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This chapter focuses on sustainability challenges in the wine industry from a tourism perspective. Wine tourism is considered an important, growing segment of the tourism sector and is a well-developed practice in many international wine-producing regions, but it comes with significant cultural, social, and environmental impacts including tourism's significant contribution to climate change and damage from overtourism. Sustainable tourism has attempted to address these issues, but serious concerns persist. The COVID-19 pandemic was an opportunity to revisit tourism's purpose and consider alternative models and approaches that better respect ecological limits and better support human flourishing. New approaches to wine tourism that go beyond sustaining tourism or minimizing tourism's negative effects are expanding. These regenerative approaches highlight wine tourism's potential to generate economic, social, cultural, and environmental benefits.

BackgroundTranexamic acid (TXA) is an antifibrinolytic drug used to prevent bleeding. It was introduced as an intervention for post-traumatic haemorrhage across emergency medical services (EMS) in the UK during 2012. However, despite strong evidence of effectiveness, prehospital TXA administration rates are low. This study used the theoretical domains framework (TDF) to identify barriers and facilitators to the administration of TXA to trauma patients by EMS providers (paramedics) in the UK.MethodsInterviews were completed with 18 UK paramedics from a single EMS provider organisation. A convenience sampling approach was used, and interviews continued until thematic saturation was reached. Semistructured telephone interviews explored paramedics’ experiences of administering TXA to trauma patients, including identifying whether or not patients were at risk of bleeding. Data were analysed inductively using thematic analysis (stage 1). Themes were mapped to the theoretical domains of the TDF to identify behavioural theory-derived barriers and facilitators to the administration of TXA to trauma patients (stage 2). Belief statements were identified and assessed for importance according to prevalence, discordance and evidence base (stage 3).ResultsBarriers and facilitators to paramedics’ administration of TXA to trauma patients were represented by 11 of the 14 domains of the TDF. Important barriers included a lack of knowledge and experience with TXA (Domain: Knowledge and Skills), confusion and restrictions relating to the guidelines for TXA administration (Domain: Social/professional role and identity), a lack of resources (Domain: Environmental context and resources) and difficulty in identifying patients at risk of bleeding (Domain: Memory, attention and decision processes).ConclusionsThis study presents a behavioural theory-based approach to identifying barriers and facilitators to the prehospital administration of TXA to trauma patients in the UK. It identifies multiple influencing factors that may serve as a basis for developing an intervention to increase prehospital administration of TXA.

ObjectiveIn the UK there are around 5400 deaths annually from injury. Tranexamic acid (TXA) prevents bleeding and has been shown to reduce trauma mortality. However, only 5% of UK major trauma patients who are at risk of haemorrhage receive prehospital TXA. This review aims to examine the evidence regarding factors influencing the prehospital administration of TXA to trauma patients.DesignSystematic literature review.Data sourcesAMED, CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Conference Proceedings Citation Index—Science, Embase and MEDLINE were searched from January 2010 to 2020; searches were updated in June 2022. Clinicaltrials.gov and OpenGrey were also searched and forward and backwards citation chasing performed.Eligibility criteriaAll primary research reporting factors influencing TXA administration to trauma patients in the prehospital setting was included.Data extraction and synthesisTwo independent reviewers performed the selection process, quality assessment and data extraction. Data were tabulated, grouped by setting and influencing factor and synthesised narratively.ResultsTwenty papers (278 249 participants in total) were included in the final synthesis; 13 papers from civilian and 7 from military settings. Thirteen studies were rated as ‘moderate’ using the Effective Public Health Practice Project Quality Assessment Tool. Several common factors were identified: knowledge and skills; consequences and social influences; injury type (severity, injury site and mechanism); protocols; resources; priorities; patient age; patient sex.ConclusionsThis review highlights an absence of high-quality research. Preliminary evidence suggests a host of system and individual-level factors that may be important in determining whether TXA is administered to trauma patients in the prehospital setting.Funding and registrationThis review was supported by Research Capability Funding from the South Western Ambulance Service NHS Foundation Trust and the National Institute for Health Research Applied Research Collaboration South West Peninsula.PROSPERO registration numberCRD42020162943.

