Cold therapy and pain relief after hot-iron disbudding in dairy calves.

Even when pain control is implemented, calves may experience pain for days after hot-iron disbudding. Whether calves seek pain relief post-disbudding offers a novel approach to assessing pain in these animals. By employing an approach-aversion paradigm, we explored the ability of cold therapy to provide immediate pain relief in disbudded calves. Calves were habituated to the manual placement of a cool or ambient pack on their forehead for a short duration simultaneous to milk reward consumption, prior to disbudding. Calves were then disbudded under local anaesthesia (procaine) and analgesia (meloxicam), and responses to the packs were observed over subsequent days. Individual calves were consistently exposed to either cool or ambient packs in different halves of a two-sided experimental pen, allowing for the testing of approach-aversion and conditioned place preference. We found calves approached milk rewards quicker and maintained contact for longer when receiving cold therapy compared to the ambient control. However, calves did not display any conditioned preference for the pen where they received the cool pack. These results add to the growing evidence of lasting pain following disbudding procedures and suggests that cold therapy provides some form of pain relief post-disbudding. Future studies should seek other ways to use cold therapy post-disbudding to reduce aversiveness and human involvement.

Advance care planning and health literacy in older dialysis patients: qualitative interview study.

OBJECTIVES: Low health literacy among older adults is associated with limited engagement in end-of-life care planning, higher hospitalisation rates and increased mortality. Frequently, older dialysis patients derive no survival benefit from dialysis and their quality of life often deteriorates further on dialysis. Older dialysis patients' values and wishes are frequently unknown during key healthcare decision making and many endure medically intensive end-of-life scenarios. The objectives of this study were to explore older dialysis patients' understanding of haemodialysis, to explore their engagement in end-of-life care planning and to explore their satisfaction with life on haemodialysis. METHODS: 15 older dialysis patients participated in qualitative semistructured interviews in two haemodialysis units in Ireland. Thematic saturation was reached. Thematic analysis, applied inductively, was used to distill the data. RESULTS: Themes identified included disempowerment among participants reflected limited health literacy, poor advance care planning compromised participant well-being, haemodialysis compromised participants' core values. CONCLUSION: Health literacy levels among older dialysis patients are poor, patient empowerment is limited and their participation in shared decision making and advance care planning is suboptimal. Consequently, healthcare decision making, including haemodialysis, may jeopardise patients' core values. Improving health literacy through enhanced patient education and improved communication skills training for clinicians is necessary to promote patient participation in shared decision making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with patients' core values. This approach will optimise the circumstances for patient-centred care.

Advance care planning in older dialysis patients: health care literacy qualitative study.

OBJECTIVES: Low health literacy among older adults is associated with limited engagement in end-of-life care plans, more hospitalisations and excess mortality. Frequently, older patients derive no survival benefit from dialysis and quality of life often deteriorates with dialysis. Older dialysis patients' values and wishes are often unknown during key healthcare decision-making and many endure medically intensive end-of-life interventions . The objectives of this study were to examine older dialysis patients' understanding of haemodialysis, their engagement in end-of-life care planning and their satisfaction with life on haemodialysis. METHODS: 15 older dialysis patients participated in qualitative semi-structured interviews in two haemodialysis units . Thematic saturation was reached. Thematic analysis, applied inductively, distilled the data. RESULTS: Themes identified included disempowerment which reflected limited health literacy, poor advance care planning compromised well-being and haemodialysis compromised their core values. CONCLUSION: Health literacy among older dialysis patients appeared poor, patient empowerment was limited and participation in shared decision-making and advance care planning suboptimal. Consequently, complex healthcare decision-making, including haemodialysis may jeopardise patients' core values. These findings have significant implications for the validity of the informed consent process prior to dialysis initiation. Improved health literacy through enhanced patient education and better communication skills for clinicians are necessary to promote patient participation in shared decision-making. Clinician training to facilitate discussion of patients' values and wishes will help guide clinicians and patients towards healthcare decisions most concordant with individual core values. This will optimise patient-centred care.

Advance care plan barriers in older patients with end-stage renal disease: a qualitative nephrologist interview study.

