Research (Articles)

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Cystic fibrosis in Pakistan : population harbouring rare variants non-responsive to CFTR modulators and the dilemma of poor health facilities
(Springer, 2025-01-24) Safdar, Anum; Ghani, Muhammad Usman; Bano, Iqbal; Mehmood, Tahir; Rafique, Hassan; Sabar, Muhammad Farooq; Akbar, Ali; Shaikh, Rehan Sadiq; University of the Punjab; University of Child Health Science Lahore; Centre for Applied Molecular Biology; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; Akbar, Ali
Background: Pathogenic mutations in the CFTR gene disrupt the normal function of the chloride ion channel CFTR protein, resulting in Cystic Fibrosis (C.F.). Pakistan's situation regarding C.F. mutation is largely unknown, complicating the disease management and treatment. This study is designed to identify the disease-causing CFTR mutations in the Pakistani C.F. cohort and perform an in silico analysis of rare/novel variants. Methodology: Ninety-five C.F. patients were recruited from pediatric healthcare facilities in different regions of Pakistan. Initially, we investigated ∆F508 mutation in all patients, followed by whole exome sequencing (W.E.S.) of nineteen patients and in silico analysis of identified rare/novel mutations. Results and discussion: Initial screening revealed that ∆F508 mutation was absent in 73.74% of cases. W.E.S. identified three novel variants (c.3036del/Q1012Hfs*11, c.488 A > T/p.K163M, c.2384del/S795Yfs*8), one rare variant (c.489 + 2T > C) previously reported in two Pakistani residing in U.K. and one (c.164 + 1G > T/p.?) extremely rare in other populations. Additionally, c.1705T > G/p.Y569D, c.653T > A/p.L218X, c.2125 C > T/p.R709X, and c.3484 C > T/p.R1162X were also identified. Most variants in our cohort are either frameshift or nonsense, while only two are missense variants. Alarmingly, most of these variants, except ∆F508, are non-responsive to modulator drugs, while the responsiveness of c.488 A > T/p.K163M is yet to be determined. High consanguinity (73.40%) and homozygous status of all mutations, except c.3036del/Q1012Hfs*11, are indicative of a high ratio of C.F. carriers in Pakistan. Conclusion: These findings represent the diverse pattern of CFTR mutations within the Pakistani population, highlighting the imperative need to improve earlier C.F. diagnostic and management facilities and to conduct research on treatment strategies other than modulator therapies.
An observation of two NHS trusts' use of organisational wellbeing interventions during the COVID-19 pandemic : lessons learnt
(Elsevier, 2024-11-20) Vijay Kumar, Varun; Deighton, Alexander; Kleyn, C Elise; Sandwell and West Birmingham NHS Trust; Barts Health NHS Trust; The University of Manchester; Acute Medicine; Medical and Dental; Vijay Kumar, Varun
Background: Healthcare workers' (HW') mental health during pandemics may be challenged due to the demands of their professional work. There is a need for effective organisational wellbeing strategies so that HW' mental health is safeguarded. In this article, we sought to examine approaches to implementing wellbeing strategies in hospital trusts, which we hope will improve future workplace planning. Methods: A pilot study comprising semi-structured interviews with five management staff in two NHS trusts (which employ approximately 5,000 staff each) in north-west England (NWE) were conducted to investigate and compare how COVID-19 impacted HW' mental health and what wellbeing strategies were implemented. Results: Lack of guidance and communication, redeployment, fatigue, post-traumatic stress disorder (PTSD) and fear of infection were common stress factors. We identified that both trusts had implemented psychological support, and usage of online resources as well as providing adequate personal protective equipment (PPE). Trust A uniquely implemented psychological screening tools to identify vulnerable HWs, whereas trust B placed an emphasis more on offering practical support to HW. Conclusion: It is likely that a whole-systems approach to improve organisational culture and reduce stigma around accessing support would be beneficial to HW wellbeing. Further research is required to optimise this support for NHS staff.