Aim Optimal airway management during out-of-hospital cardiac arrest (OHCA) is uncertain. Complications from tracheal intubation (TI) may be avoided with supraglottic airway (SGA) devices. The AIRWAYS-2 cluster randomised controlled trial (ISRCTN08256118) compared the i-gel SGA with TI as the initial advanced airway management (AAM) strategy by paramedics treating adults with non-traumatic OHCA. This paper reports the trial cost-effectiveness analysis. Methods A within-trial cost-effectiveness analysis of the i-gel compared with TI was conducted, with a 6-month time horizon, from the perspective of the UK National Health Service (NHS) and personal social services. The primary outcome measure was quality-adjusted life years (QALYs), estimated using the EQ-5D-5L questionnaire. Multilevel linear regression modelling was used to account for clustering by paramedic when combining costs and outcomes. Results 9,296 eligible patients were attended by 1,382 trial paramedics and enrolled in the AIRWAYS-2 trial (4410 TI, 4886 i-gel). Mean QALYs to 6 months were 0.03 in both groups (i-gel minus TI difference -0.0015, 95% CI –0.0059 to 0.0028). Total costs per participant up to 6 months post-OHCA were £3,570 and £3,413 in the i-gel and TI groups respectively (mean difference £157, 95% CI –£270 to £583). Based on mean difference point estimates, TI was more effective and less costly than i-gel; however differences were small and there was great uncertainty around these results. Conclusion The small differences between groups in QALYs and costs shows no difference in the cost-effectiveness of the i-gel and TI when used as the initial AAM strategy in adults with non-traumatic OHCA.

Background Falls are the most common reason for ambulance callouts resulting in non-conveyance. Even in the absence of injury, only half of those who fall can get themselves up off the floor, often remaining there over an hour, increasing risk of complications. There are recognized techniques for older people to learn how to get up after a fall, but these are rarely taught. The aim of this study was to develop an understanding of attitudes of older people, carers and health professionals on getting up following a fall. Methods A qualitative focus group and semi-structured interviews were conducted with 28 participants, including community-dwelling older people with experience of a non-injurious fall, carers, physiotherapists, occupational therapists, paramedics and first responders. Data were transcribed and analysed systematically using the Framework approach. A stakeholder group of falls experts and service users advised during analysis. Results The data highlighted three areas contributing to an individual’s capability to get-up following a fall: the environment (physical and social); physical ability; and degree of self-efficacy (attitude and beliefs about their own ability). These factors fell within the wider context of making a decision about needing help, which included what training and knowledge each person already had to manage their fall response. Staff described how they balance their responsibilities, prioritising the individual’s immediate needs; this leaves limited time to address capability in the aforementioned three areas. Paramedics, routinely responding to falls, only receive training on getting-up techniques from within their peer-group. Therapists are aware of the skillset to breakdown the getting-up process, but, with limited time, select who to teach these techniques to. Conclusion Neither therapists nor ambulance service staff routinely teach strategies on how to get up, meaning that healthcare professionals largely have a reactive role in managing falls. Interventions that address the environment, physical ability and self-efficacy could positively impact on peoples’ capability to get up following a fall. Therefore, a more proactive approach would be to teach people techniques to manage these aspects of future falls and to provide them easily accessible information.

Introduction: AIRWAYS-2 was a cluster randomised controlled trial (RCT) comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (OHCA). In order to successfully conduct this clinical trial, it was necessary for research paramedics to overcome multiple challenges, many of which will be relevant to future emergency medical service (EMS) research. This article aims to describe a number of the challenges that were encountered during the out-of-hospital phase of the AIRWAYS-2 trial and how these were overcome.Methods: The research paramedics responsible for conducting the pre-hospital phase of the trial were asked to reflect on their experience of facilitating the AIRWAYS-2 trial. Responses were then collated by the lead author. A process of iterative revision and review was undertaken by the research paramedics to produce a consensus of opinion.Results: The main challenges identified by the trial research paramedics related to the recruitment and training of paramedics, screening of eligible patients and investigation of protocol deviations / reporting errors. Even though a feasibility study was conducted prior to the commencement of AIRWAYS-2, the scale of these challenges was underestimated.Conclusion: Large-scale pragmatic cluster randomised trials are being successfully undertaken in out-of-hospital care. However, they require intensive engagement with EMS clinicians and local research paramedics, particularly when the intervention is contentious. Feasibility studies are an important part of research but may fail to identify all potential challenges. Therefore, flexibility is required to manage unforeseen difficulties.