OBJECTIVES: Older patients with end-stage renal disease are willing participants in advance care planning but just over 10% are engaged in this process. Nephrologists fear such conversations may upset patients and so tend to avoid these discussions. This approach denies patients the opportunity to discuss their end-of-life care preferences. Many patients endure medically intensive end-of-life scenarios as a result. This study aims to explore the rationale underpinning nephrologists' clinical decision-making in the management of older patients with end-stage renal disease and to make recommendations that inform policymakers and enhance advance care planning for this patient group. METHODS: A qualitative interview study of 20 nephrologists was undertaken. Nephrologists were asked about their management of end-stage renal disease in older patients, conservative management, dialysis withdrawal and end-of-life care. Eligible participants were nephrologists working in Ireland. Five nephrologists participated in a recorded focus group and 15 nephrologists participated in individual digitally recorded telephone interviews. Semistructured interviews were conducted; thematic analysis was used to distil the results. RESULTS: Three key themes emerged: barriers to advance care planning; barriers to shared decision-making; and avoidance of end-of-life care discussion. CONCLUSIONS: Advance care planning is not an integral part of the routine care of older patients with end-stage renal disease. Absence of formal training of nephrologists in how to communicate with patients contributes to poor advance care planning. Nephrologists lack clinical experience of conservatively managing end-stage renal disease and end-of-life care in older patients. Key policy recommendations include formal communication skills training for nephrologists and development of the conservative management service.

Genetic disease risks can be misestimated across global populations.

BACKGROUND: Accurate assessment of health disparities requires unbiased knowledge of genetic risks in different populations. Unfortunately, most genome-wide association studies use genotyping arrays and European samples. Here, we integrate whole genome sequence data from global populations, results from thousands of genome-wide association studies (GWAS), and extensive computer simulations to identify how genetic disease risks can be misestimated. RESULTS: In contrast to null expectations, we find that risk allele frequencies at known disease loci are significantly different for African populations compared to other continents. Strikingly, ancestral risk alleles are found at 9.51% higher frequency in Africa, and derived risk alleles are found at 5.40% lower frequency in Africa. By simulating GWAS with different study populations, we find that non-African cohorts yield disease associations that have biased allele frequencies and that African cohorts yield disease associations that are relatively free of bias. We also find empirical evidence that genotyping arrays and SNP ascertainment bias contribute to continental differences in risk allele frequencies. Because of these causes, polygenic risk scores can be grossly misestimated for individuals of African descent. Importantly, continental differences in risk allele frequencies are only moderately reduced if GWAS use whole genome sequences and hundreds of thousands of cases and controls. Finally, comparisons between uncorrected and corrected genetic risk scores reveal the benefits of considering whether risk alleles are ancestral or derived. CONCLUSIONS: Our results imply that caution must be taken when extrapolating GWAS results from one population to predict disease risks in another population.

Use of intravenous immunoglobulin for the treatment of autoimmune encephalitis: audit of the NHS experience.

OBJECTIVES: The treatments of limbic and other autoimmune encephalitis include immunosuppression, symptomatic treatment, and in the case of paraneoplastic syndromes, appropriate therapy for underlying neoplasms. When immunotherapy is considered, intravenous immunoglobulin is one option for treatment, either alone or in combination with corticosteroids. To date, however, evidence for the use of intravenous immunoglobulin in this context comes from case series/expert reviews as no controlled trials have been performed. We aimed to analyse the NHS England Database of intravenous immunoglobulin usage, which was designed to log use and guide procurement, to explore usage and therapeutic effect of intravenous immunoglobulin in autoimmune encephalitis in England. DESIGN: We conducted a retrospective audit and review of the NHS England Database on intravenous immunoglobulin use. SETTING: NHS England Database of intravenous immunoglobulin use which covers secondary and tertiary care prescribing and use of intravenous immunoglobulin for all patients in hospitals in England. PARTICIPANTS: Hospital in-patients with confirmed or suspected autoimmune/limbic encephalitis between September 2010 and January 2017. RESULTS: A total of 625 patients who were 18 years of age or older were treated with intravenous immunoglobulin for autoimmune encephalitis, of whom 398 were determined as having 'highly likely' or 'definite' autoimmune/limbic encephalitis. Ninety-six percent were treated with a single course of intravenous immunoglobulin. The availability and accuracy of reporting of outcomes was very poor, with complete data only available in 27% of all cases. CONCLUSIONS: This is the first review of data from this unique national database. Whilst there was evidence for clinical improvement in many cases of patients treated with intravenous immunoglobulin, the quality of outcome data was generally inadequate. Methods to improve quality, accuracy and completeness of reporting are crucial to maximise the potential value of this resource as an auditing tool.

