Dads in Distress: symptoms of depression and traumatic stress in fathers following poor fetal, neonatal, and maternal outcomes

BACKGROUND

This study aims to explore the prevalence of symptoms of depression and traumatic stress in fathers in the setting of poor fetal, neonatal, and maternal outcomes.

METHODS

A prospective mixed-methods study was conducted at an outer metropolitan public teaching hospital in Brisbane, Australia, with quantitative results presented here. Subjects included 28 fathers whose male partners had experienced pregnancy or childbirth complicated by a significant congenital abnormality or aneuploidy, termination of pregnancy, fetal death in-utero, stillbirth, admission to the neonatal intensive care unit or special care nursery or significant maternal morbidity, such as a postpartum haemorrhage or an emergency postpartum hysterectomy. These experiences were classified into two groups: anticipatory (time to prepare) and sudden (no warning). The fathers were screened using the Edinburgh Postnatal Depression Scale (EPDS) and the Impact of Events Scale-Revised (IES-R) to assess subjective distress at 2-3 weeks (timepoint 1) and 3-4 months (timepoint 2) after the event.

RESULTS

Data for both the EPDS and IES-R scales was available for 26 fathers (92.9%) at timepoint 1 and for 15 fathers (53.6%) at timepoint 2. High overall EPDS scores (≥10) were noted in 16/27 (59.3%) fathers at timepoint 1 and 6/15 fathers (40.0%) at timepoint 2. High overall IES-R scores ≥33 were noted in 12/26 (46.2%) fathers at timepoint 1 and 4/15 fathers (26.7%) at timepoint 2. A higher percentage of fathers who experienced anticipatory events had EPDS and IES-R score above these cut-offs at timepoint 1 (8/13 or 61.5%) compared to those experiencing sudden events (8/14 or 57.1%), however, percentages were similar between groups at time point 2 (2/7 or 28.6%% and 4/8 or 50.0%, respectively). More fathers who experienced anticipatory events had IES-R scores ≥33 at timepoint 1 (7/13 or 53.8%) compared to those experiencing sudden events (5/14 or 38.0%).

CONCLUSION

Our study indicates high rates of distress in fathers exposed to poor fetal, neonatal, and maternal outcomes, which can persist for months after the event. Increased support for fathers in this setting may be required to prevent poor mental health. Further research on the long-term effects of these adverse events is warranted.

Acute Uveitis in a Background of Streptococcal Sepsis: Infective or Inflammatory?

BACKGROUND

The pathophysiology of uveitis in a patient with post-streptococcal syndrome with evidence of bacterial sepsis may be difficult to classify as being infective or an inflammatory etiology.

CASE REPORT

Our patient presented with uveitis with systemic features of reactive arthritis and acute renal failure in a background of sepsis with group A streptococcus. Treatment with topical steroids lead to the resolution of this type of uveitis.

CONCLUSION

It is safe to consider uveitis as being inflammatory rather than infectious and treat appropriately, when evidence suggesting other features of post -streptococcal syndrome are present.

Ecogenomics of Groundwater Phages Suggests Niche Differentiation Linked to Specific Environmental Tolerance

Viruses are ubiquitous microbiome components, shaping ecosystems via strain-specific predation, horizontal gene transfer and redistribution of nutrients through host lysis. Viral impacts are important in groundwater ecosystems, where microbes drive many nutrient fluxes and metabolic processes; however, little is known about the diversity of viruses in these environments. We analyzed four groundwater plasmidomes (the entire plasmid content of an environment) and identified 200 viral sequences, which clustered into 41 genus-level viral clusters (approximately equivalent to viral genera) including 9 known and 32 putative new genera. We used publicly available bacterial whole-genome sequences (WGS) and WGS from 261 bacterial isolates from this groundwater environment to identify potential viral hosts. We linked 76 of the 200 viral sequences to a range of bacterial phyla, the majority associated with Proteobacteria, followed by Firmicutes, Bacteroidetes, and Actinobacteria. The publicly available WGS enabled mapping bacterial hosts to several viral sequences. The WGS of groundwater isolates increased the depth of host prediction by allowing host identification at the strain level. The latter included 4 viruses that were almost entirely (>99% query coverage, >99% identity) identified as integrated in the genomes of Pseudomonas, Acidovorax, and Castellaniella strains, resulting in high-confidence host assignments. Lastly, 21 of these viruses carried putative auxiliary metabolite genes for metal and antibiotic resistance, which might drive their infection cycles and/or provide selective advantage to infected hosts. Exploring the groundwater virome provides a necessary foundation for integration of viruses into ecosystem models where they are key players in microbial adaption to environmental stress. IMPORTANCE To our knowledge, this is the first study to identify the bacteriophage distribution in a groundwater ecosystem shedding light on their prevalence and distribution across metal-contaminated and background sites. Our study is uniquely based on selective sequencing of solely the extrachromosomal elements of a microbiome followed by analysis for viral signatures, thus establishing a more focused approach for phage identifications. Using this method, we detected several novel phage genera along with those previously established. Our approach of using the whole-genome sequences of hundreds of bacterial isolates from the same site enabled us to make host assignments with high confidence, several at strain levels. Certain phage genes suggest that they provide an environment-specific selective advantage to their bacterial hosts. Our study lays the foundation for future research on directed phage isolations using specific bacterial host strains to further characterize groundwater phages, their life cycles, and their effects on groundwater microbiome and biogeochemistry.

