Family doctors' attitudes toward peer support programs for type 2 diabetes and/or coronary artery disease: an exploratory survey among German practitioners.

BACKGROUND: Type 2 diabetes (T2D) and coronary artery disease (CAD) are chronic illnesses where adherence to a healthy lifestyle is crucial. If organisational and cultural factors are well managed, Peer support programs (PSP) can improve self-management, quality of life, and health outcomes. In preparation for launching a PSP, we surveyed family doctors (FD) about their attitudes toward such a program and about potential barriers, and facilitators. METHODS: In March 2020 we surveyed 896 FDs from five university teaching practice networks in North-Rhine Westphalia, Germany, via an anonymous web-based survey. The questionnaire addressed details of PSPs, including suitable patients and FDs'role. Data were analysed using descriptive and inferential statistics; qualitative material underwent content analysis by two researchers. RESULTS: A total of 165 FDs responded (response rate: 18.4%), 97% were practice owners. Respondents viewed PSPs positively (T2D: 92.0%, CAD 89.9%), especially for patients with poor self-structuring (82.7%), low motivation (76.3%) and few social contacts (67.6%). On average, FDs were able to identify 4.0 ± 3.2 patients as potential group leaders. Major facilitators reported included motivation by peers (92.5%), exercise (79.1%), and social contacts (70.1%). Waning interest over time (73.1%) and poor motivation (70.9%) were considered barriers. The majority of FDs would recommend PSPs to their patients (89.5%). They considered such a program a valuable addition to current care (79.7%). The percentage of FDs' who expected long-term benefits for their workload was relatively low (37.6%). CONCLUSIONS: In an exploratory survey among German FDs on PSPs, respondents viewed PSPs as a valuable add-on for T2D and CAD patients, while not expecting a positive impact on their workload. Communication with FDs on PSPs may need to highlight anticipated implementation outcomes such as benefits of PSPs to the practice.

Targeted colonic release formulations of mesalazine - A clinical pharmaco-scintigraphic proof-of-concept study in healthy subjects and patients with mildly active ulcerative colitis.

Colonic targeting of orally applied therapeutic drugs remains a challenge. Tablet coatings relying on gastrointestinal pH and colonic bacterial enzymes as triggers in association with an inner alkaline layer are expected to improve targeting efficiency. Mesalazine release from three differently coated tablets labelled with 1 MBq 153Sm was characterised in a single centre, open-label, parallel group study in nineteen healthy subjects and seven patients with mildly active ulcerative colitis. Two semi-organic and one aqueous-based outer coating with different ratios of enteric polymer and resistant starch were tested. All coatings showed comparable release lagtimes in biorelevant dissolution media and were not affected by neutron-activation of the samarium tracer. Mesalazine pharmacokinetics and gamma scintigraphy were used to characterise drug release, anatomical site of tablet disintegration and gastrointestinal transit. Initial tablet disintegration occurred at the ileo-caecal junction or beyond in 92 % of the subjects. Time to initial tablet disintegration was inversely correlated with maximal plasma concentrations and systemic mesalazine exposure. Although high inter-subject variability precluded detection of differences between solvent types and different enteric polymer to polysaccharide ratios, the dual pH and enzymatic triggered release system in combination with an inner alkaline layer promoted mesalazine release at the target site with high accuracy.

Transition from service to civvy street: the needs of armed forces veterans and their families in the UK.

