Memorable Patient Research Articles

Moral Distress and its Impact on Healthcare Workers in a European NICU

In a qualitative study of 15 NICU workers in a large European NICU, the author asks the subjects to consider what sorts of work environments are likely to result in moral distress and whether support by colleagues, administrators, the institution itself and even perceived societal support may reduce some kinds of moral distress. The majority of providers felt that the support of colleagues was essential; there was some disagreement about whether the larger community was aware of the nature of the work done in NICUs by health workers. These healthcare providers were also asked about memorable patient encounters.

Not a dull moment

Having now become an NQP2, Katy Sofield reflects on her journey since joining the London Ambulance Service and shares her most memorable recent patient experiences

The influence of supervisory support on clinical learning as experienced by Czech Nursing and health professional students in the context of patient safety events: A qualitative study

AimTo explore the influence of supervisory and mentoring relationships on the clinical learning experiences of Czech Nursing and health professional students in the context of patient safety events BackgroundClinical experience is integral to healthcare education, shaping skills, behaviours, values and professional identity. During clinical placements, students may encounter memorable patient safety events and experience varied reactions from mentors/supervisors/others. Some research has highlighted challenges faced by students on clinical placement. Few studies involve multiple professions, most emanating from Western Europe, the UK, the USA and Australia with little relating to central European countries such as the Czech Republic. DesignTwo stage interpretivist qualitative study based in social constructionism MethodsConvenience sample across 13 undergraduate and 18 postgraduate health professions courses. Stage 1 (2022): using SLIPPS Learning Event Recording Tool translated into Czech. 20 students’ (Midwifery=11, Nursing=1, Paramedic=1, Occupational therapy =7) submitted 21 patient safety learning event narratives. Stage 2 (2022): Focus group with 2 nursing and nine midwifery students. Phased thematic analysis involving multiple researchers. ResultsThree themes illustrate the circumstances and impact of placement mentoring/supervision experiences, conceptualised as: ‘Clinical and Emotional Companionship’, ‘Clinical and Emotional Abandonment’ and ‘Sense of agency - Professional and personal growth’. ‘Companionship’ reflected the students’ feelings of being welcomed, respected, heard, trusted and supported. Conversely ‘abandonment’ emerged from feelings of being unheard, vulnerable, humiliated, afraid, leaving students feeling abandoned, lonely and ‘useless’. Notwithstanding these conditions, students showed the ability to identify patient safety issues with agency evident in reactions such as stepping-in to try to ameliorate a situation, rather than speaking-up. Professional and personal growth was also apparent in their narratives and a conceptual diagram illustrates the students’ learning journeys in a patient safety context. ConclusionThe findings and new conceptualisations around abandonment and companionship emerging from this study expand the evidence base regarding the profound impact of clinical experience and mentorship/supervision on learning and students’ emotional wellbeing. A sense of companionship appears to play a buffering role even in challenging circumstances of involvement in or witnessing compromised patients’ safety. Allowing students a sense of belonging, to vent, grow, feel supported and safe to ask/learn - contributing to ‘emotional safety for learning’, promotes students’ behaviour that may prevent/minimize hazards or ameliorate the aftermath. However, we must not simply blame mentors/supervisors, staff, or the students themselves- they are simply part of a much larger complex environment of professional education encompassing hidden curriculums, power dynamics and professional socialisation.

Identifying factors that nurses consider in the decision-making process related to patient care during the COVID-19 pandemic.

BackgroundNurse identification of patient deterioration is critical, particularly during the COVID-19 pandemic, as patients can deteriorate quickly. While the literature has shown that nurses rely on intuition to make decisions, there is limited information on what sources of data experienced nurses utilize to inform their intuition. The objectives of this study were to identify sources of data that inform nurse decision-making related to recognition of deteriorating patients, and explore how COVID-19 has impacted nurse decision-making.MethodsIn this qualitative study, experienced nurses voluntarily participated in focused interviews. During focused interviews, expert nurses were asked to share descriptions of memorable patient encounters, and questions were posed to facilitate reflections on thoughts and actions that hindered or helped their decision-making. They were also asked to consider the impact of COVID-19 on nursing and decision-making. Interviews were transcribed verbatim, study team members reviewed transcripts and coded responses, and organized key findings into themes.ResultsSeveral themes related to decision-making were identified by the research team, including: identifying patient care needs, workload management, and reflecting on missed care opportunities to inform learning. Participants (n = 10) also indicated that COVID-19 presented a number of unique barriers to nurse decision-making.ConclusionsFindings from this study indicate that experienced nurses utilize several sources of information to inform their intuition. It is apparent that the demands on nurses in response to pandemics are heightened. Decision-making themes drawn from participants’ experiences can to assist nurse educators for training nursing students on decision-making for deteriorating patients and how to manage the potential barriers (e.g., resource constraints, lack of family) associated with caring for patients during these challenging times prior to encountering these issues in the clinical environment. Nurse practice can utilize these findings to increase awareness among experienced nurses on recognizing how pandemic situations can impact to their decision-making capability.