Evaluating the role of simple assistive devices in promoting motivation and self-care in chronic disease management
(Elsevier, 2025-03-01) Kulkarni, Sanat; Chockalingam, Nachiappan; Chambers, Ruth; Poulose, Pegin; Suresh, Shamita; Thileepan, Laxmi; Nachiappan, Nitish; University of Oxford; University of Malta; Keele University; Sandwell and West Birmingham NHS Trust; et al.; Medicine; Medical and Dental; Nachiappan, Nitish
Objective: This study evaluates the development and distribution of simple assistive devices designed to support individuals in managing their health conditions at home. The focus is on older adults from lower socio-economic groups in Stoke-on-Trent and Newcastle-under-Lyme, UK. Methods: Assistive kits were distributed to participants between December 2021 and April 2022, addressing weight management, diabetic foot care, mental wellbeing, and daily living independence. Each kit contained affordable and accessible assistive devices, including portion plates, exercise bands, and remote-operated plugs, alongside educational materials to promote self-care. Feedback was collected between March and June 2022 to assess user satisfaction and engagement. A qualitative analysis, informed by self-determination theory, explored how these kits supported autonomy, competence, and relatedness in self-management. Results: Over 90 % of recipients reported using the kits more than once weekly and an increased confidence in managing their health conditions independently. Qualitative analysis indicated that the kits facilitated motivation towards self-management by enhancing users' autonomy, competence, and social connectedness. However, barriers such as cost, availability, and lack of support were identified as limiting factors for broader adoption. Conclusions: This study highlights the potential of affordable, simple assistive devices to empower individuals in managing their health and wellbeing. The initiative demonstrates a promising approach to addressing health management challenges in lower socio-economic groups. Further research is needed to expand access and refine interventions to maximise impact and improve quality of life.
Single best answer questions as a teaching tool in medical education : an international mixed-method comparative evaluation
(Springer, 2024-09-19) Zegugu, Moemen; Chatoo, Saif Abbas; Choudhry, Anam; Metezai, Huria; Usman, Danyal; Kamal, Mohammad; El Badawey, Abdullah; Swansea University Health Board; Royal Free London NHS Trust; Oxford University Hospitals NHS Foundation Trust; Sandwell and West Birmingham NHS Trust; et al.; Internal Medicine; Medical and Dental; Kamal, Mohammad
Introduction Single Best Answer questions are an established assessment format in medical education, however, their use as a teaching tool is underexplored in the literature. We aimed to assess the effectiveness and impact of implementing Single Best Answer (SBA) questions into lecture teaching, compared to standard lectures. Methods This evaluation utilised a mixed-method retrospective approach, combining quantitative and qualitative analysis of routine teaching feedback. Over a 2-year period, 10 standard teaching sessions were initially conducted, followed by the development of 43 SBA teaching sessions aimed at improving teaching delivery. Students completed anonymised questionnaires voluntarily after each teaching session (n=3,814 in teaching with SBAs; n=868 in teaching without SBAs). Quantitative data was compared using Welch's t-test. Statistical analysis was completed using the SPSS version 26.0 software (IBM Corp., Armonk, USA), with p < 0.05 considered statistically significant. Results The mean perceived confidence increase in topics before and after teaching was significantly higher with the SBA lecture compared to the standard lecture teaching group (1.32 ± 0.14, 1.07 ± 0.12 respectively; p < 0.001). Engagement levels were significantly higher in the SBA lecture compared to the standard lecture group (4.55 ± 0.12, 4.21 ± 0.15 respectively; p < 0.001). Qualitative data supported these results. Conclusion Single Best Answer question use significantly improved student perceived learning outcomes and engagement, indicating its higher efficacy as a teaching tool in our educational programme. This evaluation highlights the potential use of SBA questions to enhance learning in medical education, further studies and testing methods are required to support its wider generalisability.
