BMJ Publishing Group Research Articles

SPONTANEOUS PNEUMOTHORAX SECONDARY TO VAPING

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Over the past decade the use of e-cigarettes has risen dramatically, particularly among teenagers. They have been proven to cause lung injury and hypoxic respiratory failure. A less commonly studied pulmonary effect of vaping is significant bullous disease with the potential to cause a spontaneous pneumothorax. CASE PRESENTATION: This is a 22 year-old male with no significant medical history presented due to sudden onset left-sided pleuritic chest pain that was unprovoked and associated with dyspnea. He smokes 1 joule every 4 days and has been smoking for 4 years. On arrival, he was found to be tachycardic and appeared uncomfortable. Electrocardiogram showed normal sinus rhythm. Computed tomography was done and revealed a large left sided pneumothorax and left lung collapse. He had a chest tube placed to suction with improvement in his symptoms. Repeat chest radiography showed significant improvement in the pneumothorax with a small apical left sided pneumothorax.The chest tube remained to suction with a continuous leak observed without resolution of the apical pneumothorax that remained stable in size. On day 8 of hospitalization, he underwent a video-assisted thoracoscopic surgery (VATS) with left upper lobe wedge resection and talc pleurodesis. A new chest tube was placed intra operatively and repeat chest radiography showed resolution of the pneumothorax with no air leak observed. Intra operative findings were suggestive of significant bullous lung disease with blebs. On day 11, the chest tube was removed successfully without recurrence of pneumothorax. He was discharged home breathing comfortably on room air. DISCUSSION: E-cigarettes contain propylene glycol and vegetable glycerin, which decompose when exposed to high temperatures generating harmful carbonyl compounds. These compounds have been shown to cause oxidative stress and release of inflammatory markers causing airway epithelial injury and impaired gas exchange. The addition of flavoring agents further causes epithelial injury and reduction in ciliary beat frequency leading to decreased mucociliary clearance and increased colonization. The indications for VATS include recurrent pneumothoraces, large bullae, incomplete expansion of the lung, and bilateral involvement. VATS has been associated with decreased hospital length of stay and rehabilitation time. CONCLUSIONS: This case highlights the need for thorough exposure history in patients with an unclear etiology for respiratory symptoms, particularly among young adults. Early recognition of candidates for VATS also leads to improved outcomes. Vaping has been associated with bullous disease, although there have not been many cases of rapidly progressing bullous disease causing pneumothorax. REFERENCE #1: Fuentes, X Fonesca, et al. "VpALI-Vaping-Related Acute Lung Injury: A New Killer Around the Block." Mayo Clinic Proceedings, U.S. National Library of Medicine, 22 Nov. 2019 REFERENCE #2: Kalra, Saminder Singh, et al. "Rapid Development of Bullous Lung Disease: a Complication of Electronic Cigarette Use." Thorax, BMJ Publishing Group Ltd, 1 Apr. 2020 REFERENCE #3: Paliouras, Dimitrios, et al. "Video-Assisted Thoracic Surgery and Pneumothorax." Journal of Thoracic Disease, AME Publishing Company, 7 Feb. 2015 DISCLOSURES: No relevant relationships by Nourhan Kika, source=Web Response No relevant relationships by Nisha Patel, source=Web Response No relevant relationships by Anthony Saleh, source=Web Response

Direct Carotid Puncture for Emergent Thrombectomy: 2-Dimensional Operative Video.