The Patient Experience Debrief Interview: How Conversations With Hospitalized Families Influence Medical Student Learning and Reflection.

To determine the effect of patient debrief interviews on pediatric clerkship student depth of reflection and learning. The authors conducted a multi-institutional, mixed-methods, cluster randomized trial among pediatric clerkship students from May 2016 to February 2017. Intervention students completed a debrief interview with a patient-caregiver, followed by a written reflection on the experience. Control students completed a written reflection on a memorable patient encounter. Three blinded authors scored written reflections according to the 4-level REFLECT rubric to determine depth of reflection. Interrater reliability was examined using kappa. REFLECT scores were analyzed using a chi-square test; essays were analyzed using content analysis. Eighty percent of eligible students participated. One hundred eighty-nine essays (89 control, 100 intervention) were scored. Thirty-seven percent of the control group attained reflection and critical reflection, the 2 highest levels of reflection, compared with 71% of the intervention group; 2% of the control group attained critical reflection, the highest level, compared with 31% of the intervention group (χ(3, N = 189) = 33.9, P < .001). Seven themes were seen across both groups, 3 focused on physician practice and 4 focused on patients. Patient-centered themes were more common in the intervention group, whereas physician-focused themes were more common in the control group. Patient debrief interviews offer a unique approach to deepen self-reflection through direct dialogue and exploration of patient-caregiver experiences during hospitalization.

Physicians\u2019 perspectives on the treatment of patients with eating disorders in the acute setting

BackgroundHospitalisation for an eating disorder is rare, however treatment in the acute medical setting can be a life-saving admission. While the multidisciplinary team delivers overall patient care, medical decisions are the responsibility of the treating physicians. Treatment decisions directly impact on patient care and outcomes. This study aimed to explore the considerations that influence the medical decisions of physicians when treating patients with eating disorders in the acute setting.MethodSemi-structured interviews were conducted with ten medical physicians who had previously treated eating disorders on a general medical unit in two Australian tertiary hospitals. An interview schedule, based on the literature and four relevant domains from the Consolidated Framework for Implementation Research, was developed. Interviews were audio recorded, transcribed verbatim and analyzed thematically. Coding and interim themes and sub-themes were developed by two dietitian researchers; these were further refined through researcher discussion and triangulation with two additional dietitian researchers.ResultsTen doctors were interviewed (3 consultants (1 adult general medical and 2 paediatricians: 13–16 years medical experience), 2 registrars (4–7 years experience), 1 resident (1 year experience), and 4 interns (< 1 year experience). Doctors described memorable patient cases, related to hospital stays over several weeks. Interviews ranged in length from 58 min to 91 min. Four themes (with five sub-themes) were developed: 1) navigating uncertainty (focusing on processes and goals and seeking information), 2) being “the good doctor” (doing the right thing), 3) seeing the big picture (depending on key players and considering short and long-term), and 4) involving family and patient.ConclusionsNon-specialist physicians described challenges in the treatment of eating disorders in the inpatient setting. They take a holistic approach that considers both short and longer-term goals, relying on specialist colleagues, the wider multidisciplinary team and sometimes family members to guide treatment decisions during admissions on general medical wards. Additional support, education and training centered on the key themes may increase physicians’ confidence and ability to make effective treatment decisions for this patient group. The results are relevant to all health professionals working in this field to better understand the priorities of medical physicians and to support them to achieve positive outcomes in the inpatient treatment of patients with eating disorders.

Hospital doctors' experiences of caring for dying patients.