What is the impact of leaders with emotional intelligence on proxy performance metrics in 21st century healthcare? - a systematic literature review
(MDPI, 2024-11-18) Chaudry, Aisha; Hussain, Parisah Maham; Halari, Simran; Thakor, Sohini; Sivapalan, Aran; Ikar, Abdul; Okhiria, Terrell; Meyer, Edgar; Hull University Teaching Hospitals NHS Trust; Royal Free London NHS Foundation Trust; Chelsea and Westminster Hospital NHS Foundation Trust; Sandwell and West Birmingham NHS Trust; et al.; Medicine; Medical and Dental; Thakor, Sohini
Emotional intelligence (EQ) in healthcare leadership has been a subject of debate regarding its significance in enhancing job performance and patient-centred care. This systematic review investigates the impact of EQ on organisational performance metrics in healthcare leaders. Eleven studies meeting the inclusion criteria were identified through a comprehensive database search. The findings suggest that EQ positively influences job satisfaction, with emotionally intelligent leaders fostering a positive work environment and commitment among employees. Moreover, EQ correlates negatively with emotional exhaustion, indicating its potential in mitigating burnout rates among healthcare professionals. EQ fosters teamwork, organisational culture and enhances job performance, with higher EQ levels in leaders associated with increased team empowerment and proactivity. Despite the compelling evidence, limitations in the study methodologies and heterogeneity in the reported outcomes challenge the establishment of definitive conclusions. Nevertheless, the findings underscore the importance of EQ in healthcare leadership and its potential to improve organisational dynamics and employee wellbeing. This review highlights the need for further research on EQ's impact on patient satisfaction and calls for the development of EQ training programmes tailored for healthcare leaders.
Evaluating the Impact of a virtual skin cancer awareness workshop for 16-19-Year-olds
(Springer, 2024-11-28) Dyson, Maya; Corriero, Anna; Sandwell and West Birmingham NHS Trust; NHS Lothian; Internal Medicine; Medical and Dental; Dyson, Maya
Introduction The incidence of malignant melanoma (MM) in the United Kingdom (UK) has significantly increased in recent years and is expected to continue to rise over the next decade. Despite the preventable nature of most MM cases, existing evidence suggests that public health education around skin cancer and sun safety is often suboptimal, particularly for secondary school populations. Unlike primary school curricula, there is no national guidance to mandate the teaching of this topic in secondary school. Early intervention through education can encourage sun-safe practices, and therefore potentially reduce the risk of MM developing. The primary aim of this study was to improve awareness of skin cancer, including its risk factors and preventive measures, amongst sixth-form students. Methods An online workshop was organised by In2MedSchool, a national widening access charitable scheme for aspiring medical students, in collaboration with the Karen Clifford Skin Cancer Charity. Plan-Do-Study-Act methodology was utilised to design and evaluate a skin cancer awareness and sun safety workshop. It addressed key topics such as MM risk factors, preventive measures, and the widely used 'ABCDE' assessment of MM. A total of 73 students from across the UK attended the virtual workshop. To maximise engagement, visual aids, low-stakes quizzing, and an interactive chat function were utilised. Participants completed anonymous pre- and post-intervention questionnaires, assessing their confidence and knowledge in understanding skin cancer risk factors and sun-safe behaviours. Confidence levels were measured using a seven-point Likert scale, and knowledge was evaluated through a ten-question assessment. Statistical analyses, including averages, medians, interquartile ranges (IQR), and Wilcoxon signed-rank tests were performed to assess the changes in participants' knowledge and confidence. Results Before the intervention, participants reported an average confidence score of 4.07 in understanding skin cancer risk factors, which significantly improved to 6.39 after the workshop, representing a 57.09% increase (p < 0.00001). Confidence in applying protective measures increased by 45.67%, from 4.51 to 6.57 (p < 0.00001). In addition, most students expressed feeling underprepared by existing sun safety programs at both primary and secondary school levels. Knowledge assessments demonstrated significant improvement, with average scores increasing from 7.49 pre-intervention to 9.10 post-intervention (21.46% improvement, p < 0.00001). The median score increased from 8 (IQR: 3) to 9 (IQR: 1) following the workshop, demonstrating a notable increase in understanding of skin cancer risk factors, protective behaviours, and early detection methods. Conclusion Our findings indicate that many secondary school students feel unprepared regarding existing skin cancer awareness and sun safety programs in school. This study provides evidence to suggest that targeted, interactive workshops have the potential to improve awareness and knowledge of this important topic in the short term. However, participants in this cohort are likely to have an established interest in medicine and healthcare, beyond that of their wider peer group. This limits the broader application of our findings. Further research that explores the longer-term impact of such interventions, including changes in attitudes and behaviours, is recommended.