Mid-term outcomes of routine proximal row carpectomy compared with proximal row carpectomy with dorsal capsular interposition arthroplasty for the treatment of late-stage arthropathy of the wrist.

AIMS: The aims of this study were to compare the mid-term outcomes of patients with late-stage arthritis of the wrist treated with proximal row carpectomy (PRC) and dorsal capsular interposition (DCI) arthroplasty with a matched cohort treated with routine PRC alone. PATIENTS AND METHODS: A total of 25 arthritic wrists (24 patients) with pre-existing degenerative changes of the proximal capitate and/or the lunate fossa of the radius were treated with PRC + DCI over a ten-year period. This group of patients were matched 1:2 with a group of 50 wrists (48 patients) without degenerative changes in the capitate or lunate fossa that were treated with a routine PRC alone during the same period. The mean age of the patients at the time of surgery was 56.8 years (25 to 81), and the demographics and baseline range of movement of the wrist, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were similar in both groups. RESULTS: At a mean follow-up of 5.9 years (1.8 to 11.8), significant improvements in mean grip strength, the flexion-extension arc of movement of the wrist, QuickDASH, and PRWE scores were seen in both groups. There was no diifference between the groups for any of the outcomes. One patient in the PRC + DCI group required additional surgery for a deep infection, while two in the PRC group had complications (one wound dehiscence requiring revision closure, one transient radial sensory neuritis). One patient in each group required total arthrodesis of the wrist for progressive degenerative radiocarpal changes. A total of 70 patients (93%) were satisfied with the outcomes. CONCLUSION: PRC with DCI is an effective form of treatment for late-stage arthritis of the wrist involving the capitolunate joint, with mid-term outcomes that are similar to those in patients without degenerative changes affecting the capitate or lunate fossa who are treated with a routine PRC alone. Cite this article: Bone Joint J 2018;100-B:197-204.

Preliminary psychometrics of the Existential Distress Scale in patients with advanced cancer.

Existential distress is of clinical concern in patients with terminal illness. Although existential distress has been used to describe a broad spectrum of psychological disturbances, its narrower definition may be confined to distress that arises when the meaning and value of one's life is unclear, and is comorbid with feelings of loneliness and low self-worth. To promote further study, we developed and pilot-tested a 10-item Existential Distress Scale (EDS). Twenty-one patients with advanced cancer were recruited from a palliative care unit. Measures of existential distress, death anxiety, depression, performance status and physical symptom burden were collected. The EDS showed promising psychometric properties, including significant associations with death anxiety and depression. Thirty-eight per cent of the sample reported great or unbearable distress on at least one existential concern. The EDS may be administered to measure existential distress in patients with advanced cancer and clinicians may find the instrument useful to initiate a structured discussion about this symptom.

Clinical outcomes for patients with liver-limited metastatic colorectal cancer: Arguing the case for specialist hepatobiliary multidisciplinary assessment.

In patients with liver-limited metastatic colorectal cancer, hepatic resection can offer a significant survival benefit over systemic therapy alone. Specialist hepatobiliary multidisciplinary meetings are currently believed to provide the best forum to discuss the management for these patients. A retrospective analysis was undertaken of patients diagnosed with liver-limited metastatic colorectal cancer over 6 months within a cancer network in the United Kingdom. In addition, patients who were diagnosed but not referred to the hepatobiliary meeting were discussed within a virtual multi-disciplinary setting. Contributors were blinded and proposed management recorded. 159 newly diagnosed patients with liver-limited metastatic colorectal cancer were identified. 68 (43%) were referred at initial diagnosis and 38 (24%) referred following systemic treatment. 35 (51%) who were discussed at baseline underwent a subsequent hepatectomy or radiofrequency ablation, as did 18 (47%) patients referred after chemotherapy. Of the remaining 53 (33%) patients not referred, imaging was available for 31 (58%). Decisions regarding potential liver-directed therapy were discussed within a multi-disciplinary setting. 13 (42%) were identified as resectable or potentially resectable and 11 (36%) may have been suitable for a clinical trial. In reality, none of these 31 patients (100%) underwent surgery or ablation. Whilst the majority of patients with liver-limited metastatic colorectal cancer were referred appropriately, this study demonstrates that a significant number with potentially resectable disease are not being discussed at specialist meetings. A review of all diagnosed cases would ensure that an increased number of patients are offered hepatic resection or ablation.

