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A 55-year-old woman with a past medical history of visceral myopathy with multiple resultant abdominal surgeries, colectomy caused by severe pseudo-obstruction, and end-stage renal disease on hemodialysis presented with complaints of nausea, abdominal distention, vomiting, and diarrhea for five days. Small-bowel obstruction was identified on CT. She subsequently developed acute gastrointestinal bleeding, anemia, and hemodynamic instability. Extensive gastric ulceration with frank hemorrhage prompted urgent subtotal gastrectomy with multiple intraoperative findings, including a necrotic distal duodenum. Surgical pathology showed invasive fungal infection of the duodenum with perforation, morphologically compatible with invasive mucormycosis. The patient was started on intravenous liposomal amphotericin B, but despite best efforts, the patient ultimately succumbed to this invasive fungal infection in addition to sepsis and multi-organ failure.

PURPOSE: Patients diagnosed with ductal carcinoma in situ (DCIS) face trade-offs when deciding among different treatments, including surgery, radiation, and endocrine therapy. A less chosen option is active monitoring. While evidence from clinical trials is not yet available, observational studies show comparable results for active monitoring and immediate treatment on cancer outcomes in select subgroups of patients. We developed and tested a web-based decision support tool (DST) to help patients explore current knowledge about DCIS and make an informed choice. METHODS: The DST, an interactive web application, was informed by literature reviews and formative work with patients, breast surgeons, and health communication experts. We conducted iterative interviews to evaluate the DST content among women with and without a history of breast cancer, as well as breast cancer experts. For usability testing, we conducted an online survey among women with and without a history of breast cancer. RESULTS: For content evaluation, 5 women with and 10 women without a history of DCIS were interviewed. The sample included 11 White and 4 non-White women, with a mean age of 64 years. The expert sample consisted of 5 attendings and a physician assistant. The feedback was used to add, clarify, or reorganize information in the DST. For usability testing, 22 participants with a mean age of 61 years were recruited including 15 White and 7 Black women and 6 women with a history of DCIS. The mean usability score was 3.7 out of 5. Most participants (86%) found that the DST provided unbiased information about treatments. To improve usability, we reduced the per-page content and added navigation cues. CONCLUSION: Content and usability evaluation showed that the DST helps patients explore trade-offs of active monitoring and immediate treatment. By adopting a personalized approach, the tool will enable informed decisions aligned with patients’ values and expectations.

An immunocompetent woman presented with headaches. She previouslyworked at a farm in upstate New York. Brain MRI noted pituitary enlargement and neurosurgerypursued trans-sphenoidal pituitary biopsy. Histopathology revealed ill-defined granulomaswith clusters of yeast, consistent with Histoplasma.

Background: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related death worldwide, with about 841,000 new cases and 782,000 deaths annually. Given the clearly defined population at risk, mostly patients with liver cirrhosis, prevention of HCC could be highly effective. Summary: Besides regular ultrasound surveillance, numerous publications have suggested protective effects of diverse drugs and nutrients. However, none of those preventive options has made it into clinical routine or practice guidelines. We therefore summarize the current status of preventive effects of drugs such as statins, acetylsalicylic acid (ASA), and metformin, but also dietary aspects and nutrients such as coffee, tea, and vitamin D supplementation. A successful implementation of some of these strategies may potentially lead to improved prevention of HCC development in patients with liver cirrhosis. Key Messages: Accumulating data suggest that particularly ASA, antidiabetic therapies, and statins may substantially decrease HCC incidence in patients at risk.

Background The unexpected outbreak of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused more than 49 million cases and an estimated 2,000,000 associated deaths worldwide. In Germany, there are currently more than 2,000,000 laboratory-confirmed coronavirus disease 2019 (COVID-19) cases including 51,800 deaths. However, regional differences also became apparent and with the second wave of infections, the detailed characterization of COVID-19 patients is crucial to early diagnosis and disruption of chains of infections. Methods Handing out detailed questionnaires to all individuals tested for COVID-19, we evaluated the clinical characteristics of negative and positive tested individuals. Expression of symptoms, symptom duration and association between predictor variables (i.e. age, gender) and a binary outcome (olfactory and gustatory dysfunction) were assessed. Results Overall, the most common symptoms among individuals who tested positive for SARS-CoV-2 were fatigue, headache, and cough. Olfactory and gustatory dysfunction were also reported by many SARS-CoV-2 negative individuals, more than 20% of SARS-CoV-2 negative tested individuals in our study reported olfactory and gustatory dysfunction. Independent of SARS-CoV-2 status, more females displayed symptoms of gustatory (29.8%, p = 0.0041) and olfactory dysfunction (22.9%, p = 0.0174) compared to men. Conclusions Bringing early SARS-CoV-2 tests to the populations at risk must be a main focus for the upcoming months. The reliability of olfactory and gustatory dysfunction in COVID-19 negative tested individuals requires deeper investigation in the future.