AimThe AIRWAYS-2 cluster randomised controlled trial compared the i-gel supraglottic airway device (SGA) with tracheal intubation (TI) as the first advanced airway management (AAM) strategy used by Emergency Medical Service clinicians (paramedics) treating adult patients with non-traumatic out-of-hospital cardiac arrest (OHCA). It showed no difference between the two groups in the primary outcome of modified Rankin Scale (mRS) score at 30 days/hospital discharge. This paper reports outcomes to 6 months.MethodsParamedics from four ambulance services in England were randomised 1:1 to use an i-gel SGA (759 paramedics) or TI (764 paramedics) as their initial approach to AAM. Adults who had a non-traumatic OHCA and were attended by a participating paramedic were enrolled automatically under a waiver of consent. Survivors were invited to complete questionnaires at three and six months after OHCA. Outcomes were analysed using regression methods.Results767/9296 (8.3%) enrolled patients survived to 30 days/hospital discharge and 317/767 survivors (41.3%) consented and were followed-up to six months. No significant differences were found between the two treatment groups in the primary outcome measure (mRS score: 3 months: odds ratio (OR) for good recovery (i-gel/TI, OR) 0.89, 95% CI 0.69–1.14; 6 months OR 0.91, 95% CI 0.71–1.16). EQ-5D-5L scores were also similar between groups and sensitivity analyses did not alter the findings.ConclusionThere were no statistically significant differences between the TI and i-gel groups at three and six months. We therefore conclude that the initially reported finding of no significant difference between groups at 30 days/hospital discharge was sustained when the period of follow-up was extended to six months.

Background Urinary incontinence (UI) may be defined as a storage symptom of the lower urinary tract resulting in the involuntary loss of urine. UI is common in women, but many of those affected do not mention symptoms to healthcare providers. The prevalence of the condition makes it likely that a large proportion of women attending for osteopathic care will be affected by symptoms of UI. It is not known whether osteopaths routinely ask about urinary UI, or provide advice. Aim The primary aim of this research was to explore osteopaths' views and experiences regarding the identification of UI in women. Methods This research was undertaken as an exploratory, qualitative study. A purposive sample of 11 osteopaths participated in semi-structured interviews. The data were analysed using a framework approach. Findings A wide variation in views and experience of identifying and providing advice for urinary incontinence in women was found. Identification of UI occurred either by practitioners asking about symptoms; by following up on comments or observations; or, by patient led discussions. Conclusions This study has identified barriers to discussing UI in routine osteopathic consultations. UI is common in women and those affected are often reluctant to seek help. Women can be helped to improve their symptoms if they are given appropriate advice. More awareness of the condition and appropriate advice may encourage more osteopaths to consider UI as part of routine care.

Sepsis a common condition, with a high mortality rate. Patients with this condition are routinely encountered by ambulance clinicians, but recognition of septic shock can be challenging. The pre-hospital phase of sepsis care provides the earliest opportunity for identification and treatment. Lactate measurement is a tool commonly used to stratify patient illness severity in sepsis, and is recommended as part of initial management in the acute hospital setting. A lack of evidence to inform the pre-hospital phase of care for patients with suspected sepsis prompted this pragmatic evaluation of point of care lactate measurement in an ambulance service. It is important to highlight that this study was carried out prior to the 2016 Sepsis-3 definitions and quickSOFA clinical criteria for recognising sepsis.

Objective: To carry out a prospective evaluation of tranexamic acid (TXA) use in trauma patients. Patients and methods: TXA was introduced to all emergency ambulances and emergency departments in the South West, UK, on 1 December 2011. We carried out a prospective evaluation of TXA use in trauma patients in the South West Peninsula between December 2011 and December 2012. We collected prehospital and hospital data on TXA administration using the Trauma Audit Research Network database. Data on prehospital administration of TXA were cross-checked with the South Western Ambulance Service Trust. Data were analysed using SPSS (version 20). Results: Altogether, 82 patients were administered TXA during the study period. The median age of the patients was 49 years (IQR 30, 66), and 72% were men. One-third of the patients arrived at hospital by air ambulance. During the first 3 months, administration of TXA was limited to one patient each month receiving the drug. However, an upward trend was observed after June until October 2012, with the increment being more than 10 fold in July, September and October 2012. Conclusion: This is the first study to evaluate the use of TXA in civilian practice in the UK. Our study shows that ambulance service personnel and emergency departments can effectively administer TXA.

