Wilderness Medical Society Clinical Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2024 Update

A panel convened to develop an evidence-based set of guidelines for the recognition and treatment of eye injuries and illnesses that may occur in the wilderness. These guidelines are meant to serve as a tool to help wilderness providers accurately identify and subsequently treat or evacuate for a variety of ophthalmologic complaints. Recommendations are graded based on the quality of their supporting evidence and the balance between risks and benefits according to criteria developed by the American College of Chest Physicians.

Geometric morphometrics and paleoproteomics enlighten the paleodiversity of Pongo

Pleistocene Pongo teeth show substantial variation in size and morphology, fueling taxonomic debates about the paleodiversity of the genus. We investigated prominent features of the enamel-dentine-junction junction (EDJ)-phylogenetically informative internal structures-of 71 fossil Pongo lower molars from various sites by applying geometric morphometrics and conducted paleoproteomic analyses from enamel proteins to attempt to identify extinct orangutan species. Forty-three orangutan lower molars representing Pongo pygmaeus and Pongo abelii were included for comparison. The shape of the EDJ was analyzed by placing five landmarks on the tip of the main dentine horns, and 142 semilandmarks along the marginal ridges connecting the dentine horns. Paleoproteomic analyses were conducted on 15 teeth of Late Pleistocene Pongo using high-resolution tandem mass spectrometry. The geometric morphometric results show variations in EDJ shape regarding aspects of the height and position of the dentine horns and connecting ridges. Despite the issue of molar position and sample size, modern molars are distinguished from fossil counterparts by their elongated tooth outline and narrowly positioned dentine horns. Proteomic results show that neither a distinction of P. pygmaeus and P. abelii, nor a consistent allocation of fossil specimens to extant species is feasible. Based on the EDJ shape, the (late) Middle to Late Pleistocene Pongo samples from Vietnam share the same morphospace, supporting the previous allocation to P. devosi, although substantial overlap with Chinese fossils could also indicate close affinities with P. weidenreichi. The hypothesis that both species represent one chronospecies cannot be ruled out. Two fossil specimens, one from Tam Hay Marklot (Laos, Late Pleistocene), and another from Sangiran (Java, Early to Middle Pleistocene), along with some specimens within the Punung sample (Java), exhibit affinities with Pongo abelii. The Punung fossils might represent a mix of early Late Pleistocene and later specimens (terminal Pleistocene to Holocene) related to modern Pongo. The taxonomy and phylogeny of the complete Punung sample needs to be further investigated.

Aquablation Therapy in Large Prostates (80-150 mL) for Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia: Final WATER II 5-Year Clinical Trial Results

PURPOSE

We report 5-year safety and efficacy outcomes of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia and large-volume prostate glands.

MATERIALS AND METHODS

A total of 101 men with moderate to severe benign prostatic hyperplasia symptoms and prostate volumes between 80 and 150 mL underwent a robotic-assisted Aquablation procedure in a prospective multicenter international trial (NCT03123250). Herein we report the final 5-year results.

RESULTS

The study successfully met its safety and efficacy performance goal, which was based upon transurethral resection of the prostate outcomes typically done in smaller prostates, at 3 months. Mean prostate volume was 107 mL (range 80-150) at baseline. Patient symptoms showed a significant improvement where the mean (SD) International Prostate Symptom Score of 22.6 (6.4) at baseline to 6.8 (4.6) at 5 years, resulting in a change score of 15.9 (7.7, P < .001). Uroflowmetry measurements also demonstrated improvement where the mean maximum urinary flow rate increased from 8.6 (SD 3.4) to 17.1 (9.8) mL/s at 5 years, resulting in a change score of 9.2 (11.1) mL/s at 5 years (P < .001). A regression analysis evaluating change in PSA as a function of baseline PSA across all time points out to 5 years resulted in a 50% reduction. A prespecified subgroup analysis using a baseline prostate volume cutoff of 100 mL showed no difference in efficacy outcomes through 5 years. Freedom from a secondary benign prostatic hyperplasia procedure at 5 years was 96.3% based on Kaplan-Meier.

CONCLUSIONS

At 5-years of prospective follow-up, the Aquablation procedure was shown to be safe with durable efficacy and low rates of retreatment in men with large prostates (80-150 mL).

A phase I study of an injectable lidocaine paste for spermatic cord block in men with chronic scrotal content pain

INTRODUCTION

Patients with chronic scrotal content pain (CSCP) lack effective, non-invasive treatment options. We aimed to determine the local and systemic safety, tolerability, pharmacokinetics (PK), and efficacy of a long-lasting local anesthetic in patients with CSCP.

METHODS

This was a prospective, single-center, open-label, single-arm, phase 1 dose-escalating trial completed between October 2019 and March 2021. Twelve patients ≥19 years old with unilateral scrotal pain lasting ≥3 months reporting an average maximum pain score over seven days of ≥4 on a 0-10 numerical rating scale (NRS) were included. Patients underwent a test spermatic cord block and those reporting a decrease of ≥2 points were included. The investigational drug, ST-01 (sustained-release lidocaine polymer solution), is a long-acting injection of lidocaine around the spermatic cord. Subjects were provided a NRS dairy and recorded their NRS score until day 28. The Chronic Epididymitis Symptom Index (CESI) was completed on days 0, 7, 14, and 28. All patients underwent an examination and assessment for adverse events (AE) on days 0, 1, 7, 14, and 28. Exploratory statistical hypothesis testing was planned for this study due to its investigative nature.