IntroductionMost Australians prefer to die well and as they wish, but not everyone can have their end-of-life wishes fulfilled. There is a knowledge gap in understanding our communities’ needs in end-of-life care.To address the gap, we engaged a Community Panel to participate in a deliberative dialogue process to hear their views about end-of-life care.Short description of practice change implementedAs a Primary Health Network, we recognise that communities have the right to influence decisions that impact their health.To improve our communities' end-of-life experience, it is important to identify and understand our communities’ needs, their values, beliefs and choices.Aim and theory of changeThe aims and the roles of the Community Panel were to:• Consider the remit: ‘What does dying well look like and how can we help people achieve this?’; and• Create a set of meaningful recommendations that can help people to achieve dying well, to be considered for future investment.Targeted populationTwenty-seven consumers and carers participated in the process. They were identified and recruited from the community/public members living in Melbourne’s north and western regions. They ranged in age, were from diverse backgrounds, and had varied end-of-life experiences.TimelineThroughout the engagement process (August 2018−December 2018), the Community Panel were supported by experienced facilitators through a range of activities. They came together for two-and-half days in November and December 2018 to work, discuss and provide recommendations on the remit.HighlightsUsing a Deliberative Democracy Process, it empowered the Panel to participate meaningfully in the following activities:• a welcome email• a ‘Meet and Greet’ session• sharing of information via an online platform• face to face engagement over two-full weekend days to respond to the remit and develop recommendations; and• follow-up meeting to present their recommendation and report to the health decision makers.Despite it being an emotive topic, we successfully demonstrated that open and safe discussions can be achieved using this innovative deliberative process, which gives a greater insight into what it is important to patients and the community. This enables more effective targeting of resource to improve outcomes.Comments on sustainabilityCommunity involvement through this process will inform more effective and sustainable planning, design and implementation of end-of-life support and services.Comments on transferabilityThis will also ensure that our service planning is relevant/applicable and transferrable to meet our future population’s needs. The deliberative process can be applied to other priority areas and programs.ConclusionsThis engagement activity has enhanced our understanding of our local communities’ needs in end-of-life care. The Panel developed a report that provided 14 consensus-driven recommendations on how to support people to die well, and a definition for what dying well entails.DiscussionsThe Panel’s recommendations are now being used to guide commissioning intentions and activities for our local communities.Lessons learnedThe process has led to a change of attitudes towards public participation from the community members, and a greater understanding across our organisation of the value of collaborative public participation.

Play is important to children's learning. When young children have interrupted time to playfully and independently explore, discover, investigate and experiment in stimulating, safe and varied environments, critical thinking and scientific inquiry are promoted. Notably, facilitating on-the-spot observations related to the 'nature of science' during play provides diverse opportunities to support children to construct scientific knowledge as a process of inquiry. This chapter describes the importance of play in early childhood and the 'nature of science' in the early years. This is followed by four case studies that highlight how studying scientific phenomena can be facilitated through play. Each case study describes the context of the children's play and how the educator/teacher expands on this to encourage their scientific explorations and thinking. The development of the case studies occurred in a school inspired Reggio Emilia educational philosophy.

Background Capecitabine is a commonly used oral chemotherapy agent. Recent data suggest that concurrent use of proton pump inhibitors may reduce the efficacy of capecitabine by decreasing its absorption through increased gastric pH. Since proton pump inhibitors are widely used, we evaluated the supportive evidence for the probability of occurrence and potential seriousness of this drug interaction. Methods The probability of occurrence was evaluated based on the clinical, pharmacokinetic and in vitro evidence using the Drug Interaction Probability Scale. The possibility of seriousness was assessed based on the potential impact on the therapeutic intent of capecitabine therapy. Results The probability of occurrence of the interaction is doubtful. Clinical findings from two retrospective post hoc analyses showed inconsistent trends towards reduced survival. Pharmacokinetics studies found no significant decrease in systemic capecitabine level with concurrent gastric acid suppression with antacid or food intake. In vitro data do not support the proposed mechanism of reduced capecitabine absorption due to increased gastric pH. The possibility of seriousness varies depending on the treatment intent of capecitabine therapy. The most and least serious possible outcome would be reduced possibility of cure or survival and symptom control, respectively. Conclusion Although the possible outcome may be serious, the probability of interaction between capecitabine and proton pump inhibitors is doubtful. Therefore, we suggest that intervention should be limited to minimal change to existing therapy plan. This may include routinely ascertaining the need for proton pump inhibitor use. Alternate acid suppressing agents may be considered based on the therapeutic intent of capecitabine therapy.

