RSS 1.0Medicine and Emergency Care
Sub-communities within this community
Recent Submissions
-
Evaluating the role of simple assistive devices in promoting motivation and self-care in chronic disease managementObjective: 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.
-
A case series of ibogaine toxicity reported to the United Kingdom National Poisons Information Service (NPIS) over a 10-year periodIntroduction: Ibogaine is a psychoactive alkaloid derived from the root bark of the West African shrub Tabernanthe iboga. It is not licensed in the United Kingdom but is used by individuals to alleviate drug or alcohol use. Methods: A retrospective analysis of telephone enquiries involving ibogaine between 1 January 2012 and 31 December 2022 to the United Kingdom National Poisons Information Service was performed. Case series: Eleven enquiries relating to seven patients were made to the United Kingdom National Poisons Information Service in this period. Five of these patients were male (71%) with the majority in the age category 31-40 years (57%). All patients presented symptomatically. The circumstances for all seven cases were recorded as "recreational abuse." The exact indication was not specified in three cases but in two cases it was being used to alleviate diacetylmorphine (heroin) use and in another two cases it was being used for relief from insomnia. Three sources of ibogaine were reported - in one case it was bought online, in one case by a dealer and in two cases it was bought from a shaman. When reported, the dose ingested ranged from 5g to 34g. Two patients took it in tablet form and four patients ingested the root bark. The time since exposure, when reported, ranged from 16 h to 1 month. Seven patients experienced neurological symptoms and six displayed features of cardiotoxicity. The most frequently reported features included cardiac arrest, hypoxia, torsade de pointes, QT interval prolongation, coma, convulsions, stupor, bradycardia, vomiting and anxiety. Conclusions: Individuals using ibogaine in variable doses to self-treat for drug use are at risk of developing severe cardiotoxicity and neurological symptoms. Further studies to quantify dose-response relationship and to further improve knowledge of its pharmacokinetics are required.
-
Impact of introducing transnasal endoscopy on expanding diagnostic endoscopy servicesIntroduction: Demand for endoscopic services is outstripping capacity in the UK. Transnasal endoscopy (TNE) utilises a narrow calibre endoscope to pass through the nasal passages, thereby reducing retching and discomfort. It is better tolerated compared with standard transoral endoscopy (TOE) but is still rarely used as a diagnostic modality. There is still uncertainty about how well it performs against TOE in diagnostic ability, cost and efficiency. Methods: We explored utilising TNE to deal with the growing demand for endoscopy. We compared findings to TOE procedures undertaken during the same time period. We evaluated cost differences, duration/time in the department for procedures as well as quality of procedures (both in terms of performance indicators as well as image quality using the validated POLPREP score). Results: A total of 241 upper gastrointestinal endoscopy procedures were evaluated (100 TNE and 141 matched TOE) between December 2021 and February 2022. TNE outperformed TOE in obtaining >95% success rate in nationally approved key performance indicators (retroflexion and duodenal intubation, both p=0.026). It also was associated with better image quality in the oesophagus with a POLPREP A3 Score (excellent image quality) in 36/98 available images compared with 26/136 TOE (p=0.028) and was equivalent to TOE in the stomach and duodenum. TNE was identified as having a key role in facilitating complex cases, previously failed via the TOE route with a success rate in 11/12 (91.7%) of such cases. TNE also shows promise in correcting misdiagnoses of short-segment Barrett's oesophagus (39%) compared with TOE (14.8%) (p=0.087). Conclusion: TNE is an emerging endoscopic modality, which shows great promise in replacing TOE in most diagnostic circumstances. In a modern healthcare service, TNE is cheaper, better tolerated and outperforms TOE in multiple domains.
-
Single best answer questions as a teaching tool in medical education : an international mixed-method comparative evaluationIntroduction 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.
