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Public awareness of ‘red flag’ symptoms for head and neck cancer is low. There is a lack of evidence regarding patient concerns and expectations in consultations for cancer assessment.
This prospective questionnaire study examined the symptoms, concerns and expectations of 250 consecutive patients attending an ‘urgent suspicion of cancer’ clinic at a tertiary referral centre.
The patients’ most frequent responses regarding their concerns were ‘no concerns’ (n = 72, 29 per cent); ‘all symptoms’ were a cause for concern (n = 65, 26 per cent) and ‘neck lump’ was a symptom causing concern (n = 37, 17 per cent). The expectations of patients attending clinic were that they would find out what was wrong with them, followed by having no expectations at all. Overall patient knowledge of red flag symptoms was lacking and their expectations were low.
Patients with non-cancer symptoms are frequently referred with suspected cancer. Patients with red flag symptoms are not aware of their significance and they have low expectations of healthcare.
Lipid-based nutrient supplements (LNS) may be beneficial for malnourished HIV-infected patients starting antiretroviral therapy (ART). We assessed the effect of adding vitamins and minerals to LNS on body composition and handgrip strength during ART initiation. ART-eligible HIV-infected patients with BMI <18·5 kg/m2 were randomised to LNS or LNS with added high-dose vitamins and minerals (LNS-VM) from referral for ART to 6 weeks post-ART and followed up until 12 weeks. Body composition by bioelectrical impedance analysis (BIA), deuterium (2H) diluted water (D2O) and air displacement plethysmography (ADP), and handgrip strength were determined at baseline and at 6 and 12 weeks post-ART, and effects of LNS-VM v. LNS at 6 and 12 weeks investigated. BIA data were available for 1461, D2O data for 479, ADP data for 498 and handgrip strength data for 1752 patients. Fat mass tended to be lower, and fat-free mass correspondingly higher, by BIA than by ADP or D2O. At 6 weeks post-ART, LNS-VM led to a higher regain of BIA-assessed fat mass (0·4 (95 % CI 0·05, 0·8) kg), but not fat-free mass, and a borderline significant increase in handgrip strength (0·72 (95 % CI −0·03, 1·5) kg). These effects were not sustained at 12 weeks. Similar effects as for BIA were seen using ADP or D2O but no differences reached statistical significance. In conclusion, LNS-VM led to a higher regain of fat mass at 6 weeks and to a borderline significant beneficial effect on handgrip strength. Further research is needed to determine appropriate timing and supplement composition to optimise nutritional interventions in malnourished HIV patients.
Epistaxis is the most common ENT emergency. This study aimed to assess one-year mortality rates in patients admitted to a large teaching hospital.
This study was a retrospective case note analysis of all patients admitted to the Queen Elizabeth University Hospital in Glasgow with epistaxis over a 12-month period.
The one-year overall mortality for a patient admitted with epistaxis was 9.8 per cent. The patients who died were older (mean age 77.2 vs 68.8 years; p = 0.002), had a higher Cumulative Illness Rating Scale-Geriatric score (9.9 vs 6.7; p < 0.001) and had a higher performance status score (2 or higher vs less than 2; p < 0.001). Other risk factors were a low admission haemoglobin level (less than 128 g/dl vs 128 g/dl or higher; p = 0.025), abnormal coagulation (p = 0.004), low albumin (less than 36 g/l vs more than 36 g/l; p < 0.001) and longer length of stay (p = 0.046).
There are a number of risk factors associated with increased mortality after admission with epistaxis. This information could help with risk stratification of patients at admission and enable the appropriate patient support to be arranged.
Determining infectious cross-transmission events in healthcare settings involves manual surveillance of case clusters by infection control personnel, followed by strain typing of clinical/environmental isolates suspected in said clusters. Recent advances in genomic sequencing and cloud computing now allow for the rapid molecular typing of infecting isolates.
To facilitate rapid recognition of transmission clusters, we aimed to assess infection control surveillance using whole-genome sequencing (WGS) of microbial pathogens to identify cross-transmission events for epidemiologic review.