An unusual case of Haemophilus influenzae associated Polyarthritis : diagnostic and therapeutic challenges in concurrent septic and reactive arthritis
(Springer, 2024-11-07) Chohan, Ashrit; Qureshi, Maahi; HUDA, MAINUL; Thozhuthumparambil, Karunakaran Pradeep; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; Chohan, Ashrit; Qureshi, Maahi; Huda, Mainul; Karunakaran Thozhuthumparambil, Pradeep
Septic arthritis and reactive arthritis are both recognized as distinct causes of swollen joints; however, they can, at times, overlap as causes of acute polyarthritis. Septic arthritis is an orthopedic emergency, typically caused by bacterial infection, and requires urgent antibiotic treatment and joint drainage to prevent irreversible joint damage. In contrast, reactive arthritis is a sterile, immune-mediated arthritis that occurs following infections and is managed with anti-inflammatory treatments such as corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs). We report the case of a 47-year-old, previously healthy male presenting with acute severe polyarthritis, including both large and small joints, fever, and flu-like symptoms. Blood cultures were positive for Haemophilus influenzae, leading to targeted antibiotic treatment for septicemia. However, given the rapid progression of asymmetrical polyarthralgia and systemic features, reactive arthritis was also suspected, and corticosteroids were commenced. Despite this, persistent fever and worsening joint symptoms raised concerns for septic arthritis in the left knee. Arthroscopy of the left knee revealed synovitis; however, the joint fluid culture was sterile on culture. Ultimately, polymerase chain reaction (PCR) of the fluid confirmed Haemophilus influenzae septic arthritis. Steroids were discontinued, and arthroscopic washout alongside targeted antibiotic therapy led to improved symptoms and inflammatory markers. However, despite gradual clinical improvement, the patient continued to have persistent polyarthralgia, raising the possibility of concurrent reactive polyarthritis alongside septic arthritis. On follow-up, rheumatology is managing chronic reactive arthritis. This case underscores the diagnostic challenges in distinguishing septic arthritis from reactive arthritis in atypical presentations, such as H. influenzae infection. Concurrent arthropathies must also be considered, and no guidelines have been found to address this possibility. This raises the challenge of implementing conflicting therapies, such as corticosteroids for reactive arthritis, that could potentially worsen septic arthritis outcomes. Recognizing the potential consequence of sepsis and septic arthritis, early antibiotic therapy was initiated. Furthermore, a persistent suspicion of septic arthritis, even in the presence of features suggestive of reactive arthritis, led to diagnosis and effective treatment. Further evidence-based guidelines are needed to aid clinicians in managing two or more co-presenting arthropathies.
Provision of acute medicine services for pregnant women in UK hospitals: Data from the Society for Acute Medicine Benchmarking Audit 2019.
(SAGE Publications, 2020-06-23) Atkin, Catherine; Prinja, Paarul; Banerjee, Anita; Holland, Mark; Lasserson, Dan; Sandwell and West Birmingham NHS Trust; University of Birmingham; Royal Wolverhampton NHS Trust; Sandwell and West Birmingham NHS Trust; Medical and Dental; Lasserson, Dan
Background: Medical problems during pregnancy are the leading cause of maternal mortality in the UK. Pregnant women often present through acute services to the medical team, requiring timely access to appropriate services, physicians trained to manage medical problems in pregnancy, with locally agreed guidance available. Methods: Data were collected through the Society for Acute Medicine Benchmarking Audit, a national audit of service delivery and patient care in acute medicine over a 24 hour period. Results: One hundred and thirty hospitals participated: 5.5% had an acute medicine consultant trained in obstetric medicine, and 38% of hospitals had a named lead for maternal medicine. This was not related to hospital size (p = 0.313). Sixty-four units had local guidelines for medical problems in pregnancy; 43% had a local guideline for venous thromboembolism in pregnancy. Centres with a named lead had more guidelines (p = 0.019). Conclusion: Current provision of services within acute medicine for pregnant women does not meet national recommendations.