RESULTS

There were no serious adverse events (SAEs) reported. All subjects reported at least one treatment-emergent adverse event (TEAE); 83% of related AEs were injection-site reactions consisting of swelling and bruising. NRS was reduced across all cohorts between baseline and end of study.

CONCLUSIONS

This study provides evidence that the novel ST-01 treatment is safe and well-tolerated.

Highly efficient and selective aqueous phase hydrogenation of aryl ketones, aldehydes, furfural and levulinic acid and its ethyl ester catalyzed by phosphine oxide-decorated polymer immobilized ionic liquid-stabilized ruthenium nanoparticles

Phosphine oxide-decorated polymer immobilized ionic liquid stabilized RuNPs catalyse the hydrogenation of aryl ketones with remarkable selectivity for the CO bond, complete hydrogenation to the cyclohexylalcohol and hydrogenation of levulinic acid to γ-valerolactone.

Evaluating the acceptability of an online patient decision aid for the surgical management of lower urinary tract symptoms secondary to benign prostatic hyperplasia

INTRODUCTION

The growing number of surgical options available to treat benign prostatic hyperplasia (BPH), may overwhelm patients and urologists when deciding on an optimal treatment. Therefore, we developed an online patient decision aid (PtDA) that includes all guideline-approved surgical modalities. The objective of this study was to assess the acceptability of the PtDA among former BPH surgery patients and urologists that treat BPH surgically.

METHODS

The International Patient Decision Aids Standards were used to develop a PtDA that includes monopolar transurethral resection of the prostate (TURP), bipolar TURP, GreenLight photovaporization, endoscopic enucleation of the prostate, Rezum, Urolift, Aquablation, open retropubic prostatectomy, and robotic simple prostatectomy as management options. Eleven urologists that regularly treat BPH and 19 patients who received BPH surgery were recruited. Alpha-testing was performed using a validated acceptability scoring system.

RESULTS

For all sections of the PtDA, most urologists agreed that the language used was easy to follow (91.9%), that the amount of information provided was adequate (63.6%), that the length of the PtDA was appropriate (63.6%), and that the outcomes reported were correct (81.8%). All 19 patient participants agreed that the language used was easy to follow, and most found that the amount of information provided was adequate (84.2%), that the length of the PtDA was appropriate (84.2%), and that the outcomes reported were well-explained (89.5%).

CONCLUSIONS

Our PtDA was found to be acceptable among urologists and patients. These results demonstrate that most of the participants either recommend the use of this tool or plan to incorporate it in their clinical practice.

Aquablation therapy in large prostates (80–150 cc) for lower urinary tract symptoms due to benign prostatic hyperplasia: WATER II 3‐year trial results

Objective

The objective of this study is to determine if Aquablation therapy can maintain its effectiveness in treating men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with large‐volume (80–150 cc) prostates at 3 years.

Subjects and Methods

One hundred one men with moderate‐to‐severe BPH symptoms and prostate volumes between 80 and 150 cc were enrolled in a prospective, nonrandomized, multicenter, international clinical trial in late 2017. Baseline, procedural, and follow‐up parameters were recorded at baseline and scheduled postoperative visits. IPSS, Qmax, and treatment failure are reported at 3 years.

Results

The mean prostate volume was 107 cc (range 80–150). Mean IPSS improved from 23.2 at baseline to 6.5 at 3 years (16.3‐point improvement, p < 0.0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 3 years (improvement of 3.4 points, p < 0.0001). Maximum urinary flow increased from 8.7 to 18.5 cc/s. At 3 year follow‐up, 6% of treated patients needed BPH medication and an additional 3% required surgical retreatment for LUTS.

Conclusions

Three‐year follow‐up demonstrates a sustained symptom reduction response along with low irreversible complications to Aquablation in men with LUTS due to BPH and prostates of 80–150 cc. Current treatment options available for men with prostates of this size have similar efficacy outcomes but are burdened with high rates of irreversible complications. There are now numerous clinical studies with Aquablation used in various prostates sizes, and it should be offered as an option to men with LUTS due to BPH.

WATER versus WATER II 2-Year Update: Comparing Aquablation Therapy for Benign Prostatic Hyperplasia in 30-80-cm3 and 80-150-cm3 Prostates

Background

Surgical options are limited when treating large (>80 cm³) prostates for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Open simple prostatectomy remains the most common procedure performed for large prostates. There is a need for novel surgical approaches with shorter learning curves and effective treatment. Aquablation could be this novel tool.

Objective

To compare the outcome of Aquablation for 30-80-cm³ prostates with the outcome for 80-150-cm³ prostates at 2-yr follow-up.

Design setting and participants

We used data from two trials. WATER is a prospective, double-blind, multicenter, international clinical trial comparing the safety and efficacy of Aquablation and transurethral resection of the prostate in the treatment of LUTS/BPH in men aged 45-80 yr with a prostate of 30-80 cm³. WATER II is a prospective, multicenter, single-arm international clinical trial of Aquablation in men with a prostate of 80-150 cm³.