AIMS:: Although many veterans make the transition from military to civilian life without difficulty, a small proportion struggle due to an impact on mental and physical wellbeing. Stigma and a reluctance to seek help further exacerbate this problem. The Armed Forces Covenant outlines the importance of ensuring that public services are aware of the specific needs of veterans; however, evidence suggests that knowledge among professional staff may be limited. METHODS:: This exploratory study included three phases. Phase 1 (questionnaires) explored the needs of veterans and their families in Warwickshire (UK) regarding information about their health and wellbeing and the barriers and facilitators to accessing local public health services. Also in Phase 1, health and public services staff knowledge of veterans' needs and the Covenant is explored. In Phase 2, both samples attended a related focus group for a more in-depth exploration of the issues identified in Phase 1; in order to inform a Phase 3 workshop to co-develop an intervention. RESULTS:: Veterans, their families and friends, wanted more information about what services do, how and when to access them and what to expect. Confusion over when to seek help for mental health 'symptoms' was highlighted. More support for families was identified, alongside a need for health and social care staff to have a better understanding of the unique experiences and needs of veterans. Only 35% of staff reported a good understanding of the Armed Forces Covenant and their responsibilities to uphold it. CONCLUSIONS:: Public health teams within UK local authorities are well placed to ensure veterans have more knowledge about and access to public services. Interventions to address stigma and veterans' reluctance to seek help were needed. To this end, interventions for local veterans, their loved ones and staff in public services, designed in co-creation with these groups, is discussed.

[Recurrent hypoglycemia due to an occult insulinoma]. / Okkultes Insulinom als Ursache rezidivierender Hypoglykämien.

A 64-year-old woman presented with a history of recurrent hypoglycemia. A prolonged fasting test revealed an increased "amended" insulin-glucose ratio. Transabdominal ultrasound (US), computed tomography (CT) scan, and magnetic resonance imaging (MRI) did not show abnormal results. An insulinoma was suspected based on a contrast-enhanced endoscopic US examination as well as a (68)gallium-DOTA-exendin-4 positron-emission tomography (PET)/CT. The diagnosis of an insulinoma was confirmed histologically after surgical removal of the tumor. Hypoglycemia did not occur during the postoperative period. The prolonged fasting test is the gold standard for the diagnosis of an insulinoma. Novel imaging procedures, such as contrast-enhanced endoscopic US or (68)gallium-DOTA-exendin-4 PET/CT are valuable additions to the diagnostic workup.

Association between cartilage degeneration and subchondral bone remodeling in patients with knee osteoarthritis comparing MRI and (99m)Tc-DPD-SPECT/CT.

OBJECTIVE: The purpose of this retrospective cross-sectional study was to investigate the association between cartilage lesions assessed with 3T-MRI and remodeling of the subchondral bone detected by (99m)Tc-DPD-SPECT/CT. DESIGN: (99m)Tc-DPD-SPECT/CT and MRI of 27 knees of 25 patients with chronic knee pain and risk factors for osteoarthritis (OA) were evaluated by one nuclear physician and one radiologist. Six regions of the knee (in total 162 regions in 27 knees) were assessed according to structural joint lesions graded with a modified Whole Organ MR imaging score (WORMS) and according to subchondral (99m)Tc-DPD-SPECT uptake. Relationships between regional WORMS scores and uptake were quantified using general estimating equations. In a secondary analysis the uptake sum with the WORMS sum per joint was compared using Spearman correlations. RESULTS: Elevated subchondral uptake was significantly associated with the grade of cartilage lesions (P < 0.0001). Mean uptake was significantly higher subjacent to full thickness cartilage lesions compared to partial thickness lesions (P < 0.0001). A similar association was observed between bone marrow edema pattern (BMEP) and cartilage lesions. The sum of uptakes per joint was positively correlated to the WORMS sum (rs = 0.42) and to the sum of cartilage lesions per joint (rs = 0.50). CONCLUSION: Both functional and structural changes of the subchondral bone in terms of scintigraphic osseous activity and the presence and degree of BMEP were significantly associated with cartilage lesions in patients with OA of the knee. This association was pronounced with full thickness lesions, indicating a possible protective effect of the cartilage layer for the subjacent bone.

Results of a prospective surgical audit of bilateral paediatric cochlear implantation in the UK.