Sleep is the best medicine: How rest facilities and EnergyPods can improve staff wellbeing.
(Elsevier, 2021-11-08) Dore, Eoin; Guerero, Daniel; Wallbridge, Thomas; Holden, Angela; Anwar, Mehreen; Eastaugh, Alison; Desai, David; Clare, Sarbjit; Sandwell and West Birmingham NHS Trust; Sandwell and West Birmingham NHS Trust; Medical and Dental; Dore, Eoin; Guerero, Daniel; Wallbridge, Thomas; Holden, Angela; Anwar, Mehreen; Eastaugh, Alison; Desai, David; Clare, Sarbjit
Introduction: Healthcare workers' wellbeing is critical to the NHS. Night shifts have a big impact on their physical and mental health. Recently there has been national funding for rest facilities. Methods: An EnergyPod was installed in the acute medical unit. The study comprised two surveys: one quantitative survey performed prior to the pod introduction and repeated 3 months after; and one qualitative survey performed immediately after pod use. Results: We observed more staff taking breaks of 30 minutes after the pod introduction (37% before vs 69% after). Of users, 81% felt more alert and 83% were more energised. Half of the respondents felt more able to drive after use.The feedback showed three themes: appreciation of designated space away from clinical areas, relaxation and improved interdisciplinary cohesion. Conclusion: We have shown consistent data that rest is important for wellbeing. We recommend the use of EnergyPods in high acuity areas.
Surgical management of a giant abdominal wall desmoid tumour.
(BMJ Publishing Group, 2021-09-03) Patel, Nandesh; Slivkova, Ralitsa; James, Sunil; Almond, Max; Sandwell and West Birmingham NHS Trust; University Hospitals Birmingham NHS Foundation Trust; Sandwell and West Birmingham NHS Trust; Medical and Dental; Patel, Nandesh; Ralitsa, Slivkova; James, Sunil
Desmoid tumours are clonal fibroblastic proliferations in soft tissues, characterised by infiltrative growth and local recurrence, but not metastasis. Various treatment strategies for desmoid tumours exist, varying from observation, medical and systemic therapy to radiotherapy and surgery. A 25-year-old woman with a background of familial adenomatous polyposis was referred with an enlarging abdominal desmoid tumour measuring 40×40×40 cm despite repeated radiofrequency ablation, surgical debulking and hormone therapy. The patient had a two-stage operation. The first stage involved excision of the desmoid tumour with full-thickness abdominal wall. The abdominal wall was not closed, and a topical negative pressure seal was applied. After 2 days, she underwent the second stage: reconstruction of the abdominal wall defect with a large porcine mesh which was covered with anterolateral thigh flaps. Postoperative complications included ileus and a fall which required further surgery. The patient was discharged 1 month after the first operation. Abdominal MRI scans were performed at 3 and 7 months postdischarge and showed no recurrence of diseaseBackground.