-
The risk of Venous Thromboembolism in children with Inflammatory Bowel DiseaseBackground: Recent studies of children with inflammatory bowel disease (IBD) demonstrate an increased venous thromboembolism (VTE) risk. However, estimates of risk are variable and case numbers are limited. The aim of this study was to provide national estimates of the risk of VTE in children with IBD. Methods: Hospital Episode Statistics was used to identify patients diagnosed with either IBD or VTE before reaching 18 years of age between 2001 and 2019. Populations and subgroups are described, and the risks of developing VTE in the general and IBD populations were calculated. Results: Children with VTE following a diagnosis of IBD or in the previous 6 months (n = 85) and with VTE without IBD (n = 4160) were studied. The absolute risk in children with IBD was 9.42 (95% confidence interval [CI], 7.4-11.4) per 10 000 patient-years, compared with 0.18 (95% CI, 18-0.19) in children without IBD. Between 6 months prior to and 1 year following IBD diagnosis was the highest absolute risk period for VTE (18.0; 95% CI, 13.7-22.4). The relative risk of VTE in children with IBD vs children without IBD was greatest in younger patient groups: the relative risk for the age band 0 to 8 years was 96.5 (95% CI, 51.8-179.9) and for 9 to 11 years was 153.1 (95% CI, 81.2-288.8) vs 14.3 (95% CI, 10.3-20.0) for 15 to 17 years. Cerebral venous sinus thrombosis represented 17.6% of pediatric VTE events in IBD patients compared with 4.2% in children without IBD (P = .001). Conclusions: This study confirms the increased risk of VTE in children with IBD compared with children without IBD. The time of greatest VTE risk was around diagnosis. Cerebral venous sinus thrombosis was significantly more common in children with IBD than other children.
-
What is the impact of leaders with emotional intelligence on proxy performance metrics in 21st century healthcare? - a systematic literature reviewEmotional 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.
-
Update from 2010 (standard operating procedure) : protocol for the 2024 British Society of Gastroenterology Guidelines on colorectal surveillance in inflammatory bowel diseaseIntroduction: The evolving landscape of inflammatory bowel disease (IBD) necessitates refining colonoscopic surveillance guidelines. This study outlines methodology adopted by the British Society of Gastroenterology (BSG) Guideline Development Group (GDG) for updating IBD colorectal surveillance guidelines. Methods and analysis: The 'Grading of Recommendations, Assessment, Development and Evaluation' (GRADE) approach, as outlined in the GRADE handbook, was employed. Thematic questions were formulated using either the 'patient, intervention, comparison and outcome' format or the 'current state of knowledge, area of interest, potential impact and suggestions from experts in the field' format. The evidence review process included systematic reviews assessed using appropriate appraisal tools. An extensive list of potential outcomes was compiled from literature and expert consultations and then ranked by GDG members. The top outcomes were identified for evidence synthesis in three key areas: utility of surveillance in IBD, quality of bowel preparation and use of advanced imaging techniques in colonoscopy for IBD. Risk thresholding exercises determined specific risk levels for different surveillance strategies and intervals. This approach enabled the GDG to establish precise thresholds for interventions based on relative and absolute risk assessments, directly informing the stratification of surveillance recommendations. Significance of effect sizes (small, moderate, large) will guide the final GRADE assessment of the evidence. Ethics and dissemination: Ethics approval is not applicable. By integrating clinical expertise, patient experiences and innovative methodologies like risk thresholding, we aim to deliver actionable recommendations for IBD colorectal surveillance. This protocol, complementing the main guidelines, offers GDGs, clinical trialists and practitioners a framework to inform future research and enhance patient care and outcomes.
-
Commencement of Atorvastatin and Ezetimibe immediately in patients presenting with acute coronary syndromeLipids are implicated in the development of coronary atherosclerosis. Achieving a significant reduction in lipid levels remains a crucial aspect of secondary prevention following an acute coronary syndrome event. Novel lipid-lowering therapies now provide clinicians with a variety of therapeutic strategies to choose from and tailor to individual patient needs. This review focuses on evidence supporting the importance of early and intensive lipid-lowering therapy use in patients presenting with acute coronary syndrome, specifically addressing data relating to atorvastatin and ezetimibe use in this high-risk cohort of patients.