Intervention

Aquablation, an ultrasound-guided, robotically executed waterjet ablative procedure.

Outcome measurements and statistical analysis

We compared 24-mo outcomes between 116 WATER and 101 WATER II study subjects. Student's t test or a Wilcoxon test was used to compare continuous variables and Fisher's test for categorical variables.

Results and limitations

The International Prostate Symptom Score (IPSS) reductions at 24 mo was 14.5 points for WATER and 17.4 points for WATER II (p = 0.31). At baseline, the maximum urinary flow rate (Q_max) was 9.4 and 8.7 cm³/s in WATER and WATER II, improving to 20.5 and 18.2 cm³/s, respectively (p = 0.60) at 24 mo. Improvements in both IPSS and Q_max were immediate and sustained throughout follow-up. At 2 yr, the surgical retreatment rate was 4% in WATER and 2% in WATER II.

Conclusions

Aquablation is effective in patients with a prostate of 30-80 cm³ and patients with a prostate of 80-150 cm³ treated for LUTS/BPH, with comparable outcomes in both groups. It has low complication and retreatment rates at 2 yr of follow-up, with durable improvements in functional outcome.

Patient summary

Outcomes of Aquablation for both small-to-moderately-sized and large prostates are similar and sustainable at 2 yr of follow-up.

Use of rituximab in idiopathic retroperitoneal fibrosis

Background

Retroperitoneal fibrosis (RPF) is characterized by the proliferation of fibrous tissue in the retroperitoneum. The majority of RPF cases are due to idiopathic or IgG4-related disease. Recent studies on IgG4-related disease have shown rituximab to be an effective treatment. The current first-line treatment for idiopathic RPF (iRPF) is glucocorticoid therapy. Relapse rates vary widely in the literature, and DMARDs remain poorly studied. We sought to evaluate the efficacy of rituximab in idiopathic RPF by quantifying changes in iRPF diameter on imaging pre- and post-rituximab therapy and response by lab parameters in 10 iRPF patients.

Methods

We selected 10 patients diagnosed with iRPF and previously treated with rituximab (1000 mg) in two doses approximately 2 weeks apart. Pre- and post-therapy contrast enhanced cross-sectional abdomen and pelvis imaging were compared. In all patients, the thickest portion of the peri-aortic disease was measured in the axial and coronal planes. The presence of acute or long standing back pressure related renal findings were documented. Details of clinical visits including patient demographics and laboratory evaluations were collected pre- and post-therapy. Statistical analysis was performed using a Wilcoxon signed rank test.

Results

The RPF diameter around the aorta before and after therapy decreased from a mean of 15.9 ± 4.9 mm to 10.6 ± 6.1 mm, respectively (p < 0.01). The craniocaudal iRPF mean length decreased from 108.6 mm ± 40.4 mm to 90.6 mm ± 45.9 mm (p = 0.02).

Conclusion

A comparison of pre and post-rituximab imaging studies revealed a statistically significant decrease in iRPF diameter following treatment with rituximab.

Aquablation for benign prostatic hyperplasia in large prostates (80-150 cc): 2-year results

INTRODUCTION

To report 2-year safety and effectiveness of the Aquablation procedure for the treatment of men with symptomatic benign prostatic hyperplasia (BPH) and large-volume 80-150 cc prostates.

MATERIALS AND METHODS

Between September-December 2017, 101 men with moderate-to-severe BPH symptoms and prostate volumes of 80-150 cc underwent an ultrasound-guided robotically executed Aquablation procedure in a prospective multicenter international clinical trial (WATER II). Baseline, procedural and follow up parameters were recorded at baseline and scheduled postoperative visits. Herein we report 2-year safety and efficacy for this cohort.

RESULTS

Mean prostate volume was 107 cc (range 80-150 cc). Mean IPSS improved from 23.2 at baseline to 5.8 at 2 years (17-point improvement, p < .0001). Mean IPSS quality of life improved from 4.6 at baseline to 1.1 at 2 years (p < .0001). Maximum urinary flow increased from 8.7 to 18.2 cc/sec. Two subjects underwent a repeat procedure for BPH symptoms over the 2-year follow up period. By 2 years or study exit, all but 2 of 74 subjects stopped taking alpha blockers. Similarly, all but 4 of 32 subjects stopped taking 5α-reductase inhibitors.

CONCLUSIONS

Two-year prospective multicenter follow up demonstrated that the Aquablation procedure is safe and effective in the treatment of men with LUTS due to BPH and prostates 80-150 cc with durable treatment efficacy, acceptable safety profile and a low retreatment rate. ClinicalTrials.gov number, NCT03123250.

Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue trial (WATER) vs WATER II: comparing Aquablation therapy for benign prostatic hyperplasia in 30-80 and 80-150 mL prostates

Objective

To compare the outcomes of Aquablation in 30–80 mL prostates with those in 80–150 mL prostates. Surgical options, especially with short learning curves, are limited when treating large prostates for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Aquablation (AquaBeam System, PROCEPT BioRobotics Inc., Redwood City, CA, USA) could solve this issue with global reproducibility, independent of prostate volume.