The provision of hospital at home care: Results of a national survey of UK hospitals
(Hindawi, 2021-10-11) Knight, Thomas; Harris, Ciara; Mas, Miquel À.; Shental, Omri; Ellis, Graham; Lasserson, Daniel; Sandwell and West Birmingham NHS Trust; University of Birmingham; Oxford University Hospitals NHS Foundation Trust; Sandwell and West Birmingham NHS Trust; Medical and Dental; Harris, Ciara; Knight, Thomas
Background: Hospital at home (HaH) replicates elements of hospital-based care in the community, to facilitate the safe management of a broad spectrum of acute illness in the patient's usual environment. The extent to which this model of care has been adopted in the United Kingdom is unknown. Methods: The Society for Acute Medicine Benchmarking Audit is a day of care survey undertaken annually within the United Kingdom. Participation is open to all hospital in the United Kingdom receiving acutely unwell medical patients. A questionnaire is used to collect hospital-level data on the structure and organisation of acute care delivery. The survey included questions designed to quantify the number of hospitals that offered HaH. When present, further questions were asked to clarify the characteristics of the HaH service in terms of workforce, range of diagnostic test and interventions. This information was used to build a picture of HaH service provision on a national scale. Results: A total of 130 hospitals contributed organisational data to SAMBA19. The capability to refer to a hospital at home service was recognised by 46.9% (n = 61) of units. The majority of these services, 83.3% (n = 50) were nurse-led. The capability to provide a physician review at home was reported in 23.3% (n = 14). The majority of services could provide intravenous antibiotics at home, but access to other simple interventions, such as intravenous diuretics or acute supplemental oxygen, is limited. Conclusion: At present, few acute hospitals for consitency in the United Kingdom have access to a hospital at home service capable of replicating essential elements of inpatient care. Our study suggests organisational change in acute care delivery and significant investment would be required to establish equal access to hospital-at-home care within the United Kingdom.
Fatal case of delayed-onset haemolytic anaemia after oral artemether-lumefantrine.
(BMJ Publishing Group, 2021-11-19) Gustafsson, Lotta; James, Sunil; Zhang, Yimeng; Thozhuthumparambil, Karunakaran Pradeep; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; Gustafsson, Lotta; James, Sunil; Zhang, Yimeng; Thozhuthumparambil, Karunakaran Pradeep.
Artemisinin derivatives are used globally in the management of falciparum malaria. Postartemisinin delayed haemolysis (PADH) is a recognised adverse event contributing to severe anaemia. To the best of our knowledge, we report the first recorded fatal case of PADH. A 60-year-old woman presented with two episodes of collapse at home and feeling generally unwell. She had recently been treated for uncomplicated falciparum malaria 1 month prior with artemether 80 mg/lumefantrine 480 mg in Congo. Her results on admission revealed an anaemia (haemoglobin 43 g/L), raised lactate dehydrogenase and positive direct antiglobulin test that suggested an intravascular haemolytic process. She made a capacitous decision to refuse blood products in line with her personal beliefs. Despite best supportive treatment, she did not survive. This case highlights the importance of postartemisinin follow-up and should encourage discussion and careful consideration of its use in the context of lack of access to/patient refusal of blood products.
Poly (ADP-ribose) polymerase inhibitor therapy and mechanisms of resistance in epithelial ovarian cancer
(Frontiers Media, 2024-07-29) Kulkarni, Sanat; Gajjar, Ketankumar; Madhusudan, Srinivasan; Sandwell and West Birmingham NHS Trust; University of Birmingham; Nottingham University Hospitals; University of Nottingham; Acute Medicine; Medical and Dental; Kulkarni, Sanat
Advanced epithelial ovarian cancer is the commonest cause of gynaecological cancer deaths. First-line treatment for advanced disease includes a combination of platinum-taxane chemotherapy (post-operatively or peri-operatively) and maximal debulking surgery whenever feasible. Initial response rate to chemotherapy is high (up to 80%) but most patients will develop recurrence (approximately 70-90%) and succumb to the disease. Recently, poly-ADP-ribose polymerase (PARP) inhibition (by drugs such as Olaparib, Niraparib or Rucaparib) directed synthetic lethality approach in BRCA germline mutant or platinum sensitive disease has generated real hope for patients. PARP inhibitor (PARPi) maintenance therapy can prolong survival but therapeutic response is not sustained due to intrinsic or acquired secondary resistance to PARPi therapy. Reversion of BRCA1/2 mutation can lead to clinical PARPi resistance in BRCA-germline mutated ovarian cancer. However, in the more common platinum sensitive sporadic HGSOC, the clinical mechanisms of development of PARPi resistance remains to be defined. Here we provide a comprehensive review of the current status of PARPi and the mechanisms of resistance to therapy.
