Debate: the per rectal/digital rectal examination exam in the emergency department, still best practice?

BACKGROUND: Emergency medicine practice in the UK and Ireland offers a junior and middle grade doctor great learning opportunities that force engagement with multiple specialties, life-saving procedures, exposure to a myriad of patient presentations, and opportunities for best practices in medicine. MAIN BODY: The emergency department (ED) can be a hectic and dynamic environment; communication from the ED to specialists is essential to ensure best clinical outcomes for patients. The "per rectal" (PR) or "digital rectal exam" (DRE) can be a very difficult diagnostic test for even the most skilled operator to discern pathological versus normal; we propose this is especially the case in the emergency department patient population. Some specialists require this exam performed by an unskilled junior doctor with varying results prior to reviewing a referred and sick patient. The PR/DRE benefits may be limited in the ED setting for some pathologies, and the result of the exam may have limited impact in the overall treatment plan in the ED. CONCLUSION: This short paper reviews the indications, benefits, shortfalls, and limitations of the PR/DRE in the emergency department setting and offers novel alternatives to maximize best practice, ensure best clinical outcomes for patients, and, to first, do no harm.

Public Health Crisis: the Need for Primary Prevention in Failed and Fragile States.

OBJECTIVE: A new 'normal' in global affairs may be erupting from large global powers to that of non-state actors and proxies committing violence through scaled conflict in a post-Westphalian world generating significant global health policy challenges. Health security of populations are multifactorial and indirectly proportional to war, conflict and disaster. Preventing conflict and avoiding the health vacuum that occurs in war and violence may be best practices for policy makers. This paper considers an approach of applying clinical primary prevention principles to global health policy. METHODS: Brief policy review of current standards and practices in health security in fragile and failed states and prevention; and definitions discussion. A short case study series are presented with best practices, with risk and outcome review. RESULTS: The global balance of power and order may be shifting through geopolitical transference and inadequate action by major global power brokers. Health security in at risk nation-states may be decreasing as a result. CONCLUSION: Small scale conflict with large-scale violence threatens health security and may experience increased incidence and prevalence in fragile and failed states. Preventative policy to resuscitate fragile and failed states and prevent further external and internal shocks may support health and promote a positive feedback loop of further state stability and increased health security. Public health policy shift to mitigate state failure and public health crisis in war and conflict through the basis of primary prevention may provide best practices and maximize health security for at risk populations.

Management of Clinical Stage I Nonseminomatous Germ Cell Testicular Tumors: A 25-year Single-center Experience.

BACKGROUND: Surveillance after orchiectomy alone has become popular in the management of clinical stage I nonseminomatous germ cell testicular tumors (CSI NSGCTT). Efforts to identify patients at high risk of disease progression led to a search for risk factors in CSI NSGCTT. The aim of this study was to analyze a 25-year single-center experience with risk-adapted therapeutic approaches-active surveillance (AS) versus adjuvant chemotherapy (ACT). PATIENTS AND METHODS: From January 1992 to January 2017, a total of 485 patients with CSI NSGCTT were stratified into the AS group (low-risk patients) and the ACT group (high-risk patients). Differences between relapse rates and overall survival rates in these groups were statistically analyzed. RESULTS: In the AS group, relapse occurred in 52 (17.3%) of 301 patients with a median follow-up of 7.2 months (range, 2-86 months). Six (2.0%) patients of this group died, with a median follow-up of 34.3 months (range, 11-102 months). In the ACT group, relapse occurred in 2 (1.1%) of 184 patients with a median follow-up of 56.2 months (range, 42-70 months). One (0.54%) patient died at 139.4 months following orchiectomy. The relapse rate for the AS group was 16.7 times higher than that for the ACT group. The groups did not differ in overall survival. The 3-year overall survival of all patients with CSI NSGCTT was 99.1% (95% confidence interval, 97.7%-99.7%). Three of a total of 7 deaths occurred thereafter. CONCLUSIONS: The policy of AS is recommended only in patients with low-risk CSI NSGCTT.

Public Health Crisis in War and Conflict - Health Security in Aggregate.

OBJECTIVE: Public health status of populations is multifactorial and besides other factors it is linked to war and conflict. Public health crisis can erupt when states go to war or are invaded; health security may be reduced for affected populations. METHODS: This study reviews in aggregate multiple indices of human security, human development and legitimacy of the state in order to describe a predictable global health portrait. RESULTS: Paradigm shift of large global powers to that non-state actors and proxies impact regional influence through scaled conflict and present major global health challenges for policy makers. Small scale conflict with large scale violence threatens health security for at-risk populations. CONCLUSIONS: The paper concludes that health security is directly proportional to state security.

Commentary: expectations for global health program prioritization from a selection of international students studying at a European university.