Reporting health research translation and impact in the curriculum vitae: a survey

Background

Increasingly, health researchers must demonstrate the impact and real-life applications of their research. We investigated how health researchers with expertise in knowledge translation report research translation activities and impact on their curriculum vitae (CV).

Methods

We conducted a cross-sectional survey of health researchers with expertise in knowledge translation as we anticipated best practices in CV reporting from this specialized group. Our survey asked participants about their reporting of research translation and impact activities on their CVs, intention to report, and barriers and facilitators to reporting such activities on their CVs. We calculated univariate descriptive statistics for all quantitative data. Linear regression models determined predictors of researchers’ intention to report research translation and impact activities on their CVs. We analyzed open-ended qualitative responses using content analysis.

Results

One hundred and fifty-three health researchers responded to the survey (response rate = 29%). Most respondents were Canadian, were female, and had a doctoral degree. Eighty-two percent indicated they reported at least one research translation and/or impact indicator on their CVs. Of those, health researchers commonly reported the following: advisory/regulatory committee membership related to research program (83%), research translation award(s) (61%), and academic performance assessments (59%). Researchers least commonly indicated the following: citation metric scores (31%), summaries of impact (21%), and requests to use research materials and/or products (19%). Fewer than half of the health researchers intended to report knowledge translation (43%) and impact (33%) on their CVs. Strong beliefs about capabilities and consequences of reporting research translation and/or impact were significant predictors of intention. Main barriers were as follows: CV templates do not include research translation and impact activities, participants perceived employers do not value research translation and impact activities, and lack of metrics to evaluate research translation and impact. Ninety-six percent were unaware of a CV template formatted to include research translation and/or impact reporting.

Conclusions

Knowledge translation and impact indicators on the CV are inconsistently reported by our sample of health researchers. Modifiable barriers should be addressed to support more consistent reporting of such activities, including providing a CV template that includes research translation and impact as well as clear metrics to quantify them.

Building an integrated knowledge translation (IKT) evidence base: colloquium proceedings and research direction

Background

Integrated knowledge translation (IKT) is a model of research co-production, whereby researchers partner with knowledge users throughout the research process and who can use the research recommendations in practice or policy. IKT approaches are used to improve the relevance and impact of research. As an emerging field, however, the evidence underpinning IKT is in active development. The Integrated Knowledge Translation Research Network represents a collaborative interdisciplinary team that aims to advance the state of IKT science.

Methods

In 2017, the Integrated Knowledge Translation Research Network issued a call to its members for concept papers to further define IKT, outline an IKT research agenda, and inform the Integrated Knowledge Translation Research Network’s special meeting entitled, Integrated Knowledge Translation State of the Science Colloquium, in Ottawa, Canada (2018). At the colloquium, authors presented concept papers and discussed knowledge-gaps for a research agenda and implications for advancing the IKT field. We took detailed field notes, audio-recorded the meeting and analysed the data using qualitative content analysis.

Results

Twenty-four participants attended the meeting, including researchers (n = 11), trainees (n = 6) and knowledge users (n = 7). Seven overarching categories emerged from these proceedings – IKT theory, IKT methods, IKT process, promoting partnership, definitions and distinctions of key IKT terms, capacity-building, and role of funders. Within these categories, priorities identified for future IKT research included: (1) improving clarity about research co-production/IKT theories and frameworks; (2) describing the process for engaging knowledge users; and (3) identifying research co-production/IKT outcomes and methods for evaluation.

Conclusion

The Integrated Knowledge Translation State of the Science Colloquium initiated a research agenda to advance IKT science and practice. Next steps will focus on building a theoretical and evidence base for IKT.

Oncoplastic conservative surgery for breast cancer: long-term outcomes of our first ten years experience

OBJECTIVE

The main goal of oncoplastic breast surgery (OBS) is to optimize cosmetic outcomes and reduce patient morbidity, while still providing an oncologically-safe surgical outcome and extending the target population of conservative surgery. Although the growing number of reported experiences with oncoplastic surgery, few studies account for the long-term outcomes.

PATIENTS AND METHODS

Between January 2000 and December 2010, 1024 consecutive oncoplastic surgeries were performed and prospectively included in a database. Demographic data, histological and oncological evaluation and surgical complications were recorded. The role of tumor and patients' characteristics on the development of local recurrence and metastases were assessed by multivariate analysis.

RESULTS

Median follow up was 74.2 months. The average age of patients was 56.24. In 869 patients (84.9%) an invasive tumor and in 155 (15.1%) an in situ tumor (11% DCIS and 4% LIN) was found. The average size of the tumor was 24.5 mm. A positive margin presented in 67 (6.5%) patients. Forty patients (50%) underwent re-excision and 39 (49.4%) underwent mastectomy. The overall breast conservation rate was 96.2%. Reported complications were: 17 wound infections (1.7%); 106 hematomas (10.4%); 94 lymphorrheas (9.2%), 48 partial wound dehiscence (4.7%). Local recurrences (LR) were observed in 49 patients (4.7%). The risk of local recurrence was significantly higher in the group of patients with lymphovascular invasion and with high grade (G) (p < 0.05). 52 (5.07%) distant metastases were reported and the related risk was significantly higher in the group of patients with lymphovascular invasion and with negative receptors (p < 0.05).

