the project, we describe the creation and maintenance of the Facebook Group and how feedback from the group members was obtained. Facebook data were used to investigate levels and types of engagement in the closed Facebook group. We reflect on the challenges of using this method of engaging the public in health research. Results: A total of 289 people joined the 'Risk Communication of Cardiovascular disease in NHS Health Checks' PPIE closed Facebook group. They provided feedback, which was used to inform aspects of the study, including participant‐facing documents, recruitment, camera position and how the methodology being used (video‐recorded Health Checks and follow‐up interviews) would be received by the public. Discussion: Using a closed Facebook group to facilitate PPIE offered a flexible approach for both researchers and participants, enabled a more inclusive method to PPIE (compared with traditional methods) and allowed rapid feedback. Challenges included maintaining the group, which was more labour intensive than anticipated and managing members' expectations. Suggestions for best practice include clear communication about the purpose of the group, assigning a group co‐ordinator to be the main point of contact for the group, and a research team who can dedicate the time necessary to maintain the group. Conclusion: The use of a closed Facebook group can facilitate effective PPIE. Its flexibility can be beneficial for researchers, patients and public who wish to engage in the research process. Dedicated time for sustained group engagement is important. Patient or Public Contribution: Patient representatives were engaged with the development of the research described in this paper and a patient representative reviewed the manuscript. [ABSTRACT FROM AUTHOR]

Many countries have adopted new triage recommendations for use in the event that intensive care beds become scarce during the COVID‐19 pandemic. In addition to establishing the exact criteria regarding whether treatment for a newly arriving patient shows a sufficient likelihood of success, it is also necessary to ask whether patients already undergoing treatment whose prospects are low should be moved into palliative care if new patients with better prospects arrive. This question has led to divergent ethical guidelines. This paper explores the distinction between withholding and withdrawing medical treatment during times of scarcity. As a first central point, the paper argues that a revival of the ethical distinction between doing and allowing would have a revisionary impact on cases of voluntary treatment withdrawal. A second systematic focus lies in the concern that withdrawal due to scarcity might be considered a physical transgression and therefore more problematic than not treating someone in the first place. In light of the persistent disagreement, especially concerning the second issue, the paper concludes with two pragmatic proposals for how to handle the ethical uncertainty: (1) triage protocols should explicitly require that intensive care attempts are designed as time‐limited trials based on specified treatment goals, and this intent should be documented very clearly at the beginning of each treatment; and (2) lower survival prospects can be accepted for treatments that have already begun, compared with the respective triage rules for the initial access of patients to intensive care. [ABSTRACT FROM AUTHOR]

Treatment of Epilepsy with Electrical Status Epilepticus During Slow-Wave Sleep and Factors Related to the Response to Treatment.Purpose:To elucidate the effect of treatment of epilepsy with electrical status epilepticus during slow sleep (ESES) and factors related to the response to treatment.Methods:We studied 26 patients with ESES who were admitted to Okayama University Hospital (age range, 2y0m to 9y7m). Patients were treated with one or more of the following therapies: (a) high-dose valproate (VPA) therapy (plasma level,>100μg/ml), (b) a combination therapy of VPA and ethosuximide (ESM), (c) a short cycle of high-dose diazepam (DZP; 0.54–1 mg/kg/day, orally or intrarectally for 6–14 days), and (d) synthetic adrenocorticotropic hormone (ACTH) therapy (Cortrosyn-Z; 0.01–0.036 mg/kg/day, intramuscularly, for 11–43 days). Basically, we started treatment with high-dose VPA therapy. When this failed or yielded adverse side effects, we tried the combination therapy of VPA and ESM. When both were unsuccessful, we tried a short cycle of high-dose DZP or synthetic ACTH therapy. All patients were followed up for≥2 years. We also investigated response patterns to treatments and mental outcome in each patient.Results:Treatment effects: Regarding the initial effects, treatment was defined as effective when continuous spike–waves during slow-wave sleep (CSWSs) were suppressed (≥1 month with markedly decreased or no diffuse spike-waves during slow-wave sleep). In terms of initial effect, high-dose VPA was effective in 12 (50%) of 24 trials; combination therapy with VPA and ESM in six (43%) of 14 trials; a short cycle of high-dose DZP, in six (75%) of eight trials; and synthetic ACTH, in three (43%) of seven trials. However, CSWSs recurred within 1 year of treatment in two patients treated with high-dose VPA, in four treated with a short cycle of high-dose DZP, and in all three treated with synthetic ACTH. Response patterns and mental outcomes: Subjects were divided into two groups: 15 patients with favorable EEG response to the initial treatment maintained throughout the clinical course (group A), and 11 patients with no favorable EEG response to the initial treatment, or deterioration after an initial favorable response (group B). All patients except one in group A were treated with high-dose VPA or the combination therapy of VPA and ESM or both. All patients except two in group B were treated with a short cycle of high-dose DZP or synthetic ACTH after the failure of high-dose VPA or both or the combination therapy of VPA and ESM or both. Comparing these two groups, ages at onset of ESES were significantly lower in group B (p= 0.0009). Organic brain lesions such as brain malformations were seen more often in group B. Mental deterioration after the onset of ESES was observed significantly more often in group B (p= 0.037). Regarding mental outcome, patients with normal mentality or slight mental retardation predominated in group A, whereas those with severe mental retardation were found only in group B.Conclusions:Remission of ESES was achieved in approximately half of the patients treated with high-dose VPA therapy or combination therapy with VPA and ESM or both. Even when these treatments were ineffective, a short cycle of high-dose DZP or synthetic ACTH therapy was effective in most cases. However, the effects of the latter two treatments were only temporary. Group B was characterized by early-onset patients associated with organic brain lesions. These patients responded poorly to treatment and consequently had mental deterioration and poor mental outcomes. Thus response to ESES treatment may be related to the underlying organic brain lesion(s). To prevent poor mental outcome, we believe that it is critical to achieve remission as early as possible by using intensive treatment. An Investigation of Growth and Growth Disorders in School-Aged Patients with Post-West Syndrome.Purpose:To contribute to improved quality of life (QOL) for school-aged children with epilepsy, we investigated growth and growth disorders in patients with the post-West syndrome, who may be at greater risk for short stature.Methods:The 26 school-aged epilepsy patients with post-West syndrome (p-WS) were studied after informed consent was obtained from the parents. The patients consisted of seven who had cryptogenic WS[M/F= 3:4; mean age, 8 years; without cerebral palsy and nutritional problem (six of seven cases, 85.7%)] and 19 who had symptomatic WS[M/F= 11:8; mean age, 8.3 years; with cerebral palsy and required tube feeding (10 of 19 cases, 52.6%)]. The cross-sectional height SD score (HSDS), ratio of bone age to chronologic age (BA/CA), serum insulin-like growth factor (IGF-1) and other biochemical markers (serum ALP, Ca, IP, total protein and total albumin) were measured. The differences between the p-WS patients, divided into cryptogenic WS and symptomatic WS, and age-matched children with epilepsy were compared. The correlation between growth disorders and some clinical factors was investigated.Results:(a) The mean HSDS and the rate of short stature (HSDS≤−2.0 SD) in the p-WS patients were−1.89 SD (−5.94 to+0.63 SD) and 11 of 26 cases (42.3%), respectively. Obvious growth retardation without bone maturational delay (BA/CA: 0.88) was noticed in the p-WS patients compared with 56 age-matched epilepsy patients we reported previously (mean HSDS,−0.75 SD; HSDS≤−2.0 SD; 10 of 56 cases, 17.9%). Especially the symptomatic WS group showed markedly shorter stature (mean HSDS,−2.34 SD) and lower serum IGF-1 and ALP levels (mean, 110 ng/ml and 465 IU/L, respectively) compared with the cryptogenic WS group, who showed growth similar to that of age-matched epilepsy controls. (b) Markedly short stature (HSDS≤−2.0 SD) and abnormally low serum IGF-1 levels (≤−2.0 SD) were observed most frequently in the patients with cerebral palsy and feeding problems (eight of 11 cases, 72.7%, and five of 11 cases, 45.5%, respectively), followed by patients with prenatal etiology and those with poor seizure prognosis. However, the therapeutic regimens and the EEG findings showed no correlation with the growth disorders (3). Severely short stature (HSDS≤−3 SD, six of 26 cases, 23.1%) was noticed exclusively in the symptomatic WS group with cerebral palsy and feeding difficulties, as a result of an almost bedridden state and malnutrition.Conclusions:We have great concerns about the QOL of school-aged children with epilepsy and previously reported their growth and growth disorders as a part of the studies to improve their QOL. In this study, we investigated the growth in p-WS patients who may be at greater risk for short stature. Marked growth retardation was observed in the p-WS patients, especially in those with symptomatic WS, compared with age-matched controls and cryptogenic WS. Definite short stature (HSDS≤−2 SD) and low IGF-1 levels were observed mostly in patients with the complications of cerebral palsy requiring tube feeding, regardless of their EEGs and therapeutic regimens. It is particularly noteworthy that markedly short stature (HSDS≤−3 SD, six of 26, 23.1%) was observed exclusively in the symptomatic WS cases with cerebral palsy and feeding difficulties. The growth disorders may be a result of severe motor disturbances, leading to an almost bedridden state, and low IGF-1 levels may be due to malnutrition. Few reports exist of growth disorders in school-aged epilepsy patients, especially in the p-WS patients. As a base for comprehensive medicine for children with epilepsy to improve QOL, further accumulation of findings on growth and growth disorders is required. Long-Term Prognosis of Infantile Spasms (ISs): Late Relapses of Other Seizures After the Last IS.Purpose:The timing of discontinuation of drug treatment should vary with individual epileptic syndromes. Epilepsies with early onset probably deserve protracted periods of treatment (>5 years) because they are usually severe. In such cases, late relapses of other seizures are not uncommon, whereas precise studies are not known. In this study, we analyzed the long-term prognosis of infantile spasms (ISs) with special reference to late relapses.Methods:Between1969 to 2001, 52 children with ISs were treated at our facilities. Among them, 35 patients (19 boys and 16 girls) who had been followed up for>5 years were analyzed in this study. The follow-up period ranged from 5 to 33 years, with an average of 15.3 years. Adrenocorticotropic hormone (ACTH) therapy was used in 26 cases. Patients were divided into three groups according to the seizure status after the last IS; group I (G-I), eight seizure-free cases after the last IS; group II (G-II), eight cases with a seizure-free period of>5 years; and group III (G-III): 19 cases who continued to have seizures or relapsed within 5 years.Results:The classification of ISs and the mental status of 35 patients were analyzed in each group. Although the ratio of cryptogenic to symptomatic cases was the same in G-I (4:4) and G-II (4:4), G-III included many symptomatic cases (3:16). Mental status was assessed by the ratio of normal mentality/mild delay/moderate delay/severe delay. It was better in G-I (2:4:2:0) than in G-II (1:2:5:0), whereas G-III had many cases with severe mental delay (0:1:5:13). Next, we analyzed the forms of other seizures after the last IS in each group. The most common form of other seizures was partial seizures in G-II (seven of eight cases), often with secondary generalization (five of seven cases), and Lennox–Gastaut syndrome in G-III (nine of 19 cases). Then late relapses of other seizures were analyzed in G-II that had eight patients with seizure-free periods for>5 years (>10 years for five of eight patients, and 5–10 years for the remaining three). Ages at relapses after the last IS ranged from 5 years 11 months to 19 years 2 month, with an average of 11 years 11 months). The drug-free period of these eight cases ranged from 0 to 7 years, with an average of 2 years 6 months. Four patients were drug free for several years. For late relapses, focal paroxysmal discharges were found in the EEGs of seven patients. Focal discharges were most commonly found in the temporal region (five cases), followed by the frontal (one case) and the occipital region (one case). The prognosis of other seizures after a long seizure-free period was good in six cases, whereas in the other two patients, seizures were refractory to treatment. Refractory cases include cryptogenic as well as symptomatic cases.Discussion:Among 35 patients with ISs followed up for>5 years, eight (23%) cases had late relapses>5 years after the last IS. Five of eight cases had seizure-free periods of>10 years, and four cases had drug-free periods of several years. Four of eight cases were cryptogenic. From these observations, long-term follow-up is necessary, even in cryptogenic cases that have been seizure free and drug free for long periods. Other seizures that occurred after long seizure-free periods were mostly partial seizures with secondary generalization. These seizures, however, were fortunately not so therapy resistant. [ABSTRACT FROM AUTHOR]