Thyrotoxic periodic paralysis : a case report with patient perspective
(Rila, 2024) Baranskaya, Aliaksandra; Zhang, Yimeng; Lee, Brian; Sandwell and West Birmingham NHS Trust; Acute Medical Unit; Medical and Dental; Baranskaya, Aliaksandra; Zhang, Yimeng; Lee, Brian
We present a case report on a spot diagnosis of Thyrotoxic Periodic Paralysis (TPP) with a unique first-person account of events from the patient. It illustrates the importance of pattern recognition and exemplifies how timely treatment enables quick resolution of a life-threatening medical emergency. Patient X's account affirms the condition's insidious onset and rapid deterioration. This case highlights the need for raising awareness of diseases that are more prevalent in specific ethnic groups and is particularly crucial for work in culturally diverse environments. We hope by sharing our experience, readers will be prompted to consider TPP as a differential diagnosis for acute limb weakness in an acute setting; with prompt testing of thyroid function and initiation of the appropriate treatments.
Cat scratch disease sepsis in an immunocompromised patient.
(BMJ Publishing Group, 2021-07-13) James, Sunil; Thozhuthumparambil, Karunakaran Pradeep; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; James, Sunil; Thozhuthumparambil, Karunakaran Pradeep.
As a greater number of households have pets, the likelihood of zoonotic infections can rise too. Although in most healthy individuals these infections are self-limiting, they are more serious and can lead to adverse outcomes in the immunocompromised. There is minimal information available for the immunocompromised patient who are pet owners or on pet handling. We report a case of cat scratch disease-related sepsis in an immunocompromised patient. This case illustrates the need for a detailed history, including a pet history, in immunocompromised patients presenting with fever of unknown origin and the need for UK-based information for the immunocompromised on pet care and risks associated with having a pet.
'From highs to lows : a cautionary tale of nitrous oxide recreational use leading to sub-acute combined degeneration of the cord'
(Oxford University Press, 2024-07-13) Osman, Ayman; Yousif, Dalia; Hickman, Simon; Branagh, William; Bolton NHS Foundation Trust; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; Yousif, Dalia
Background: Several causes lead to subacute combined degeneration (SACD) of the spinal cord, with nitrous oxide (N2O) inhalation rapidly emerging as the leading cause of functional Vitamin B12 deficiency [1]. Case presentation: A 28-year-old man presented with numbness in the extremities and an unstable gait despite having a normal serum Vitamin B12 level. He also disclosed the recreational abuse of N2O. Magnetic Resonance Imaging (MRI) of the cervical spine revealed abnormal signals consistent with SACD. The patient's condition gradually improved after treatment with high dose Vitamin B12. Given the increasing number of N2O-induced SACD cases, the potential for drug abuse requires vigilance from clinicians. Conclusion: Healthcare providers are urged to inquire about a patient's history of N2O inhalation to prevent the missed diagnosis of SACD.
Brainstem stroke presenting as isolated bilateral ptosis.
(BMJ Publishing Group, 2021-07-12) James, Sunil; Thozhuthumparambil, Karunakaran Pradeep; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; James, Sunil; Thozhuthumparambil, Karunakaran Pradeep.
Pure midbrain infarctions not involving surrounding structures are an uncommon clinical phenomenon. A midbrain infarction that results in isolated bilateral ptosis as the only neurological deficit is much rarer and an easy diagnosis to miss; therefore, potentially leading to further downstream complications. We describe the case of an elderly patient who presented with isolated bilateral ptosis, initially thought to be consequent to myasthenia gravis but subsequently identified to have a perforator infarct in the midbrain, resulting in his symptoms.
Bilateral optic disc swelling resulting from lymphocytic meningitis and posterior uveitis secondary to syphilis.
(BMJ Publishing Group, 2021-05-19) James, Sunil; Thozhuthumparambil, Karunakaran Pradeep; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; James, Sunil; Thozhuthumparambil, Karunakaran Pradeep.
