BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Assessing the risk to the conservation status of temperate rainforest from exposure to mining, commercial logging, and climate change: a Tasmanian case study

Formal protected areas are a critical conservation measure so long as their tenure is defined and secure and they are well managed. Protected areas in developed countries are assumed to meet these criteria and therefore have not attracted the level of attention given to the adequacy of protected areas in developing countries. We investigate this assumption using as a case study the southern temperate rainforests of Tasmania, Australia. We examine the extent to which these rainforests are protected from potential exposure to mining, commercial logging and climate change. We analyse the tenure of Tasmania\u27s rainforests and identify the protected area categories that prohibit or allow mining or logging. We also model the potential distribution of Nothofagus cunninghamii, a dominant rainforest canopy tree species, to future climate and compare this with modelled current and future forest fire danger index. Results showed that 90% of the total area of Tasmanian rainforest (715,773 ha− 1) is in a reserve. However, the area of rainforest in reserves secured from mining and/or commercial logging is only 47% (335,863 ha− 1) as 43% (308,897 ha− 1) is in a reserve category where these land uses are permitted. The protected area category with the highest level of protection, prohibiting all mining and logging, is the Tasmanian Wilderness World Heritage Area which encompasses 325,920 ha− 1 of temperate rainforest. During a recent legislative review, 66,012 ha− 1 of rainforest in protected areas was downgraded to a reserve category that permits logging or mining. A key conservation instrument therefore is the Management Plan for the World Heritage Area as it overrides land use activities otherwise permitted including the 21,257 ha− 1 which is on a State-defined land tenure that allows for logging or mining. Climate change impacts, as modelled, suggest the main conservation challenges are in maintaining the integrity of the remaining intact rainforest blocks and better managing ignitions from lightning strikes and arsonists in the coniferous and alpine rainforests. Allowing structural degradation and fragmentation to intact rainforest blocks will reduce their capacity to buffer meso-climatic variability and resist fire events thereby undermining their ecosystem integrity. Noting that Aichi Target 11 includes the requirement that reserves are effectively managed, our case study highlights that assessing the effectiveness of a reserve system is not necessarily a straightforward matter as governance systems and regulatory frameworks involve a mix of international obligations, national and subnational policies and statutes, along with other agreements, administrative arrangements and plans of management, which can provide for a range of land use activities and be subject to modification over time

The role of hyperpolarized 129xenon in MR imaging of pulmonary function.

In the last two decades, functional imaging of the lungs using hyperpolarized noble gases has entered the clinical stage. Both helium (3He) and xenon (129Xe) gas have been thoroughly investigated for their ability to assess both the global and regional patterns of lung ventilation. With advances in polarizer technology and the current transition towards the widely available 129Xe gas, this method is ready for translation to the clinic. Currently, hyperpolarized (HP) noble gas lung MRI is limited to selected academic institutions; yet, the promising results from initial clinical trials have drawn the attention of the pulmonary medicine community. HP 129Xe MRI provides not only 3-dimensional ventilation imaging, but also unique capabilities for probing regional lung physiology. In this review article, we aim to (1) provide a brief overview of current ventilation MR imaging techniques, (2) emphasize the role of HP 129Xe MRI within the array of different imaging strategies, (3) discuss the unique imaging possibilities with HP 129Xe MRI, and (4) propose clinical applications