Managing pregnancy-related stroke risk with known bilateral internal carotid artery webs.

Carotid webs are intraluminal shelf-like projections caused by thickening of the arterial tunica intima. Due to their projections forming a nidus for thrombus formation and subsequent embolus, they are considered to be a rare cause of ischaemic strokes. We report a case of a woman with a background of recurrent ischaemic strokes due to bilateral carotid webs who presented with a twin pregnancy. We use this case to discuss how her pregnancy-related stroke risk was subsequently medically managed.

Cardio pulmonary resuscitation (CPR) in the frail and those with multiple health conditions: Outcomes before and during the COVID pandemic.

Coronavirus 2019 (COVID-19)-era resuscitation guidelines advised personal protective equipment before chest compressions and proactive advanced care planning. We investigated the impact of COVID-19 on cardiopulmonary resuscitation (CPR) outcomes according to scoring of frailty and of multiple health conditions. A retrospective single-centre analysis of clinical and electronic records for all adult cardiac arrest calls on wards between June 2020 and June 2021 was performed. Data were compared with a cohort pre-COVID (March 2017-March 2018). In total, 62 patients received CPR in 2020-21 compared with 113 in 2017-18. Similar rates of return of spontaneous circulation (ROSC) and a statistically insignificant survival increase from 23.8% to 32.2% (p=0.210). There were linear relationships between Clinical Frailty Scale (CFS) or Charlson Comorbidity Index (CCI) and diminished survival in the pooled data (both p<0.001). Both increasing frailty (measured by CFS) and comorbidity (measured by CCI) were associated with reduced survival from CPR. However, survival and ROSC during COVID-19 were no worse than before the pandemic.

Assessing the extinction risk of insular, understudied marine species.

Hydrothermal vents are rare deep-sea oases that house faunal assemblages with a similar density of life as coral reefs. Only approximately 600 of these hotspots are known worldwide, most only one-third of a football field in size. With advancing development of the deep-sea mining industry, there is an urgent need to protect these unique, insular ecosystems and their specialist endemic faunas. We applied the IUCN (International Union for the Conservation of Nature) Red List criteria to assess the extinction risk of vent-endemic molluscs with varying exposure to potential deep-sea mining. We assessed 31 species from three key areas under different regulatory frameworks in the Indian, West Pacific, and Southern Oceans. Three vent mollusc species were also examined as case studies of different threat contexts (protected or not from potential mining) to explore the interaction of local regulatory frameworks and IUCN Red List category assignment. We found that these assessments were robust even when there was some uncertainty in the total range of individual species, allowing assessment of species that have only recently been named and described. For vent-endemic species, regulatory changes to area-based management can have a greater impact on IUCN Red List assessment outcomes than incorporating additional data about species distributions. Our approach revealed the most useful IUCN Red List criteria for vent-endemic species: criteria B and D2. This approach, combining regulatory framework and distribution, has the potential to rapidly gauge assessment outcomes for species in insular systems worldwide.

Evaluación del Riesgo de Extinción de Especies Marinas Insulares Poco Estudiadas Resumen Los respiraderos hidrotermales son oasis poco comunes en las profundidades del mar en donde se encuentran conjuntos de fauna con una densidad similar a la de los arrecifes de coral. A nivel mundial, sólo se conocen aproximadamente 600 de estos puntos calientes, la mayoría solamente del tamaño de un tercio de una cancha de fútbol. Conforme avanza el desarrollo de la industria minera en mares profundos, también hay una urgente necesidad por proteger estos ecosistemas únicos e insulares y a su fauna endémica especialista. Aplicamos el criterio de la Lista Roja de la UICN (Unión Internacional para la Conservación de la Naturaleza) para evaluar el riesgo de extinción que tienen los moluscos endémicos de los respiraderos ante una exposición variable a la potencial minería de mar profundo. Evaluamos 31 especies de tres áreas importantes bajo diferentes marcos regulatorios en los océanos Índico, Pacífico Occidental y del Sur. Analizamos tres especies de moluscos de los respiraderos como estudios de caso para diferentes contextos de amenazas (protegidas o no de la minería potencial) para explorar la interacción de los marcos regulatorios locales y la clasificación categórica dentro de la Lista Roja de la UICN. Descubrimos que estos análisis eran sólidos incluso cuando existía algo de incertidumbre en cuanto a la extensión total de la especie individual, lo que permite la valoración de especies que han sido descritas y nombradas recientemente. Para las especies endémicas de las chimeneas, los cambios regulatorios a un manejo basado en el área pueden tener un mayor impacto sobre los resultados de evaluación de la Lista Roja de la UICN que la incorporación de datos adicionales sobre la distribución de las especies. Nuestra estrategia reveló los criterios más útiles de la Lista Roja de la UICN para las especies endémicas de las chimeneas: los criterios B y D2. Esta estrategia, que combina un marco regulatorio con la distribución, tiene el potencial para medir rápidamente los resultados de las evaluaciones para las especies que se encuentran en sistemas insulares en todo el mundo.