Aim: To describe existing evidence on non-pharmacological interventions to manage sleep disturbance in children with neurodisabilities.Method: We systematically reviewed non-pharmacological interventions aimed at improving non-respiratory sleep disturbance in children with neurodisability. Sixteen databases, grey literature, and reference lists of included papers were searched up to February 2017. Two researchers (B.B., C.M., G.S., A.S., A.P.) undertook screening, data extraction, and quality appraisal.Results: Twenty-five studies were included: 11 randomized controlled trials and 14 before-and-after studies. All studies were at high or unclear risk of bias. Parent-directed interventions were categorized as comprehensive tailored interventions (n=9), comprehensive non-tailored interventions (n=8), and non-comprehensive interventions (n=2). Six 'other' non-pharmacological interventions were included. Seventy-one child and parent sleep-related outcomes were measured across the included studies. We report the two most commonly measured outcomes: the Child Sleep Habits Questionnaire and sleep onset latency. Five studies reported significant improvements on at least one of these outcomes.Interpretation: Various types of non-pharmacological intervention for managing sleep disturbance have been evaluated. Clinical heterogeneity and poor study quality meant we could not draw definitive conclusions on the effectiveness of these interventions. Current clinical guidance recommends parent-directed interventions as the first approach to managing sleep disturbance; prioritizing research in this area is recommended.What This Paper Adds: Existing evidence on non-pharmacological interventions to manage sleep disturbance in children with neurodisabilities is predominately of poor quality. Most included studies evaluated parent-directed interventions of varying content and intensity. There was very little consistency between studies in the outcome measures used. There is some evidence that parent-directed interventions may improve child outcomes. [ABSTRACT FROM AUTHOR]

At its inception, "brain death" was proposed not as a coherent concept but as a useful one. The 1968 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death gave no reason that "irreversible coma" should be death itself, but simply asserted that the time had come for it to be declared so. Subsequent writings by chairman Henry Beecher made clear that, to him at least, death was essentially a social construct, and society could define it however it pleased. The first widely endorsed attempt at a philosophical justification appeared thirteen years later, with a report from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research and a seminal paper by James Bernat, Charles Culver, and Bernard Gert, which introduced the insightful tripartite scheme of concept, criterion, and tests for death. Their paper proposed that the correct concept of death is the "permanent cessation of functioning of the organism as a whole," which tenuously remains the mainstream concept to this day. In this essay, I focus on this mainstream concept, arguing that equating brain death with death involves several levels of incoherence: between concept and criterion, between criterion and tests, between tests and concept, and between all of these and actual brain death praxis. [ABSTRACT FROM AUTHOR]

Background: Based on subjective experience, patients can identify research priorities important for health services research. A systematic method for priority setting has been developed by the James Lind Alliance. Objective: This article reviews the literature on the research priorities of patients, caregivers and health‐care professionals and presents the prioritized research themes and prioritization methods used. Search strategy: Three electronic databases were searched on 22 May 2018. The search was not limited to any time period or language. Inclusion criteria: The included studies reported the identification and prioritization of research priorities involving patients, relatives and caregivers. Each included paper addressed a specific ICD‐coded health problem, and at least one‐third of the sample involved in the prioritization process was affected by the health problem. Data extraction and synthesis: The 10 top‐ranked research priorities were included in the thematic analysis. With an inductive approach, a system of identified themes and subthemes was developed from the research priorities. Each research priority was assigned to one research theme. Main results: The priority lists of 34 publications involving 331 research priorities were included. Nine main themes represent the content of the research priorities. The most frequently represented main themes are 'Treatment', 'Patients' and 'Health condition'. The distribution of the research priorities varied depending on the health conditions and prioritization methods. Discussion and conclusions: This review provides a comprehensive overview of the overarching research themes in research priorities of affected individuals. The results can guide future patient‐oriented research. [ABSTRACT FROM AUTHOR]