CONCLUSIONS

Oncoplastic surgery provides an acceptable oncological long-term outcome and can be used to treat with conservative surgery also a selected population of patients who would had otherwise undergone mastectomy in the past.

Overcoming the challenges of cancer drug resistance through bacterial-mediated therapy

Despite tremendous efforts to fight cancer, it remains a major public health problem and a leading cause of death worldwide. With increased knowledge of cancer pathways and improved technological platforms, precision therapeutics that specifically target aberrant cancer pathways have improved patient outcomes. Nevertheless, a primary cause of unsuccessful cancer therapy remains cancer drug resistance. In this review, we summarize the broad classes of resistance to cancer therapy, particularly pharmacokinetics, the tumor microenvironment, and drug resistance mechanisms. Furthermore, we describe how bacterial-mediated cancer therapy, a bygone mode of treatment, has been revitalized by synthetic biology and is uniquely suited to address the primary resistance mechanisms that confound traditional therapies. Through genetic engineering, we discuss how bacteria can be potent anticancer agents given their tumor targeting potential, anti-tumor activity, safety, and coordinated delivery of anti-cancer drugs.

Oncological safety of stromal vascular fraction enriched fat grafting in two-stage breast reconstruction after nipple sparing mastectomy: long-term results of a prospective study

OBJECTIVE

Autologous fat transfer (AFT) is commonly used to treat implant palpability and prevent fibrosis and thinning in mastectomy skin flaps. A major limit to this procedure is volume retention over time, leading to the introduction of fat enrichment with stromal vascular fraction (SVF+AFT). Oncological concerns have been raised over the injection of an increased concentration of progenitors cells (ASCs) in the SVF. The aim of the study is to evaluate the long-term cancer recurrence risk of SVF+AFT cases compared to AFT, in patients undergoing Nipple Sparing Mastectomy (NSM).

PATIENTS AND METHODS

A prospective study was designed to compare three groups of patients undergoing NSM followed by SVF+AFT, AFT or none (control group), after a two-stage breast reconstruction. Patients were strictly followed-up for at least 5-years from the second stage reconstructive procedure. Loco-regional and systemic recurrence rate were evaluated over time as the primary outcome. Logistic regression was used to investigate which factors were associated with recurrence events and independent variables of interest were: surgical technique, age above 50 years old, lympho-vascular invasion, oncological stage, adjuvant or neoadjuvant chemotherapy, adjuvant radiotherapy and adjuvant hormone therapy.

RESULTS

41 women were included in G1 (SVF+AFT), 64 in G2 (AFT), and 64 in G3 (control group). Loco-regional recurrence rate was 2.4% for G1, 4.7% for G2, and 1.6% for G3. Systemic recurrence was 7.3%, 3.1%, and 3.1%, respectively. Among the variables included, there were no significant risk factors influencing a recurrence event, either loco-regional or systemic. In particular, SVF+AFT (G1) did not increase the oncological recurrence.

CONCLUSIONS

Our data suggest that both centrifuged and SVF-enhanced fat transfer have a similar safety level in comparison to patients who did not undergo fat grafting in breast reconstruction after NSM.

Neoadjuvant chemotherapy in patients with breast cancer: Does response in the breast predict axillary node response?

INTRODUCTION

Determining the extent of residual disease in the breast and axilla following neoadjuvant chemotherapy (NACT) is vital for surgical planning. Traditionally patients with incomplete radiological response in the breast after NACT undergo axillary node clearance, regardless of axillary clinical and radiological response. The aim of this study was to determine whether radiological and/or pathological response in the breast to NACT were predictive of axillary response.

MATERIALS AND METHODS

A retrospective cohort study of patients with operable breast cancer with histologically proven axillary lymph node involvement who received NACT and underwent definitive surgical treatment between 1/1/2016 and 31/12/2018 were included. All had MRI and/or US of the breast and axilla before, mid-treatment and at the end of NACT.

RESULTS

The 83 patients had a median age of 50 years (range 25-77). MRI had a positive predictive value (PPV) of 52.6% and negative predictive value (NPV) of 81.8% for breast pathological complete response (pCR). For axillary pCR, US had a PPV of 60.0% and NPV of 89.6%. Only 71% of patients had radiological concordance; 15.9% had radiological complete response (rCR) in breast and axilla whilst 55.1% had neither breast nor axillary rCR. 85.6% of patients had pathological concordance (20.5% with breast and axillary pCR: 65.1% with residual disease in both).

CONCLUSION

Radiological and pathological response in the breast to NACT does not accurately predict axillary response. The axilla and the breast should be viewed and assessed as two separate entities for treatment plans.

Reliability of the sourcil method of acetabular index measurement in developmental dysplasia of the hip

PURPOSE

The ability to monitor and study developmental dysplasia of the hip (DDH) requires validated radiographic outcome measures. The sourcil method of acetabular index measurement (AI-S) has not yet been shown to be a reliable measure of acetabular dysplasia in a DDH population, despite its widespread use. The aims of this study were to test the reliability of the AI-S method in a DDH population, and to compare the reliability of the AI-S method with that of the classic lateral edge method (AI-L).