Health outcomes after out of hospital cardiac arrest (OHCA) are extremely poor, with only 7–9% of patients in the United Kingdom (UK) surviving to hospital discharge. Currently emergency medical services (EMS) use either tracheal intubation or newer supraglottic airway devices (SGAs) to provide advanced airway management during OHCA. Equipoise between the two techniques has led to calls for a well-designed randomised controlled trial.The primary objective of the AIRWAYS-2 trial is to assess whether the clinical effectiveness of the i-gel, a second-generation SGA, is superior to tracheal intubation in the initial airway management of OHCA patients in the UK. Paramedics recruited to the AIRWAYS-2 trial are randomised to use either tracheal intubation or i-gel as their first advanced airway intervention. Adults who have had a non-traumatic OHCA and are attended by an AIRWAYS-2 paramedic are retrospectively assessed against eligibility criteria for inclusion.The primary outcome is the modified Rankin Scale score at hospital discharge. Secondary objectives are to: (i) estimate differences between groups in outcome measures relating to airway management, hospital stay and recovery at 3 and 6 months; (ii) estimate the cost effectiveness of the i-gel compared to tracheal intubation. Because OHCA patient needs immediate treatment there are several unusual features and challenges to the design and implementation of this trial; these include level of randomisation, the automatic enrolment model, enrolment of patients that lack capacity and minimisation of bias.Patient enrolment began in June 2015. The trial will enrol 9070 patients over two years. The results are expected to influence future resuscitation guidelines.Trial Registration ISRCTN: 08256118.

Aims To explore EMS experiences of participating in a large trial of airway management during out-of-hospital cardiac arrest (AIRWAYS-2), specifically to explore: 1. Any changes in views and practice as a result of trial participation. 2. Experiences of trial training. 3. Experiences of enrolling critically unwell patients without consent. 4. Barriers and facilitators for out-of-hospital trial participation. Methods An online questionnaire was distributed to 1523 EMS providers who participated in the trial. In-depth telephone interviews explored the responses to the online questionnaire. Quantitative data were collated and presented using simple descriptive statistics. Qualitative data collected during the online survey were analysed using content analysis. Interpretive Phenomenological Analysis was used for qualitative interview data. Results Responses to the online questionnaire were received from 33% of the EMS providers who participated in AIRWAYS-2, and 19 providers were interviewed. EMS providers described barriers and facilitators to trial participation and changes in their views and practice. The results are presented in five distinct themes: research process; changes in airway management views and practice; engagement with research; professional identity; professional competence. Conclusions Participation in the AIRWAYS-2 trial was enjoyable and EMS providers valued the study training and support. There was enhanced confidence in airway management as a result of taking part in the trial. EMS providers indicated existing variability in training, experience and confidence in tracheal intubation, and expressed a preference for the method of airway management to which they had been randomised. There was support for the stepwise approach to airway management, but also concern regarding the potential loss of tracheal intubation from ‘standard’ EMS practice. The views and practices of the EMS providers expressed in this research will usefully inform the design of future similar trials.

Background The research study titled “Cluster randomised trial of the clinical and cost effectiveness of the i-gel supraglottic airway device versus tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (AIRWAYS-2)” is a large-scale study being run in the English emergency medical (ambulance) services (EMS). It compares two airway management strategies (tracheal intubation and the i-gel) in out-of-hospital cardiac arrest. We describe the methods used to minimise bias and the challenges associated with the set-up, enrolment, and follow-up that were addressed. Methods AIRWAYS-2 enrols adults without capacity when there is no opportunity to seek prior consent and when the intervention must be delivered immediately. We therefore adopted a cluster randomised design where the unit of randomisation is the individual EMS provider (paramedic). However, because paramedics could not be blinded to the intervention, it was necessary to automatically enrol all eligible patients in the study to avoid bias. Effective implementation required engagement with four large EMS and 95 receiving hospitals. Very high levels of data capture were required to ensure study integrity, and this necessitated collaborative working across multiple organisations. We sought to manage these processes by using a large and comprehensive electronic study database, implementing efficient trial procedures and comprehensive training. Results Successful implementation of the study design was facilitated by the approaches used. The necessary regulatory and ethical approvals to conduct the study were secured, and benefited from strong patient and public involvement. Early and continued consultation with decision makers within the four participating EMS resulted in a coordinated approach to study set-up. All receiving hospitals gave approval and agreed to collect data. A comprehensive database and programme of training and support were implemented. More than 1500 paramedics have been recruited to the study, and patient enrolment and follow-up has proceeded as planned. Conclusion Care provided by EMS needs to be based on evidence. Although participants may be experiencing life-threatening emergencies, high-quality pre-hospital research is possible in well-designed and well-managed studies. The approaches described here can be used to support successful research that will lead to improved treatment and outcomes in similar patient groups. Trial registration ISRCTN08256118. Registered on 22 July 2014. Electronic supplementary material The online version of this article (10.1186/s13063-019-3203-0) contains supplementary material, which is available to authorized users.