BACKGROUND: Following the approval of bilateral paediatric cochlear implantation in 2009, the prospective multi-centre UK National Paediatric Cochlear Implant Audit was established to collect a large dataset of paediatric implantations. The aim of the surgical part of the audit, reported here, was to collect data on surgical practice, outcomes and complications. METHODS: Data from 14 surgical centres was collected prospectively, including simultaneous and sequential bilateral as well as unilateral implantations. Data collected included age at implantation, aetiology of deafness, implant type, duration of surgery, the use of electrophysiological testing, and the use of pre- and post-operative imaging. Details of major and immediate minor complications were also recorded. RESULTS: 1397 CI procedures in 961 CI recipients were included; 436 bilateral simultaneous, 394 bilateral sequential, 131 unilateral. The overall major complication rate was 1.6% (0.9% excluding device failure) and was similar following bilateral CI compared to sequential and unilateral CI. CONCLUSION: This prospective multi-centre audit provides evidence that bilateral paediatric CI is a safe procedure in the UK, thus endorsing its role as a major therapeutic intervention in childhood deafness.

Evidence of high sugar intake, and low fibre and mineral intake, in the gluten-free diet.

BACKGROUND: The only therapy for coeliac disease (CD) is a long-term gluten-free diet (GFD). Little is known about the detailed composition of such a diet. AIM: To clarify the nutritional composition of a GFD and to compare it with a non-GFD diet in representative non-CD populations. METHODS: A total of 139 consecutive patients with CD were invited to fill in a prospective validated 5-day food diary, of whom data from 93 were analysed. Results were compared with data from the National Diet and Nutrition Survey of Adults and the UK Women's Cohort Study (UKWCS). RESULTS: Individuals consuming a strict GFD generally had similar intakes of energy and nutrients to those of comparison populations, but a higher proportion of carbohydrate intake was obtained from nonmilk extrinsic sugars and intakes of nonstarch polysaccharides were low. Compared with the UKWCS sample, female patients adhering to a GFD had lower intakes of magnesium, iron, zinc, manganese, selenium and folate. In male patients, intakes of magnesium and selenium were particularly low. CONCLUSIONS: This study reinforces the need for clinicians to recognize that avoidance of gluten cannot be the sole focus of a gluten-free diet. Maintenance of adequate intakes of essential nutrients and in particular complex carbohydrates must also be the goal for patients.

Lessons learnt from an audit of 95 cases of major nasal reconstruction.

BACKGROUND: Several texts detail the possible complications of nasal reconstruction but few critically describe a series. We present an audit of the complications of 95 major nasal reconstructions. METHODS: This is a retrospective analysis of 95 consecutive major nasal reconstructions (49 male, 46 female, aged between 4 and 92 years) over a 16-year period treated in a tertiary refer-ral centre. RESULTS: Fifty-eight patients in our series required nasal reconstruction after Moh's Micrographic surgery for a morpheiform basal cell or a squamous cell carcinoma. Eight patients had further removal using frozen section to determine the margins, as the disease was very extensive. Minor procedures with local random flaps or full thickness skin grafts were excluded. Ninety-five patients underwent major reconstructive procedures and had an average of 2.8 operations. SUMMARY: The main problem was the suboptimal contouring of the alar margin in 6 of 54 patients who had a full thickness defect repaired. Other complications included telangectasia or hair growth requiring laser ablation (13), stenosis of the nasal valve area (2), ectropion after a cheek advancement flap, donor site haematoma of the pinna, and neuropathic pain.

Advance care planning in care homes for older people: an English perspective.

Advance care planning (ACP) as a process of discussing and recording wishes for future care and treatment is increasingly being promoted and discussed in the UK, reflecting recent changes in legislation. This study describes current ACP practice in care homes for older people drawing on data from a questionnaire survey (n = 213) of, and interviews (n = 15) with, care home managers. Whilst consultation about general care is taking place in the majority of homes surveyed using both formal and informal processes, the number of residents that have completed any ACP processes varies. Managers face intrinsic and extrinsic challenges related to the ascertaining of, and the implementing of wishes as they address ACP in the care home context. Until these wider contextual factors are addressed it will be difficult for staff in care homes to effectively undertake and implement ACP in care homes.

The presence of ovarian hormone receptors in the nasal mucosa and their relationship to nasal symptoms.