Objectives To aid the development of treatment for cognitive impairment in bipolar disorder, the International Society for Bipolar Disorders (ISBD) convened a task force to create a consensus-based guidance paper for the methodology and design of cognition trials in bipolar disorder. Methods The task force was launched in September 2016, consisting of 18 international experts from nine countries. A series of methodological issues were identified based on literature review and expert opinion. The issues were discussed and expanded upon in an initial face-to-face meeting, telephone conference call and email exchanges. Based upon these exchanges, recommendations were achieved. Results Key methodological challenges are: lack of consensus on how to screen for entry into cognitive treatment trials, define cognitive impairment, track efficacy, assess functional implications, and manage mood symptoms and concomitant medication. Task force recommendations are to: (i) enrich trials with objectively measured cognitively impaired patients; (ii) generally select a broad cognitive composite score as the primary outcome and a functional measure as a key secondary outcome; and (iii) include remitted or partly remitted patients. It is strongly encouraged that trials exclude patients with current substance or alcohol use disorders, neurological disease or unstable medical illness, and keep non-study medications stable. Additional methodological considerations include neuroimaging assessments, targeting of treatments to illness stage and using a multimodal approach. Conclusions This ISBD task force guidance paper provides the first consensus-based recommendations for cognition trials in bipolar disorder. Adherence to these recommendations will likely improve the sensitivity in detecting treatment efficacy in future trials and increase comparability between studies. [ABSTRACT FROM AUTHOR]

Turbodynamic blood pumps are used clinically as ventricular assist devices ( VADs). They are mostly operated at a constant rotational speed, which results in a reduced pulsatility. Previous research has analyzed pulsing pump speeds (speed modulation) to alter the interaction between the cardiovascular system and the blood pump. In those studies, sine- or square-wave speed profiles that were synchronized to the natural cardiac cycle were analyzed in silico, in vitro and in vivo. The definitions of these profiles with respect to both timing and speed levels vary among different research groups. The current paper provides a definition of the timing of these speed profiles such that the resulting hemodynamic effects become comparable. The results published in the literature are summarized and compared using this definition. Further, applied to a turbodynamic VAD, a series of measurements is conducted on a hybrid mock circulation using a constant speed as well as different types of square-wave speed profiles and a sine-wave speed profile. When a consistent definition of the timing of the speed profiles is used, the hemodynamic effects observed in previous work are in agreement with the measurement data obtained for the current paper. These findings allow the conclusion that the speed modulation of turbodynamic VADs represents a consistent tool to systematically change the ventricular load and the pulsatility in the arterial tree. The timing that yields the minimal left ventricular load also yields the minimal arterial pulse pressure. [ABSTRACT FROM AUTHOR]

Aim: Previous research indicates that preventive intervention is likely to benefit patients “at risk” of psychosis, in terms of functional improvement, symptom reduction and delay or prevention of onset of threshold psychotic disorder. The primary aim of the current study is to test outcomes of ultra high risk (UHR) patients, primarily functional outcome, in response to a sequential intervention strategy consisting of support and problem solving (SPS), cognitive‐behavioural case management and antidepressant medication. A secondary aim is to test biological and psychological variables that moderate and mediate response to this sequential treatment strategy. Methods: This is a sequential multiple assignment randomised trial (SMART) consisting of three steps: Step 1: SPS (1.5 months); Step 2: SPS vs Cognitive Behavioural Case Management (4.5 months); Step 3: Cognitive Behavioural Case Management + Antidepressant Medication vs Cognitive Behavioural Case Management + Placebo (6 months). The intervention is of 12 months duration in total and participants will be followed up at 18 months and 24 months post baseline. Conclusion: This paper reports on the rationale and protocol of the Staged Treatment in Early Psychosis (STEP) study. With a large sample of 500 UHR participants this study will investigate the most effective type and sequence of treatments for improving functioning and reducing the risk of developing psychotic disorder in this clinical population. [ABSTRACT FROM AUTHOR]

Objectives: Cognition is a new treatment target to aid functional recovery and enhance quality of life for patients with bipolar disorder. The International Society for Bipolar Disorders (ISBD) Targeting Cognition Task Force aimed to develop consensus‐based clinical recommendations on whether, when and how to assess and address cognitive impairment. Methods: The task force, consisting of 19 international experts from nine countries, discussed the challenges and recommendations in a face‐to‐face meeting, telephone conference call and email exchanges. Consensus‐based recommendations were achieved through these exchanges with no need for formal consensus methods. Results: The identified questions were: (I) Should cognitive screening assessments be routinely conducted in clinical settings? (II) What are the most feasible screening tools? (III) What are the implications if cognitive impairment is detected? (IV) What are the treatment perspectives? Key recommendations are that clinicians: (I) formally screen cognition in partially or fully remitted patients whenever possible, (II) use brief, easy‐to‐administer tools such as the Screen for Cognitive Impairment in Psychiatry and Cognitive Complaints in Bipolar Disorder Rating Assessment, and (III) evaluate the impact of medication and comorbidity, refer patients for comprehensive neuropsychological evaluation when clinically indicated, and encourage patients to build cognitive reserve. Regarding question (IV), there is limited evidence for current evidence‐based treatments but intense research efforts are underway to identify new pharmacological and/or psychological cognition treatments. Conclusions: This task force paper provides the first consensus‐based recommendations for clinicians on whether, when, and how to assess and address cognition, which may aid patients’ functional recovery and improve their quality of life. [ABSTRACT FROM AUTHOR]

Abstract: Patients with cirrhosis and portal hypertension often develop complications from a variety of organ systems leading to a multiple organ failure. The combination of liver failure and portal hypertension results in a hyperdynamic circulatory state partly owing to simultaneous splanchnic and peripheral arterial vasodilatation. Increases in circulatory vasodilators are believed to be due to portosystemic shunting and bacterial translocation leading to redistribution of the blood volume with central hypovolemia. Portal hypertension per se and increased splanchnic blood flow are mainly responsible for the development and perpetuation of the hyperdynamic circulation and the associated changes in cardiovascular function with development of cirrhotic cardiomyopathy, autonomic dysfunction and renal dysfunction as part of a cardiorenal syndrome. Several of the cardiovascular changes are reversible after liver transplantation and point to the pathophysiological significance of portal hypertension. In this paper, we aimed to review current knowledge on the pathophysiology of arterial vasodilatation and the hyperdynamic circulation in cirrhosis. [ABSTRACT FROM AUTHOR]

Abstract: This paper addresses how musical metaphors can be useful in understanding the substructure of psychotherapy by considering how our patients resonate inside us, what that resonance does to and for us, and how these acoustic properties seem to be foundational in the construction of the therapist as an instrument of healing. From this perspective, psychotherapy involves “living music” with another person, as the process of psychotherapy always involves the passing of sound back and forth across an interpersonal divide. This requires both psychotherapist and patient to step into the roles of performer and audience member. Additionally, psychotherapists can be meaningfully thought of not only as an “instrument” of healing, but also an “instrumentalist” who produces unique “therapeutic music.” Moreover, the patient and therapist cocreate the concert space in which treatment is performed. This concert space has unique “architectural,” and thus acoustic, properties within which we hear and remember one another. [ABSTRACT FROM AUTHOR]

LINKED CONTENT: This article is linked to Sorda et al papers. To view these articles, visit https://doi.org/10.1111/apt.16618 and https://doi.org/10.1111/apt.16726 [ABSTRACT FROM AUTHOR]