Urinary incontinence (UI) is a common condition, affecting approximately one third of women over the age of forty. Recommended first-line management in the majority of cases consists of simple, conservative, self-help measures, and the condition is often highly preventable and treatable. Despite this, many affected by symptoms do not seek help from healthcare providers and do not mention their symptoms when attending for appointments. Rather than seeking help, women will often adopt coping strategies, sometimes to the detriment of their health and wellbeing. Osteopaths are likely to encounter a large proportion of women experiencing symptoms of UI, but may be unaware that their patients are affected by the condition. An extensive body of literature examining the factors that may affect the help-seeking behaviour of women experiencing UI exists and an exploration of this was undertaken in order to consider these factors in the context of osteopathic practice. The factors affecting whether an individual would seek help for urinary symptoms can be described in terms of the triggers that prompt an individual to seek help and also in terms of the barriers that might prevent or delay this. An appreciation of these, along with the risk factors and treatment options may be considerations for osteopaths when treating their female patients. The implications for providing advice to patients should be considered in light of this.

Importance The optimal approach to airway management during out-of-hospital cardiac arrest is unknown. Objective To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest. Design, Setting, and Participants Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018. Interventions Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy. Main Outcomes and Measures The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration. Results A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women [36.3%]), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], −0.6% [95% CI, −1.6% to 0.4%]). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% [95% CI, 6.3% to 10.2%]). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients [77.6%] vs 4161 of 4883 patients [85.2%] in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients [26.1%] in the SGA group vs 1072 of 4372 patients [24.5%] in the TI group; adjusted RD, 1.4% [95% CI, −0.6% to 3.4%]; aspiration: 729 of 4824 patients [15.1%] vs 647 of 4337 patients [14.9%], respectively; adjusted RD, 0.1% [95% CI, −1.5% to 1.8%]). Conclusions and Relevance Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.

At times we encounter clinical problems for which there are no directly applicable evidence-based solutions, but we are compelled by circumstances to act. When doing so we rely on related evidence, general principles of best medical practice, and our experience. Each “Current Clinical Practice” feature article in Seminars in Oncology describes such a challenging presentation and offers treatment approaches from selected specialists. We invite readers' comments and questions, which, with your approval, will be published in subsequent issues of the Journal. It is hoped that sharing our views and experiences will better inform our management decisions when we next encounter similar challenging patients. Please send your comments on the articles, your challenging cases, and your treatment successes to me at dr.gjmor ris@gmail.com. I look forward to a lively discussion. Gloria J. Morris, MD, PhD Current Clinical Practice Feature Editor

BackgroundFeedback and audit are ways of reflecting upon professional practice (Ivers et al, 2012). Opportunities for feedback have been cited as one of the mechanisms which ambulance staff develop their decision-making skills and reflect on their practice (Ivers et al, 2014).MethodsA digital patient outcome feedback intervention (POFI) was designed and tested. POFI reported patient outcomes, clinical investigations and treatment after conveyance to hospital. A data sharing agreement between one hospital and ambulance service was secured. Ambulance staff were surveyed and interviewed regarding its desirability, impact and usability. Descriptive and thematic data analysis was performed.ResultsRespondents were enthusiastic about feedback, reflected in a good response rate to the first survey (N=186). This was not matched by high POFI usage or the second survey (N=28). This may be because it is not yet easily accessible or well known. Respondents indicated feedback is likely to improve decision-making confidence, enhance self-efficacy and patient safety. They felt it would contribute to learning through self-reflection, enhancing knowledge and skills and thus continue professional development. Feedback provides an opportunity to clear up mysteries and support wellbeing.ConclusionsFeedback is desirable, but requires a commitment by ambulance services and hospital sites to share data and then feedback system with staff. There are pockets of interest, nationally, in giving feedback to ambulance staff. This project is the only one known, using a digital mechanism. Other projects give personalised feedback through ‘post-boxes’ or other written requests. Further study could be carried out in collaboration with these similar projects. It is important to work out the best mechanism of sharing data, to suit information governance requirements, whilst also contributing to ambulance confidence, learning and wellbeing.