Emergent thrombectomy for large vessel occlusion is now a standard procedure within neurosurgery. In general, thrombectomy is attempted via a femoral artery puncture. However, due to anatomic variability and arterial tortuosity, target vessels cannot be catheterized in roughly 5% of patients.1 Radial artery access is an alternative to femoral artery access; however, target arteries for thrombectomy cannot be catheterized via the femoral or radial arteries in a small subset of patients. Direct carotid puncture is an alternative route of access for emergent thrombectomy in acute stroke.2,3 In this video, we present a patient with an acute right middle cerebral artery occlusion who was taken for emergent thrombectomy after consenting for the procedure. Because of unfavorable arterial anatomy, the right internal carotid artery could not be successfully catheterized via femoral or radial arterial punctures. We ultimately catheterized the right internal carotid artery and middle cerebral artery via a direct carotid puncture. We review the technique for direct carotid puncture, and discuss the outcomes associated with this method of access in the setting of acute large vessel occlusion. We also discuss complications associated with direct carotid puncture. Direct carotid puncture is an acceptable bail-out technique in the setting of emergent thrombectomy when femoral and/or radial access is not possible. Figure at 2:18 republished from Sekhar LN, Iwai Y, Wright DC, Bloom M. Vein graft replacement of the middle cerebral artery after unsuccessful embolectomy: case report. Neurosurgery. 1993;33(4):723-727, by permission of the Congress of Neurological Surgeons. Table at 6:05 modified from Roche A, Griffin E, Looby S, et al. Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke. J NeuroIntervent Surg. 2019;11(7):647-652, ©The Authors, 2019, with permission from Dr Sarah Power. Table at 6:22 reproduced from Jadkhav AP, Ribo M, Grandhi R, et al. Transcervical access in acute ischemic stroke. J NeuroIntervent Surg. 2014:6(9):652-657, ©2013, with permission from the BMJ Publishing Group Ltd.

Twenty-five years ago

The first issue of Injury Prevention appeared in March 1995. Its birth followed a tough gestation, but with the support of Alex Williamson and the blessings of Richard Smith, the...

Psychiatric experience with perpetrators.

Reprinted from: Lansen, J. (1991). Psychiatric experience with perpetrators and countertransference feelings in the therapist. Journal of Medical Ethics, 17(Suppl), 55-57. doi: https:/doi.org/10.1136/jme.17.suppl.55 © 1991 BMJ Publishing Group Ltd and Institute of Medical Ethics. All rights reserved.

成人院外心停止患者に対する病院前の高度な気道確保：全国救急蘇生統計コホート研究(Pre–hospital advanced airway management for adults with out–of–hospital cardiac arrest: nationwide cohort study)

要旨【目的】院外心停止患者に対する病院前の高度な気道確保は不良な生存・神経学的アウトカムと関連することが，これまでの多くの観察研究で報告されてきた。成人院外心停止患者に対する病院前の高度な気道確保と生存との関連を明らかにすることを目的として本研究を行った。【対象】2014年1月から2016年12月までの本邦の全国救急蘇生統計（ウツタインデータ）を対象に，連続登録された院外心停止成人症例について，心電図の初回記録をもとに「電気ショック適応（心室細動または無脈性心室頻拍）」および「電気ショック非適応（無脈性電気活動または心静止）」の2つのサブコホートに分類した。時間依存性傾向スコアに基づいて同一時点（分）で心肺蘇生時処置として高度な気道確保を受けた患者と高度な気道確保を受けていない患者とを連続的にマッチングさせた。1か月後または1か月以内の退院時の生存割合を主要アウトカムとした。【結果】適格患者310,620名のうち，電気ショック適応群の患者20,516名中8,459名（41.2%）および電気ショック非適応群の患者290,104名中121,890名（42.0%）が心肺蘇生時に高度な気道確保を受けた。時間依存性傾向スコアによる連続マッチングを行った後，電気ショック適応群の患者16,114名および電気ショック非適応群の患者236,042名を同一時点（分）でそれぞれマッチングさせた。電気ショック適応群では，高度な気道確保を受けた患者と受けなかった患者の間で生存割合に差はみられず，それぞれ8,057名中1,546名（19.2%）および8,057名中1,500名（18.6%）であった（調整リスク比1.00，95%信頼区間0.93–1.07）。電気ショック非適応群では，高度な気道確保を受けた患者は受けなかった患者よりも生存割合が高く，それぞれ118,021名中2,696名（2.3%）および118,021名中2,127名（1.8%）であった（調整リスク比1.27，1.20–1.35）。【結論】成人院外心停止患者における時間依存性傾向スコア連続マッチング解析において，電気ショック適応リズムの患者では高度な気道確保と生存に関連がなかったのに対し，電気ショック非適応リズムの患者では高度な気道確保は生存と関連した。