LINKED CONTENT: This article is linked to Sorda et al papers. To view these articles, visit https://doi.org/10.1111/apt.16618 and https://doi.org/10.1111/apt.16657 [ABSTRACT FROM AUTHOR]

Objective The aim of the present paper is to study the indications for fluid bolus therapy (FBT) and its associated physiological changes in ED patients. Methods Prospective observational study of FBT in a tertiary ED, we recorded indications, number, types and volumes, resuscitation goals and perceived success rates of FBT. Moreover, we studied key physiological variables before, 10 min, 1 h and 2 h after FBT. Results We studied 500 FBT episodes (750 [500-1250] mL). Median age was 59 (36-76) years and 57% were male. Shock was deemed present in 135 (27%) patients, septic shock in 80 (16%), and cardiogenic shock in 30 (6%). Overall, 0.9% saline (84%) was the most common fluid and hypotension the most common indication (70%). 'Avoidance of hospital/ICU admission' was the goal perceived to have the greatest success rate (85%). However, although mean arterial pressure (MAP) increased ( P < 0.01) and heart rate (HR) decreased ( P = 0.04) at 10 min ( P = 0.01), both returned to baseline at 1 and 2 h. In contrast, respiratory rate (RR) increased at 1 ( P < 0.01) and 2 h ( P = 0.03) and temperature decreased at 1 and 2 h (both P < 0.001). In patients with shock, 1 h after FBT, there was a median 3 mmHg increase in MAP ( P = 0.01) but no change in HR ( P = 0.44), while RR increased ( P < 0.01) and temperature decreased ( P = 0.01). Conclusions In ED, FBT is used mostly in patients without shock. However, after an immediate haemodynamic effect, FBT is associated with absent or limited physiological changes at 1 or 2 h. Even in shocked patients, the changes in MAP at 1 or 2 h after FBT are small. [ABSTRACT FROM AUTHOR]

The aim of this paper is to reflect upon the management interventions of non-invasive ventilation (NIV) and diuretic therapy that were implemented for a patient admitted to an intensive care unit (ICU) with acute cardiogenic pulmonary oedema. Acute pulmonary oedema is a serious and life-threatening complication of acute heart failure, particularly if this results from an ischaemic event. Statistics highlight that of those patients treated for acute cardiogenic pulmonary oedema, approximately only one third were alive after 1 year. Many of these patients will require intensive care management in order to restore homeostasis. It is therefore imperative that nurses understand the condition and the relevant management of it in order to maximize the already poor prognosis. Using Driscoll's (2000) reflective model to guide critical thinking, this paper reflects on the management of one patient who was admitted to ICU with acute cardiogenic pulmonary oedema as a result of heart failure. Although there are many aspects of patient management that can be explored, specific care interventions that this patient received in relation to NIV and diuretic therapy will be considered. The evidence base for their use, together with the relevant nursing management issues, and patient implications will be critically analysed and outlined. This paper identifies that standard therapy for acute cardiogenic pulmonary oedema is largely supportive and aimed at promoting gaseous exchange. It also highlights that nurses have a key role in ensuring that these essential treatments are as efficacious as possible. By using a reflective analysis approach, this paper highlights how reflecting on practice improves knowledge and understanding of the use of NIV and diuretic therapy interventions and should facilitate nurses working in ICU to become more competent in ensuring that the treatment provided for acute cardiogenic pulmonary oedema is as successful as possible. [ABSTRACT FROM AUTHOR]

BACKGROUND: This research arose from a concern that the recovery of patients was being hindered by a lack of understanding and emphasis on psychosocial care during hospitalization. AIMS AND OBJECTIVES: This paper describes some of the findings from a study that was undertaken to explore and describe, from the perspective of hospitalized patients in Western Australia, the perceived therapeutic effect of interpersonal interactions that were experienced during hospitalization. DESIGN: Grounded theory method. METHODS: Interviews were conducted with 40 patients who were, or who recently had been, hospitalized. Seventy-eight hours of participant observation were also performed and during that time patients and nurses were observed and informally interviewed. Relevant documentation such as nursing care plans and patient notes were also reviewed. RESULTS: Emotional comfort was identified as a therapeutic state that patients perceived as enhancing their recovery. Personal control was found to be a central feature of emotional comfort and this accounted for the way in which patients interpreted therapeutic and non-therapeutic interpersonal interactions that they encountered during hospitalization. This paper will describe the conditions that patients perceived had either promoted or inhibited their emotional comfort. These were identified as the level of security, level of knowing and level of personal value. These conditions had been affected by the interpersonal interactions that had been experienced. The characteristics of therapeutic and non-therapeutic interpersonal interactions will be described. CONCLUSIONS: The results from this study provide further insight into and understanding of the therapeutic effect of psychosocial aspects of patient care. Specifically, these results emphasize the importance that patients in hospital place on all the interpersonal interactions that they experience during hospitalization. RELEVANCE TO CLINICAL PRACTICE. The identification of the characteristics of interpersonal interactions that facilitated emotional comfort provides directions for enhancing the therapeutic potential of all interpersonal interactions experienced by patients in hospital. Copyright 2004 Blackwell Publishing Ltd [ABSTRACT FROM AUTHOR]

The article presents information about abstracts of various papers that will be discussed at the Poster Session of the 6th European Congress on Epileptology that will be held on June 1, 2004. One of the papers that will be discussed is "Pharmacological Outcomes in People With Learning Disability and Epilepsy," by K. Kelly. Epilepsy is common in people with a learning disability. Researchers undertook a prospective outcome study on patients with a learning disability and epilepsy referred to the Epilepsy Unit in Glasgow, Scotland, between 1998 and 2001. Other papers that will be discussed are "Outcomes of Therapy in Patients With Epilepsy," by T.V. Mitrokhina, and A.V. Lebedeva and "Outcomes of Add on Treatment With New Generation Antiepileptic Drugs for Partial Epilepsy Patients," by D. Nikodijevic-Kedeva.

This paper explores the concept of comfort within conceptual frameworks that identify comfort as a key component. The paper focuses on two main issues: firstly, descriptions of comfort and how comfort is defined; secondly, the relationship between comfort and other core concepts and how it is similar to, or differs from these concepts. The descriptions of comfort identify the difficulty of defining comfort and note that historical interpretations of comfort have changed over time. Key authors provide different perspectives of comfort and hence a uniform definition is not evident. The degree to which patients' perspectives are represented varies within the frameworks which suggests that further clarity is needed in this area. The relationship between comfort and other concepts considers the boundaries between comfort and two concepts: nursing as therapy and caring. Comfort tends to be seen as a minor aspect of these concepts focusing on relief of discomfort or actions that demonstrate caring. The paper concludes that there is a lack of clarity around the use of the term comfort which fits with a view of comfort as an emerging concept. Descriptions of comfort are clearly evident in the literature but differ in relation to the authors' views of nursing. The relationship between comfort and nursing as therapy and caring is also complex and highlights the debate in relation to comfort as a part of caring or as the overall focus of care. [ABSTRACT FROM AUTHOR]

ABSTRACT Background The IO route is an established method of obtaining vascular access in children in acute and emergency situations and is now increasingly being used in adults as an alternative to intravenous access, yet a paucity of evidence exists regarding its use, effectiveness and implementation. Aim and objectives The aim of this literature review is to present a detailed investigation critiquing contemporary practices of intraosseous (IO) vascular access in adult patients. Specific objectives identified led to the exploration of clinical contexts, IO device/s and anatomical sites; education and training requirements; implications and recommendations for emergency health care practice and any requirements for further research. Search strategies An exploratory literature review was undertaken in acknowledgement of the broad and complex nature of the project aim. Five electronic search engines were examined iteratively from June 2013 to February 2014. The search terms were 'intraosseous' and 'adult' which were purposely limited because of the exploratory nature of the review. Studies that met the inclusion criteria of primary research articles with an adult focus were included. Research with a paediatric focus was excluded. Secondary research, reviews, case reports, editorials and opinion papers were excluded. Conclusion IO vascular access is considered an alternative intravascular access route although debate considering the preferred anatomical site is ongoing. Documented practices are only established in pre-hospital and specialist emergency department settings; however, variety exists in policy and actual practice. Achieving insertion competence is relatively uncomplicated following minimal preparation although ongoing skill maintenance is less clear. IO vascular access is associated with minimal complications although pain is a significant issue for the conscious patient especially during fluid administration. Relevance to clinical practice The IO route is clearly a valuable alternative to problematic intravascular access. However, further research, including cost effectiveness reviews, is required to gain clarity of whole acute care approaches. [ABSTRACT FROM AUTHOR]