BackgroundThe participation of over 1500 study paramedics in AIRWAYS-2 provides a unique opportunity for an in depth exploration of how the views and practice of study paramedics, in advanced airway management, may have developed as a result of their participation in AIRWAYS-2, and how their experiences can inform future trials in out-of-hospital cardiac arrest (OHCA). Future prehospital guidelines and practice will not only be shaped by the results of large trials such as AIRWAYS-2, but also by the views and attitudes of UK paramedics towards OHCA, airway management and research. This study allows an opportunity to add depth and understanding to the results of AIRWAYS-2.Study aimsTo explore paramedics’ experiences of participating in a large cluster randomized trial of airway management during OHCA, specifically:The challenges of enrolling patients who are critically unwell and unable to consent;Barriers and facilitators to successful research in OHCA patients;The impact on paramedics’ clinical practice and airway management during and after the trial;The role of advanced airway management during OHCA.MethodsContent analysis of an online survey of 1500 study paramedics to assess their experiences of participating in the trial and to establish any changes in their views and practice.Thematic analysis of telephone interviews with study paramedic to explore the findings of the online questionnaire. Exploring any changes in views and practice around advanced airway management as a result of participating in the trial; assessing experiences of trial training and enrolling critically unwell patients without consent, and exploring the barriers and facilitators for trial participation and the views of paramedics on the future role of advanced airway management during OHCA.Results and conclusionsThe study is in the analysis phase and is due to complete and report by the 31st January 2019.

Minocycline has been used in the treatment of leprosy since the demonstration of its efficacy in inhibiting Mycobacterium leprae growth in 1987. Hyperpigmentation, a well-documented adverse effect, classically shows 3 clinical and histological patterns: type I consists of blue-black pigmentation in areas of current or previous inflammation, type II consists of blue-gray pigmentation of normal skin, often seen on the legs, and type III consists of diffuse muddy-brown pigmentation accentuated on sun-exposed sites. Whereas type I hyperpigmentation stains positively for hemosiderin and type III hyperpigmentation stains positively for melanin, type II hyperpigmentation stains positively for both. We describe 2 patients with leprosy on minocycline therapy who developed multiple patches of blue-gray pigmentation within preexisting leprosy lesions. Biopsies from both patients demonstrated deposition of brownish-black pigment granules within the cytoplasm of foamy histiocytes that was highlighted by both Perls and Fontana-Masson stains. Given the clinical and histological findings in our patients, it is as yet unclear whether this coexistent type I clinical pattern and type II histopathologic pattern of pigmentation is unique to multibacillary leprosy. These findings provide support for the existence of additional subtypes of minocycline-induced hyperpigmentation that do not adhere to the classic 3-type model described.

Sequential print images and text, injected with Deleuze's cinematic concept of the time image, create a blended graphic novel/zine within the framework of the folding of an origami mask. the politics of art making is investigated through Deleuze and Guattari's three political lines of subject construction, and the fold. This opens up possibilities for positive, continual change in the artist and viewer selves, with relevancy to art and its education.

Two films, Ghost World and Art School Confidential, serve as backdrops for an examination of art education, revealing identity conflicts among artist, student, and teacher. This article addresses ideas of uniqueness, uniformity, professionalism, and nakedness through the concept of personal dress. This critical discussion explores the influence of society on the Lacanian identity in terms of the Imaginary, Symbolic, and Real registers. Clothing expresses personal identity while providing a mask for the lack of a unified self. In exposing dynamics between conflicting identities, the phantom reality of self and the possibility of self-questioning to artists/educators, this article suggests a repressive ghost in the academic host and a suppressive ghost in the host-self.