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement.

OBJECTIVE: Six per cent of hospital patients experience a patient safety incident, of which 12% result in severe/fatal outcomes. Acutely sick patients are at heightened risk. Our aim was to identify the most frequently reported incidents in acute medical units and their characteristics. DESIGN: Retrospective mixed methods methodology: (1) an a priori coding process, applying a multi-axial coding framework to incident reports; and, (2) a thematic interpretative analysis of reports. SETTING: Patient safety incident reports (10 years, 2005-2015) collected from the National Reporting and Learning System, which receives reports from hospitals and other care settings across England and Wales. PARTICIPANTS: Reports describing severe harm/death in acute medical unit were identified. MAIN OUTCOME MEASURES: Incident type, contributory factors, outcomes and level of harm were identified in the included reports. During thematic analysis, themes and metathemes were synthesised to inform priorities for quality improvement. RESULTS: A total of 377 reports of severe harm or death were confirmed. The most common incident types were diagnostic errors (n = 79), medication-related errors (n = 61), and failures monitoring patients (n = 57). Incidents commonly stemmed from lack of active decision-making during patient admissions and communication failures between teams. Patients were at heightened risk of unsafe care during handovers and transfers of care. Metathemes included the necessity of patient self-advocacy and a lack of care coordination. CONCLUSION: This 10-year national analysis of incident reports provides recommendations to improve patient safety including: introduction of electronic prescribing and monitoring systems; forcing checklists to reduce diagnostic errors; and increased senior presence overnight and at weekends.

Frailty, multimorbidity and in-hospital cardiopulmonary resuscitation: predictable markers of outcome?

BACKGROUND: This study's aim was to investigate an association between outcome from in-hospital cardiopulmonary resuscitation (CPR) and increasing burden of comorbidities and frailty. METHODS: Retrospective analysis of prospectively collected data from contemporaneous patient notes and electronic records of all patients who suffered an in-hospital cardiac arrest between 1 April 2017 and 31 March 2018 in a hospital that includes a tertiary cardiology department. RESULTS: A total of 113 patient records were assessed. Patient frailty was assessed based on calculation of Rockwood clinical frailty score (CFS) and comorbidity assessment based on Charlson comorbidity index (CCI). A linear correlation has been identified between increasing CCI and reduced survival (ANOVA = p<0.001) and rates of return of spontaneous circulation (ROSC) (ANOVA = 0.013). No patients with a CFS above 6 survived to 1 year. A linear correlation was identified between increasing CFS and reduced probability of ROSC (ANOVA p=0.002), survival to discharge (ANOVA p=0.003) and 1 year (ANOVA p=0.001). CONCLUSION: Our findings suggest an association between increasing patient multimorbidity and frailty and poorer outcome post cardiac arrest.

Slumped posture on chest X-ray-association with mortality and length of hospital stay in older hospitalised patients.

INTRODUCTION: frail, older patients are occasionally incapable of keeping their head out of the field of view of a chest radiograph (CXR) resulting in a 'slumpogram'. This study aims to explore a possible link between a slumped appearance on a CXR; mortality and length of hospital stay. METHODS: the CXRs of patients aged over 65 admitted to a Health Board with a catchment area of approximately 300,000 were investigated in a retrospective analysis of all CXRs taken during the first week of January 2015. Slumped patients were compared to age matched controls. The degree of slumping was measured by the number of ribs covered and the MA/C factor (the shortest distance between the angle of the mandible and a line drawn between the heads of both acromion divided by the length of the patient's clavicle). Outcomes investigated included length of hospital stay and 18-month mortality. RESULTS: 806 CXRs were viewed with 53 slumped patients and 53 matched controls identified. In all patients aged over 65 there was a statistically significant correlation between the length of stay and the number of ribs covered by the patients' head (P = 0.038). The MA/C factor was also associated with length of stay (P = 0.025). In patients over 80 there was a significant association between the number of ribs covered and death (P = 0.015). CONCLUSION: a slumped CXR may be associated with longer hospitalisation or death. The results of this small study require further revalidation but if true could help inform clinical decision making.

Mirtazapine-induced steatosis
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Mirtazapine is a commonly used drug indicated for the treatment of severe depression. It works as a presynaptic α2-adrenoreceptor antagonist that increases central noradrenergic and serotonergic neurotransmission, and it is metabolized by the p450 cytochrome oxidase system. There is evidence within the literature to suggest a link between antidepressants and increased liver enzymes, although case reports demonstrating a link between mirtazapine specifically and steatosis are sparse. Here, we present a case of mirtazapine-induced steatosis in a 48-year-old office worker. She presented with painless jaundice of 2 days duration and generalized lethargy and peripheral edema present for 3 weeks beforehand. Extensive investigations were undertaken to identify the cause of her jaundice but no biochemical, blood-borne, or anatomical cause could be found. Mirtazapine was subsequently stopped, and her liver function, both clinically and biochemically, improved rapidly. She made a full recovery after discontinuation of her mirtazapine.
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Prenatal development is linked to bronchial reactivity: epidemiological and animal model evidence.