Background Patients have in many studies been identified with progressive bone loss and peri-implantitis problems, but few studies are available where these groups of patients have been followed up. Purpose The purpose of this paper is to study further progression of bone loss in a cohort of 182 patients that have been reported to suffer from 'progressive' bone loss and peri-implantitis. Materials and Methods Altogether, 182 patients that have earlier been identified to suffer from 'progressive' bone loss formed the present study group. Data from patients' files have been retrieved, and intraoral radiographs have been analyzed for further bone level changes. Bone loss has been measured from time of inclusion into the present group to last available radiographs. Within each patient, one or several implants were diagnosed to suffer from 'progressive' bone loss (affected), whereas others are not (unaffected). Results Altogether, 145 patients (80%) were radiographically followed up on an average of 9.1 years ( SD 3.77) after inclusion. Twenty-four implants (3.1%) were lost in 16 patients (11%). Marginal bone loss was on an average 0.3 mm ( SD 0.75) at stable implants with only small differences between 'affected' and 'unaffected' implants. In total, 67 implants (8.6%) presented an annual bone loss of >0.2 mm. Oral hygienist treatment and/or peri-implantitis surgery did not neither reduce implant failure rate nor marginal bone loss in 88 treated patients as compared with untreated patients. Conclusions Less than one-third of the patients identified with 'progressive bone loss' showed one or more implants as failures or with high annual bone loss (>0.2 mm) during follow-up (11.6% of implants). Treated patients (oral hygienist and/or surgery) did not perform better than untreated patients with regard to bone loss or implant failure. [ABSTRACT FROM AUTHOR]

Intravenous immune globulin (IVIG) was developed initially as an immunoglobulin replacement therapy for primary humoral immunodeficiency, but is now widely used in the treatment of autoinflammatory and autoimmune pathologies. In a small number of patients, hemolytic sequelae have been observed after IVIG administration. The lack of a simple one-to-one correlation between measurable hemagglutinins and hemolysis has led to complicated hypotheses involving coincident necessary variables (e.g., a two-hit hypothesis) and also to the positing of causal factors other than hemagglutinins. One such hypothesis is that immune complexes (ICs) contained within IVIG lead to hemolysis. IVIG-mediated hemolysis was addressed at a recent meeting sponsored by the Food and Drug Administration; the Plasma Protein Therapeutics Association; and the National Heart, Lung, and Blood Institute. The primary literature was reviewed at this meeting followed by detailed discussion. Participants concluded that there is both a theoretical basis by which ICs could contribute to hemolysis after IVIG administration and some published data in support of such a possibility. However, the reported data contain substantial caveats, and the existing evidence does not rise to a level sufficient to either confirm or reject a role for ICs. More detailed and focused human studies will be required to further assess the potential role of ICs in IVIG induced hemolysis. This paper summarizes the relevant literature and expands upon the conclusions of this workshop. [ABSTRACT FROM AUTHOR]

Meniere's disease is a poorly understood, disabling syndrome causing spells of vertigo, hearing fluctuation, tinnitus, and aural fullness. In this paper, we present a review of the histopathology, cytochemistry, and imaging of Meniere's disease. Histopathology is significant for neuroepithelial damage with hair cell loss, basement membrane thickening, and perivascular microvascular damage. Cytochemical alterations are significant for altered AQP4 and AQP6 expression in the supporting cell, and altered cochlin and mitochondrial protein expression. Current developments include imaging techniques to determine the degree and presence of endolymphatic hydrops, and future studies will endeavor to correlate the observance of hydrops with clinical findings. [ABSTRACT FROM AUTHOR]

Introduction Palliative patients with metastatic bone pain endure long waiting times and multiple visits to radiation therapy departments for treatment. This can prolong suffering and may be a factor in patients consenting for treatment. Rapid Access Palliative Clinics ( RAPC) have been established around the world to provide a multidisciplinary approach to consultation, simulation and treatment on the same day. This paper describes the implementation and evaluation of a RAPC at Waikato Regional Cancer Centre ( WRCC) by reducing the time from referral to first specialist appointment ( FSA). Methods The structure and process for the RAPC day was outlined and the roles of staff were defined. A retrospective study was undertaken of the 261 consecutive patients seen in the RAPC from April 2009 to April 2013. Tracking sheets were created to record patient information at the initial consultation. Follow-up telephone calls were used to assess the patient post-treatment. Patient information was entered into a database. Results A total of 226 patients received radiation therapy treatment to 307 sites. All patients were seen within 1 week of referral. Sixty-three per cent of patients were simulated and treated on the same day. The change in radiation therapy fractionation prescriptions was statistically significant ( P = 0.0012). There was a statistically significant difference between initial and follow-up pain scores ( P < 0.0001 ). Conclusion Evaluation of the clinic has shown that it compares favourably with similar international clinics. The RAPC has decreased the referral to FSA for palliative radiation therapy and reduced the number of visits the patient has to endure due to an increase in single fraction prescriptions. This has resulted in rapid reduction in pain for the majority of patients. [ABSTRACT FROM AUTHOR]

Key Clinical Message The survival of multiple myeloma patients has improved very significantly over the last decade. Still median overall survival is inferior to 5 years. A small proportion of patients survive longer than 10 years. In this paper we discuss four cases illustrating the nonhomogeneous clinical presentation and evolution of this subset of patients. Surprisingly, these long survivors do not always have deep responses and some require frequent treatments, which include autologous stem cell transplantation and novel drugs. The authors discuss several aspects of these clinical histories, including treatment options, raising hypothesis on their relation with long survivorship which may be important to have in consideration when studying this subject. [ABSTRACT FROM AUTHOR]

Background Methylchloroisothiazolinone ( MCI) and methylisothiazolinone ( MI) are the active ingredients in commonly used preservative systems (e.g. Kathon CG®). MCI/ MI is present in the European baseline patch test series at 100 ppm aq. Since 1986, 200 ppm (dose 0.006 mg/cm2) has been used in Sweden without causing skin irritation. Centres in Spain, the United Kingdom and Ireland have also used 200 ppm in their baseline series. Objectives To find the optimal patch test concentration for MCI/ MI. Materials and methods MCI/ MI 100 ppm aq. and MCI/ MI 200 ppm aq. were simultaneously patch tested in 3300 consecutively tested dermatitis patients at eight European patch test clinics and one US patch test clinic. With the Finn Chambers® technique (diameter 8 mm), 15 µl was micropipetted on to the filter paper in the chamber. The corresponding volume for Van der Bend® chambers was 20 µl, and that for IQ Chambers® was 25 µl. Results Contact allergy to MCI/ MI at 100 and 200 ppm was found in 1.2% and 2.1% of patients, respectively ( p < 0.001). Conclusions MCI/ MI 200 ppm aq. (dose 0.006 mg/cm2) diagnoses significantly more contact allergy than the presently used concentration of 100 ppm (dose 0.003 mg/cm2), without resulting in more adverse reactions. MCI/ MI at 200 ppm should therefore be considered for inclusion in the European baseline test series. [ABSTRACT FROM AUTHOR]