Background A shift from a predominantly emergency service, towards one where a wide range of conditions are managed and treated on scene presents numerous challenges for ambulance services and clinicians. The effective management of a broad range of patients and conditions in the ambulance setting will have an impact on other parts of the health service including emergency departments and primary care. Methods A two part online survey was distributed to operational staff working for a regional UK ambulance service. Clinicians were asked to report their experiences of accessing patient information and making decisions about patient management based on four hypothetical patient scenarios. Results A survey of clinical staff (n = 302) revealed that (i) the vast majority experienced difficulties in accessing patients’ health information, (ii) this was particularly true in the out of hours period and (iii) They felt that better access would likely lead to more appropriate selection of care pathways. Conclusions Decisions regarding the most appropriate care for patients presenting to the ambulance service are best informed by access to accurate and complete health information and records. An understanding of patients’ pre-existing medical conditions, recent treatments and health information is needed for the selection of the most appropriate care; this information is often difficult to obtain in the ambulance service setting. Electronic supplementary material The online version of this article (doi:10.1186/s12873-015-0054-1) contains supplementary material, which is available to authorized users.

Large lecture classes can often be quite impersonal. Creating a teaching team, consisting of the instructor, graduate assistants, and a few undergraduates, is one of the ways the University of Arizona has adopted in order to make the large lecture class more personal. As members of the Department of Mathematics we train the undergraduates, who are part of the teaching team, in ways to help their peers. Here we share the background of the program established at the University of Arizona and the particulars about the training of undergraduates to help their peers in mathematics

Self-awareness is not something we are born with, but an understanding that grows over time. Crucially, says Maria Robinson, it relies on a baby's experience of interacting with others

Sarcoidosis is a multi-system, granulomatous disease, which affects the skin in approximately 20 to 30 percent of cases. Recognition of cutaneous sarcoidosis can be challenging because of the wide range of skin lesion morphologies. Ulcerative sarcoidosis is uncommon. We present a 35-year-old woman with pretibial ulcerative sarcoidosis, indurated tattoos, and hilar lymphadenopathy.

Morbihan disease, which consists of solid facial edema, is a rare complication of rosacea, a common cutaneous disorder in middle-aged individuals. The characteristic features of Morbihan disease are its chronic course, typical clinical picture, lack of specific laboratory and histopathologic findings, and refractoriness to therapeutic measures. Since its initial description in 1957, only a small number of cases have been reported in the dermatologic literature. We report a 54-year-old man who developed a two-year duration of erythema and edema that affects the upper and mid face, with accentuation in the periorbital region. Patch tests excluded an allergic contact dermatitis and histopathologic investigation showed small, nodular clusters of epithelioid cells in the dermis that were consistent with sarcoidal granulomata. A diagnosis of Morbihan disease was made owing to the combination of clinical and histopathologic findings. Therapeutic options for the disease remain unsatisfactory and treatments reported in the literature include systemic glucocorticoids, oral tetracyclines, thalidomide, isotretinoin, ketotifen, and clofazimine. Our patient failed a six-to-seven months course of minocycline prior to presentation and has since experienced improvement on gradually-increasing doses of isotretinoin.

The leishmaniases are a group of diseases caused by species of Leishmania and transmitted by the bite of the female sandfly. The major clinical forms include localized or disseminated cutaneous, mucocutaneous, and visceral disease. Localized cutaneous leishmaniasis is most frequently caused by L. major and L. tropica in the Old World and by L. braziliensis, L. mexicana, and related species in the New World. L. donovani generally causes visceral disease in the Old World. We describe a case of disseminated cutaneous leishmaniasis caused by L. donovani in a traveller returning to the United States from Italy. Dermatologists should be aware of the clinical manifestations of leishmaniasis.

Generalized essential telangiectasia, which is a rare condition that is characterized by the progressive development of telangiectases on the skin, is a clinical diagnosis of exclusion. We present a 65-year-old man with a ten-month history of an asymptomatic eruption of the trunk and proximal aspects of the arms and hands that was comprised of macules and patches of telangiectases. The clinical presentation, associated diseases, hypotheses regarding pathogenesis, differential diagnoses, and reports on treatment modalities are reviewed. The relatively new association of this entity with systemic signs that include hemorrhage as well as the occurrence of generalized essential telangiectasia in patients with a history of hepatitis is discussed.