Patients and Methods

Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue (WATER [W‐I]; NCT02505919) is a prospective, double‐blind, multicentre, international clinical trial comparing Aquablation and transurethral resection of the prostate (TURP) for the treatment of LUTS/BPH in prostates between 30 and 80 mL. WATER II (W‐II; NCT03123250) is a prospective, multicentre, single‐arm international clinical trial of Aquablation in prostates between 80 and 150 mL. We compare baseline parameters and 12‐month outcomes in 116 W‐I and 101 W‐II study patients. Students’ t‐test or Wilcoxon tests were used for continuous variables and Fisher’s test for binary variables.

Results

The mean (SD) operative time was 33 (17) and 37 (13) min in W‐I and W‐II, respectively. Actual treatment time was 4 and 8 min in W‐I and W‐II, respectively. The mean change in the International Prostate Symptom Score was substantial averaging (at 12 months) 15.1 in W‐I and 17.1 in W‐II (P = 0.605). By 3 months, Clavien–Dindo grade ≥II events occurred in 19.8% of W‐I patients and 34.7% of W‐II patients (P = 0.468).

Conclusion

Aquablation clinically normalises outcomes between patients with 30–80 mL prostates and patients with 80–150 mL prostates treated for LUTS/BPH, with an expected increase in the risk of complications in larger prostates. Long‐term outcomes of procedure durability are needed.

The earliest mustelid in North America

Until now, the pre-Miocene fossil record of mustelids in North America has been restricted to specimens attributable to oligobunine taxa and isolated remains tentatively allocated to the genus Plesictis. In the present study, we report on a nearly complete cranium and a referred dentary of a new genus and species of mustelid. The specimens were recovered from the Turtle Cove and Kimberly Members of the John Day Formation, Oregon, USA.

These excellently preserved specimens more confidently confirm the presence of mustelids in the Early and Late Oligocene (Early and Late Arikareean) of North America. Like the holotype specimen of ‘Plesictis’ julieni, the new species lacks an alisphenoid canal and a postprotocrista on the M1 (synapomorphies of Mustelidae), but retains a dorsally deep suprameatal fossa (a feature occasionally suggested to be unique to Procyonidae). Phylogenetic analyses, applying parsimony and Bayesian inference to combined molecular (five genes totalling 5490 bp) and morphological data, recover this new species of mustelid as sister-species to ‘Plesictis’ julieni. The results of these analyses reveal that the new genus is a close relative of other species of Plesictis and several taxa traditionally allied with Oligobuninae, thereby rendering Oligobuninae paraphyletic. We further discuss the significance of the relatively small size of this new mustelid as it relates to predictions based on increased aridification of the palaeoclimate and the expansion of open habitats in the Oligocene.

Aquablation for benign prostatic hyperplasia in large prostates (80-150 mL): 6-month results from the WATER II trial

OBJECTIVE

To present 6-month safety and effectiveness data from a multicentre prospective study of aquablation in men with lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) with prostate volumes between 80 and 150 mL.

METHODS

Between September and December 2017, 101 men with LUTSattributable to BPHwere prospectively enrolled at 16 centres in Canada and the USA.

RESULTS

The mean prostate volume was 107 mL. The mean length of hospital stay after the aquablation procedure was 1.6 days (range: same day to 6 days). The primary safety endpoint (Clavien-Dindo grade 2 or higher or any grade 1 event resulting in persistent disability) at 3 months occurred in 45.5% of men, which met the study design goal of < 65% (P < 0.001). At 6 months, 22% of the patients had experienced a Clavien-Dindo grade 2, 14% a grade 3 and 5% a grade 4 adverse event. Bleeding complications requiring intervention and/or transfusion were recorded in eight patients prior to discharge and in six patients after discharge. The mean International Prostate Symptom Score improved from 23.2 ± 6.3 at baseline to 6.7 ± 5.1 at 3 months, meeting the study's primary efficacy endpoint goal (P < 0.001). The maximum urinary flow rate increased from 8.7 to 18.8 mL/s (P < 0.001) and post-void residual urine volume decreased from 131 at baseline to 47 at 6 months (P < 0.0001). At 6 months, prostate-specific antigen concentration reduced from 7.1 ± 5.9 ng/mL at baseline to 4.0 ± 3.9 ng/mL, a 44% reduction.

CONCLUSIONS

Aquablation is safe and effective in treating men with larger prostates (80-150 mL), without significant increase in procedure or resection time.

Aquablation among novice users in Canada: A WATER II subpopulation analysis

INTRODUCTION

Surgical management options for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) associated with prostates of small to moderate volume (<80 cc) are numerous; however, for men with enlarged prostates (>80 cc), many of these options are neither safe nor effective. Recently, Aquablation (PROCEPT BioRobotics, Inc., U.S.), a precise ultrasound-guided, robotically executed prostatic ablative procedure, has become available with U.S. Food and Drug Administration approval. Herein, we present three-month safety and efficacy data from the cohort of Canadian men included in the WATER II trial.

METHODS

WATER II is a prospective clinical trial of the Aquablation system for the treatment of BPH in men with prostate volumes between 80 and 150 cc. Only patients from Canada were included for this analysis. At baseline, subjects completed International Prostate Symptom Score (IPSS), as well as several validated questionnaires, uroflowmetry and post-void residual volume measurements, and underwent standard laboratory blood assessment. These were repeated at one and three months post-Aquablation.