The aim of this study was to examine, by means of a postal questionnaire, the experience of all grades of doctors caring for patients dying in an acute hospital in Scotland. A postal questionnaire was sent to 306 doctors working in inpatient medical and surgical specialties, emergency medicine, anaesthetics and intensive care medicine in an acute hospital. There was an overall 41% response rate (127/306). Of responding doctors 55% had cared for 10 or more patients in the previous year. A quarter of respondents had personal experience of bereavement outside of clinical practice within the previous year. A total of 65% of responding doctors agreed that their most memorable patient death had had a strong emotional impact upon them. Responding doctors reported benefit from peer support. There was no association between length of time as a doctor and difficulty rating for talking to patients about death (p-value: 0.203). There was no association between difficulty rating and length of time working as a doctor when talking to relatives about death and dying (p-value: 0.205). We considered the questionnaire responses in relation to Scottish Government policy and initiatives associated with the care of the dying, and the future training and support of doctors caring for this group of patients and their relatives. Doctors describe similar experiences in terms of communication difficulties and emotional effects of caring for dying patients irrespective of their length of time working as a doctor.

Ronald W. Busuttil, MD, PhD: William P. Longmire, Jr, Chair of Surgery, Chief of Liver and Pancreas Transplantation, Director, UCLA-Dumont Transplant & Liver Cancer Center.

Ronald W. Busuttil, MD, PhD: William P. Longmire, Jr, Chair of Surgery, Chief of Liver and Pancreas Transplantation, Director, UCLA-Dumont Transplant & Liver Cancer Center.

From a Single Child to Uniform Newborn Screening: My Lucky Life in Pediatric Medical Genetics.

Mike, a memorable young patient with untreated phenylketonuria, as well as others affected by genetic disorders that could be treated if diagnosed in infancy, launched my six-decade career. This autobiographical article reflects on my childhood, early research, and professional experiences in pediatric genetics. My laboratory research focused on inborn errors of metabolism, including the glycogen storage diseases. My effort to organize newborn screening through the recommended uniform screening panel shaped and standardized newborn screening nationwide. Looking ahead, the expansion of whole-genome and whole-exome sequencing into newborn screening raises ethical and policy issues regarding informed consent procedures and the storage and use of residual blood spots.

Tears for the City: The Biblical Basis for Population-Focused Nursing.

Most nurses can describe a memorable patient, one who moved them deeply, and one who made them remember why they chose nursing as a calling. Thinking of a population with an emotional connection is usually more difficult. Current nursing practice includes the ability to serve a population or community as client. This article describes core functions of public health-assessment, policy development, and assurance, while offering biblical resources the Christian nurse has to consider a population with the same compassion as one does an individual.

Trauma International – Truly New, Truly International

Trauma is one of the most basic faculty of medicine and treatment of injured is the oldest known speciality. The burden of trauma in immense and with current technological developments road traffic accidents and industrial accidents present with varied patient profiles. There is always a need for personalised care which also depends on the expertise of the surgeon involved. The infrastructure and facilities for trauma care also vary across the world and many practices are modified according to local needs. Care of the injured involves orthopaedic surgeon, general surgeon, plastic surgeon and occasionally vascular surgeon, neurosurgeon and other allied faculties. Multispecialty collaboration is needed for successful treatment of any trauma scenario. The entire point of the first paragraph is that trauma surgery is a very multifaceted speciality and involves complex decision making and requires equally complex specialities to be symbiotic. The same should reflect in the Trauma literature and this is the basic aim of starting the new journal. Trauma International is primarily a journal of Orthopaedic trauma and surgery, but it will also provide platform for all specialities involved in trauma care. Many a times while reading a journal we feel that many articles are almost irrelevant as far as practical patient care is concerned. There are many articles that wouldd focus on statistical or analytic part more than the actual clinical relevance of the study. Trauma International will focus on publishing most clinically relevant articles that will be useful in day to day clinical practice. The format of the articles will be easy to read with clinical relevance highlighted separately. Editors will be frequently commenting on the articles and will be clarifying any difficult issues that they feel require simplification . Readers will be allowed to comment online as well as through letter to editor channel. On other hand we will be including formats like technique videos, tips and tricks, innovations, most memorable patient etc where surgeons would be encouraged to share their experience and also help other learn from their experiences. The whole exercise is to provide the reader something that they can interact with and not something dead and unresponsive. Only participation from the readers and surgeon community can help us realise this dream There exists a lot of resistance especially from the surgeons from publications. This resistance is mostly because they are not familiar with the format of articles and submission process. Trauma international will be providing few solutions to overcome this resistance and encourage surgeons to publish. Firstly, as mentioned earlier we will be keeping simple formats of article submission which will be easy for beginners to write. Secondly, we have a collaboration with the orthopaedic research group and they have taken up the responsibility to guide the authors in terms of writing manuscript. This will be helpful, especially to authors who do not have English as their first language. The process will involve review and revision of primary draft and also help in formatting article as per journal guidelines. Thirdly along with Trauma International we are also launching a dedicated Journal of Trauma and Injury Case Reports. This journal will focus on providing platform to first time authors . This will be done through a special peer review process we call as ‘assistive peer review’. Here the along with providing the review, the reviewers will also suggest and correct the manuscript at most places. This will help the authors understand their errors and also help them learn methods used to correct the errors. This Assistive Peer Review will also be provided for Trauma International. We believe these initiatives will help trauma surgeons to publish more and participate in creating a global literature. Trauma International has received great support especially from the international community and we are proud to say that members of more than 40 countries have joined the Editorial board of Trauma International. This makes the journal a truly international journal. Since trauma is one of the most widespread practiced branch, we will be including more members till we have at least one member form each country in the world. This will help us collaborate and learn from each other in much better ways. We would like to thank all our contributors of the first issue. Special thanks to Dr DD Tanna for sharing his life experiences with us and letting us know about his journey as a trauma surgeon. I think we have promised a lot in this opening editorial but then we are equally passionate about holding ourselves to every promise that we made here. We invite suggestions and also invite you all to participate actively with the journal. With this we leave you to enjoy the issue. Dr Ashok Shyam Editor – Trauma International