METHODS

From an institutional database, standardized anteroposterior hip radiographs were obtained from a cohort of 35 female patients (70 hips) at two and five years of age who had been treated nonoperatively for DDH. Three observers independently measured the acetabular index using the AI-L and AI-S methods on all 70 hips at two time points, four weeks apart.

RESULTS

The inter-rater reliability intraclass correlation coefficient (ICC) for the AI-L and AI-S methods was between good and excellent at 0.94 (confidence interval (CI) 0.89 to 0.96) and 0.91 (CI 0.87 to 0.94), respectively. The ICCs for intra-rater reliability for the AI-L method were excellent at 0.93 (CI 0.90 to 0.95), 0.95 (CI 0.93 to 0.97) and 0.95 (CI 0.94 to 0.97) for raters 1, 2 and 3, respectively. The ICCs for intra-rater reliability for the AI-S method were between good and excellent at 0.91 (CI 0.87 to 0.93), 0.93 (CI 0.90 to 0.95) and 0.90 (CI 0.86 to 0.93) for raters 1, 2 and 3 respectively.

CONCLUSION

Both AI-S and AI-L methods are equally reliable radiographic measures of DDH.

LEVEL OF EVIDENCE

Level III (diagnostic).

The forgotten father in obstetric medicine

The role of fathers prior to conception, during pregnancy, and in the post-partum period has generally not been a key consideration for Obstetric Physicians. However, this view may need challenging. This paper outlines the key importance of fathers in all phases of obstetric medical care. We review the contribution of paternal factors such as genetics, health, and lifestyle to fetal development, pregnancy complications, and maternal and neonatal wellbeing. The role of fathers in complex care decisions during pregnancy is also reviewed. Postpartum, fathers have a substantial role in shaping the future of the family unit through encouraging breastfeeding and creating a supportive environment for motherhood. This review proposes areas for future research and recommends an evidence-based change in practice in obstetric medicine that focuses on recognizing the role of fathers in the pregnancy journey.

Transcriptomic analysis of the highly efficient oil-degrading bacterium Acinetobacter venetianus RAG-1 reveals genes important in dodecane uptake and utilization

The hydrocarbonoclastic bacterium Acinetobacter venetianus RAG-1 has attracted substantial attention due to its powerful oil-degrading capabilities and its potential to play an important ecological role in the cleanup of alkanes. In this study, we compare the transcriptome of the strain RAG-1 grown in dodecane, the corresponding alkanol (dodecanol), and sodium acetate for the characterization of genes involved in dodecane uptake and utilization. Comparison of the transcriptional responses of RAG-1 grown on dodecane led to the identification of 1074 genes that were differentially expressed relative to sodium acetate. Of these, 622 genes were upregulated when grown in dodecane. The highly upregulated genes were involved in alkane catabolism, along with stress response. Our data suggest AlkMb to be primarily involved in dodecane oxidation. Transcriptional response of RAG-1 grown on dodecane relative to dodecanol also led to the identification of permease, outer membrane protein and thin fimbriae coding genes potentially involved in dodecane uptake. This study provides the first model for key genes involved in alkane uptake and metabolism in A. venetianus RAG-1.

Analysis of the transcriptome of the oil-degrading bacterium Acinetobacter venetianus RAG-1 helps in identification of genes that are involved in uptake and metabolism of alkanes, thus helping in bioremediation.

Lasiodiplodia species fungal osteomyelitis in a multiple myeloma patient

Lasiodiplodia species are environmental fungi that have been reported as a cause of infection in both immunocompetent and immunocompromised patients. We present a case of fungal osteomyelitis caused by Lasiodiplodia species in a patient with multiple myeloma after autologous stem cell transplant. The patient was successfully treated with a combination of surgery and oral voriconzole. To the best of our knowledge, this is the first reported case of fungal osteomyelitis caused by Lasiodiplodia species.

An investigation into the aetiology of flexible flat feet: the role of subtalar joint morphology

AIMS

There is increasing evidence that flexible flatfoot (FF) can lead to symptoms and impairment in health-related quality of life. As such we undertook an observational study investigating the aetiology of this condition, to help inform management. The hypothesis was that as well as increased body mass index (BMI) and increased flexibility of the lower limb, an absent anterior subtalar articulation would be associated with a flatter foot posture.

PATIENTS AND METHODS

A total of 84 children aged between eight and 15 years old were prospectively recruited. The BMI for each child was calculated, flexibility was assessed using the lower limb assessment scale (LLAS) and foot posture was quantified using the arch height index (AHI). Each child underwent a sagittal T1-weighted MRI scan of at least one foot.

RESULTS

An absent anterior subtalar articulation (p < 0.001) and increased LLAS (p = 0.001) predicted a low AHI. BMI was not a significant predictive factor (p = 0.566).

CONCLUSION

This is the first study to demonstrate the importance of the morphology of the subtalar joint on the underlying foot posture in vivo.

TAKE HOME MESSAGE

Flexibility of the lower limb and absence of the anterior facet of the subtalar joint are associated with flexible FF and may influence management of this common condition.