RESULTS

A total of 19 subjects who met inclusion and exclusion criteria were enrolled at three Canadian academic sites. Mean pre-, one-month, and three-month post-treatment IPSS scores were 21.2±5.5, 9.9±6.9 (p<0.0001), and 5.0±4.5 (p<0.0001), respectively. Mean pre-, one-month, and three-month post-treatment maximum urinary flow rates (Qmax) were 6.6±3.1 ml/s, 19.5±6.1 ml/s (p<0.0001), and 23.1±9.2 ml/s (p<0.0001), respectively. The Clavien-Dindo grade 2 or higher event rate at three months was 31.6% (six events).

CONCLUSIONS

In this short-term, three-month analysis of Canadian men, Aquablation appears to provide a strong surgical alternative in patients with LUTS/BPH due to larger prostate volumes, with impressive functional outcomes, relatively short operative time and length of hospital stay, and acceptable complication and low transfusion rates.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Significant differences in struvite and cystine stone frequency seen among Chinese nephrolithiasis patients living in North America compared to those living in China

Background

Interracial disparities in nephrolithiasis prevalence have been reported, but the interplay between genetics and the environment for urinary stone disease risk factors is poorly understood. To examine how environment may alter genetic predisposition for stone formation, we established the International Chinese Consortium on Nephrolithiasis (ICCON) as a multi-institutional collaboration to examine patterns of nephrolithiasis presentation between Chinese patients living in different countries.

Methods

Chinese patients undergoing percutaneous nephrolithotomy (PCNL) at six participating institutions in China and North America over 4 years were reviewed retrospectively. Patient demographics and clinical data were compared between Chinese patients living in China and North America.

Results

A total of 806 patients were included, encompassing 721 Chinese patients living in China and 85 living in North America. Nephrolithiasis patients living in China were more likely to be male (67% vs. 56%, P=0.02), present at a younger age (48.6±15.0 vs. 55.0±13.0 years, P<0.01), and have a lower BMI (24.6±4.0 vs. 25.9±5.7, P=0.04) but were less likely to form struvite stones (5.5% vs. 14.1%, P<0.01). No cystine stone patients were seen in North American Chinese patients, whereas 1.8% of nephrolithiasis patients living in China presented with cystine stones. Similar rates of calcium-based and uric acid calculi as well as urinary pH were seen among both groups.

Conclusions

Significant differences exist between Chinese nephrolithiasis patients living in China compared to those living in North America, highlighting the importance of environmental factors in addition to genetics in modulating risk for urinary stone disease.

Short Communication: The Pre-transport management of antemortem stress in cattle: Impact on carcass yield

Grumpelt, B., Hoffer, W., Curie, O., Jones, O., Jones, K., Kimmel, D., McDonald, B., Paterson, R. and Schaefer, A. 2015. Short Communication:The Pre-transport management of antemortem stress in cattle: Impact on carcass yield. Can. J. Anim. Sci. 95: 557–560. Transport and handling of cattle can have a significant impact on carcass weight loss. The purpose of the present study was to examine the effect of providing pre-transport nutritional therapy containing selective amino acids, electrolytes and an energy source, on carcass weight loss. One hundred and ninety British crossbred steers averaging 611 kg were used in the study. The treatment cattle received 1 kg of a nutritional supplement top dressed onto their normal silage diet 24 h prior to transport. Following a 1-h transport period the cattle were processed at a federally inspected beef plant and both hot and cold carcass yield as well as yield grade and quality grade were assessed. Cattle provided with pre-transport nutritional therapy demonstrated a reduction in percentage live weight loss (P<0.01) as well as 1.2% greater hot carcass yield as a proportion of pre-treatment farm weight (P<0.01). The data suggest the use of nutritional support pre-transport is beneficial to carcass yield.

Preparticipation Evaluation for Climbing Sports

Climbing is a popular wilderness sport among a wide variety of professional athletes and amateur enthusiasts, and many styles are performed across many environments. Potential risks confront climbers, including personal health or exacerbation of a chronic condition, in addition to climbing-specific risks or injuries. Although it is not common to perform a preparticipation evaluation (PPE) for climbing, a climber or a guide agency may request such an evaluation before participation. Formats from traditional sports PPEs can be drawn upon, but often do not directly apply. The purpose of this article was to incorporate findings from expert opinion from professional societies in wilderness medicine and in sports medicine, with findings from the literature of both climbing epidemiology and traditional sports PPEs, into a general PPE that would be sufficient for the broad sport of climbing. The emphasis is on low altitude climbing, and an overview of different climbing styles is included. Knowledge of climbing morbidity and mortality, and a standardized approach to the PPE that involves adequate history taking and counseling have the potential for achieving risk reduction and will facilitate further study on the evaluation of the efficacy of PPEs.

Inter-professional prescribing masterclass for medical students and non-medical prescribing students (nurses and pharmacists): a pilot study

BACKGROUND AND AIMS

Prescribing errors cause significant patient morbidity and mortality. Current legislation allows prescribing by different health professions. Inter-professional collaboration and learning may result in safer prescribing practice. This study aimed to develop, pilot and test the feasibility of a simulated inter-professional prescribing masterclass for non-medical prescribing students, medical students and pharmacists.