Role of supplementary material in biomedical journal articles: surveys of authors, reviewers and readers

ObjectiveMany journals permit authors to submit supplementary material for publication alongside the article. We explore the value, use and role of this material in biomedical journal articles from the perspectives...

IN THIS ISSUE

We are delighted to announce that the Shanghai Archives of Psychiatry will be changing its name to General Psychiatry and will be published by the BMJ Publishing Group in 2018. These changes will serve important steps for the journal to become a truly international platform for eastern and western mental health professionals to exchange new research findings and service developments. We believe it will increase the degree of recognition and influence of the journal at internationally, and increase China’s voice in the world’s psychiatric field

Should we recommend e-cigarettes to help smokers quit?

© Published by the BMJ Publishing Group Limited. Smokers want to vape, it can help them quit, and it's less harmful than smoking, say Paul Aveyard and Deborah Arnott. But...

IN THIS ISSUE

We are delighted to announce that Shanghai Archives of Psychiatry will be published by BMJ Publishing Group as of mid 2018. BMJ is an international publisher of medical publications. This change will work as an important step for the journal to become a truly international platform for eastern and western mental health professionals to exchange new research findings and service developments.The current management team of the journal are keen to work in partnership with BMJ to further build the journal to be strong and impactful for international audiences. For more upcoming change information, please refer to the official website of our journal (www.shanghaiarchivesofpsychiatry.org) and the announcement of BMJ official website in future.

PWE-062 Fructose Intolerance in Pelvic Radiation Disease; Is It More Common than We Realised?

Introduction Guidelines have recently been published regarding the management of Pelvic Radiation Disease (PRD) and late effects of cancer care. 1 The guidelines have been shown in peer reviewed studies to be effective in the management of PRD. 2 The guidelines include a number of investigations for certain symptoms and include carbohydrate tolerance tests for substrates such as fructose. That said there are currently no published case series or studies evaluating the prevalence and diagnostic yield of fructose breath testing in PRD. We have recently set up a dedicated late effects of cancer care and pelvic radiation disease clinic in Cardiff and audited the results of our fructose tolerance breath tests. Patients with diarrhoea, bloating or abdominal pain were investigated with fructose breath testing as per these guidelines. Methods We audited the results for all fructose breath tests in 2014 in patients with suspected PRD via a database search and correlation with clinical notes. Total of 82 patients were identified as having a fructose breath tests in the 1 year period) 20 of which were being investigated for suspected PRD. (10 Male, 10 female, median age 65.5) Results 45% of fructose breath tests in patients with suspected PRD were positive (n = 9) All of these patients were referred with either diarrhoea, bloating or abdominal pain. Of these patients with positive tests, 44% were found to have a dual pathology (n = 4) with other diagnoses including small intestinal bacterial overgrowth, lactose intolerance and bile acid diarrhoea. Conclusion Fructose intolerance is common in patients with diarrhoea, bloating and abdominal pain in PRD. The diagnostic yield of testing is high and should be considered as a differential diagnosis in these patients. It is important to recognise that dual pathology frequently occurs and that an algorithmic approach is useful in these patients. References 1 Andreyev HJN, Muls AC, Norton C, Ralph C, Watson L, Shaw C, et al . Guidance: The practical management of the gastrointestinal symptoms of pelvic radiation disease. Frontline Gastroenterology [Internet]. BMJ Publishing Group Ltd; 2014 Jun 17;flgastro–2014–100468. Available from: http://fg.bmj.com/content/early/2014/06/17/flgastro-2014-100468.abstract 2 Andreyev HJN, Benton BE, Lalji A, Norton PC, Kabir M, GaugeGage PH, et al . ArticlesAlgorithm-based management of patients with gastrointestinal symptoms in patients after pelvic radiation treatment (ORBIT): a randomised controlled trial. Lancet. Elsevier Ltd; 2013 Sep 20;1–9. Disclosure of Interest None Declared

