Advances in biliary atresia: from patient care to research

Biliary atresia, the most common cause of liver transplantation in children, remains a challenge for clinicians and investigators. The development of new therapeutic options, besides the typical hepatoportoenterostomy, depends on a greater understanding of its pathogenesis and how it relates to the clinical phenotypes at diagnosis and the rate of disease progression. In this review, we present a perspective of how recent research has advanced the understanding of the disease and has improved clinical care protocols. Molecular and morphological analyses at diagnosis point to the potential contributions of polymorphism in the CFC1 and VEGF genes to the pathogenesis of the disease, and to an association between the degree of bile duct proliferation and long-term outcome. In experimental models, cholangiocytes do not appear to have antigen-presenting properties despite a substantial innate and adaptive immune response that targets the biliary epithelium and produces duct obstruction. Initial clinical trials assessing the efficacy of corticosteroids in decreasing the inflammation and improving outcome do not show a superior effect of corticosteroids as an adjuvant treatment following hepatoportoenterostomy. The best outcome still remains linked to an early diagnosis and surgical treatment. In this regard, the Yellow Alert campaign by the Sociedade Brasileira de Pediatria and the inclusion of the Stool Color Card in the health booklet given to every neonate in Brazil have the potential to decrease the age of diagnosis, shorten the time between diagnosis and surgical treatment, and improve the long-term outcome of children with this devastating disease.

Continuity of patient care in day surgery

Continuity is a part of high-quality patient care. The purpose of this study was to analyse what factors are important in the continuity of patients’ care, and how well continuity is achieved in different stages of the care of day surgical patients. Day surgery has become significantly more prevalent in the past few decades, and in order for it to be carried out successfully, continuity in care is particularly essential. The study was carried out in two stages. In the first stage (2001–2005) of the study, continuity was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. The first stage also entailed an analysis of matters important to the patient and problems concerning the achievement of care continuity, carried out by interviewing 25 day surgical patients. In the second stage (2006–2015), the degree to which the continuity of day surgical patient care was achieved was analysed from the perspective of patients (n=203, 58%) and nurses working in day surgery units (n=83, 69%), and suggestions for developing the continuity of day surgery patient care were made. In this study continuity of care was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. Within these categories, several important factors for the patient were found. According to both patients and nurses, continuity of care is generally achieved to a high degree. Continuity of care is improved by patients being acquainted with and meeting the staff attending to them (nurse and surgeon) before and after the operation. From patients’ perspective, there is room for improvement especially in terms of being admitted to care and in the carer-patient relationship. From nurses’ perspective, there is room for improvement in terms of the smoothness of care. Nurses evaluated the continuity of care to be the least successful before and after the operation. An extensive social and health care reform is planned in Finland in the coming years, aiming to enhance social and health care services and to create smoothly functioning service and care. As a topic of further study supporting the development of the service system, it is important to follow the patient’s progress throughout the entire chain of care, e.g. as a case study. On the other hand, there is also a need to study the views of nurses and other health care professionals in health care, e.g. in primary health care.

The heliospheric Hale cycle over the last 300 years and its implications for a “lost” late 18th century solar cycle

A Hale cycle, one complete magnetic cycle of the Sun, spans two complete Schwabe cycles (also referred to as sunspot and, more generally, solar cycles). The approximately 22-year Hale cycle is seen in magnetic polarities of both sunspots and polar fields, as well as in the intensity of galactic cosmic rays reaching Earth, with odd- and even-numbered solar cycles displaying qualitatively different waveforms. Correct numbering of solar cycles also underpins empirical cycle-to-cycle relations which are used as first-order tests of stellar dynamo models. There has been much debate about whether the unusually long solar cycle 4 (SC4), spanning- 1784–1799, was actually two shorter solar cycles combined as a result of poor data coverage in the original Wolf sunspot number record. Indeed, the group sunspot number does show a small increase around 1794–1799 and there is evidence of an increase in the mean latitude of sunspots at this time, suggesting the existence of a cycle ‘‘4b’’. In this study, we use cosmogenic radionuclide data and associated reconstructions of the heliospheric magnetic field (HMF) to show that the Hale cycle has persisted over the last 300 years and that data prior to 1800 are more consistent with cycle 4 being a single long cycle (the ‘‘no SC4b’’ scenario). We also investigate the effect of cycle 4b on the HMF using an open solar flux (OSF) continuity model, in which the OSF source term is related to sunspot number and the OSF loss term is determined by the heliospheric current sheet tilt, assumed to be a simple function of solar cycle phase. The results are surprising; Without SC4b, the HMF shows two distinct peaks in the 1784–1799 interval, while the addition of SC4b removes the secondary peak, as the OSF loss term acts in opposition to the later rise in sunspot number. The timing and magnitude of the main SC4 HMF peak is also significantly changed by the addition of SC4b. These results are compared with the cosmogenic isotope reconstructions of HMF and historical aurora records. These data marginally favour the existence of SC4b (the ‘‘SC4b’’ scenario), though the result is less certain than that based on the persistence of the Hale cycle. Thus while the current uncertainties in the observations preclude any definitive conclusions, the data favour the ‘‘no SC4b’’ scenario. Future improvements to cosmogenic isotope reconstructions of the HMF, through either improved modelling or additional ice cores from well-separated geographic locations, may enable questions of the existence of SC4b and the phase of Hale cycle prior to the Maunder minimum to be settled conclusively.

Balancing the role of the dental school in teaching, research and patient care; including care for underserved areas

Inequalities within dentistry are common and are reflected in wide differences in the levels of oral health and the standard of care available both within and between countries and communities. Furthermore there are patients, particularly those with special treatment needs, who do not have the same access to dental services as the general public. The dental school should aim to recruit students from varied backgrounds into all areas covered by the oral healthcare team and to train students to treat the full spectrum of patients including those with special needs. It is essential, however, that the dental student achieves a high standard of clinical competence and this cannot be gained by treating only those patients with low expectations for care. Balancing these aspects of clinical education is difficult. Research is an important stimulus to better teaching and better clinical care. It is recognized that dental school staff should be active in research, teaching, clinical work and frequently administration. Maintaining a balance between the commitments to clinical care, teaching and research while also taking account of underserved areas in each of these categories is a difficult challenge but one that has to be met to a high degree in a successful, modern dental school.

Gothic Taste and Russian Culture of the 18th Century

This project was an experiment in widening the traditional borders of study in the field and looking at the phenomenon of Gothic taste in many genres and kinds of art. The Gothic taste was a major element in the cultural image of the Enlightenment both in western Europe and in Russia. It was an essential component in the world outlook of an educated person and without studying this phenomenon it is impossible to fully understand the thinking of artistic professionals, amateurs and users in Russian society in the 18th century. Mr. Khatchatourov first analysed the reasons for the importance of Gothic taste in the culture of the European Enlightenment and then studied its linguistic and lexicographic evolution in 18th century Russian culture. He sought to determine the semantic context which actively formed the human mind set in the Enlightenment, including potential users and producers of articles in the Gothic taste. He then looked at the process of absorption of this concept by those forms of art which express it most strongly, in particular architecture and the theatre. His study was based on a comprehensive historical and culturological study using a wide range of sources, a formal stylistic method approach considering the interaction of non-classical styles of the Enlightenment with the dominant classicism, and an iconographic approach which revealed the essential aspects in a new image synthesis of the culture of the Enlightenment.

[The untellable patient's history]

An essay with personal touch on the interaction between patients and professionals seen from the perspective of an anonymous writer that is presumably preoccupied with midlife reflections.