METHODS AND RESULTS

A three-scenario, simulated patient session was designed and implemented by an expert panel. Medical students, non-medical prescribing students and pharmacists worked together to formulate and implement evidence-based prescriptions. The Readiness for Inter-professional Learning Score (RIPLS) and a self-efficacy score were administered to the students and the Trust in Physician Score to the simulated patients. Overall, the RIPLS and self-efficacy scores increased. Pharmacists showed the highest rating in the Trust in Physician score. Post masterclass group discussions suggested that the intervention was viewed as a positive educational experience.

CONCLUSION

An inter-professional prescribing masterclass is feasible and acceptable to students. It increases self-efficacy, readiness for inter-professional learning and allows students to learn from, about and with each other. A larger study is warranted and the use of feedback from simulated patients explored further.

Intraocular pressure is not associated with acute mountain sickness

OBJECTIVE

Acute mountain sickness (AMS) is common at high altitude and may lead to high altitude cerebral edema (HACE) if not properly recognized. Previous studies have suggested that AMS is associated with increases in intracranial pressure (ICP). Increased ICP has been associated with increased intra-ocular pressure (IOP). This study was designed to determine the association between IOP and AMS.

METHODS

Subjects were recruited from a convenience sample of travelers in the Khumbu region of Nepal, elevation 14,410 ft (4392 m). Study participation involved completion of a questionnaire to assess for AMS by the Lake Louise Score (LLS), followed by three IOP measurements in each eye. Investigators were blinded to the LLS. Subjects with a history of ocular surgery were excluded. Three IOP measurements per eye were made using an applanation tonometer (Tono-Pen XL(®), Reichart Technologies) and averaged across both eyes. Multivariable logistic regression analysis was used to estimate the association between IOP and AMS while adjusting for age, ascent or descent, and use of acetazolamide. IOP and blood O2 saturation were compared using a Spearman correlation coefficient.

RESULTS

161 subjects were enrolled with a median age of 36 (IQR: 29-45) years; 60% were male, 75% were ascending, and 64% were taking acetazolamide; additionally, 38%, (95% CI: 31%-47%) were diagnosed with AMS (LLS ≥3). The median IOP was 21 (IQR 18-24) mmHg. The logistic regression model demonstrated no association between IOP and AMS as measured by LLS (odds ratio [OR] 1.0, 95% CI: 0.9-1.1),age (OR 1.0, 95% CI: 0.9-1.0) or with use of acetazolamide (OR 1.4, 95% CI: 0.6-2.6). Ascent (OR 0.4, 95% CI: 0.2-0.9) was negatively associated with IOP but not significantly so. IOP and O2 saturation were not correlated (p=0.93).

CONCLUSIONS

IOP measured at high altitude is not associated with the diagnosis of AMS. Other approaches to diagnose AMS easily and accurately are needed.

Chikungunya, climate change, and human rights

Chikungunya is a re-emerging arbovirus that causes significant morbidity and some mortality. Global climate change leading to warmer temperatures and changes in rainfall patterns allow mosquito vectors to thrive at altitudes and at locations where they previously have not, ultimately leading to a spread of mosquito-borne diseases. While mutations to the chikungunya virus are responsible for some portion of the re-emergence, chikungunya epidemiology is closely tied with weather patterns in Southeast Asia. Extrapolation of this regional pattern, combined with known climate factors impacting the spread of malaria and dengue, summate to a dark picture of climate change and the spread of this disease from south Asia and Africa into Europe and North America. This review describes chikungunya and collates current data regarding its spread in which climate change plays an important part. We also examine human rights obligations of States and others to protect against this disease.

Autosomal recessive bestrophinopathy associated with angle-closure glaucoma

PURPOSE

Abnormalities in the BEST1 gene have recently been recognised as causing autosomal recessive bestrophinopathy (ARB). ARB has been noted to have a variable phenotypic presentation, distinct from that of autosomal dominant Best vitelliform macular dystrophy (BVMD). Both conditions are associated with deposits in the retina, a reduced or absent electro-oculography (EOG) light rise, and the risk of developing angle-closure glaucoma. Herein, we describe the clinical and genetic characteristics of a young male diagnosed with ARB associated with angle-closure glaucoma resulting from a novel homozygous mutation in BEST1.

METHODS

All research involved in this case adhered to the tenets of the Declaration of Helsinki. The proband underwent slitlamp examination, retinal autofluorescence imaging and optical coherence tomography after presenting with deteriorating vision. The findings prompted genetic testing with bi-directional DNA sequencing of coding and flanking intronic regions of BEST1. The proband's family members were subsequently screened.

RESULTS

A provisional diagnosis of ARB was made based on the findings of subretinal and schitic lesions on fundoscopy and retinal imaging, together with abnormal EOG and electroretinography. Genetic testing identified a novel homozygous mutation in BEST1, c.636+1 G>A. Family members were found to carry one copy of the mutation and had no clinical or electrophysiological evidence of disease. The proband was additionally diagnosed with angle-closure glaucoma requiring topical therapy, peripheral iridotomies and phacoemulsification.

CONCLUSIONS

Phenotypic overlap, reduced penetrance, variable expressivity and the ongoing discovery of new forms of bestrophinopathies add to the difficulty in distinguishing these retinal diseases. All patients diagnosed with ARB or BVMD should be examined for narrow angles and glaucoma, given their frequent association with these conditions.