Chronic cardiorespiratory disease is associated with low birthweight suggesting the importance of the developmental environment. Prenatal factors affecting fetal growth are believed important, but the underlying mechanisms are unknown. The influence of developmental programming on bronchial hyperreactivity is investigated in an animal model and evidence for comparable associations is sought in humans. Pregnant Wistar rats were fed either control or protein-restricted diets throughout pregnancy. Bronchoconstrictor responses were recorded from offspring bronchial segments. Morphometric analysis of paraffin-embedded lung sections was conducted. In a human mother-child cohort ultrasound measurements of fetal growth were related to bronchial hyperreactivity, measured at age six years using methacholine. Protein-restricted rats' offspring demonstrated greater bronchoconstriction than controls. Airway structure was not altered. Children with lesser abdominal circumference growth during 11-19 weeks' gestation had greater bronchial hyperreactivity than those with more rapid abdominal growth. Imbalanced maternal nutrition during pregnancy results in offspring bronchial hyperreactivity. Prenatal environmental influences might play a comparable role in humans.

Live liver donation, ethics and practitioners: 'I am between the two and if I do not feel comfortable about this situation, I cannot proceed'.

This paper discusses the views of 17 healthcare practitioners involved with transplantation on the ethics of live liver donations (LLDs). Donations between emotionally related donor and recipients (especially from parents to their children) increased the acceptability of an LLD compared with those between strangers. Most healthcare professionals (HCPs) disapproved of altruistic stranger donations, considering them to entail an unacceptable degree of risk taking. Participants tended to emphasise the need to balance the harms of proceeding against those of not proceeding, rather than calculating the harm-to-benefits ratio of donor versus recipient. Participants' views suggested that a complex process of negotiation is required, which respects the autonomy of donor, recipient and HCP. Although they considered that, of the three, donor autonomy is of primary importance, they also placed considerable weight on their own autonomy. Our participants suggest that their opinions about acceptable risk taking were more objective than those of the recipient or donor and were therefore given greater weight. However, it was clear that more subjective values were also influential. Processes used in live kidney donation (LKD) were thought to be a good model for LLD, but our participants stressed that there is a danger that patients may underestimate the risks involved in LLD if it is too closely associated with LKD.

Do members of the British public know how to contact emergency medical services when abroad?

There is increased demand for emergency healthcare by the public when abroad. This study aimed to investigate adults' reported level of knowledge about how to contact emergency healthcare services while abroad. A street survey was administered at various times, over several days, to 554 members of the general public who had been abroad in the previous 18 months. Only 33.6% [95% confidence interval (29.6%-37.7%)] of respondents reported that they knew the emergency medical number for the country last visited. This did not differ by sex (34.2% males vs. 33% females). Those fluent in the language of the country last visited were more likely to report knowing the emergency number for that country (54%), compared with those who were not (24.8%) (P<0.001). It is concerning that the majority of the general public do not appear to know how to contact emergency medical services while abroad. More targeted health education campaigns that address this are needed.

Muscular strength and function in patients with cystic fibrosis.

BACKGROUND: For 20 years, physical activity has been an important component in the treatment of cystic fibrosis (CF) patients in Sweden. Data concerning physical performance in terms of muscular strength in these patients are limited OBJECTIVE: To compare muscular strength and function in patients with CF with those aspects in a healthy control group (CG). DESIGN: Thirty-three patients with CF (16 women) aged 16 to 35 years and 20 healthy individuals matched for age and gender were included in the study. All participants had undertaken regular physical training two to three times per week. The following tests were performed: vertical jumping ability; hand-grip strength; abdominal strength; arm/shoulder strength; quadriceps muscle strength; and a functional test of leg muscle endurance. RESULTS: Patients with CF showed decreased muscle strength and function compared to control subjects (women: maximal hand-grip strength in the right [p = 0.02] and the left hand [p = 0.001]; sustained hand-grip strength in the left hand [p = 0.002]; and in leg muscle endurance [p = 0.02]; men: the number of sit-ups performed within 30 s [p = 0.03]; and left leg isokinetic quadriceps strength at 180 degrees per second [p = 0.02]). The differences were not related to pancreatic or pulmonary function. There was no significant difference between the CF group and the CG in any other test results. CONCLUSIONS: Our study showed few differences in muscular performance between patients with CF and healthy control subjects. Both groups had regular moderate-to-high activity levels. Further studies are needed to evaluate whether the small but significant differences might be related to metabolic abnormalities in skeletal muscles in CF patients.