Experiencing patient death in clinical practice: Nurses’ recollections of their earliest memorable patient death

BackgroundDeath and dying are inevitable life encounters, but a nurse's first experience with patient death may pose considerable cognitive, emotional and clinical challenges. This paper reports the findings of the second phase of a study; the first has been reported elsewhere. This phase explored the earliest memorable patient death experiences of New Zealand registered nurses. MethodA purposeful, self-selected sub-sample of a larger study of New Zealand registered nurses, took part in individual face-to-face semi-structured interviews. Interpretative phenomenological analysis was utilised to seek to understand participants’ experiences. Thematic analysis was undertaken to identify emerging themes, with participants’ own words used as theme headings, where their phrases provided succinct or powerful descriptors. ResultsA diverse participant group of twenty, currently practising, New Zealand registered nurses provided rich and detailed descriptions of their earliest memorable experience with patient death. Participants from a variety of training backgrounds described patient deaths, which occurred in a range of settings – some only a few months prior, others – more than thirty years ago. Seven emergent themes, and features of more positive, or negative experiences were identified: Event Significance; Emotional Challenges; Sharing the Experience; Learning; Feeling Unprepared, Responses to Death and Finding Benefits. ConclusionFor participants in this study, there was considerable evidence that their earliest memorable patient death was a significant event. Furthermore, although most participants’ experiences were characterised by emphatic or poignant description, there was most often a balance of challenges and rewards.

Familial carotenaemia and carotenoderma

Clinical and Experimental DermatologyVolume 39, Issue 6 p. 771-772 CPD ● A memorable patient Familial carotenaemia and carotenoderma M. Chattopadhyay, Corresponding Author M. Chattopadhyay Department of Dermatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK Correspondence: Dr Moumita Chattopadhyay, Department of Dermatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road Cambridge Cambridge, CB2 0QQ, UK E-mail: drmchattopadhyay@yahoo.co.ukSearch for more papers by this authorR. Pramanik, R. Pramanik St John's Institute of Dermatology, King's College London (Guy's Campus), UKSearch for more papers by this authorJ. A. McGrath, J. A. McGrath St John's Institute of Dermatology, King's College London (Guy's Campus), UKSearch for more papers by this authorN. P. Burrows, N. P. Burrows Department of Dermatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UKSearch for more papers by this author M. Chattopadhyay, Corresponding Author M. Chattopadhyay Department of Dermatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UK Correspondence: Dr Moumita Chattopadhyay, Department of Dermatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road Cambridge Cambridge, CB2 0QQ, UK E-mail: drmchattopadhyay@yahoo.co.ukSearch for more papers by this authorR. Pramanik, R. Pramanik St John's Institute of Dermatology, King's College London (Guy's Campus), UKSearch for more papers by this authorJ. A. McGrath, J. A. McGrath St John's Institute of Dermatology, King's College London (Guy's Campus), UKSearch for more papers by this authorN. P. Burrows, N. P. Burrows Department of Dermatology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, UKSearch for more papers by this author First published: 30 May 2014 https://doi.org/10.1111/ced.12317Citations: 1 Conflict of interest: the authors declare that they have no conflicts of interest. 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.Citing Literature Volume39, Issue6August 2014Pages 771-772 RelatedInformation