AltitudeOmics: the integrative physiology of human acclimatization to hypobaric hypoxia and its retention upon reascent

An understanding of human responses to hypoxia is important for the health of millions of people worldwide who visit, live, or work in the hypoxic environment encountered at high altitudes. In spite of dozens of studies over the last 100 years, the basic mechanisms controlling acclimatization to hypoxia remain largely unknown. The AltitudeOmics project aimed to bridge this gap. Our goals were 1) to describe a phenotype for successful acclimatization and assess its retention and 2) use these findings as a foundation for companion mechanistic studies. Our approach was to characterize acclimatization by measuring changes in arterial oxygenation and hemoglobin concentration [Hb], acute mountain sickness (AMS), cognitive function, and exercise performance in 21 subjects as they acclimatized to 5260 m over 16 days. We then focused on the retention of acclimatization by having subjects reascend to 5260 m after either 7 (n = 14) or 21 (n = 7) days at 1525 m. At 16 days at 5260 m we observed: 1) increases in arterial oxygenation and [Hb] (compared to acute hypoxia: PaO₂ rose 9±4 mmHg to 45±4 while PaCO₂ dropped a further 6±3 mmHg to 21±3, and [Hb] rose 1.8±0.7 g/dL to 16±2 g/dL; 2) no AMS; 3) improved cognitive function; and 4) improved exercise performance by 8±8% (all changes p<0.01). Upon reascent, we observed retention of arterial oxygenation but not [Hb], protection from AMS, retention of exercise performance, less retention of cognitive function; and noted that some of these effects lasted for 21 days. Taken together, these findings reveal new information about retention of acclimatization, and can be used as a physiological foundation to explore the molecular mechanisms of acclimatization and its retention.

Evaluation and medical management of the kidney stone patient

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Improvement in out-of-hours outcomes following the implementation of Hospital at Night

BACKGROUND

Hospital at Night (H@N) is a Department of Health (England) driven programme being widely implemented across UK. It aims to redefine how medical cover is provided in hospitals during the out-of-hours period.

AIM

To investigate whether the implementation of H@N is associated with significant change in system or clinical outcomes.

DESIGN

An observational study for 14 consecutive nights before, and 14 consecutive nights after the implementation of H@N. Data were collected from the Combined surgical and medical Assessment Unit (CAU), the 18 medical/surgical wards (The Ward Arc) and the four High Dependency Units (The Critical Care corridor) within the Royal Infirmary of Edinburgh.

METHODS

Following an overnight episode of clinical concern, data were gathered on response time, seniority of reviewing staff, patient outcome and the use of Standardized Early Warning Score (SEWS).

RESULTS

Two hundred and nine episodes of clinical concern were recorded before the implementation of H@N and 216 episodes afterwards. There was no significant change in response time in the CAU, Ward Arc or Critical Care corridor. However, significant inter-speciality differences in response time were eradicated, particularly in the Critical Care corridor. Following the implementation of H@N, patients were reviewed more frequently by senior medical staff in CAU (28% vs. 4%, P < 0.05) and the Critical Care corridor (50% vs. 22%, P < 0.001). Finally there was a reduction in adverse outcome (defined as unplanned transfer to critical care/cardiac arrest) in the Ward Arc and CAU from 17% to 6% of patients reviewed overnight (P < 0.01). SEWS was more frequently and accurately recorded in CAU.

CONCLUSION

This is the first study that we are aware of directly comparing out-of-hours performance before and after the implementation of H@N. Significant improvements in both patient and system outcomes were observed, with no adverse effects noted.

Assessment of clinical risk in the out of hours hospital prior to the introduction of Hospital at Night

Overnight medical cover in hospital is less than during daylight hours. We aimed to quantify the numbers of patients deteriorating overnight and their clinical outcome. Data was collected in real time on use of the Standardised Early Warning Score (SEWS), 'time to doctor', seniority of medical review and clinical outcome. 136 incidents of clinical concern were noted on the general wards with a median response time of 5 minutes for SEWS>4 and 10 minutes if SEWS<4. 159 incidents were recorded in critical care. There was significant inter-speciality variation in median response times and seniority of responding staff, particularly within critical care, which recorded the slowest times across the hospital. This will be reassessed following the establishment of Hospital at Night.

Prediction of in-hospital mortality and length of stay using an early warning scoring system: clinical audit

This aim of this study was to assess the impact of the introduction of a standardised early warning scoring system (SEWS) on physiological observations and patient outcomes in unselected acute admissions at point of entry to care. A sequential clinical audit was performed on 848 patients admitted to a combined medical and surgical assessment unit during two separate 11-day periods. Physiological parameters (respiratory rate, oxygen saturation, temperature, blood pressure, heart rate, and conscious level), in-hospital mortality, length of stay, transfer to critical care and staff satisfaction were documented. Documentation of these physiological parameters improved (P<0.001-0.005) with the exception of oxygen saturation (P=0.069). The admission early warning score correlated both with in-hospital mortality (P<0.001) and length of stay (P=0.001). Following the introduction of the scoring system, inpatient mortality decreased (P=0.046). Staff responding to a questionnaire indicated that the scoring system increased awareness of illness severity (80%) and prompted earlier interventions (60%). A standardised early warning scoring system improves documentation of physiological parameters, correlates with in-hospital mortality, and helps predict length of stay.

