SUMMARYThe interpersonal dynamics between patient and doctor remain a daily challenge for clinicians, and reflective practice is a tool that allows them better understanding of how patients engage with treatment. The interpersonal dynamics consultation is a form of group-based reflective practice for patients with difficult relational (interpersonal) styles. It includes the whole multidisciplinary team in a systematic consultation in order to arrive at new understanding and management plans for these patients. Interpersonal dynamics consultations have been used successfully for many years in mental healthcare, and this article has arisen from a project exploring their application in physical healthcare settings. The project works to promote effective working at the interface of physical and mental healthcare and facilitates the important translational work of making psychiatry and psychotherapeutic ideas applicable in a broader context. This article outlines the interpersonal dynamics consultation model and illustrates its use in three fictitious cases from different medical specialties.LEARNING OBJECTIVESAfter reading this article you will be able to:•describe the ways in which reflective practice is beneficial to clinical work•describe the basic structure of the interpersonal dynamics consultation, including the four interpersonal perspectives•recognise the types of cases where interpersonal dynamics consultation might be most useful.DECLARATION OF INTERESTNone.

We had previously experienced a case involving prolonged cardiopulmonary resuscitation (CPR) on Mt. Fuji (3776 m), demanding strenuous work by the rescuers. The objective of this study was to compare the effect of compression-only and conventional CPR on oxygen saturation of rescuers in a hypoxemic environment.Changes in percutaneous arterial oxygen saturation (SpO2) and heart rate during CPR action were measured in a hypobaric chamber with barometric pressure adjusted to be equivalent to 3700 m above sea level (630–640 hPa). Thirty-three volunteers performed CPR with or without breaths using a CPR mannequin.In a 3700-m-equivalent environment, SpO2 was reduced only when CPR was performed without breaths (P < .05, one-way analysis of variance (ANOVA) post hoc Tukey test). Heart rate increased during CPR regardless of the presence or absence of breaths. Mean scores on the Borg scale, a subjective measure of fatigue, after CPR action in the 3700-m-equivalent environment were significantly higher (15 ± 2) than scores after CPR performed at sea level (11 ± 2, P < .01, paired t-test). No lethal dysrhythmia was found in subjects with a wearable electrode shirt.Prolonged CPR at high altitude exerts a significant physical effect upon the condition of rescuers. Compression-only CPR at high altitude may deteriorate rescuer oxygenation, whereas CPR with breaths might ameliorate such deterioration.

ObjectivesDesaturation leading to hypoxemia may occur during rapid sequence intubation (RSI). Apneic oxygenation (AO) was developed to prevent the occurrence of oxygen desaturation during the apnea period. The purpose of this study was to determine if the application of AO increases the average lowest oxygen saturation during RSI when compared to usual care (UC) in the emergency setting. MethodsA randomized controlled trial was conducted at an academic, urban, Level I trauma center. All patients requiring intubation were included. Exclusion criteria were patients in cardiac or traumatic arrest or if preoxygenation was not performed. An observer, blinded to study outcomes and who was not involved in the procedure, recorded all times, while all saturations were recorded in real time by monitors on a secured server. Two-hundred patients were allocated to receive AO (n = 100) or UC (n = 100) by predetermined randomization in a 1:1 ratio. ResultsA total of 206 patients were enrolled. There was no difference in lowest mean oxygen saturation between the two groups (92, 95% confidence interval [CI] = 91 to 93 in AO vs. 93, 95% CI = 92 to 94 in UC; p = 0.11). ConclusionThere was no difference in lowest mean oxygen saturation between the two groups. The application of AO during RSI did not prevent desaturation of patients in this study population.

Purpose: To assess the movement of rectum, mesorectum, and rectal primary during a course of preoperative chemoradiotherapy.Methods and Materials: Seventeen patients with Stage II or III rectal cancer had a planning CT scan with rectal contrast before commencement of preoperative chemoradiation. The scan was repeated during Weeks 1, 3, and 5 of chemoradiation. The rectal primary (gross tumor volume), rectum, mesorectum, and bladder were contoured on all four scans. An in-house biomechanical model-based deformable image registration technique, Morfeus, was used to measure the three-dimensional spatial change in these structures after bony alignment. The required planning target volume margin for this spatial change, after bone alignment, was also calculated.Results: Rectal contrast was found to introduce a systematic error in the position of all organs compared with the noncontrast state. The largest change in structures during radiotherapy was in the anterior and posterior directions for the mesorectum and rectum and in the superior and inferior directions for the gross tumor volume. The planning target volume margins required for internal movement for the mesorectum based on the three scans acquired during treatment are 4 mm right, 5 mm left, 7 mm anterior, and 6 mm posterior. For the rectum, values were 8 mm duright, 8 mm left, 8 mm anterior, and 9 nun posterior. The greatest movement of the rectum occurred in the upper third.Conclusions: Contrast is no longer used in CT simulation. Assuming bony alignment, a nonuniform margin of 8 mm anteriorly, 9 mm posteriorly, and 8 mm left and right is recommended. (C) 2011 Elsevier Inc.