BJOG Editors‐in‐chief since 1902

Charles James Cullingworth was born in Leeds in 1841. His father was a businessman who sent Charles to Wesley College in Sheffield, where he passed the matriculation examination of the University of London in 1858. After helping his father for several years with a view to becoming a lawyer, his father died, and Charles was able to sell the business and change to a medical career. He was initially apprenticed to a general practitioner while attending a course at the Leeds School of Medicine, qualifying as a member of the Royal College of Surgeons in 1865. After 18 months in general practice, he was elected resident physician assistant at the Manchester Royal Infirmary, and was so efficient that he took over the substantive post within weeks. In 1872, needing an improved income, he took up the post of Police Surgeon in Manchester, which he then held until 1882, meanwhile becoming a member of the Royal College of Physicians of London. In 1873, he was also appointed surgeon to St Mary's Hospital for Women in Manchester. Wanting to develop an academic component to his police work, in 1879 he was appointed lecturer in medical jurisprudence at Owens College (founded in 1851, subsequently merging with the federal Victoria University, which in 1903–4 split into the Universities of Manchester, Leeds, and Liverpool) and took a Doctor of Medicine (MD) degree at Durham University. Because of his interests in obstetrics and gynaecology, he was appointed to the chair of obstetric medicine at Owens College in 1885. While in Manchester, he was honorary librarian and secretary to the Manchester Medical Society. Having developed a large and lucrative private practice, and established himself as a senior academic within the North of England, in 1888 he was persuaded to take up the post of obstetric physician to St Thomas’ Hospital in London. It was here that he did his most important research, studying the pathology of pelvic inflammation, and its relationship with ectopic pregnancy. He published his book ‘Diseases of the Fallopian Tubes’ in 1895. He championed the admission of women to the medical register, the registration and training of midwives, and popularised the work of Oliver Wendell Holmes on puerperal fever (Holmes, like Semmelweiss, attributed it to inadequate antisepsis). He wrote many papers in major medical journals, and was fond of quoting Tennyson and Browning. A keen supporter of the establishment of our journal, it was entirely appropriate for him to become editor in 1906, although he had by then already been suffering angina for 6 years. He died of a heart attack in May 1908. Happily married to Emily Mary Freeman, with one daughter, he was widely liked and admired by his colleagues for being a ‘willing slave to the dictates of his conscience’. In a letter to the Debating Society at Leeds, he declared that only putting the patients’ needs above financial considerations could ‘raise the medical life out of the category of the sordid and self-seeking into that of the unselfish and ennobling’. Philip Steer is Emeritus Editor, BJOG. For a full disclosure of interests, please go to www.BJOG.org. Photo source: reproduced from BMJ, 1908;1:1269 with permission from BMJ Publishing Group Ltd.

Neurovascular coupling during cortical spreading depolarization and -depression.