Naming, blaming and shaming?

Few doctors at the centre of complaints or disciplinary proceedings wish to be publicly named. Publication of a doctor's name can adversely affect his or her reputation, patients, and family members, even if the allegation is ultimately not upheld. Yet, there is a strong public interest in freedom of speech and transparency of complaints and disciplinary processes. In determining whether to grant name suppression, complaints agencies and disciplinary tribunals are required to balance competing public and private interests. In New Zealand, the Health and Disability Commissioner has responsibility for investigating complaints about the quality of medical care. The Commissioner's current practice is not to publicly name doctors under investigation, or even those who are found to have breached a patient's rights. This approach fits well the non-punitive, rehabilitative focus of New Zealand's medical regulatory system. In the rare cases where a matter reaches the threshold for disciplinary action, the balance tips in favour of disclosure.

A new technique for reconstructing the medial patellofemoral ligament

Many surgical techniques exist for treating patella instability. Over recent years, attention has focussed on reconstruction of the medial patellofemoral ligament (MPFL). We report a procedure involving a lateral release, distal realignment of the tibial tubercle and anatomic reconstruction of the MPFL using a graft composed of a redundant strip of medial retinacular tissue. Nineteen patients (twenty-one knees) with chronic patellofemoral instability who had failed conservative treatment underwent this procedure and were assessed clinically and radiologically at an average of 23 months post-operation. No patients were lost to follow-up. There was no recurrence of subluxation or dislocation. All achieved levels of activity comparable to or improved compared to pre-operative uninjured levels. This combined procedure incorporating a previously un-described method of reconstructing the MPFL gives superior results compared to previous studies. No graft donor site morbidity occurred and patient outcome scores, especially objective stability of the patella to lateral shift, were excellent.

Protecting patients' rights in New Zealand

For 30 years, medical malpractice litigation has effectively been barred in New Zealand by accident compensation laws. Victims of medical error are rehabilitated and compensated through a no-fault, state-funded compensation scheme. Patients' rights (and providers' duties) are set out in a Code of Consumers' Rights, which applies to all providers of health and disability services, ranging from surgeons to traditional Maori healers and unpaid caregivers. Organisational providers such as hospitals are also covered. Complaints alleging a breach of the Code are resolved at the lowest appropriate level by a statutory Ombudsman, the Health and Disability Commissioner. Resolution techniques include advocacy, mediation and investigation, which may result in a finding of breach of the Code. The emphasis is on "resolution, not retribution" and "learning, not lynching". The Commissioner makes remedial recommendations, but does not award damages. Competence concerns are referred to professional registration boards, and serious breaches are referred for disciplinary proceedings. The New Zealand model of legislating patients' rights and enforcing them via an independent Commissioner is an interesting variant of professional self-regulation, and seeks to promote resolution of individual complaints and systemic improvements in health care quality. Investigation reports are widely distributed to promote learning. Despite initial professional resistance, the Office is becoming recognised for its key role in a regulatory system where medical malpractice claims are barred. A case study involving misdiagnosis of a fatal heart attack illustrates the flexibility of the New Zealand response to medical errors.

Reflective testing: how useful is the practice of adding on tests by laboratory clinicians?

AIMS

To investigate the clinical value and practice of reflective testing, a new term to describe the practice of adding on tests when reporting or clinically authorising results.

METHODS

A consultant medical biochemist collected over a calendar year (2001) copies of clinical biochemistry reports on samples to which he had added on either iron studies (iron, total iron binding capacity (TIBC), and percentage saturation), or vitamin D. Iron studies and vitamin D were added on when biochemical results, available clinical information, demographic data, and clinical experience-or combinations thereof-suggested the possibility of haemochromatosis or vitamin D deficiency, respectively. The number of reports that the consultant authorised was estimated for the same calendar year. The number and percentage of raised TIBC percentage saturation and low vitamin D results from the tests that were added on were collated.

RESULTS

Raised TIBC saturation values were found in 28 patients (18.7% of the iron studies added on), of whom 16 were subsequently genotyped, eight having a genotype consistent with haemochromatosis. Thirty one patients with vitamin D deficiency (23.1% of the vitamin D tests added on) were identified.

CONCLUSIONS

The addition of iron studies and vitamin D tests by a laboratory clinician, when reporting, resulted in the identification of patients with haemochromatosis and vitamin D deficiency. The practice of adding on tests should be called reflective testing, because it is discretionary and is based on the clinical judgement of a laboratory clinician in the interpretation of results.

Patients' rights in New Zealand: complaints resolution and quality improvement

"Patients' rights" has become a familiar catchword in western countries in recent years. In New Zealand the Office of the Health and Disability Commissioner was established in 1994 to promote and protect patients' rights. The Commissioner also facilitates the resolution of complaints relating to the infringement of patients' rights as set out in the Code of Health and Disability Services Consumers' Rights. Victims of medical misadventure in New Zealand are compensated through a no-fault, state-funded rehabilitation and compensation scheme. The regulatory environment is rehabilitative rather than punitive. This framework is consistent with a systems approach to reducing errors and improving patient safety, and the Commissioner seeks to use the resolution of individual complaints as a tool for improving the quality of care throughout the health care system.