Clinical isolates of Staphylococcus aureus, Enterococcus faecium, Pseudomonas aeruginosa, and Klebsiella pneumoniae were obtained prospectively at an academic medical center, from September 1, 2016, to September 30, 2017. Isolate genomes were sequenced, followed by single-nucleotide variant analysis; a cloud-computing platform was used for whole-genome sequence analysis and cluster identification.
Most strains of the 4 studied pathogens were unrelated, and 34 potential transmission clusters were present. The characteristics of the potential clusters were complex and likely not identifiable by traditional surveillance alone. Notably, only 1 cluster had been suspected by routine manual surveillance.
Our work supports the assertion that integration of genomic and clinical epidemiologic data can augment infection control surveillance for both the identification of cross-transmission events and the inclusion of missed and exclusion of misidentified outbreaks (ie, false alarms). The integration of clinical data is essential to prioritize suspect clusters for investigation, and for existing infections, a timely review of both the clinical and WGS results can hold promise to reduce HAIs. A richer understanding of cross-transmission events within healthcare settings will require the expansion of current surveillance approaches.
There is little consensus on how best to manage head and neck cancer with palliative intent. Predicting outcome is difficult and reported survival varies. The present study sought to delineate local practice and outcomes in patients treated with palliative intent.
The clinical records of all head and neck cancer patients treated with palliative intent presenting between 2015 and 2016 to our multidisciplinary team were reviewed.
Eighty-four patients (21.5 per cent) were treated with palliative intent. All had squamous cell carcinoma. Mean survival time was 151 days (standard deviation = 121.1; range, 8–536 days). Of the patients, 83.3 per cent had a palliative care referral; 74.1 per cent had a hospice referral. Patients received a variety of interventions, and there was an associated complication in 8.2 per cent. The mean number of days spent in hospital for interventions was 11.9 days (standard deviation = 12.5; range, 0–41 days).
Different interventions are used to manage head and neck cancer patients with palliative intent, and these may be associated with significant morbidity. Survival time is variable, often several months; thus, any treatment must take into account morbidity in conjunction with the patient's wishes.
Antimicrobial stewardship programs are effective in optimizing antimicrobial prescribing patterns and decreasing the negative outcomes of antimicrobial exposure, including the emergence of multidrug-resistant organisms. In dialysis facilities, 30%–35% of antimicrobials are either not indicated or the type of antimicrobial is not optimal. Although antimicrobial stewardship programs are now implemented nationwide in hospital settings, programs specific to the maintenance dialysis facilities have not been developed.
To quantify the effect of an antimicrobial stewardship program in reducing antimicrobial prescribing.
Study design and setting
An interrupted time-series study in 6 outpatient hemodialysis facilities was conducted in which mean monthly antimicrobial doses per 100 patient months during the 12 months prior to the program were compared to those in the 12-month intervention period.
Implementation of the antimicrobial stewardship program was associated with a 6% monthly reduction in antimicrobial doses per 100 patient months during the intervention period (P=.02). The initial mean of 22.6 antimicrobial doses per 100 patient months decreased to a mean of 10.5 antimicrobial doses per 100 patient months at the end of the intervention. There were no significant changes in antimicrobial use by type, including vancomycin. Antimicrobial adjustments were recommended for 30 of 145 antimicrobial courses (20.6%) for which there were sufficient clinical data. The most frequent reasons for adjustment included de-escalation from vancomycin to cefazolin for methicillin-susceptible Staphylococcus aureus infections and discontinuation of antimicrobials when criteria for presumed infection were not met.
Within 6 hemodialysis facilities, implementation of an antimicrobial stewardship was associated with a decline in antimicrobial prescribing with no negative effects.
In Scotland, patients with suspected head and neck cancer are referred on the basis of the Scottish Referral Guidelines for Suspected Cancer, rather than the National Institute for Health and Care Excellence guidelines. A chest X-ray should be requested by the general practitioner at the same time as referral for persistent hoarseness. The evidence for this is level 4.