BACKGROUND: There is evidence in the literature showing a link between ovarian hormones and changes to nasal physiology. OBJECTIVES: The aim of this pilot study was to identify and quantify female hormone receptor positive cells in the nasal mucosa and to establish if there is a correlation with rhinitic symptoms. METHODS: Twenty-five adult patients attending a university hospital for routine, elective nonrhinological ENT procedures under general anaesthetic (mainly tonsillectomy) were recruited pre-operatively. Background information about each participant was recorded. Biopsies were taken from the inferior turbinates. These were analysed using immunohistochemistry techniques to assess for the presence of Progesterone, Oestrogen-alpha (ERalpha) and Oestrogen-beta (ERbeta) receptors. The mean number of cells positive for the receptors in each biopsy was deduced using a stratified random sampling technique. RESULTS: All nasal biopsies were negative for progesterone and ERalpha receptors. ERbeta receptors were present in the mucosal glands in 24 out of the 25 biopsies. Using unpaired t-tests to compare the sexes, smoking status and atopic history no statistical difference was shown between any of these groups (p > 0.05). However, the rhinitis quality of life questionnaire score and the mean number of ERbeta receptor positive cells per biopsy showed a positive correlation (Pearson correlation of 0.4, p < 0.05). CONCLUSIONS: The number of oestrogen receptor positive cells appears unaffected by sex, smoking history, hormone status, age or atopy. However, there is a significant positive relationship between the mean number of ERbeta positive cells and nasal symptoms. Pharmacological downregulation of ERbeta positive cells may reduce rhinitic symptoms and is the subject of further research.

Does hormone replacement therapy in post-menopausal women have any effect upon nasal physiology?

BACKGROUND: Previous studies have suggested that the female menstrual cycle, pregnancy and the oral contraceptive pill have an effect upon nasal physiology. OBJECTIVES: This study aimed to assess the effects upon nasal physiology of female hormone replacement therapy in post-menopausal women. This has not been previously studied. METHODS: Twenty post-menopausal women (age range 36 to 70 years; mean age 57.0 years) underwent measurements of the nasal airway, including anterior rhinoscopy, peak nasal inspiratory flow rate, acoustic rhinometry, anterior rhinomanometry, mucociliary clearance time and rhinitis quality of life questionnaire. Measurements of nasal patency were recorded prior to commencing hormone replacement therapy and at a time point 77-195 days (mean 101.9 days) following commencement. RESULTS: There was no statistical difference found for any of the variables, using the paired t-test (p > 0.05 for all). CONCLUSIONS: Female hormone replacement therapy has no discernable effect upon nasal physiology and should not be considered a cause of rhinitic symptoms.

The impact of follicular lymphoma on health-related quality of life.

BACKGROUND: The purpose of this study was to determine whether there was a relationship between disease activity and health functioning, as measured by a range of patient-reported outcome (PRO) measures in patients with follicular lymphoma (FL). PATIENTS AND METHODS: A total of 222 patients with FL were recruited from eight sites across the UK and they completed a number of PRO measures. The participants were analyzed across five disease states: 'active disease-newly diagnosed', 'active disease-relapsed', 'partial response', 'complete response' and 'disease free'. The relationship between these disease states and their level of health functioning was assessed as well as the relationship between being 'on' or 'off' chemotherapy and disease state. RESULTS: In terms of health-related quality of life (HRQoL), participants in the relapsed category had the lowest mean physical well-being, emotional well-being, functional well-being and social well-being score. In a regression analysis, the 'active disease-relapsed' group acted as a significant predictor for each PRO variable. In addition, the remission group acted as a significant predictor of high anxiety scores as measured by the Hospital Anxiety and Depression Scale. CONCLUSION: The results of this study demonstrate that various aspects of patient-reported health outcomes differ according to disease state in patients with FL. For those patients who have relapsed, they are more likely to experience worse HRQoL and other patient-reported health outcomes than patients newly diagnosed, in partial or complete remission or when completely disease free.

[123I-Metaiodobenzylguanidine- (MIBG-) scintigraphy: paradoxical positivity in an oncocytic adrenocortical carcinoma]. / 123I-Methyljodbenzylguanidin- (MIBG-) Szintigraphie: Paradoxe Nuklidspeicherung eines onkozytären Nebennierenrindenkarzinoms.