Cerenkov luminescence imaging (CLI) for image-guided cancer surgery

Cerenkov luminescence imaging (CLI) is a novel molecular optical imaging technique based on the detection of optical Cerenkov photons emitted by positron emission tomography (PET) imaging agents. The ability to use clinically approved tumour-targeted tracers in combination with small-sized imaging equipment makes CLI a particularly interesting technique for image-guided cancer surgery. The past few years have witnessed a rapid increase in proof-of-concept preclinical studies in this field, and several clinical trials are currently underway. This article provides an overview of the basic principles of Cerenkov radiation and outlines the challenges of CLI-guided surgery for clinical use. The preclinical and clinical trial literature is examined including applications focussed on image-guided lymph node detection and Cerenkov luminescence endoscopy, and the ongoing clinical studies and technological developments are highlighted. By intraoperatively guiding the oncosurgeon towards more accurate and complete resections, CLI has the potential to transform current surgical practice, and improve oncological and cosmetic outcomes for patients.

The clinical performance of the M4 decision support model to triage women with a pregnancy of unknown location as at low or high risk of complications

STUDY QUESTION

What are the adverse outcomes associated with using the M4 model in everyday clinical practice for women with pregnancy of unknown location (PUL)?

SUMMARY ANSWER

There were 17/835 (2.0%) adverse events and no serious adverse events associated with the performance of the M4 model in clinical practice.

WHAT IS KNOWN ALREADY

The M4 model has previously been shown to stratify women classified as a PUL as at low or high risk of complications with a good level of test performance. The triage performance of the M4 model is better than single measurements of serum progesterone or the hCG ratio (serum hCG at 48 h/hCG at presentation).

STUDY DESIGN, SIZE, DURATION

A prospective multi-centre cohort study of 1022 women with a PUL carried out between August 2012 and December 2013 across 2 university teaching hospitals and 1 district general hospital.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women presenting with a PUL to the early pregnancy units of the three hospitals were recruited. The final outcome for PUL was either a failed PUL (FPUL), intrauterine pregnancy (IUP) or ectopic pregnancy (EP) (including persistent PUL (PPUL)), with EP and PPUL considered high-risk PUL. Their hCG results at 0 and 48 h were entered into the M4 model algorithm. If the risk of EP was ≥5%, the PUL was predicted to be high-risk and the participant was asked to re-attend 48 h later for a repeat hCG and transvaginal ultrasound scan by a senior clinician. If the PUL was classified as 'low risk, likely failed PUL', the participant was asked to perform a urinary pregnancy test 2 weeks later. If the PUL was classified as 'low risk, likely intrauterine', the participant was scheduled for a repeat scan in 1 week. Deviations from the management protocol were recorded as either an 'unscheduled visit (participant reason)', 'unscheduled visit (clinician reason)' or 'differences in timing (blood test/ultrasound)'. Adverse events were assessed using definitions outlined in the UK Good Clinical Practice Guidelines' document.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 835 (82%) women classified as a PUL were managed according to the M4 model (9 met the exclusion criteria, 69 were lost to follow-up, 109 had no hCG result at 48 h). Of these, 443 (53%) had a final outcome of FPUL, 298 (36%) an IUP and 94 (11%) an EP. The M4 model predicted 70% (585/835) PUL as low risk, of which 568 (97%) were confirmed as FPUL or IUP. Of the 17 EP and PPUL misclassified as low risk, 5 had expectant management, 7 medical management with methotrexate and 5 surgical intervention.Nineteen PUL had an unscheduled visit (participant reason), 38 PUL had an unscheduled visit (clinician reason) and 68 PUL had deviations from protocol due to a difference in timing (blood test/ultrasound).Adverse events were reported in 26 PUL and 1 participant had a serious adverse event. A total of 17/26 (65%) adverse events were misclassifications of a high risk PUL as low risk by the M4 model, while 5/26 (19%) adverse events were related to incorrect clinical decisions. Four of the 26 adverse events (15%) were secondary to unscheduled admissions for pain/bleeding. The serious adverse event was due to an incorrect clinical decision.

LIMITATIONS, REASONS FOR CAUTION

A limitation of the study was that 69/1022 (7%) of PUL were lost to follow-up. A 48 h hCG level was missing for 109/1022 (11%) participants.

WIDER IMPLICATIONS OF THE FINDINGS

The low number of adverse events (2.0%) suggests that expectant management of PUL using the M4 prediction model is safe. The model is an effective way of triaging women with a PUL as being at high- and low-risk of complications and rationalizing follow-up. The multi-centre design of the study is more likely to make the performance of the M4 model generalizable in other populations.

STUDY FUNDING/COMPETING INTERESTS

None.

TRIAL REGISTRATION NUMBER

Not applicable.

Lessons from a Balint group scheme led by psychiatry trainees for year 3 bristol medical students on their medicine/surgery placements

Background

The UK General Medical Council highlights the centrality of effective communication, reflective practice and the doctor-patient relationship in medical practice. A decline in empathy has been documented as occurring within clinical and early postgraduate years, potentially affecting diagnostic processes and patient engagement. Access to Balint groups can enhance awareness of the patient beyond the medical model, but remains limited at many UK medical schools. This scheme offered Balint groups to Bristol medical students in their first clinical year, demonstrating that this method is relevant beyond psychiatry.