This audit identified adherence to this recommendation and X-ray results. All ‘urgent suspicion of cancer’ referrals to the ENT department in the National Health Service Greater Glasgow and Clyde for 2015–2016 were audited.
Persistent hoarseness for more than 3 weeks instigated referral in 318 patients (15.7 per cent). Chest X-ray was performed in 120 patients (38 per cent), which showed: no abnormality in 116 (96.7 per cent), features of infection in 2 (1.7 per cent) and something else in 2 patients (1.7 per cent). No chest X-ray altered the management of a patient.
Performance of chest X-ray does not alter management and its removal from the Scottish Referral Guidelines for Suspected Cancer is recommended.
This paper presents 5 kHz stereo particle image velocimetry and OH planar laser induced fluorescence measurements of transversely forced swirl flames. The presence of transverse forcing on this naturally unstable flow both influences the natural instabilities, as well as amplifies disturbances that may not necessarily manifest themselves during natural oscillations. By manipulating the structure of the acoustic forcing field, both axisymmetric and helical modes are preferentially excited away from the frequency of natural instability. The paper presents a method for spatially interpolating the phase locked
planar velocity and flame position data, extracting the full three-dimensional structure of the helical disturbances. These helical disturbances are also decomposed into symmetric and anti-symmetric disturbances about the jet core, showing the subsequent axial evolution (in magnitude and phase) of each of these underlying disturbances. It is shown that out-of-phase acoustic forcing excites
modes, but the flow field preferentially amplifies the counter-winding, co-rotating helical disturbance over the co-winding, counter-rotating helical disturbance. This causes the flow and flame to transition from a transverse flapping near the jet exit to a precessing motion further downstream. In contrast, in-phase forcing promotes axisymmetric
disturbances which dominate the flow field over the entire axial domain. In both cases, the amplitudes of the anti-symmetric disturbances about the jet core grow with downstream distance before saturating and decaying, while the symmetric disturbances appear nearly negligible. It is suggested that this saturation and decay is due to linear effects (e.g. a negative spatial growth rate), rather than nonlinear interactions.
The study of the mechanical properties of nanostructured systems has gained importance in theoretical and experimental research in recent years. Carbon nanotubes (CNTs) are one of the strongest nanomaterials found in nature, with Young’s Modulus (EY) in the order 1.25 TPa. One interesting question is about the possibility of generating new nanostructures with 1D symmetry and with similar and/or superior CNT properties. In this work, we present a study on the dynamical, structural, mechanical properties, fracture patterns and EY values for one class of these structures, the so-called pentagraphene nanotubes (PGNTs). These tubes are formed rolling up pentagraphene membranes (which are quasi-bidimensional structures formed by densely compacted pentagons of carbon atoms in sp3 and sp2 hybridized states) in the same form that CNTs are formed from rolling up graphene membranes. We carried out fully atomistic molecular dynamics simulations using the ReaxFF force field. We have considered zigzag-like and armchair-like PGNTs of different diameters. Our results show that PGNTs present EY ∼ 800 GPa with distinct elastic behavior in relation to CNTs, mainly associated with mechanical failure, chirality dependent fracture patterns and extensive structural reconstructions.
Recently, a new 2D carbon allotrope structure, named phagraphene (PG), was proposed. PG has a densely array of penta-hexa-hepta-graphene carbon rings. PG was shown to present low and anisotropic thermal conductivity and it is believed that this anisotropy should be also reflected in its mechanical properties. Although PG mechanical properties have been investigated, a detailed and comprehensive study is still lacking. In the present work we have carried out fully atomistic reactive molecular dynamics simulations using the ReaxFF force field, to investigate the mechanical properties and fracture patterns of PG membranes. The Young’s modulus values of the PG membranes were estimated from the stress-strain curves. Our results show that these curves present three distinct regimes: one regime where ripples dominate the structure and mechanical properties of the PG membranes; an elastic regime where the membranes exhibit fully planar configurations; and finally am inelastic regime where permanent deformations happened to the PG membrane up to the mechanical failure or fracture.