We report a 52-year-old man with a one-year history of multiple, firm, skin-colored nodules on the vertex of the scalp. Histopathologic examination was consistent with a spiradenoma, which is a rare, benign adnexal tumor of controversial histogenesis. Multiple spiradenomas may arise in association with Brooke-Spiegler syndrome, which is an autosomal dominant condition of multiple cyclindromas, trichoeptheliomas, and cyclindromas.

We present a unique case of S. marcescens folliculitis of the trunk in a 46-year-old woman with a history of facial acne vulgaris during her teen years. Her eruption occurred at the time of elective ambulatory surgery when she was treated with pre and post-operative antibiotics. The diagnosis of S. marcescens folliculitis was made on the basis of histopathologic features and tissue culture of a skin biopsy specimen of a pustule after her eruption was unresponsive to conventional treatment for inflammatory acne vulgaris. The history and pathophysiology of gram-negative folliculitis in the setting of acne vulgaris is reviewed.

A 41-year-old woman with a prior diagnosis of lupus erythematous presented with a five-year history of small, erythematous, flesh-colored papules and nodules that coalesced into symmetrically-distributed plaques on her upper back. A biopsy specimen showed an interstitial, granulomatous mixed-cell dermatitis with eosinophils. These clinicopathologic findings are consistent with a diagnosis of lupus erythematous-associated interstitial granulomatous dermatitis.

A 60-year-old man presented with intermittent, tender, erythematous nodules on the legs that were associated with mild arthralgias. He was otherwise asymptomatic but reported a history of lupus anticoagulant antibodies that were discovered incidentally on laboratory screening at the approximate time that his lesions first occurred. A biopsy specimen showed a septal and lobular panniculitis with neutrophils, histiocytes, numerous eosinophils, foci of fibrosis, and fat necrosis but no vascular pathology. An elevated activated partial thromboplastin time (PTT), appreciably elevated levels of anti-beta-2 glycoprotein I antibody (IgM and IgG), and moderately elevated levels of anticardiolipin antibody (IgM and IgG) were present. The onset and recurrence of his skin condition coincided with increased antiphospholipid antibody levels and treatment with 81 mg aspirin daily was associated with improvement.

A 63-year-old woman with a ten-year history of systemic lupus erythematosus presented with a three-year history of a large, pruritic lesion that was located on the back and a pruritic lesion that was located on the right thumb. She was a baker by profession for many years during which time she often stood with her back to a hot oven. Physical examination of the lower back showed a large, atrophic, and reticulated plaque with a hyperpigmented border. On the right thumb was a well-demarcated, erythematous plaque with adjacent loss of the medial nail plate on the affected finger. Histopathology of both skin lesions showed cutaneous lupus erythematosus. This patient displays the Koebner phenomenon to heat in cutaneous (discoid) lupus erythematosus. We propose the term lupus ab-igne to describe her skin lesions. There are a few reports of the Koebner phenomenon occurring in patients with lupus erythematosus in response to contact dermatitis, tattoos, zoster, operative scars, scratching, or pressure from clothing. To our knowledge, this is the first report of heat as the physical factor leading to the formation of cutaneous lupus lesions.

A 60-year-old man presented with intermittent, tender, erythematous nodules on the legs that were associated with mild arthralgias. He was otherwise asymptomatic but reported a history of lupus anticoagulant antibodies that were discovered incidentally on laboratory screening at the approximate time that his lesions first occurred. A biopsy specimen showed a septal and lobular panniculitis with neutrophils, histiocytes, numerous eosinophils, foci of fibrosis, and fat necrosis but no vascular pathology. An elevated activated partial thromboplastin time (PTT), appreciably elevated levels of anti-beta-2 glycoprotein I antibody (IgM and IgG), and moderately elevated levels of anticardiolipin antibody (IgM and IgG) were present. The onset and recurrence of his skin condition coincided with increased antiphospholipid antibody levels and treatment with 81 mg aspirin daily was associated with improvement.

A 50-year-old woman presented with a long history of multiple, flesh-colored papules and nodules on her central face, neck, and upper shoulders, as well as pink papules on her scalp. They were neither pruritic nor tender, but the patient desired treatment for cosmesis. Histopathologic examination of a representative facial lesion was consistent with a trichoepithelioma and an upper forehead papule was consistent with cylindroma. She reported a positive family history of similar lesions.