My Most Memorable Patient - Can't Ventilate, Can't Intubate in a patient with tracheal stenosis

My Most Memorable Patient - Can't Ventilate, Can't Intubate in a patient with tracheal stenosis

My Most Memorable Patient: Can't ventilate, Can't intubate in a patient with tracheal stenosis

My Most Memorable Patient: Can't ventilate, Can't intubate in a patient with tracheal stenosis

Superior vena cava obstruction presenting as acute allergy

Clinical and Experimental DermatologyVolume 38, Issue 8 p. 955-956 CPD ● A memorable patient Superior vena cava obstruction presenting as acute allergy A. S. W. Yong, Corresponding Author A. S. W. Yong Department of Dermatology, Norfolk and Norwich University Hospitals, Norwich, UK Correspondence: Dr Adrian S. W. Yong, Department of Dermatology, Norfolk and Norwich University Hospitalls Colney Lane, Norwich, NR4 7UY, UK E-mail: adrian.yong@nnuh.nhs.ukSearch for more papers by this authorS. S. Haque Hussain, S. S. Haque Hussain Department of Dermatology, Cambridge University Hospitals, Cambridge, UKSearch for more papers by this authorN. Marrouche, N. Marrouche Department of Dermatology, Norfolk and Norwich University Hospitals, Norwich, UKSearch for more papers by this authorC. E. H. Grattan, C. E. H. Grattan Department of Dermatology, Norfolk and Norwich University Hospitals, Norwich, UKSearch for more papers by this author A. S. W. Yong, Corresponding Author A. S. W. Yong Department of Dermatology, Norfolk and Norwich University Hospitals, Norwich, UK Correspondence: Dr Adrian S. W. Yong, Department of Dermatology, Norfolk and Norwich University Hospitalls Colney Lane, Norwich, NR4 7UY, UK E-mail: adrian.yong@nnuh.nhs.ukSearch for more papers by this authorS. S. Haque Hussain, S. S. Haque Hussain Department of Dermatology, Cambridge University Hospitals, Cambridge, UKSearch for more papers by this authorN. Marrouche, N. Marrouche Department of Dermatology, Norfolk and Norwich University Hospitals, Norwich, UKSearch for more papers by this authorC. E. H. Grattan, C. E. H. Grattan Department of Dermatology, Norfolk and Norwich University Hospitals, Norwich, UKSearch for more papers by this author First published: 20 April 2013 https://doi.org/10.1111/ced.12134Citations: 1 Conflict of interest: none declared. 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.Citing Literature Volume38, Issue8December 2013Pages 955-956 RelatedInformation

Keratosis lichenoides chronica masquerading as discoid lupus erythematosus

Clinical and Experimental DermatologyVolume 38, Issue 3 p. 327-329 CPD • A memorable patient Keratosis lichenoides chronica masquerading as discoid lupus erythematosus J. S. Wee, J. S. Wee Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this authorA. Viros, A. Viros Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this authorL. Ffolkes, L. Ffolkes Department of Pathology, St George’s Hospital, London, UKSearch for more papers by this authorK. Misch, K. Misch Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this authorJ. Natkunarajah, J. Natkunarajah Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this author J. S. Wee, J. S. Wee Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this authorA. Viros, A. Viros Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this authorL. Ffolkes, L. Ffolkes Department of Pathology, St George’s Hospital, London, UKSearch for more papers by this authorK. Misch, K. Misch Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this authorJ. Natkunarajah, J. Natkunarajah Department of Dermatology, Kingston Hospital, Kingston upon Thames, Surrey, UKSearch for more papers by this author First published: 21 March 2013 https://doi.org/10.1111/j.1365-2230.2012.04477.xCitations: 3 Dr Jamie S. Wee, Department of Dermatology, Kingston Hospital, Surrey, KT2 7QB, UK E-mail: drjamie.wee@gmail.com Conflict of interest: none declared. 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 Citing Literature Volume38, Issue3April 2013Pages 327-329 RelatedInformation