-
The determinants of long-term outcomes after colorectal cancer surgery : a literature reviewColorectal cancer (CRC) is a common malignancy associated with high mortality. Surgical care is an effective colorectal cancer management technique, and it is therefore crucial that a review of the determinants of patients' long-term outcomes after CRC surgery is conducted. This article aims to provide healthcare professionals and policymakers with insights into the determinants of long-term outcomes following CRC surgery while acknowledging the interconnected impact of the early recovery and post-operative periods. For this review, PubMed and Google Scholar were used to search for literature on the determinants of long-term outcomes of patients post-colorectal cancer surgery. The determinants included pre-operative factors, CRC surgery factors (anatomical location of the lesion, select operative techniques, and cancer disease stage), adherence to the Enhanced Recovery After Surgery (ERAS) guidelines, post-operative complications, presence of an ostomy, physical activity levels, psychosocial factors, recurrence, and follow-up strategies. Selection criteria were published articles between 1994 and 2024 on colorectal cancer, its surgery, and determinants of outcomes. Several key determinants influence long-term outcomes following colorectal cancer surgery, including preoperative factors, CRC surgery factors, adherence to the ERAS guidelines, postoperative complications, the presence of an ostomy, physical activity levels, psychosocial factors, recurrence, and follow-up strategies. These determinants collectively impact survival, quality of life, functional recovery, and psychosocial well-being. On the one hand, negative outcomes following colorectal cancer surgery are often linked to preoperative factors such as poor nutritional status, sarcopenia, and inadequate adherence to ERAS guidelines during the perioperative period. Minimally invasive surgeries, while as effective as open surgeries for early-stage CRC, may be less suitable for advanced stages and often involve prolonged operating times - a factor linked to poorer outcomes. Complications of CRC surgery, such as anastomotic leakage, chronic surgical site pain, bowel dysfunction, and urological issues, further contribute to negative long-term outcomes. High recurrence rates are also linked to poor prognoses, emphasizing the importance of regular surveillance and timely interventions, though these can lead to patient anxiety and overtreatment. The presence of an ostomy can impact psychosocial adjustment and overall quality of life, further influencing long-term outcomes. On the other hand, positive outcomes are associated with regular physical activity post-surgery, which significantly aids long-term recovery irrespective of preoperative activity levels. Psychosocial support networks also play a crucial role in mitigating mental health challenges often faced after CRC surgery. Collectively, these determinants underscore the complexity of long-term outcomes in colorectal cancer surgery and highlight the importance of a holistic approach to patient care.
-
Evaluating the Impact of a virtual skin cancer awareness workshop for 16-19-Year-oldsIntroduction 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.
-
Automated decision making in Barrett's oesophagus : development and deployment of a natural language processing toolManual decisions regarding the timing of surveillance endoscopy for premalignant Barrett's oesophagus (BO) is error-prone. This leads to inefficient resource usage and safety risks. To automate decision-making, we fine-tuned Bidirectional Encoder Representations from Transformers (BERT) models to categorize BO length (EndoBERT) and worst histopathological grade (PathBERT) on 4,831 endoscopy and 4,581 pathology reports from Guy's and St Thomas' Hospital (GSTT). The accuracies for EndoBERT test sets from GSTT, King's College Hospital (KCH), and Sandwell and West Birmingham Hospitals (SWB) were 0.95, 0.86, and 0.99, respectively. Average accuracies for PathBERT were 0.93, 0.91, and 0.92, respectively. A retrospective analysis of 1640 GSTT reports revealed a 27% discrepancy between endoscopists' decisions and model recommendations. This study underscores the development and deployment of NLP-based software in BO surveillance, demonstrating high performance at multiple sites. The analysis emphasizes the potential efficiency of automation in enhancing precision and guideline adherence in clinical decision-making.
-
An unusual case of Haemophilus influenzae associated Polyarthritis : diagnostic and therapeutic challenges in concurrent septic and reactive arthritisSeptic 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.