The radial artery is a vessel frequently used in various medical procedures which carry a risk of complications. One such method used to minimize the number of complications is a profound knowledge of the artery’s diameter, which allows for appropriate selection of an instrument to use for puncture. The purpose of this study is to determine the diameter of the radial artery and its depth from the skin surface in young adults. Material and methods 96 volunteers participated in the study. The average age of the volunteers was 20.43 years. All participants underwent a B-mode ultrasonography to measure the distal radial artery’s diameter. Certified anthropometric instruments were used to determine the relation between the artery diameter and the selected basic anthropometric parameters. Results The mean right arterial diameter for the entire examined population at the level of the styloid process was mean 1.42 (SD 0.26) mm and its distance to the skin was mean 4.00 (SD1.20) mm. Statistical analysis revealed the presence of moderate positive relationship between the diameter of the radial artery and body weight and between the diameter of the radial artery and BMI. A weak correlation between the artery diameter and the width of the wrist was also present. Conclusion In the present work, we aimed to determine the dimensions of the distal section of the radial artery in young people free from symptoms of cardiovascular diseases. The obtained initial study results advise selecting instruments for vascular puncture individually, with special attention paid to slender people with slim wrists.

Reliable and accurate analysis of inhibitors is vital for decisions on efficiency and cost-effectiveness of scale inhibitor squeeze treatments. Recent developments have resolved issues for residual sulphonated polymer chemistries which were previously difficult to isolate. Attention now is directed to challenges associated with phosphonate based inhibitors, particularly when assay is required from a multi-component produced water sample containing other P based inhibitor species which currently poses a significant challenge. This paper describes the advantages and limitations of techniques used for phosphorus assay including inductively coupled plasma spectroscopy, ion chromatography and wet chemical methods (e.g. Phospho-molybdenum blue, PMB) approaches. Field examples are discussed to emphasize the analytical challenge with cases whereby speciation is readily achieved and others where this is not the case. To overcome the limitations of these methods, novel approaches for analysis of P – containing inhibitors (in the presence of other –containing additives) include time resolved fluorescence spectroscopy (TRF) and mass spectrometry (MS) detection (which also require development) are considered with potential benefits and limitations / interferences highlighted. These are discussed with highlights of TRF development presented. This technique shows significant scope and potential with promising results showing speciation and discrimination of both polymeric and phosphonate based scale inhibitors as well as a phosphate ester based corrosion inhibitor. This paper highlights the concept that for residual scale inhibitor assay, one analytical approach does not fit all environments and applications. However the availability of a range of techniques, some of which are still in development, allows for effective monitoring in complex, multi-component environments. The paper highlights development opportunities for some of the newer approaches such as TRF and MS as well as discussing their limitations in complex produced fluids.

Purpose – The purpose of this paper is to describe the development of Real Lives: a community interest company that provides peer support for people who face significant mental health challenges using personal budgets. Design/methodology/approach – The paper offers a descriptive summary of the vision behind Real Lives and the successful realisation of this vision in practice based on interviews by the first author with the directors, Operational Manager, Cafe Manager and “Peers and Allies for in Living” who provide support to clients. Findings – The successful development of Real Lives shows that it is possible to utilise peer support and personal budgets to a create small, values based, financially viable organisation outside the statutory sector that is part of its community and can provide outside the statutory sector. A service for people facing significant mental health challenges that is personalised, recovery-focused and puts the client in control and is focused on helping them to do the things they want to do and pursue their aspirations. Originality/value – Real Lives is an innovative recovery-focused service that is part of its community and offers a model for utilising Self-Directed Support and personal budgets and that might be replicated by others.

Dynamic vapour sorption (DVS) is a gravimetric technique used to measure the weight loss/gain of a material as a function of humidity. It is possible to use organic solvents on many commercially available instruments. The most common experiment carried out using DVS analysers is the construction of sorption isotherms for materials. The raw data are usually presented as normalised weight percentage versus time. Sorption isotherms are conventionally presented as equilibrium water content versus relative humidity. This chapter considers the principles of the technique and discusses its application to a wide range of samples, including food, pharmaceuticals, textiles, building materials and explosives.

a Medical and Social Affairs, The National Family Safety Program, Saudi Arabia b Child Protection Research Center, American Humane Association, USA c PICU and Pediatric Emergencies, Hotel-Dieu Hospital, Beirut, Lebanon d Department of Child and Adolescent Psychiatry/Psychotherapy, University, Ulm, Germany e Department of Children, Schools and Families, England, United Kingdom f Child and Youth Welfare Unit, Australian Institute of Health and Welfare, Australia g Child Protection Unit Department of Pediatrics, University of the Philippines, Philippines h Kind & Gezin, Belgium i Child, Youth and Family, New Zealand j Surveillance and Epidemiology Division, Public Health Agency of Canada, Canada