Cortical spreading depolarizations (CSDs) are self-propagating waves of transient loss of neuronal transmembrane ion gradients, followed by prolonged suppression of neuronal activity (spreading depression). CSDs emerge spontaneously in animal models of traumatic brain injury,1 subarachnoid hemorrhage,2 and in focal ischemia3 where they are associated with infarct growth.4 In humans, CSDs have been demonstrated in traumatic brain injury,5 subarachnoid hemorrhage,6,7 and malignant hemispheric stroke,8 and they are believed to be the brain mechanism underlying migraine aura.9 CSDs are associated with dramatic changes in cerebral blood flow (CBF). During the depolarization phase of CSDs induced in healthy and well-perfused brain tissue in animal models, an early hyperemic response is observed, typically followed by prolonged oligemia after the neuronal repolarization. Despite the initial CBF increase, tissue hypoxia may develop in more distant territories of capillary supply.10,11 Similar CBF changes have been observed in patients with migraine aura.12–14 In the injured brain, CSDs can be accompanied by severe initial CBF reduction instead of a CBF increase during the depolarization phase, termed spreading ischemia.15 When this inverse hemodynamic response is observed, the energy-dependent recovery from CSD is delayed in a characteristic fashion, indicating a severe mismatch between oxygen supply and demand2 and a high risk of tissue damage.16 In rat and cat models of focal ischemia, CSD-related CBF transients range from monophasic, positive CBF responses in peri-ischemic tissue, over biphasic transients in mildly ischemic tissue, to negative CBF transients in more severe ischemia.17–19 During CSD in animal models, capillary flow patterns become severely disturbed.10,20,21 The passage of a CSD causes erythrocytes in some capillaries to reduce their speed, whereas other capillaries reveal 4-fold increases in flow or higher. …

PA.31 Midwives views of the implementation of the Birmingham Symptom-specific Obstetric Triage System (BSOTS)

BackgroundThe need to develop a standardised triage system to prioritise clinical urgency of women when unscheduled pregnancy related attendances occur has been identified.1 We have developed, implemented and evaluated a...

PA.09 Evaluation of the implementation of the Birmingham Symptom-specific Obstetric Triage System (BSOTS)

BackgroundConfidential Enquiries1 and local audit have identified the need to develop a standardised triage system to prioritise clinical urgency of women when unscheduled pregnancy related attendances occur. We have developed,...

Myocardial Clefts, Crypts, or Crevices

With the increasing accuracy of cardiac imaging techniques, new findings, not or rarely observed before, come to light. In particular, the improvement in high spatial resolution of a multiplanar imaging technique such as cardiac magnetic resonance (CMR), associated with its increased contrast between blood and endocardial border surface of current cine images, led the appreciation of subtle left ventricular (LV) wall structural features, not seen or neglected by 2-dimensional echocardiography. This is the case of myocardial clefts, described both in hypertrophic cardiomyopathy (HCM) and in healthy volunteers, thus providing another hot potato to the hands of the clinical cardiologist. Article see p 259 These myocardial invaginations have been variably called clefts, crypts, fissures, crevices, and atypical LV noncompaction. Although the etiopathogenesis remains a matter of debate, it is a common belief that they represent a failure to resorb the trabeculated part of ventricular wall during normal embryological development, as seen in isolated LV noncompaction.1,2 Before the development of coronary circulation, the myocardium consists of a spongy meshwork of interwoven myocardial fibers organized into trabeculae with deep recesses, the latter communicating with the LV cavity and enabling a direct blood supply to the myocardium. Myocardial crypts have been described within the LV wall of patients with HCM since early postmortem studies.3–5 In particular, to the best of our knowledge, the first pathological description of a myocardial cleft dates back to 1958, in the historical publication of Donald Teare.3 Noteworthy, Teare …

SAT0025 The Association Serum Interleukin 17 and Interleukin 23 Levels with Clinical and Radiological Parameters in Rheumatoid Arthritis Patients

BackgroundRheumatoid arthritis (RA) is a chronic, inflammatory disease which causes symmetrical destructive changes in diartrodial synovial joints (1). Cytokines play an important role in RA pathogenesis. Th 17 cells are...

Alternative metrics for measuring the quality of articles and journals.

Alternative metrics for measuring the quality of articles and journals.