A great deal of research has addressed the elevation of C-reactive protein (CRP) among psoriatic patients and the role of this marker in assessment of disease severity and progression. However, there are some discrepancies in this area. We sought to figure out the relationship between CRP values and disease severity as well as the changes in marker levels after treatment through an extensive literature review. Comparison between CRP levels in psoriatic patients and those in healthy or non-psoriatic individuals was also another focus of this review. A thorough search in Pubmed and Embase was conducted for articles investigating different aspects of CRP measurement in patients with psoriasis. Overall, 32 articles were found to meet our inclusion criteria. Of 28 studies comparing the CRP values in psoriatic patients with those of controls, 24 found a statistically significant difference. In addition, 12 out of 16 papers examining the association between disease severity and CRP values noted significant results. With regard to CRP changes over the course of a treatment, all 15 studies addressing this issue revealed a significant decrease in marker levels. In conclusion, high CRP levels only for moderate and severe forms of disease might be inferred from the literature and there is no sufficient evidence suggesting a similar association for mild disease as well. Moreover, CRP may serve interchangeably with Psoriasis Area and Severity Index ( PASI) as a measure of disease severity in the case of untreated psoriatic patients who do not have disease related arthritis. For other patients, however, a careful clinical examination and PASI calculation still remain the mainstay of severity assessment. [ABSTRACT FROM AUTHOR]

Wilson's disease is an autosomal recessively inherited copper overload disorder that leads to hepatic and/or neurologic symptoms. More than a century after the first description of Wilson's disease, the available medical treatment options have not been standardized. The efficacy of the commonly used drugs is satisfactory for hepatic disease, but disappointing in the neurologic patients, including the risk of neurologic deterioration after the initiation of chelation therapy. An approach to overcome this problem is the careful and systematic assessment of biochemical response patterns and the quantitative monitoring of symptoms using validated rating scales. Standardized dosage strategies that address changes in copper pools might improve adherence and reduce side effects. Such an approach may reduce long-term morbidity. In this paper, we discuss considerations for an effective medical treatment and requirements for future studies in Wilson's disease. [ABSTRACT FROM AUTHOR]

Adulthood cardiovascular diseases ( CVD) burdening in adulthood have been suggested to have possible predisposition early in life. We aimed to systematically review the literatures on retinal microvasculature among paediatric population in relation to a range of environmental and systemic changes. Papers with quantitative retinal vascular assessment and epidemiological design were reviewed. Conclusion This review supports the theory that major vascular diseases have pathological predisposition early in life by providing morphological evidence on retinal microcirculation in vivo. [ABSTRACT FROM AUTHOR]

The article presents information about abstracts of various papers that will be discussed at the Novartis Satellite Symposium that will be held on June 1, 2004. One of the papers that will be discussed is "Laying the Foundations for Epilepsy Diagnosis and Treatment," by P. Ryvlin. The accurate diagnosis and optimal care of patients with de novo partial seizures offer many challenges to the physician. Auras, when isolated or associated with minor loss of awareness, are often misinterpreted as reflecting psychiatric or cardiovascular disorders, leading to an average delay of several years before the epilepsy can be recognized. Other papers that will be discussed are "Modern AED Monotherapy: Fulfilling the Needs of Growing Children With Partial Seizures," by B. Bourgeois and "Time for Change? Oxcarbazepine Monotherapy in the Diverse Adult Population," by D. Schmidt.

What's known on the subject? and What does the study add? A consensus statement published in 2011 summarised current research, clinical approaches, and treatment options for nocturia. Since that time, new research has refined our understanding of nocturia in clinically important ways and new evidence has been presented on the efficacy and outcomes of several treatment methods for this underreported, infrequently recognised, and undertreated problem in adults. This paper provides updated guidance to clinicians in light of recent advances in the field. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Lee and Liu et al. (2012) 2009 pandemic Influenza A (H1N1): clinical and laboratory characteristics in pediatric and adult patients and in patients with pulmonary involvement. Influenza and Other Respiratory Viruses 6(601), e152-e161. Background To better understand clinical and laboratory characteristics in children, adults, and patients with lung involvement suffering 2009 pandemic influenza A (H1N1). Methods A total of 442 patients with 2009 pandemic influenza A (H1N1) were retrospectively analyzed. Results Comparing to their adult counterpart ( n = 55), pediatric patients ( n = 387) had significantly higher frequencies of fever, rhinorrhea, cough, sore throat, nausea/vomiting, and longer length of fever; lower frequencies of chest pain and dyspnea; higher incidence of lymphopenia; and lower incidence of elevated serum C-reactive protein. Among the 227 patients with radiographs available, lung involvement was found in 19 (8·4%) (52·6% consolidation and 47·4% interstitial infiltrations), including 18 children and one adult. One child with lung consolidation died of multiorgan failure. Significant findings in patients with lung involvement included predominant young age (≤10 years), prolonged fever, and delayed oseltamivir therapy (≥48 hours after onset of illness); higher frequencies of dyspnea, nausea/vomiting, and altered consciousness; and higher incidences of leukopenia, elevated serum creative kinase, and lactic dehydrogenase. Conclusions Among patients with 2009 pandemic influenza A (H1N1), we found significant difference in clinical manifestations between children and adults, and significant differences in clinical and laboratory manifestations between patients with lung involvement and those without. On the basis of data from this study and the existing literature, early treatment with oseltamivir is recommended for patients with 2009 pandemic influenza A (H1N1), regardless of age. [ABSTRACT FROM AUTHOR]

OBJECTIVE • To evaluate the impact of urisheaths vs absorbent products (APs) on quality of life (QoL) in men with moderate to severe urinary incontinence (UI). PATIENTS AND METHODS • A randomized, controlled, crossover trial in 61 outpatient adult men with stable, moderate to severe UI, with no concomitant faecal incontinence, was conducted from June 2007 to February 2009 in 14 urology centres. • Participants tested Conveen Optima urisheaths (Coloplast, Humlebaek, Denmark) with collecting bags and their usual AP in random order for 2 weeks each. • The impact of each on QoL was measured using the King’s Health Questionnaire (KHQ) and the short form-12 acute questionnaire, and each patient’s preference was recorded. • A 10-item patient questionnaire was also used to assess the product main advantages on an 11 point scale (0: worst; 10: best). A 72-h leakage diary was used to record the number and severity of leaks and daily product consumption. Safety was measured as the number of local adverse events. RESULTS • All dimensions of the KHQ were scored lower with urisheaths, indicating an improvement in QoL. The greatest mean score reductions were in Limitations of Daily Activities ( − 10.24, P= 0.01) and Incontinence Impact ( −7.05, P = 0.045). • The majority (69%) of patients preferred Conveen Optima urisheaths to their usual AP ( P = 0.002). • Urisheaths scored significantly higher for all categories in the patient questionnaire (efficacy, self-image, odour management, discretion, skinintegrity) except ease of use. • Safety was considered to be good. CONCLUSIONS • Conveen Optima urisheaths showed apositive impact on QoL (according to the KHQ results) in moderate to severe incontinent men, who were long-term usersof APs, and participants largely preferred urisheaths. • Conveen Optima urisheaths should be recommended to incontinent men in preference to APs. [ABSTRACT FROM AUTHOR]

Eosinophilic esophagitis (EoE) is a newly recognized condition that appears to be increasing in incidence for as yet unknown reasons. It can occur at any age and presents both to gastroenterologists and allergists. Clinical manifestations range from gastrointestinal symptoms (vomiting, feeding difficulties, dysphagia or food bolus impaction) to co-existing atopic conditions (asthma, allergic rhinitis or eczema). The diagnosis requires demonstration of at least 15 eosinophils per high power field on esophageal histology, usually in the context of resistance to proton pump inhibitor treatment or a normal 24-h esophageal pH monitoring study. The differential diagnosis between EoE and gastroesophageal reflux disease (GERD) can be problematic as there is significant clinical overlap between both conditions. Although difficult-to-manage esophageal strictures are well recognized in patients with long-standing EoE, little is known about risk factors for the development of this complication. There is a paucity of data on both the natural history and optimal long-term management of EoE. Current treatment options include food allergen elimination diets, use of topical aerosolized corticosteroids, or a combination of the two. Pediatric case studies have been provided to illustrate the complexity of decision points that often arise in the management of these patients. This paper aims to discuss the various strategies currently available to clinicians in the management of EoE and highlights gaps in the current evidence base that urgently require further research. [ABSTRACT FROM AUTHOR]