Methods

Initial focus groups with medical students indicated that many felt unable to discuss distressing aspects of clinical encounters. During 2013-2014, a Balint scheme run by psychiatry trainees was started for 150 students in their psychiatry placements. During 2014-15, the scheme was introduced to all third-year medical students on their medicine/surgery placement. Balint leaders have group supervision with a psychoanalytic psychotherapist. Evaluation of the scheme was based on pre-and post-group questionnaires and leaders’ process notes.

Results

Sixteen groups led by 12 trainees were run twice over the year to serve 246 medical students. Two example cases are discussed here. Students appreciated the chance to discuss complex encounters with patients in a supportive peer environment, and work through a range of emotionally challenging issues.

Conclusions

Novel aspects of this work include the implementation of Balint groups within medicine and surgery placements; the enrolment of psychiatry trainees as leaders with group supervision and leadership training workshops from the UK Balint Society; and the scale of the scheme.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Knowledge 'Translation' as social learning: negotiating the uptake of research-based knowledge in practice

BACKGROUND

Knowledge translation and evidence-based practice have relied on research derived from clinical trials, which are considered to be methodologically rigorous. The result is practice recommendations based on a narrow view of evidence. We discuss how, within a practice environment, in fact individuals adopt and apply new evidence derived from multiple sources through ongoing, iterative learning cycles.

DISCUSSION

The discussion is presented in four sections. After elaborating on the multiple forms of evidence used in practice, in section 2 we argue that the practitioner derives contextualized knowledge through reflective practice. Then, in section 3, the focus shifts from the individual to the team with consideration of social learning and theories of practice. In section 4 we discuss the implications of integrative and negotiated knowledge exchange and generation within the practice environment. Namely, how can we promote the use of research within a team-based, contextualized knowledge environment? We suggest support for: 1) collaborative learning environments for active learning and reflection, 2) engaged scholarship approaches so that practice can inform research in a collaborative manner and 3) leveraging authoritative opinion leaders for their clinical expertise during the shared negotiation of knowledge and research. Our approach also points to implications for studying evidence-informed practice: the identification of practice change (as an outcome) ought to be supplemented with understandings of how and when social negotiation processes occur to achieve integrated knowledge. This article discusses practice knowledge as dependent on the practice context and on social learning processes, and suggests how research knowledge uptake might be supported from this vantage point.

Powerful fermentative hydrogen evolution of photosynthate in the cyanobacterium Lyngbya aestuarii BL J mediated by a bidirectional hydrogenase

Cyanobacteria are considered good models for biohydrogen production because they are relatively simple organisms with a demonstrable ability to generate H₂ under certain physiological conditions. However, most produce only little H₂, revert readily to H₂ consumption, and suffer from hydrogenase sensitivity to O₂. Strains of the cyanobacteria Lyngbya aestuarii and Microcoleus chthonoplastes obtained from marine intertidal cyanobacterial mats were recently found to display much better H₂ production potential. Because of their ecological origin in environments that become quickly anoxic in the dark, we hypothesized that this differential ability may have evolved to serve a role in the fermentation of the photosynthate. Here we show that, when forced to ferment internal substrate, these cyanobacteria display desirable characteristics of physiological H₂ production. Among them, the strain L. aestuarii BL J had the fastest specific rates and attained the highest H₂ concentrations during fermentation of photosynthate, which proceeded via a mixed acid fermentation pathway to yield acetate, ethanol, lactate, H₂, CO₂, and pyruvate. Contrary to expectations, the H₂ yield per mole of glucose was only average compared to that of other cyanobacteria. Thermodynamic analyses point to the use of electron donors more electronegative than NAD(P)H in Lyngbya hydrogenases as the basis for its strong H₂ production ability. In any event, the high specific rates and H₂ concentrations coupled with the lack of reversibility of the enzyme, at the expense of internal, photosynthetically generated reductants, makes L. aestuarii BL J and/or its enzymes, a potentially feasible platform for large-scale H₂ production.

Comparative genomic analyses of the cyanobacterium, Lyngbya aestuarii BL J, a powerful hydrogen producer