The effects of partial carpal fusions on wrist range of motion.

UNLABELLED: The objective of this investigation was to evaluate the effects of different partial wrist fusions on wrist motion. A total of 20 cadaveric wrists were tested in the intact state and after undergoing either a four-corner fusion or 2- and 3-bone fusion. The moment-rotation behaviour was measured in 24 directions of wrist motion about the forearm axis. The 2- and 3-bone fusion groups demonstrated increased radial deviation and pure flexion. Pure flexion was decreased in the four-corner fusion group. Radial extension and pure extension were decreased in all treatments compared with normal range of motion. Increasing the number of carpal bones within the fusion construct did not alter the functional axis of the wrist. Essentially equivalent motion is possible with 2-bone, 3-bone and four-corner fusions, with the exceptions of pure flexion and radial deviation. This data may influence surgeons when choosing between treatment methods. LEVEL OF EVIDENCE: N/A.

The gap between policy and practice: a systematic review of patient-centred care interventions in chronic heart failure.

Patient-centred care (PCC) is recommended in policy documents for chronic heart failure (CHF) service provision, yet it lacks an agreed definition. A systematic review was conducted to identify PCC interventions in CHF and to describe the PCC domains and outcomes. Medline, Embase, CINAHL, PsycINFO, ASSIA, the Cochrane database, clinicaltrials.gov, key journals and citations were searched for original studies on patients with CHF staged II-IV using the New York Heart Association (NYHA) classification. Included interventions actively supported patients to play informed, active roles in decision-making about their goals of care. Search terms included 'patient-centred care', 'quality of life' and 'shared decision making'. Of 13,944 screened citations, 15 articles regarding 10 studies were included involving 2540 CHF patients. Three studies were randomised controlled trials, and seven were non-randomised studies. PCC interventions focused on collaborative goal setting between patients and healthcare professionals regarding immediate clinical choices and future care. Core domains included healthcare professional-patient collaboration, identification of patient preferences, patient-identified goals and patient motivation. While the strength of evidence is poor, PCC has been shown to reduce symptom burden, improve health-related quality of life, reduce readmission rates and enhance patient engagement for patients with CHF. There is a small but growing body of evidence, which demonstrates the benefits of a PCC approach to care for CHF patients. Research is needed to identify the key components of effective PCC interventions before being able to deliver on policy recommendations.

A pathway to empowerment: evaluating a cancer education and support programme in New Zealand.

Support programmes often benefit cancer patients and their families. This study evaluates how the Living Well Cancer Education Programme (LWCEP), from the Cancer Society of New Zealand, meets the needs of its clients. A purposeful sample of 21 participants representing the normal range of demographic characteristics (age, gender, diagnosis and geographical location) for the programme, participated in semi-structured interviews. Demographic data were subjected to a frequency analysis. Main data were collected and analysed using a constructivist grounded theory approach regarding the experiences of the participants with being on the programme and recommendations for future development. Of the 21 participants, 14 were cancer patients (eight women and six men) and seven were support people (five women and two men). The LWCEP was described as a safe, supportive and stimulating environment, provided a powerful sense of belonging, empowered participants to gain perspective, enhance their confidence and communication skills and make increasingly informed choices. Consistent with a previous evaluation focussing on the facilitators of the LWCEP, there was a strong desire for better promotion of the programme to the wider community, establishment of a better referral pathway and the potential to offer two separate programmes depending on the stage of a patient's journey.

Outcomes and indications for intervention in non-operative management of paediatric liver trauma: a 5 year retrospective study.