Percutaneous cholecystostomy is well established as a temporising treatment option in selected patients presenting with acute cholecystitis. However, some patients who undergo cholecystostomy will have persistent discharge, which precludes catheter removal, or may not be medically suitable for future cholecystectomy. In these circumstances, percutaneous cystic duct stenting is a novel treatment option. It may delay or avoid the need for cholecystectomy, and thereby provide definitive treatment in a subset of patients who have acute cholecystitis and a high anaesthetic risk or limited life expectancy. Current application has been limited largely to patients with pre-existing malignant common bile duct strictures, but there is potential for the application to be broadened to include other subsets of patients. In this paper, we describe the technique used for percutaneous cystic duct stenting in a patient and report on its effectiveness. We also explore the technical considerations and consider the application of the procedure on other groups of patients. [ABSTRACT FROM AUTHOR]

Background: It is widely accepted that service users should be actively involved in new service developments, but there remain issues about how best to consult with them and how to reconcile their views with those of service providers. Aims: This paper uses data from The Aphasia in Scotland study, set up by NHS Quality Improvement Scotland to identify the direction of the development of services for people with aphasia in Scotland. It examines the views both of those who provide and of those who receive those services. Methods & Procedures: The study integrated findings from a questionnaire to all speech and language therapists treating people with aphasia across Scotland with findings from focus groups with service users and aphasia practitioners. Outcomes & Results: Three themes were identified: (1) public and professional awareness of the impact of aphasia on the individual and their family; (2) current service provision and gaps in services; and (3) directions for the future development of services and barriers to change. Although the impact of aphasia is well recognized amongst most professionals (that is, not just speech and language therapists), considerable concern was expressed about the level of knowledge amongst professionals who do not specialize in stroke care and about public awareness of aphasia. Service providers indicated a shift in the model of service delivery of which the service users were largely unaware. Although the majority of speech and language therapists spend most of their time providing one-to-one therapy, and this is valued by service users, there is undoubtedly an emerging shift towards a focus on broader social function and the inclusion of the person with aphasia in supportive social networks. This creates tensions because of the existing pressure for individualized models of delivery. Concern was expressed by practitioners, although not echoed by patients, about the transition from the acute sector to primary care. Practitioners also expressed concern about the introduction of more recent services like NHS 24 and e-health initiatives, which rely on means of communication that may be particularly challenging for people with aphasia. Conclusions & Implications: The findings from this study indicate that although there are clearly common perspectives, the views of people with aphasia about services do not necessarily coincide with those of service providers. This is an important consideration when initiating consultation and highlights the need for clarity on the part of practitioners in identifying the aims and objectives of their ervices as far as people with aphasia are concerned. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Cameron S, Glasier A, Muir A, Scott G, Johnstone A, Quarrell H, Oroz C, McIntyre M, Miranda D, Todd G. Expedited partner therapy for Chlamydia trachomatis at the community pharmacy. BJOG 2010;117:1074–1079. Objective Expedited partner treatment (EPT) for uncomplicated Chlamydia trachomatis at the pharmacy is an alternative approach to partner notification that has not yet been evaluated within the UK. The aim of this study was to evaluate EPT for partners using pharmacies in Lothian. Design A pilot study over 18 months. Setting Selected healthcare settings and community pharmacies in Lothian, Scotland, UK. Population Sexual partners of index cases with uncomplicated C. trachomatis. Methods Index cases with uncomplicated C. trachomatis were given a pharmacy voucher to pass onto sexual partners. Partners could redeem vouchers for free treatment (azithromycin) at one of 90 pharmacies in the area. Main outcome measures The main outcome measure was the proportion of vouchers redeemed. Secondary outcomes included patient satisfaction, as determined at a telephone follow-up of a subgroup of female index cases from one study site, 1 month later. Results In total 577 vouchers were issued to chlamydia-positive index patients of mean age 22.9 years (range 15–47 years). A total of 231 vouchers were redeemed (40%), at a median of 2 days after issue. Only 4% of partners attended a clinic for treatment. Most index patients surveyed reported that partners were satisfied with this method of treatment (48 out of 55; 87%). Conclusions Expedited partner treatment for uncomplicated chlamydia at a pharmacy is a popular choice, and increases options on where, when and how partners are treated. [ABSTRACT FROM AUTHOR]

In this paper the author describes clinical work with forensic and anti-social personality disordered patients where the clinician is placed in a countertransference situation where, in the course of what is good therapeutic work, he experiences an overwhelming sense of having failed the patient. The author utilizes Glasser's idea of ‘identification with the neglector’ and Hinshelwood's writings on patients with disordered relations to care, to examine this experience, and he differentiates it from the concept of ‘identification with the aggressor’. Two clinical illustrations are used to highlight the issues discussed and show how with this patient group much of the clinical work is done in the countertransference. [ABSTRACT FROM AUTHOR]

Exudative retinal detachment is the most common source of visual loss associated with malignant melanoma of the uveal tract. Management has historically been conservative, leading to irreversible visual loss from photoreceptor damage during the several months needed for post-radiation resolution. The purpose of this paper is to describe timely vitreoretinal surgical intervention for exudative retinal detachments associated with choroidal melanomas. This was an interventional case series including six consecutive patients with malignant melanoma who experienced VA reduction secondary to associated exudative retinal detachment. Patients underwent complete ophthalmic evaluation and B-scan ultrasound. Treatment included proton-beam radiation or brachytherapy, prognostic transretinal tumour biopsy with 25-gauge vitrector and surgical treatment of exudative retinal detachment, including vitrectomy and drainage of subretinal fluid at the time of irradiation. Successful management of exudative retinal detachments associated with choroidal melanomas was observed in all cases, with significant restoration of vision. Steady regression of tumour thickness was noted clinically and ultrasonographically, without extrascleral extension or metastasis, and with no recurrence of exudative retinal detachment found over follow up. In the present study, the investigators have showed effective surgical treatment of exudative retinal detachment associated with malignant melanoma. These patients had significant restoration of vision, confirming that timely intervention of exudative retinal detachment associated with malignant melanoma can reverse visual loss in these patients. These findings are in contrast to previous reports of irreversible visual loss after exudative retinal detachments, and suggest that photoreceptor atrophy might play a role in visual loss associated with chronic exudative retinal detachments. [ABSTRACT FROM AUTHOR]

The paper proposes an optimal response-adaptive procedure for a general class of responses using a combination of two clinically relevant optimality criteria. We provide a thorough development for trials involving two treatments and sketch the possible extension for multiple treatments. Some related asymptotic results are worked out. We provide simulation studies to compare the performance of the proposed procedure with some of the existing competitors. We illustrate our methodology on data from a real clinical trial. [ABSTRACT FROM AUTHOR]

Pathological vascular remodelling is a key contributor to the symptomatology of pulmonary arterial hypertension (PAH), and reversing this process may offer the best hope for improving this debilitating condition. The vascular remodelling process is believed to be due to endothelial cell dysfunction and to involve altered production of endothelial cell-derived vasoactive mediators. The observation that circulating plasma levels of the vasoactive peptide endothelin (ET)-1 are raised in patients with PAH, and that ET-1 production is increased in the pulmonary tissue of affected individuals, makes it a particularly interesting target for a therapeutic intervention in PAH. Clinical trials with ET receptor antagonists (ETRAs) show that they provide symptomatic benefit in patients with PAH, thereby proving the clinical relevance of the ET system as a therapeutic target. In this paper, we review the role of ET-1 together with the available data on the roles of the specific ET receptors and ETRAs in PAH. In particular, we discuss the possible role of ET receptor selectivity in the vascular remodelling process in PAH and whether selective ETA or nonselective ETA/ETB blockade offers the greatest potential to improve symptoms and alter the clinical course of the disease. [ABSTRACT FROM AUTHOR]