We describe the investigation of two temporally coincident illness clusters involving salmonella and Staphylococcus aureus in two states. Cases were defined as gastrointestinal illness following two meal events. Investigators interviewed ill persons. Stool, food and environmental samples underwent pathogen testing. Alabama: Eighty cases were identified. Median time from meal to illness was 5·8 h. Salmonella Heidelberg was identified from 27 of 28 stool specimens tested, and coagulase-positive S. aureus was isolated from three of 16 ill persons. Environmental investigation indicated that food handling deficiencies occurred. Colorado: Seven cases were identified. Median time from meal to illness was 4·5 h. Five persons were hospitalised, four of whom were admitted to the intensive care unit. Salmonella Heidelberg was identified in six of seven stool specimens and coagulase-positive S. aureus in three of six tested. No single food item was implicated in either outbreak. These two outbreaks were linked to infection with Salmonella Heidelberg, but additional factors, such as dual aetiology that included S. aureus or the dose of salmonella ingested may have contributed to the short incubation periods and high illness severity. The outbreaks underscore the importance of measures to prevent foodborne illness through appropriate washing, handling, preparation and storage of food.
Credibility and trustworthiness are the bedrock upon which any science is built. The strength of these foundations has been increasingly questioned across the sciences as instances of research misconduct and mounting concerns over the prevalence of detrimental research practices have been identified. Consequently, the purpose of this article is to encourage our scientific community to positively and proactively engage in efforts that foster a healthy and robust industrial and organizational (I-O) psychology. We begin by advancing six defining principles that we believe reflect the values of robust science and offer criteria for evaluating proposed efforts to change scientific practices. Recognizing that the contemporary scientific enterprise is a complex and diverse network of actors and institutions, we then conclude by identifying 12 stakeholders who play important roles in achieving a culture of robust science in I-O psychology and offer recommendations for actions we can take as members of these groups to strengthen our science.
Introduction: The majority of attempts to stop smoking end in failure. One way to improve success may be to explore different combinations of existing cessation medications.
Aims: This observational study examined ‘triple therapy’ (varenicline + nicotine patch + nicotine lozenge) in 36 smokers trying to quit.
Methods: A 12-week, observational study exploring tolerability, via adverse events (AEs) elicited at each of nine phone assessments. Secondary outcomes included satisfaction rates, medication changes and self-reported quit rates at week 12.
Results: Thirty five of thirty six participants reported at least one AE. Insomnia (75%), abnormal dreams (72%) and nausea (64%) were most common. Most were mild to moderate. No deaths, hospitalisations, cardiovascular events or suicidality were reported. Six participants (17%) decreased the dose of at least one medication, 5 (14%) decreased the dose then discontinued at least one medication and 13 (36%) discontinued at least one medication without trying a lesser dose. Participants were highly satisfied with their medications, and 58% reported quitting at 12 weeks, with 38% reporting prolonged abstinence.
Conclusions: Despite high rates of AEs and medication changes, high rates of satisfaction and self-reported quitting, with no serious AEs, were observed with triple therapy. Additional data on tolerability and efficacy are needed.
Potential energy released from the capsize of ice-shelf fragments (icebergs) is the immediate driver of the brief explosive phase of ice-shelf disintegration along the Antarctic Peninsula (e.g. the Larsen A, Larsen B and Wilkins ice shelves). The majority of this energy powers the rapidly expanding plume of ice-shelf fragments that expands outward into the open ocean; a smaller fraction of this energy goes into surface gravity waves and other dynamic interactions between ice and water that can sustain the continued fragmentation and break-up of the original ice shelf. As an initial approach to the investigation of ice-shelf fragment capsize in ice-shelf collapse, we develop a simple conceptual model involving ideal rectangular icebergs, initially in unstable or metastable orientations, which are assembled into a tightly packed mass that subsequently disassembles via massed capsize. Computations based on this conceptual model display phenomenological similarity to aspects of real ice-shelf collapse. A promising result of the conceptual model presented here is a description of how iceberg aspect ratio and its statistical variance, the two parameters related to ice-shelf fracture patterns, influence the enabling conditions to be satisfied by slow-acting processes (e.g. environmentally driven melting) that facilitate ice-shelf disintegration.