AIM: To determine the applicability of accurate computed tomography (CT) evaluation and embolization as non-operative management for liver trauma in a paediatric population. MATERIAL AND METHODS: A retrospective observational study of 37 children (mean age 10.5 years) with hepatic trauma (28 blunt, 9 penetrating) admitted to a trauma referral centre over a 5 year period. All patients were evaluated with CT and scored with an Association for the Surgery of Trauma score. Inpatient information was reviewed for demographics, associated injuries, modes of management, efficacy and complications of management, and outcome.Statistical analysis was performed. RESULTS: There were seven contusions, two grade I, two grade II, nine grade III, and 17 grade IV liver lacerations. Only two patients (grade IV, penetrating) underwent surgery for the management of bowel perforation. All children had non-surgical treatment of their liver trauma: three cases (grade IV) had primary angiography due to CT evidence of active bleeding and embolization was performed in two of these. Seven patients (two grade III, five grade IV)had angiography during the follow-up for evidence of a complicating pseudoaneurysm and embolization was performed in six of them. Embolization was successful in all the children; one minor complication occurred (cholecystitis). Endoscopic retrograde cholangiopancreatography (ERCP) plus stenting was performed in two cases for a bile leak. All 37 children had a positive outcome. CONCLUSION: The present study demonstrates that non-operative management of hepatic trauma is applicable to children and may have a higher success rate than in adults.

Evidence for horizontal and vertical transmission in Campylobacter passage from hen to her progeny.

Campylobacter is an important human pathogen, and consumption of undercooked poultry has been linked to significant human illnesses. To reduce human illness, intervention strategies targeting Campylobacter reduction in poultry are in development. For more than a decade, there has been an ongoing national and international controversy about whether Campylobacter can pass from one generation of poultry to the next via the fertile egg. We recognize that there are numerous sources of Campylobacter entry into flocks of commercial poultry (including egg transmission), yet the environment is often cited as the only source. There has been an abundance of published research globally that refutes this contention, and this article lists and discusses many of them, along with other studies that support environment as the sole or primary source. One must remember that egg passage can mean more than vertical, transovarian transmission. Fecal bacteria, including Campylobacter, can contaminate the shell, shell membranes, and albumen of freshly laid fertile eggs. This contamination is drawn through the shell by temperature differential, aided by the presence of moisture (the "sweating" of the egg); then, when the chick emerges from the egg, it can ingest bacteria such as Campylobacter, become colonized, and spread this contamination to flock mates in the grow house. Improvements in cultural laboratory methods continue to advance our knowledge of the ecology of Campylobacter, and in the not-so-distant future, egg passage will not be a subject continuously debated but will be embraced, thus allowing the development and implementation of more effective intervention strategies.

Manganese-enhanced MRI predicts the histological grade of hepatocellular carcinoma in potential surgical candidates.

AIM: To evaluate the role of manganese-enhanced magnetic resonance (Mn-MRI) in predicting tumour differentiation prior to liver transplant or resection for hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The inclusion criteria were patients with HCC who underwent Mn-MRI prior to transplantation or resection from 2001-2008. T1-weighted MRI images were acquired at 0 and 24h after manganese dipyridoxal diphosphate (MnDPDP) intravenous contrast medium and reviewed prospectively. Manganese retention at 24h was correlated with tumour differentiation and disease-free survival. RESULTS: Eighty-six patients underwent Mn-MRI (transplantation 60, resection 26); 114/125 lesions (91%) that were arterialised as evidenced at computed tomography (CT) and had manganese uptake on MRI were HCC. There were 11 false positives (9%) that were regenerative nodules. Ten of fourteen non-manganese-retaining HCC (71%) were poorly differentiated, compared with only 13/114 manganese-retaining HCC (11%) (p<0.0001). Sensitivity, specificity, positive and negative predictive values of non-retention of MnDPDP in predicting poorly differentiated tumours were 0.43, 0.96, 0.71 and 0.88. Median disease-free survival of patients with non-manganese-retaining HCC was less than for patients with manganese-retaining HCC (14±5 months versus 39±3 months, log rank p=0.025). CONCLUSION: Non-manganese-retaining HCCs are likely to be poorly differentiated and have a poor prognosis. Manganese-enhanced MRI appears to have a role in preoperative assessment of HCC and warrants further evaluation.

Thyroid cancer risk in Belarus among children and adolescents exposed to radioiodine after the Chornobyl accident.