-
The diagnostic accuracy of colon capsule endoscopy in Inflammatory bowel disease - a systematic review and meta-analysisColon capsule endoscopy (CCE) has regained popularity for lower gastrointestinal investigations since the COVID-19 pandemic. While there have been systematic reviews and meta-analyses on colonic polyp detection using CCE, there is a lack of comprehensive evidence concerning colonic inflammation. Therefore, this systematic review and meta-analysis aimed to assess the diagnostic accuracy of CCE for colonic inflammation, predominantly ulcerative colitis (UC) and Crohn's disease (CD). Methods: We systematically searched electronic databases (EMBASE, MEDLINE, PubMed Central, and Cochrane Library) for studies comparing the diagnostic accuracy between CCE and optical endoscopy as the standard reference. A bivariate random effect model was used for the meta-analysis. Results: From 3797 publications, 23 studies involving 1353 patients were included. Nine studies focused on UC, and ten focused on CD. For UC, CCE showed a pooled sensitivity of 92% (95% CI, 88-95%), a specificity of 71% (95% CI, 35-92%), and an AUC of 0.93 (95% CI, 0.89-0.97). For CD, the pooled sensitivity was 92% (95% CI, 89-95%), and the specificity was 88% (95% CI, 84-92%), with an AUC of 0.87 (95% CI, 0.76-0.98). Overall, for inflammatory bowel disease, the pooled sensitivity, specificity, and AUC were 90% (95% CI, 85-93%), 76% (95% CI, 56-90%), and 0.92 (95% CI, 0.94-0.97), respectively. Conclusions: Despite the challenges around standardised disease scoring and the lack of histological confirmation, CCE performs well in diagnosing inflammatory bowel disease. It demonstrates high sensitivity in both UC and Crohn's terminal ileitis and colitis and high specificity in Crohn's disease. Further studies are needed to evaluate the diagnostic accuracy of other colonic inflammatory conditions.
-
Duty of Candour legislation in post-colonoscopy colorectal cancer : a prospective cohort studyBackground: This study investigated the application of Duty of Candour (DoC) legislation in the context of post-colonoscopy colorectal cancers (PCCRCs). DoC mandates transparent disclosure of notifiable safety incidents to patients in the English National Health Service, including incidences leading to severe or moderate harm. This study aimed to analyze the application of DoC in PCCRCs, improve understanding of the legislation, and identify challenges in DoC implementation. Methods: A national audit of PCCRCs was conducted between September 2021 and May 2022. PCCRCs were identified using linked administrative datasets, and root-cause analyses were performed using structured templates. "Avoidability" and harm were categorized into specific levels, and guidance was provided on improving consistency in judgments. Results: 16% of 1724 PCCRCs resulted in major harm or death, of which 27% (75) were probably or definitely avoidable. Hospitals deemed DoC discharge necessary in only 53% of these cases. When including moderate harm, 11% of all PCCRCs would trigger DoC discharge, yet this was deemed necessary in only 45% of such cases. Conclusions: There is inconsistent application of DoC in PCCRC cases. Challenges include determining "avoidability" and harm, particularly when diagnosis is delayed. Clearer guidance and definitions of harm are needed to improve adherence to regulations.
-
Pain and Operative Technologies Used in Office Hysteroscopy: A Systematic Review of Randomized Controlled Trials.Objective: To identify technologies associated with the least operative pain in women undergoing operative office hysteroscopic procedures. Data sources: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched until January 2021 using a combination of keywords "hysteroscop*," "endometrial ablation," "outpatient," "ambulatory," "office," and associated Medical Subject Headings. Methods of study selection: Randomized controlled trials evaluating the effect of hysteroscopic devices on pain experienced by women undergoing operative office hysteroscopy were included. Data were also collected regarding efficacy, procedural time, adverse events, and patient/clinician acceptability and/or satisfaction. Tabulation, integration, and results: The search returned 5347 records. Ten studies provided data for review. Two trials compared endometrial ablation using bipolar radiofrequency with thermal balloon energy, with no significant difference in pain observed (p <.05). Seven trials evaluated technologies for endometrial polypectomy, of which, 4 compared energy modalities: miniature bipolar electrode resection against resectoscopy (N = 1), morcellation (N = 2), and diode laser resection (N = 1). Two studies compared hysteroscope diameter, and one study compared methods of polyp retrieval. A significant reduction in pain was found using morcellators rather than miniature bipolar electrosurgical devices (p <.001), 22Fr rather than 26Fr resectoscopes (p <.001), and 3.5-mm fiber-optic hysteroscopes with 7Fr forceps rather than 5-mm lens-based hysteroscopes with 5Fr forceps (p <.05). One study investigating septoplasty showed significant reduction in pain when cold mini-scissors, rather than a miniature bipolar electrode, were used (p = .013). Average procedural times ranged from 5 minutes 28 seconds to 22 minutes. The incidence of adverse events was low, and data regarding efficacy and acceptability/satisfaction were limited. Conclusion: Pain is reduced when mechanical technologies such as morcellators and scissors are used compared with electrical devices for removing structural lesions in the office. For hysteroscopic and ablative procedures, smaller and quicker devices are less painful. Large-scale RCTs investigating patient pain and experience with modern operative devices in the office setting are urgently needed.