The filamentous, non-heterocystous cyanobacterium Lyngbya aestuarii is an important contributor to marine intertidal microbial mats system worldwide. The recent isolate L. aestuarii BL J, is an unusually powerful hydrogen producer. Here we report a morphological, ultrastructural, and genomic characterization of this strain to set the basis for future systems studies and applications of this organism. The filaments contain circa 17 μm wide trichomes, composed of stacked disk-like short cells (2 μm long), encased in a prominent, laminated exopolysaccharide sheath. Cellular division occurs by transversal centripetal growth of cross-walls, where several rounds of division proceed simultaneously. Filament division occurs by cell self-immolation of one or groups of cells (necridial cells) at the breakage point. Short, sheath-less, motile filaments (hormogonia) are also formed. Morphologically and phylogenetically L. aestuarii belongs to a clade of important cyanobacteria that include members of the marine Trichodesmiun and Hydrocoleum genera, as well as terrestrial Microcoleus vaginatus strains, and alkalyphilic strains of Arthrospira. A draft genome of strain BL J was compared to those of other cyanobacteria in order to ascertain some of its ecological constraints and biotechnological potential. The genome had an average GC content of 41.1%. Of the 6.87 Mb sequenced, 6.44 Mb was present as large contigs (>10,000 bp). It contained 6515 putative protein-encoding genes, of which, 43% encode proteins of known functional role, 26% corresponded to proteins with domain or family assignments, 19.6% encode conserved hypothetical proteins, and 11.3% encode apparently unique hypothetical proteins. The strain's genome reveals its adaptations to a life of exposure to intense solar radiation and desiccation. It likely employs the storage compounds, glycogen, and cyanophycin but no polyhydroxyalkanoates, and can produce the osmolytes, trehalose, and glycine betaine. According to its genome, BL J strain also has the potential to produce a plethora of products of biotechnological interest such as Curacin A, Barbamide, Hemolysin-type calcium-binding toxin, the suncreens scytonemin, and mycosporines, as well as heptadecane and pentadecane alkanes. With respect to hydrogen production, initial comparisons of the genetic architecture and sequence of relevant genes and loci, and a comparative model of protein structure of the NiFe bidirectional hydrogenase, did not reveal conspicuous differences that could explain its unusual hydrogen producing capacity.

Diversity in hydrogen evolution from bidirectional hydrogenases in cyanobacteria from terrestrial, freshwater and marine intertidal environments

We characterized a set of 36 strains of cyanobacteria isolated from terrestrial, freshwater and marine intertidal settings to probe their potential to produce hydrogen from excess reductant, in the hope of finding novel strains with improved traits for biohydrogen production. The set was diverse with respect to origin, morphology, taxonomy and phylogeny. We found that about one half of the strains could produce hydrogen from hydrogenases in standard assays, a trait that corresponded invariably with the presence of homologues of the gene hoxH, coding for subunit H in the bidirectional Ni-Fe hydrogenase. Strains from freshwater and intertidal settings had a high incidence of hydrogen producing, hoxH containing strains, but all terrestrial isolates were negative for both. While specific rates of hydrogen production varied among strains, some novel strains displayed rates several fold higher than those previously reported. We detected two different patterns in hydrogen production. Pattern 1, corresponding to that previously known in Synechocystis PCC 6803, encompassed strains whose hydrogenase system produced hydrogen only temporarily to revert to hydrogen consumption within a short time and after reaching moderate hydrogen concentrations. Cyanobacteria displaying pattern 2, in the genera Lyngbya and Microcoleus, tended to have higher rates, did not reverse the direction of the reaction and reached much higher concentrations of hydrogen at steady state, making them of interest as potential platforms for biohydrogen production.

Evaluation of the Charlson comorbidity index to predict outcome after esophagectomy in older patients

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Background: Esophagectomy remains a preferred treatment for several neoplastic and non-neoplastic conditions; however it is often avoided in elderly patients with several co-morbid conditions. Several centers endorse the use of the Charlson comorbidity index to predict surgical outcomes in high risk patients. To date, this standard measure of co-morbidity has not been used to predict surgical outcomes following esophagectomy in elderly (age ≥70) patients.

Methods: We reviewed data from an IRB-approved, prospectively maintained thoracic surgery database over a three-year period (March, 2006 – March, 2009). We compared incidence of post-operative events, total length of stay, 30-day mortality, rate of readmission, and calculated Charlson comorbidity indices (CCI) for all patients. A validated electronic application was used to calculate CCI based on patient age, BMI, substance use, malignancy, and co-morbid diseases (CV, respiratory, GI, endocrine, inflammatory, psychiatric, neurologic, and immunologic).

Results: There were 75 patients below the age of 70 and 41 patients ≥ 70 years old who underwent esophagectomy over the 3-year period studied. Patients over the age of 70 had a significantly higher CCI (5.02) than patients under the age of 70 (3.19, p < 0.05). However, the 30 day mortality in patients ≥ 70 (0.0%) and under 70 (2.3%) was not significantly different between groups (p = 0.33). There was no difference in median length of hospital stay (7 days vs. 7 days, p = 0.95) and rate of readmission (7.5% vs. 9.3%, p = 0.74) when comparing patients ≥ 70 and < 70 years old, respectively. Patients ≥ 70 had a significantly lower incidence of complications than patients under the age of 70 (34.1% vs. 60.0%, p < 0.05).

Conclusions: Patients ≥ 70 years old had higher Charlson comorbidity indices than patients < 70 years old, however surgical outcomes in both groups following esophagectomy were similar. In this population, CCI may not be a valid tool for measuring surgical risk perhaps due to the inclusion of age in the index. Future study will focus on the development of a co-morbidity index which can predict outcomes following esophagectomy and is not biased by age.

No significant financial relationships to disclose.

The role of superficial venous surgery in the management of venous ulcers: a systematic review

BACKGROUND

The complicated natural history of venous ulcers requires the continued development and improvement of treatments to ensure the most effective management. Compression therapy or surgical correction of superficial venous incompetence (SVI) are currently the main methods employed for the treatment for venous ulceration (VU). This review compares and summates the healing and recurrence rates for each treatment modality used over the last thirty years.