Medical education: what the West could learn from Africa

Medical EducationVolume 46, Issue 3 p. 336-336 letters to the editor Medical education: what the West could learn from Africa Kieran Walsh, Kieran Walsh BMJ Publishing Group, BMJ Learning, London, UKSearch for more papers by this author Kieran Walsh, Kieran Walsh BMJ Publishing Group, BMJ Learning, London, UKSearch for more papers by this author First published: 10 February 2012 https://doi.org/10.1111/j.1365-2923.2011.04172.x Kieran Walsh, BMJ Publishing Group, BMJ Learning, 8 Elmhurst Villas, London SE15 3AE, UK. Tel: 00 44 207 383 6550; Fax: 00 44 207 383 6242; E-mail: kmwalsh@bmjgroup.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume46, Issue3March 2012Pages 336-336 RelatedInformation

Sequential testing: costs and cost savings may be greater

Medical EducationVolume 45, Issue 12 p. 1262-1262 letter to the editor Sequential testing: costs and cost savings may be greater Kieran Walsh, Kieran Walsh BMJ Publishing Group, BMJ Learning, London, UKSearch for more papers by this author Kieran Walsh, Kieran Walsh BMJ Publishing Group, BMJ Learning, London, UKSearch for more papers by this author First published: 29 November 2011 https://doi.org/10.1111/j.1365-2923.2011.04082.xCitations: 2 Dr Kieran Walsh, BMJ Publishing Group, BMJ Learning, 8 Elmhurst Villas, London SE15 3AE, UK. Tel: 00 44 207 383 6550; Fax: 00 44 207 383 6242; E-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume45, Issue12December 2011Pages 1262-1262 RelatedInformation

Campaign to Revitalise Academic Medicine Kicks Off: We Need a Deep and Broad International Debate to Begin

The BMJ and a range of partners, including other journals published by the BMJ Publishing Group, the Lancet, Canadian Medical Association Journal, Dutch Journal of Medicine, Medical Journal of Australia, Croatian Medical Journal, the Academy of Medical Sciences, and many others have initiated a project to bring people together to debate whether the existing structure of academic medicine is still fundamentally sound and, if not, to propose alternatives to it. (1) I have taken on the challenge of coordinating this project, and I invite readers to join me in this enterprise. To achieve the project's broad goals (box 1) we begin from the position that "more of the same" is not enough. We need to be free to propose radical changes to the fundamental nature of academic medicine (is the balance between bench and applied research all wrong?); its name (should it become "academic health care" or should we drop "academic"?); its home base (are hospitals the wrong place to train doctors?); its relation to service (why are they so often far apart?); its methods of training and certification (should medical education be lecture based and far shorter?); and its responsibilities (should it be held accountable for inequities in health care at the global level?). Our approach will be inclusive and is designed to ensure a broad input of opinions. Rather than allowing the process to be taken over by a few experts with vested interests, we will build consensus by inviting a range of global stakeholders to contribute their views. We are especially interested in the views of the "customers" of academic medicine--patients, politicians, the public. Anyone can contribute their views right now, as a rapid response to this article at bmj.com In addition, our project web page is under development (www.bmj.com/academicmedicine), and this will contain regular updates, news, and collected resources. Box 1. Goals of the project Development of strategy on the following issues: * How should academic medicine look in the 21st century * How can we increase the impact of academic medicine on the rest of medicine and on health and health care * How should academic medicine be positioned internationally within medicine and also in the wider intellectual arena * How can recruitment to and job satisfaction of those working in academic medicine be increased Box 2. Four advisory groups * Perspectives forum--patients, health professionals, government representatives, and medical unions * Ad hoc consultants--providing systematic reviews and other factual summaries about the efficacy of different educational, organisational, and administrative approaches, and trends in human resources in academic medicine * Communications consortium--disseminating surveys, drafts, and reports to everybody who is joined up to the campaign or may want to give input * International advisory panels--deans and chairs whose support could help establish funding, profile, and implementation; also used as an ongoing sounding board The proposed structure is as follows. …