-
Pneumocystis pneumonia causing cavitating lung nodules in an immunocompetent individual.Pneumocystis jirovecii pneumonia (PCP) is a potential life-threatening pulmonary infection which commonly manifests in immunosuppressed patients especially with HIV, with underlying malignancies, severe malnutrition as well as those on immunosuppressive treatments. There have been case reports of symptomatic PCP in individuals with a normally functioning immune system with typical clinical features and radiologic findings of bilateral and diffuse interstitial opacities. However, PCP in immunocompetent individuals presenting with lung nodules had been rarely reported. We report a 53-year-old immunocompetent gentleman who presented with subacute cough, progressive shortness of breath and radiographic findings of multiple lung nodules with central cavitation. The diagnosis of PCP was made by detection of PCP DNA PCR in bronchoalveolar lavage sample following fibreoptic bronchoscopy. This case also highlights the atypical radiographic findings of multiple cavitating lung nodules as a presentation of PCP in an immunocompetent patient.
-
Prediction of long-term survival after gastrectomy using random survival forests.Background: No well validated and contemporaneous tools for personalized prognostication of gastric adenocarcinoma exist. This study aimed to derive and validate a prognostic model for overall survival after surgery for gastric adenocarcinoma using a large national dataset. Methods: National audit data from England and Wales were used to identify patients who underwent a potentially curative gastrectomy for adenocarcinoma of the stomach. A total of 2931 patients were included and 29 clinical and pathological variables were considered for their impact on survival. A non-linear random survival forest methodology was then trained and validated internally using bootstrapping with calibration and discrimination (time-dependent area under the receiver operator curve (tAUC)) assessed. Results: The median survival of the cohort was 69 months, with a 5-year survival of 53.2 per cent. Ten variables were found to influence survival significantly and were included in the final model, with the most important being lymph node positivity, pT stage and achieving an R0 resection. Patient characteristics including ASA grade and age were also influential. On validation the model achieved excellent performance with a 5-year tAUC of 0.80 (95 per cent c.i. 0.78 to 0.82) and good agreement between observed and predicted survival probabilities. A wide spread of predictions for 3-year (14.8-98.3 (i.q.r. 43.2-84.4) per cent) and 5-year (9.4-96.1 (i.q.r. 31.7-73.8) per cent) survival were seen. Conclusions: A prognostic model for survival after a potentially curative resection for gastric adenocarcinoma was derived and exhibited excellent discrimination and calibration of predictions.
-
Primary leptomeningeal lymphoma masquerading as infectious tubercular meningitis.Primary central nervous system lymphoma (PCNSL) is infrequent and often poses diagnostic conundrums due to its protean manifestations. We present the case of a South Asian young man presenting with raised intracranial pressure and a lymphocytic cerebrospinal fluid (CSF) with pronounced hypoglycorrhachia. Progression of the neuro-ophthalmic signs while on early stages of antitubercular treatment led to additional investigations that produced a final diagnosis of primary leptomeningeal lymphoma. Treatment with chemoimmunotherapy (methotrexate, cytarabine, thiotepa and rituximab (MATRix)) achieved full radiological remission followed by successful autologous transplant. This case highlights the difficulties and diagnostic dilemmas when PCNSL presents as a chronic meningeal infiltrative process. While contextually this CSF is most often indicative of central nervous system tuberculosis and justifies empirical treatment initiation alone, it is essential to include differential diagnoses in the investigation work-up, which also carry poor prognosis without timely treatment. High suspicion, multidisciplinary collaboration and appropriate CSF analysis were the key for a correct diagnosis.
-
Provision of acute medicine services for pregnant women in UK hospitals: Data from the Society for Acute Medicine Benchmarking Audit 2019.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.