Idiopathic intracranial hypertension (IIH) is being diagnosed more often in the UK due to the rise in obesity. In fact, patients who present with bilateral optic disc swelling are habitually put on the papilloedema pathway, often without consideration of other diagnoses. We report the case of a middle-aged woman diagnosed with papilloedema and managed as IIH, until, cerebrospinal fluid (CSF) analysis revealed evidence of lymphocytic meningitis secondary to syphilis. The patient was treated successfully with intravenous antibiotics. Syphilis is the great masquerader and should be a diagnosis to consider in patients who have CSF findings incongruent with their clinical presentation.
Azithromycin versus standard care in patients with mild-to-moderate COVID-19 (ATOMIC2): an open-label, randomised trial.
(Elsevier, 2021-07-09) Hinks, Timothy S C; Cureton, Lucy; Knight, Ruth; Wang, Ariel; Cane, Jennifer L; Barber, Vicki S; Black, Joanna; Dutton, Susan J; Melhorn, James; Jabeen, Maisha; Moss, Phil; Garlapati, Rajendar; Baron, Tanya; Johnson, Graham; Cantle, Fleur; Clarke, David; Elkhodair, Samer; Underwood, Jonathan; Lasserson, Daniel; Pavord, Ian D; Morgan, Sophie; Richards, Duncan; University of Oxford; University Hospital Llandough; St George's Hospital; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; Lasserson, Daniel
Background: The antibacterial, anti-inflammatory, and antiviral properties of azithromycin suggest therapeutic potential against COVID-19. Randomised data in mild-to-moderate disease are not available. We assessed whether azithromycin is effective in reducing hospital admission in patients with mild-to-moderate COVID-19. Methods: This prospective, open-label, randomised superiority trial was done at 19 hospitals in the UK. We enrolled adults aged at least 18 years presenting to hospitals with clinically diagnosed, highly probable or confirmed COVID-19 infection, with fewer than 14 days of symptoms, who were considered suitable for initial ambulatory management. Patients were randomly assigned (1:1) to azithromycin (500 mg once daily orally for 14 days) plus standard care or to standard care alone. The primary outcome was death or hospital admission from any cause over the 28 days from randomisation. The primary and safety outcomes were assessed according to the intention-to-treat principle. This trial is registered at ClinicalTrials.gov (NCT04381962) and recruitment is closed. Findings: 298 participants were enrolled from June 3, 2020, to Jan 29, 2021. Three participants withdrew consent and requested removal of all data, and three further participants withdrew consent after randomisation, thus, the primary outcome was assessed in 292 participants (145 in the azithromycin group and 147 in the standard care group). The mean age of the participants was 45·9 years (SD 14·9). 15 (10%) participants in the azithromycin group and 17 (12%) in the standard care group were admitted to hospital or died during the study (adjusted OR 0·91 [95% CI 0·43-1·92], p=0·80). No serious adverse events were reported. Interpretation: In patients with mild-to-moderate COVID-19 managed without hospital admission, adding azithromycin to standard care treatment did not reduce the risk of subsequent hospital admission or death. Our findings do not support the use of azithromycin in patients with mild-to-moderate COVID-19.
Banter within the NHS : a tool for boosting morale or a front for workplace bullying?
(Elsevier, 2024-06) Dicks-Ilori, Lucy; Morgan, Marianne; Yuan, Mengshi; Clare, Sarbjit; Sandwell and West Birmingham NHS Trust; Acute Medicine; Medical and Dental; Dicks-Ilori, Lucy; Morgan, Marianne; Yuan, Mengshi; Clare, Sarbjit
Workplace humour, such as banter between colleagues, is a widespread means of developing relationships and relieving daily work stresses. Despite this, banter in the workplace is a prevalent theme of harassment and bullying claims. With staff morale at an all-time low among NHS employees, efforts must be made to identify and rectify issues which work to damage staff experiences within the organisation. We aimed to explore both the positive and negative impacts of banter on NHS staff well-being. We discuss the role of staff training on the appropriate use of workplace humour, with reference to a workshop delivered to NHS employees, educating them on the appropriate use of banter.

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