METHODS

Sixty-one articles investigating compression and superficial venous surgical treatments were obtained from a systematic search of electronic databases (Medline, Embase, The Cochrane Library, and Google Scholar) and then an expanded reference list review. Patient demographics, CEAP classification, patterns of venous insufficiency, type of intervention, length of follow up, healing and recurrence rates for venous ulceration was assessed. Inadequate data in seven reports led to their exclusion. Recent randomised controlled trials (RCTs) specifically comparing superficial surgery to compression therapy were reviewed and data from non-randomised and/or 'small' clinical studies prior to 2000 underwent summation analysis.

RESULTS

Five RCTs since 2000 demonstrate a similar healing rate of VU with surgery and conservative compression treatments, but a reduction in ulcer recurrence rate with surgery. The effect of deep venous incompetence (DVI) on the ulcer healing is unclear, but sub-group analysis of long-term data from the ESCHAR trial suggests that although surgery results in a less impressive reduction in ulcer recurrence in patients with DVI, these patients appear to still benefit from surgery due to the haemodynamic and clinical benefits that result. The RCTs also highlight that a significant proportion of VU patients are unsuitable for surgical treatment. Summation of data from earlier studies (before 2000), included twenty-one studies employing conservative compression alone resulted in an overall healing rate of 65% (range 34-95%) and ulcer recurrence of 33% (range 0-100%). In thirty-one studies investigating superficial venous surgery, the overall rate of ulcer healing was 81% (range 40-100%) with a post-operative recurrence rate of 15% (range 0-55%). The duration of follow up care in the surgical studies was approximately twice as long as in the conservative studies, which would lend to more reliable recurrence data.

CONCLUSIONS

Evidence from the current literature, would suggest that superficial venous surgery is associated with similar rates of ulcer healing to compression alone, but with less recurrence. The effects of post-operative compression and DVI on the efficacy of surgery are still unclear.

Effect of harmonic scalpel on seroma formation following surgery for breast cancer: a prospective randomized study

PURPOSE

With the escalating cost of healthcare provision, surgical techniques that could lead to shorter postoperative stay and reducing cost of health provision are welcomed. We report the results of a prospective randomized trial to investigate the role of harmonic scalpel (HS) in reducing postsurgical seroma formation, complications, pain and consequent cost in breast surgery.

PATIENTS AND METHODS

Thirty-three procedures were carried out on 32 women. Patients were prospectively randomized to either HS or electrocautery (EC). The two cohorts were accordingly matched and postsurgical seroma volumes, complications and pain scores were documented.

RESULTS

There were 16 procedures in the HS and 17 in the EC group. First 48 h drainage, total drained volume, aspirated volume, operative time, pain score, number of patients that developed seromas, number of clinic visits for aspiration, complications and required analgesia were comparable in the two groups. Multivariate analysis showed no significant correlation between the total amount of seroma drainage and the known risk factors (body mass index/BMI, size of the invasive tumor and number of positive nodes).

CONCLUSION

No significant reduction in seroma formation or wound complications and pain could be found with the use of HS. We were unable to demonstrate any significant clinical advantages with the use of HS or cost benefit.

Setup for in situ x-ray diffraction study of swift heavy ion irradiated materials

An in situ x-ray diffraction (XRD) setup is designed and installed in the materials science beam line of the Pelletron accelerator at the Inter-University Accelerator Centre for in situ studies of phase change in swift heavy ion irradiated materials. A high vacuum chamber with suitable windows for incident and diffracted X-rays is integrated with the goniometer and the beamline. Indigenously made liquid nitrogen (LN2) temperature sample cooling unit is installed. The snapshots of growth of particles with fluence of 90 MeV Ni ions were recorded using in situ XRD experiment, illustrating the potential of this in situ facility. A thin film of C60 was used to test the sample cooling unit. It shows that the phase of the C60 film transforms from a cubic lattice (at room temperature) to a fcc lattice at around T=255 K.

A comparative study of two devices used for cervical cell sampling raises some doubts about liquid-based cytology

The objective of this study was to compare the quality of smears obtained by a newly designed cervical cell sampler (the implement) to those obtained with the cervex brush, using liquid-based cytology (LBC). A prospective randomized controlled trial with the approval of the local ethics committees after informing the Medical Devices Agency in the UK was used in this study. The study was carried out in colposcopy clinics in two district general NHS Trust Hospitals in London. A total of 200 women were recruited (100 from each hospital). The women were randomized into two groups, each of them having two smears at the same time. One hundred (50%) of the women had their first smear with the new implement, and the other 100 (50%) had their first smear with the cervex brush. The main outcome of this study is good-quality smears, assessed by evidence of effective sampling of the transformation zone, including immature metaplastic cells and also endocervical cells. Eighty-five percent of the smears taken by the new implement showed good-quality smears compared to 91% of those taken by the cervex brush, a statistically marginally nonsignificant result, with P value = 0.052 (McNemar exact test). A larger number of good-quality smears, judged by evidence of sampling of transformation zone, were obtained with the cervex brush, though the difference was statistically marginally nonsignificant, using the British society for clinical cytology criteria. Surprisingly, despite the use of LBC, there was a higher rate of inadequate smears obtained with both the devices (8% with each) compared to our previous study using the conventional slide test (1.3% with the new implement and 1.8% with the Jordan's spatula).