Pursed lips breathing

It is pleasing to see increased research activity that focuses on therapeutic management of dyspnoea and, in particular, greater recognition of the important role that breathing techniques can provide in the amelioration of symptoms associated with Chronic Obstructive Pulmonary Disease (COPD). For many years, the concept of breathing exercises has been poorly understood and, therefore, treatments underutilised. Pursed lip breathing (PLB) sits within that poorly defined toolbox termed ‘breathing exercises’. Traditionally, breathing exercises are insufficiently described, the terminology used is at best, arbitrary, and frequently the same name is given to different interventions. Generally, there is little attempt to standardise the therapy delivered or the breathing technique performed. The American Thoracic Society guidelines describe the technique of PLB as involving ‘a nasal inspiration followed by expiratory blowing against partially closed lips, avoiding forceful exhalation’. Bhatt et al. in the article published in this edition of Chronic Respiratory Disease ‘Volitional pursed lips breathing in stable COPD patients improves exercise’ make the further distinction that ‘exhalation should continue slowly over 4 to 6 seconds without cheek puffing or forced exhalation’. This description of PLB enables better standardisation of a technique that has been the focus of debate for many years. The primary contention surrounding PLB is not so much whether it is effective; over a decade ago, there was sufficient evidence to say that PLB reduces respiratory rate, minute ventilation, and carbon dioxide level; increases tidal volume, arterial oxygen pressure, and oxygen saturation; and we ourselves showed positive effects on respiratory rate and time to recovery post exercise. As such, many people with COPD spontaneously adopt this technique; the contention around PLB concerns its use in people with COPD who do not naturally perform the technique and whether reductions in respiratory rate and oxygen saturation translate into improved exercise tolerance and perception of dyspnoea. Bhatt’s article addresses this question nicely. Giving patients adequate training in the technique and excluding any subjects who used it automatically (none did) they performed, in a randomised order, two 6-minute walk tests (6MWT), including an earlier practice test, with and without the use of PLB. These were patients with severe lung impairment (mean FEV1 38% predicted). Interestingly, the population was, on average, relatively young (mean age 53 years) with a fairly short duration of symptoms for such impairment suggesting that these may be patients who have not had sufficient time, or experience, to develop additional coping strategies such as PLB. One memorable patient from our clinic, when asked why he used PLB, told us it was because he was taught it by another patient in the rehabilitation class and finding it helpful he had continued to use it. Clinically we see patients adopting PLB during periods of acute illness, and the use of PLB at rest is an indicator of increased work of breathing. In Bhatt’s article, use of PLB in this group of patients with severe COPD, unaccustomed to the technique, resulted in a small but statistically significant improvement in a 6-minutewalk distance (6MWD); the improvement however just failed to reach the lower confidence interval of the minimally clinically important difference in 6MWD. Whether these effects are accompanied by improvements in the perception of dyspnoea are as yet unknown. Furthermore, since oxygen saturation was not recorded, we cannot make a comment on the role of PLB in patients who show exercise desaturation. In this study, as in others, there was no consistent

“REACTIONS” - A Memorable Patient

“REACTIONS” - A Memorable Patient All of us at some point in our careers get enlightened by our patients regarding even the subtle aspects of the practice of clinical medicine. In one of our routine hectic outpatients, we had this routine referral regarding a lady in her mid fifties with carcinoid syndrome. As the lady was being ushered into the examination bays, I frantically tried to recap the classical symptoms associated with the condition so that I can touch base with the patient before deciding about further management. Mustering what I could from my memory, I went to greet my patient and initiate the consultation. Before I could proceed to elicit the symptoms which I could recollect, the pleasant lady thrust into my hands a neatly typed paper aptly titled ‘Re-actions’ to highlight her symptoms.

Acute haemorrhagic oedema in a 5-year-old boy

Clinical and Experimental DermatologyVolume 38, Issue 1 p. 116-117 CPD • A memorable patient Acute haemorrhagic oedema in a 5-year-old boy V. M. Smith, V. M. Smith York Hospital, York, Yorkshire, UKSearch for more papers by this authorA. S. Highet, A. S. Highet York Hospital, York, Yorkshire, UKSearch for more papers by this author V. M. Smith, V. M. Smith York Hospital, York, Yorkshire, UKSearch for more papers by this authorA. S. Highet, A. S. Highet York Hospital, York, Yorkshire, UKSearch for more papers by this author First published: 25 June 2012 https://doi.org/10.1111/j.1365-2230.2012.04424.x Dr Vanessa M. Smith, York Hospital, Wigginton Road, York, YO31 8HE, UK E-mail: vanessasmith@doctors.org.uk Conflict of interest: none declared. 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. Volume38, Issue1January 2013Pages 116-117 RelatedInformation