The subaqueous margins of calving glaciers have the potential to make significant contributions to glacier mass loss. However, to date, very little is known about the morphology and development of subaqueous margins. A unique combination of sub-bottom profile and bathymetric data collected between 2008 and 2010 in proglacial lakes at Mueller, Hooker and Tasman glaciers in New Zealand’s Southern Alps reveal subaqueous ice ramps extending up to 510 m from the terminus of each glacier. Ice ramp surfaces are undulating and covered with a thick layer (up to 10 m) of unsorted sediment derived from supraglacial and englacial debris, lateral moraines and deltaic deposits. A cyclic calving pattern, relatively stable lake level and the debris cover appear to control the development and maintenance of these ice ramps. High subaerial retreat rates generally correspond to high subaqueous calving rates, although the highest subaerial retreat rates are not associated with the largest ice ramp. Debris mantling the subaqueous ice ramp surfaces insulates the ice from melting and also reduces buoyant forces acting on the terminus. Comparisons with previous studies show that the ice ramps evolve over time with changes in glacier dynamics and water-body properties.
Patients with cardiovascular diseases are common in the emergency department (ED), and continuity of care following that visit is needed to ensure that they receive evidence-based diagnostic tests and therapy. We examined the frequency of follow-up care after discharge from an ED with a new diagnosis of one of three cardiovascular diseases.
We performed a retrospective cohort study of patients with a new diagnosis of heart failure, atrial fibrillation, or hypertension, who were discharged from 157 non-pediatric EDs in Ontario, Canada, between April 2007 and March 2014. We determined the frequency of follow-up care with a family physician, cardiologist, or internist within seven and 30 days, and assessed the association of patient, emergency physician, and family physician characteristics with obtaining follow-up care using cause-specific hazard modeling.
There were 41,485 qualifying ED visits. Just under half (47.0%) had follow-up care within seven days, with 78.7% seen by 30 days. Patients with serious comorbidities (renal failure, dementia, COPD, stroke, coronary artery disease, and cancer) had a lower adjusted hazard of obtaining 7-day follow-up care (HRs 0.77-0.95) and 30-day follow-up care (HR 0.76-0.95). The only emergency physician characteristic associated with follow-up care was 5-year emergency medicine specialty training (HR 1.11). Compared to those whose family physician was remunerated via a primarily fee-for-service model, patients were less likely to obtain 7-day follow-up care if their family physician was remunerated via three types of capitation models (HR 0.72, 0.81, 0.85) or via traditional fee-for-service (HR 0.91). Findings were similar for 30-day follow-up care.
Only half of patients discharged from an ED with a new diagnosis of atrial fibrillation, heart failure, and hypertension were seen within a week of being discharged. Patients with significant comorbidities were less likely to obtain follow-up care, as were those with a family physician who was remunerated via primarily capitation methods.
We report a novel approach to the instantaneous photoinitiated synthesis of mixed anatase-rutile nanocrystalline TiO2 thin films with a three-dimensional nanostructure through pulsed white light irradiation of photosensitive Ti-organic precursor films. Pulsed photoinitiated pyrolysis accompanied by instantaneous self-assembly and crystallization occurred to form graphitic oxides-coated TiO2 nanograins. Subsequent pulsed light irradiation working as in situ pulsed photothermal treatment improved the crystalline quality of TiO2 film despite its low attenuation of light. The non-radiative recombination of photogenerated electrons and holes in TiO2 nanograins, coupled with inefficient heat dissipation due to low thermal conductivity, produces enough heat to provide the thermodynamic driving force for improving the crystalline quality. The graphitic oxides were reduced by pulsed photothermal treatment and can be completely removed by oxygen plasma cleaning. This photoinitiated nanofabrication technology opens a promising way for the low-cost and high-throughput manufacturing of nanostructured metal oxides as well as TiO2 nanocrystalline thin films.