BACKGROUND: Previous studies showed an increased risk of thyroid cancer among children and adolescents exposed to radioactive iodines released after the Chornobyl (Chernobyl) accident, but the effects of screening, iodine deficiency, age at exposure and other factors on the dose-response are poorly understood. METHODS: We screened 11 970 individuals in Belarus aged 18 years or younger at the time of the accident who had estimated (131)I thyroid doses based on individual thyroid activity measurements and dosimetric data from questionnaires. The excess odds ratio per gray (EOR/Gy) was modelled using linear and linear-exponential functions. RESULTS: For thyroid doses <5 Gy, the dose-response was linear (n=85; EOR/Gy=2.15, 95% confidence interval: 0.81-5.47), but at higher doses the excess risk fell. The EOR/Gy was significantly increased among those with prior or screening-detected diffuse goiter, and larger for men than women, and for persons exposed before age 5 than those exposed between 5 and 18 years, although not statistically significant. A somewhat higher EOR/Gy was estimated for validated pre-screening cases. CONCLUSION: 10-15 years after the Chornobyl accident, thyroid cancer risk was significantly increased among individuals exposed to fallout as children or adolescents, but the risk appeared to be lower than in other Chornobyl studies and studies of childhood external irradiation.

Visceral adiposity is closely correlated with neck circumference and represents a significant indicator of insulin resistance in WHO grade III obesity.

OBJECTIVE: Although associations between visceral adiposity (intra-abdominal fat mass) and insulin resistance are well established, previous data include few subjects with WHO grade III obesity [body mass index (BMI) > 40 kg/m(2)]. We have investigated the relationship between visceral adiposity and insulin resistance using computed tomography (CT)-quantified fat mass and the homeostasis model assessment for insulin resistance (HOMA-IR) in patients with severe obesity. PATIENTS AND METHODS: Eighteen nondiabetic subjects with BMI > 40 kg/m(2) were recruited. BMI, and waist, hip and neck circumferences were measured. Fasting plasma insulin and glucose were measured to calculate HOMA-IR. A single slice CT scan was taken at L4 and visceral and abdominal subcutaneous adipose tissue (VAT and ASAT, respectively) quantified using 'SliceOmatic' image analysis software. RESULTS: A close correlation was demonstrated between VAT and HOMA-IR (r(2) = 0.46, P = 0.002), whereas ASAT showed no relationship. Neck circumference correlated with both VAT (r(2) = 0.67, P < 0.0001) and HOMA-IR (r(2) = 0.35, P = 0.01). Waist circumference only correlated significantly with VAT (r(2) = 0.25, P = 0.03). CONCLUSIONS: Visceral adiposity remains a strongly significant indicator of insulin resistance in WHO grade III obesity. Neck circumference surpasses other anthropometric measurements as a powerful marker of both VAT and insulin resistance.

Role of imaging in the management of pancreatic mass.

Pancreatic cancer is the second commonest malignant gastrointestinal neoplasm. Modern imaging techniques have greatly increased sensitivity in diagnosing and staging pancreatic cancers. Multidetector CT in particular, plays a critical role in local staging and determining the resectability of pancreatic tumours. MR and endoscopic ultrasound are valuable in those groups of patients in whom CT findings alone are inconclusive in tumour characterisation and local staging, particularly vascular involvement. In this article we review the current established concepts and the role of imaging in the multidisciplinary management of pancreatic tumours together with a comprehensive review of the literature.

Vanishing liver tumours.

Spontaneous resolution of liver tumours is a rare, but recognized entity that has been reported to occur within the spectrum of benign and malignant liver tumours occurring in both adult and paediatric population. The aetiology of this unusual phenomenon is not clearly understood. In this article we present case examples of various benign and malignant liver tumours that have regressed spontaneously without treatment together with a review of the literature, and a summary of the current understanding of the pathogenesis of these tumours.

Paraovarian adrenal rest with MRI features characteristic of an adrenal adenoma.

We report MR and sonographic imaging features of an incidentally detected paraovarian adrenal rest in a 44-year-old woman who was being evaluated for menorrhagia. This is the first report of chemical shift imaging identifying the presence of lipid within an adrenal rest as well as rapid washout of contrast. Both of these MR characteristics are typically seen with an adrenal adenoma.