BACKGROUND: Some university curricula struggle to present evidence-based promotion of global health principles and global health diplomacy within an undergraduate setting. The de facto global health paradigm has experienced significant stress and pressure from epidemics, war and violence, climate change and resource challenges. These stressors may lead to increased morbidity and mortality, in turn requiring medical professionals to play a larger role in global health action across borders. METHODS: In the academic year 2014-2015, an English-speaking international medical school promoted a global health forum with pre-course readings and a pre-attendance quiz. All students from the university were invited to attend and the event was not mandatory. RESULTS: The one-day-event culminated in expert speakers, discussions and a post-event questionnaire to gauge students' reactions and expectations as future physicians regarding the most pressing global health topics. Emphasis was also placed on what future doctors foresee as pressing issues in forthcoming global health policy and programming. This paper is a brief commentary of the Global Health Forum in Prague 2014, and presents novel results from a post-event student questionnaire, with conclusions provided by students on innovative global health policy.

Healthcare system financing and profits: all that glitters is not gold.

The objective of this paper is an analysis of two main attributes of healthcare systems. First of the main attributes is the trend of ever growing expenditures of healthcare systems all across the world. Second attribute is the efficiency of chosen mixed healthcare systems, where mixed system is one which features involvement of both private and public sector. Countries chosen for analysis are USA as the country with high private sector influence on healthcare, France with its mediocre influence and Japan, where the private companies participate in health care but are very strictly regulated by a zero profit rule, and the Czech Republic, where public sector dominates the health care. The result is that the systems with higher influence of the private sector tend to have lesser occupancy, not significantly better performance and higher expenditures. This raise doubts whether the private sector brings anything of value for the patients within the healthcare system. However, more detailed analysis should be carried out to confirm or refuse this hypothesis.

Strikingly different effects of hydrogen bonding on the photodynamics of individual nucleobases in DNA: comparison of guanine and cytosine.

Ab initio surface hopping dynamics calculations were performed to study the photophysical behavior of cytosine and guanine embedded in DNA using a quantum mechanical/molecular mechanics (QM/MM) approach. It was found that the decay rates of photo excited cytosine and guanine were affected in a completely different way by the hydrogen bonding to the DNA environment. In case of cytosine, the geometrical restrictions exerted by the hydrogen bonds did not influence the relaxation time of cytosine significantly due to the generally small cytosine ring puckering required to access the crossing region between excited and ground state. On the contrary, the presence of hydrogen bonds significantly altered the photodynamics of guanine. The analysis of the dynamics indicates that the major contribution to the lifetime changes comes from the interstrand hydrogen bonds. These bonds considerably restricted the out-of-plane motions of the NH(2) group of guanine which are necessary for the ultrafast decay to the ground state. As a result, only a negligible amount of trajectories decayed into the ground state for guanine embedded in DNA within the simulation time of 0.5 ps, while for comparison, the isolated guanine relaxed to the ground state with a lifetime of about 0.22 ps. These examples show that, in addition to phenomena related to electronic interactions between nucleobases, there also exist relatively simple mechanisms in DNA by which the lifetime of a nucleobase is significantly enhanced as compared to the gas phase.

Does stacking restrain the photodynamics of individual nucleobases?

Nonadiabatic photodynamical simulations of 4-aminopyrimidine (4-APy) used as a model for adenine were performed by embedding it between two stacking methyl-guanine (mGua) molecules to determine the effect of spatial restrictions on the ultrafast photodeactivation mechanism of this nucleobase. A hybrid multiconfigurational ab initio/molecular mechanical approach in combination with surface hopping was used. During the dynamics the formation of a significant fraction of intrastrand hydrogen bonding from 4-APy to mGua above and below is observed. These findings show that this type of hydrogen bond may play an important role for the photodynamics within one DNA strand and that it should be of interest even in irregular segments of double stranded nucleic acids structures. The relaxation mechanism of internal conversion to the ground state is dominated by ring puckering, and an overall elongation of the lifetime of the embedded system by approximately 20% as compared to the isolated 4-APy is computed.

Microhydration of guanine...cytosine base pairs, a theoretical Study on the role of water in stability, structure and tautomeric equilibrium.

The potential energy surfaces of guanine...cytosine complexes and microhydrated guanine...cytosine (one and two water molecules) were investigated by the molecular dynamics/quenching method (MD/Q), using the empirical potential Parm94 force field, implemented in the Amber program package. The calculations were conducted for all the possible combinations of the four most stable tautomers of guanine and three of cytosine (covering the canonical forms in both cases). The obtained structures were sorted by their structural motifs into three main groups: planar hydrogen-bonded; stacked; and T-shaped structures. The most stable structures found at the empirical potential energy surfaces were fully reoptimised at the second-order Møller-Plesset perturbation theory as well as using the density functional method with an empirical dispersion term (DFT-D). A combination of the canonical form of guanine and cytosine and canonical cytosine with a guanine tautomer where the hydrogen is switched from position N9 to N7 are energetically preferred in microsolvated systems as well as those without the presence of a solvent. The rising number of water molecules leads to smaller differences between the stability of the various combinations of the tautomers of bases in the base pairs. For some of the tautomer combinations (mainly the enol-enol combination), two water molecules are sufficient for the preference of stacked structures over the H-bonded ones. The interaction energies and geometries obtained by the second-order Møller-Plesset perturbation theory method and the much less computationally demanding DFT-D method are comparable, except for stacked complexes, where the interaction energies are overestimated on average by 3 kcal mol(-1) at the MP2 level.