(123)I-metaiodobenzylguanidine (MIBG), a radio-labeled catecholamine analogue, is used for the imaging of pheochromocytoma based on the selective uptake of MIBG by chromaffin tissues. MIBG scintigraphy displays high sensitivity (90%) and specificity (close to 100%). In contrast, the false-positive uptake of MIBG by adrenal cortical carcinoma is rare. Here, we report a metastatic oncocytic adrenal cortical carcinoma with MIBG uptake used for therapeutic purposes.

Structures, energetics, and infrared spectra of the Cl- -(H2S)n, and Br- -(H2S)n anion clusters from ab initio calculations.

Anion clusters formed between a chloride or bromide anion and H2S molecules have been investigated using ab initio methods. Cluster structures, binding energies, and vibrational properties were predicted at the MP2 level with basis sets of aug-cc-pvtz and aug-cc-pvdz quality. Vibrational self consistent field (VSCF) calculations were employed to correct the predicted harmonic vibrational frequencies of the dimer complexes for anharmonicity. The major finding of this work is that the clusters all feature "solvated anion" structural motifs, with an anion bound to perturbed, yet intact, H2S ligands. The binding energies of the H2S ligands to the anion decrease with larger cluster size, and this is reflected in blue shifted vibrational stretching frequencies.

Infrared spectra and ab initio calculations for the F- -(CH4)n (n = 1-8) anion clusters.

Infrared spectra of mass-selected F- -(CH4)n (n = 1-8) clusters are recorded in the CH stretching region (2500-3100 cm-1). Spectra for the n = 1-3 clusters are interpreted with the aid of ab initio calculations at the MP2/6-311++G(2df 2p) level, which suggest that the CH4 ligands bind to F- by equivalent, linear hydrogen bonds. Anharmonic frequencies for CH4 and F--CH4 are determined using the vibrational self-consistent field method with second-order perturbation theory correction. The n = 1 complex is predicted to have a C3v structure with a single CH group hydrogen bonded to F-. Its spectrum exhibits a parallel band associated with a stretching vibration of the hydrogen-bonded CH group that is red-shifted by 380 cm-1 from the nu1 band of free CH4 and a perpendicular band associated with the asymmetric stretching motion of the nonbonded CH groups, slightly red-shifted from the nu3 band of free CH4. As n increases, additional vibrational bands appear as a result of Fermi resonances between the hydrogen-bonded CH stretching vibrational mode and the 2nu4 overtone and nu2+nu4 combination levels of the methane solvent molecules. For clusters with n < or = 8, it appears that the CH4 molecules are accommodated in the first solvation shell, each being attached to the F- anion by equivalent hydrogen bonds.

Safe magnetic resonance scanning of patients with metallic middle ear implants.

OBJECTIVE: To determine the MR scanning risk to patients with otologic implants. DESIGN: We used a repeated-measures study with an additional control measure to assess two aspects of risk; (i) movement of the device in the magnetic field, and (ii) absorption of energy leading to local heating. We used an ex vivo test method that met with international standards. We measured the effects in a Philips Intera Achieva 3 Tesla (T) MR scanner using a Sense Head 8 channel RF coil. SETTING: University-based magnetic resonance research facility. MAIN OUTCOME MEASURES: Heating or displacement of the stapedectomy pistons. RESULTS: No evidence of displacement or heating was found. CONCLUSION: Complying with the ex vivo standard testing protocols, the Schuknecht and McGee wire pistons (device product numbers 140106 and 140108, respectively) were found to be safe in a 3 T MR scanner. These conclusions can be extrapolated to the in vivo case.

How we do it: improving the success of endoscopic pharyngeal pouch stapling.

A simple technique to improve the success rate of endoscopic stapling diverticulotomy of pharyngeal pouches is described. Equipment used is readily available. This technique can be used in difficult cases when the pouch cannot be visualised using a Weerda diverticuloscope. It reduces the need for conversion to an open surgical procedure with associated increased risk of complications.