Rheumatoid arthritis (RA) is a chronic inflammatory disease that decreases physical function and imposes substantial medical costs. Comorbid conditions are common in patients with RA and they adversely affect quality of life and RA-related outcomes such as work disability and mortality. Rheumatologists have the important responsibility to consider comorbidities and their risks when treating patients and to adapt therapies to the specific situation of individual patients. This paper discusses the common comorbidities in patients with RA and management approaches. [ABSTRACT FROM AUTHOR]

This paper makes the case that the widely used evidence-based ‘CBT’ approaches remain unsuccessful in many eating disorder patients. Six critical ‘personal reflections’ are formulated on why many patients remain totally resistant toward our therapeutic endeavours. My reflections suggest that probably many roads may lead to Rome. Copyright © 2008 John Wiley & Sons, Ltd and Eating Disorders Association. [ABSTRACT FROM AUTHOR]

The author comments on the paper by Abraham Brafman about the psychotherapy sessions given to a patient. He centers on the idea of what the patient needs which he believes has no objective means to evaluate. He stresses that a person's self-diagnosis and the therapist's diagnosis are not static factors. He also reflects on the importance of the starting frequency on therapy sessions wherein mistakes can be made depending on the patients' conditions.

Background: The purpose of the present paper was to investigate the efficacy of vitamin E in children with immunotolerant-phase chronic hepatitis B virus (CHB) infection. Methods: Fifty-eight immunotolerant children were prospectively and randomly recruited into two groups. Group 1 (study group) included 30 patients who received vitamin E at a dose of 100 mg/day throughout 3 months; group 2 (control group) contained 28 patients who did not receive any medication. Comparison of serological, virologic, and biochemical response ratios were done at the end of the therapy and after 6 months of vitamin E discontinuation. Results: Mean alanine transaminase (ALT) values in group 1 at the beginning of the therapy, 3 months after the therapy initiation and 6 months after discontinuation were 30.4 ± 7.3 IU/L, 31.3 ± 7.8 IU/L and 32.1 ± 8.5 IU/L, respectively. The mean hepatitis B virus (HBV)-DNA load of group 1 at onset, and at the third and ninth months of the treatment were 3106 ± 718 pg/mL, 3530 ± 137 pg/mL and 3364 ± 1246 pg/mL, respectively. These changes in both ALT and HBV-DNA values did not reach significant levels ( P > 0.05). In group 2, mean ALT values at the beginning of therapy, and at the third and ninth months were 28.0 ± 1.8 IU/L, 34.6 ± 8.1 IU/L, and 34.1 ± 7.0 IU/L, respectively ( P > 0.05), and mean viral load of HBV-DNA was 4227 ± 1435 pg/mL, 3368 ± 2673 pg/mL, and 3018 ± 2814 pg/mL, respectively ( P > 0.05). There was no statistically significant difference between group 1 and group 2 at the third and ninth months in the mean ALT values and viral load of HBV-DNA ( P > 0.05). Hepatitis B s antigen and hepatitis B e antigen clearance or hepatitis B s antibody and hepatitis B e antibody seroconversion were not observed in either group. Conclusion: As a first study investigating the effect of vitamin E in children with immunotolerant CHB infection, no beneficial effect could be demonstrated. Different immunomodulator protocols should be considered for future investigations. [ABSTRACT FROM AUTHOR]

Objectives: The use of patient-based outcomes to measure therapeutic effectiveness is increasing, because a growing number of clinical scientists are attempting to evaluate the impact of therapy on the recipient. There are indications that patients suffering from temporomandibular disorders (TMDs) may also show a reduced oral health-related quality of life (OHQoL). It was the purpose of this paper to answer the question as to whether therapeutic interventions in TMD patients have a positive effect on their OHQoL. Material and methods: A systematic electronic search (Ovid Medline® 1966–2006; Science Citation Index 1945–2006) of the literature was carried out to identify pertinent articles of randomized and non-randomized clinical trials. Reports on retrospective and prospective studies that specifically focused on OHQoL changes in TMD patients as a consequence of therapeutic interventions were included. The reference lists of the identified articles were screened to find additional pertinent publications. Results: The investigation yielded seven relevant contributions from Medline®. A quantitative analysis of the seven identified articles was not possible. There was considerable heterogeneity among the investigations with regard to study design, patient characteristics, and provided therapy. Three of the identified articles reported about prospective controlled studies, of which one was an RCT. Four additional investigations were retrospective. According to the results of the only RCT, a 6-week course of the non-selective cyclooxygenase (COX) inhibitor naproxen may lead to slightly better OHQoL in patients with temporomandibular joint (TMJ) arthralgia than the selective COX-2 inhibitor celecoxib. The two other articles reporting of a controlled study showed that selective serotonine uptake inhibitors accompanied by psychological therapy improved OHQoL in individuals with TMJ arthralgia. In contrast, TMJ surgery did not improve OHQoL. Conclusion: It appears that all therapeutic interventions reported in the identified publications led to at least some improvement of OHQoL. The only exception were patients with multiple TMJ surgeries. [ABSTRACT FROM AUTHOR]

Objective The aim of this paper was to analyse the results of treatment of anal fistulas retrospectively. Methods Between 1992 and 2004, 407 patients were operated on for perianal fistula. In the follow-up period, 107 patients were lost, so 300 patients were analysed in the study. The mean follow-up time was 4.2 years. Analysed parameters included: types of surgical procedures in different kinds of fistulas and postoperative complications. Various types of surgical procedures and their effectiveness were described. Late results were assessed taking into account healing time, duration of sick leave, recurrence rate and incidence of anal sphincter dysfunction. Severity of gas and stool incontinence was assessed according to the Cleveland Clinic Incontinence Score. Results In our study, subcutaneous fistula was diagnosed in 23.3%, inter-sphincteric in 18%, trans-sphincteric in 37.7%, supra-sphincteric in 16% and extra-sphincteric in 5% of patients. Single-tract fistulas were present in 88.7% and multi-tract fistulas were present in 11.3%. Overall, 242 patients had primary fistulas and 58 patients had recurrent fistulas. The most frequently performed procedures were cutting seton (139 patients) and radical fistulectomy (104 patients). Recurrent fistulas developed in 14.3%. Postoperative gas and/or stool incontinence was noticed in 10.7%. The recurrence rate was 5.4% in patients with primary fistula and in 51.7% patients presenting with a recurrent fistula. Gas and stool incontinence developed in 3.7% of patients with primary fistulas and in 39.7% of patients presenting with recurrent fistulas. Recurrence rate was 12% in the patients of single-tract fistulas and 32.4% in the patients of multi-tract fistulas. Postoperative gas and/or stool incontinence occurred in 8.3% of patients of single-tract fistulas and in 29.4% of patients of multi-tract fistulas. Conclusions The complication rate was 10-fold higher in patients presenting with a recurrent fistula than in those with primary fistulas and threefold higher in patients with multi-tract fistulas than in those with single-tract fistulas. [ABSTRACT FROM AUTHOR]

The argument that scarce health care resources should be distributed so that patients in ‘need’ are given priority for treatment is rarely contested. In this paper, we argue that if need is to play a significant role in distributive decisions it is crucial that what is meant by need can be precisely articulated. Following a discussion of the general features of health care need, we propose three principal interpretations of need, each of which focuses on separate intuitions. Although this account may not be a completely exhaustive reflection of what people mean when they refer to need, the three interpretations provide a starting-point for further debate of what the concept means in its specific application. We discuss combined interpretations, the meaning of grading needs, and compare needs-based priority setting to social welfare maximisation. [ABSTRACT FROM AUTHOR]