Introduction: Causes of hyponatraemia in older patients are multivariate and in the case of SIADH may often be drug induced. Diagnostic and treatment algorithms are unclear for this important age group. Methods: The author group identified 6 broad themes for consensus and formulated 42 separate consensus statements within these 6 themes. Statements were then circulated to geriatricians, general practitioners and other doctors to test agreement at the European level. Results: 64 responses were evaluated from around Europe. Agreement was achieved in 86% of the statements following amendment and redistribution of 6 of the statements. The survey and its feedback prompted the development of 13 recommendations related to the diagnosis and treatment of hyponatraemia including SIADH. Conclusion: The series of 13 recommendations developed here is intended to increase clarity for clinicians managing older patients with hyponatraemia and SIADH. Surprisingly, despite the lack of clear guidelines or recommendations for this age group consensus levels for the author-based statements were high among the respondents.

Brief report on a card-based board game used as a dermatology revision tool with the aim of increasing the confidence of final year medical students.

Approximately 15% of elderly patients are readmitted within 28 days of discharge. This costs the NHS and patients. Previous studies show telephone contact with patients -post-discharge can reduce readmission rates. This service -evaluation used a cohort design and compared 30-day emergency readmission rate in patients identified to receive a community nurse follow-up with patients where no attempt was made. 756 patients across seven hospital wards were -identified; 303 were identified for the intervention and 453 in a -comparison group. Hospital admission and readmission data was extracted over 6 months. Where an attempt to contact a patient was made post-discharge, the readmission rate was 9.24% compared to 15.67% where no attempt to -contact was made (p=0.011). After adjustment for -confounding using logistic regression, there was evidence of reduced readmissions in the 'attempt to contact' group odds ratio = 1.93 (95% c-onfidence interval = 1.06-3.52, p=0.033). Of the patients who community nurses attempted to contact, 288 were contacted, and 202 received a home visit with general practitioner -referral and medications advice being the most common -interventions initiated. This service evaluation shows that a simple intervention where community nurses attempt to contact and visit geriatric patients after discharge causes a significant reduction in 30-day hospital readmissions. Keywords: Discharge; geriatrics; readmission; telephone contract.

Report on an interactive teaching workshop for foundation year doctors at a district general hospital to assess whether teaching skills training for foundation-year doctors improves confidence in teaching.

An abstract from the 31st European Congress of Pathology reporting on a clinicopathological, molecular and cytogenetic study of 4 cases of superficial CD34+ fibroblastic tumour.

A 30-year-old male American football player presented to the acute medical unit with left-hand and hemifacial spasms. History and examination revealed hemifacial spasms in keeping with seizure-like activity possibly due to symptomatic hypocalcaemia. Subsequent investigations revealed an adjusted calcium of 1.87 mmol/L and, hence, he was managed with intravenous calcium replacement. He presented two further times in a 1-month period, with subjective limb weakness, despite normal adjusted calcium. During his third admission, he developed slurred speech and a marked facial droop, with absence of power in the right upper limb. Imaging revealed acute and old infarctions in the left middle cerebral artery territory and appearances consistent with left internal carotid artery dissection. This presentation of arterial stroke is atypical but with potentially grave consequences if missed. There is limited literature on the presentation of hemifacial spasm, and its association with ischaemic or haemorrhagic stroke represents a key learning point. Keywords: calcium and bone; stroke.

Background: There is a perception among ear, nose, and throat (ENT) surgeons that oral antibiotics are over-prescribed for acute otitis externa (AOE), and the potential for topical therapy as first-line treatment is not fully realized in primary care. We evaluated the prescription rate of topical and oral antibiotics for AOE in primary care and in patients referred to the ENT emergency clinic. Methods: A systematic review was performed by searching the MEDLINE, Embase, PubMed, and Google Scholar databases between January 1990 and October 2020. The quality of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. The outcome measures were the rate of topical and oral antibiotic prescriptions for AOE by primary care practitioners and the rate of oral antibiotic prescriptions that were not indicated. Results: Seven studies met the inclusion criteria. The overall quality of evidence was moderate. The rate of topical antibiotic prescriptions was between 77% and 95%, and oral antibiotics varied between 6% and 30% in patients that were managed only in primary care. Patients that were referred to an ENT emergency clinic had initially been treated by primary care practitioners with topical antibiotics in 14%-60% of cases and oral antibiotics in 16%-17%. The most commonly prescribed oral antibiotics were Amoxicillin and Co-amoxiclav (amoxicillin/clavulanic acid). No study had comprehensively reviewed the indication for oral antibiotics. Conclusion: The rate of topical antibiotic prescriptions for AOE was high in primary care; however, the rate was frequently suboptimal in patients attending the ENT emergency clinic. Although the rate of oral antibiotic prescriptions was relatively low, the choice of antibiotic for empirical treatment frequently did not cover the typical bacteria in AOE. There is a need for improvement in primary care prescribing of topical therapy prior to referral to the ENT emergency clinic.

Importance: A standardized pathology classification system for melanocytic lesions is needed to aid both pathologists and clinicians in cataloging currently existing diverse terminologies and in the diagnosis and treatment of patients. The Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) has been developed for this purpose. Objective: To revise the MPATH-Dx version 1.0 classification tool, using feedback from dermatopathologists participating in the National Institutes of Health-funded Reducing Errors in Melanocytic Interpretations (REMI) Study and from members of the International Melanoma Pathology Study Group (IMPSG). Evidence review: Practicing dermatopathologists recruited from 40 US states participated in the 2-year REMI study and provided feedback on the MPATH-Dx version 1.0 tool. Independently, member dermatopathologists participating in an IMPSG workshop dedicated to the MPATH-Dx schema provided additional input for refining the MPATH-Dx tool. A reference panel of 3 dermatopathologists, the original authors of the MPATH-Dx version 1.0 tool, integrated all feedback into an updated and refined MPATH-Dx version 2.0. Findings: The new MPATH-Dx version 2.0 schema simplifies the original 5-class hierarchy into 4 classes to improve diagnostic concordance and to provide more explicit guidance in the treatment of patients. This new version also has clearly defined histopathological criteria for classification of classes I and II lesions; has specific provisions for the most frequently encountered low-cumulative sun damage pathway of melanoma progression, as well as other, less common World Health Organization pathways to melanoma; provides guidance for classifying intermediate class II tumors vs melanoma; and recognizes a subset of pT1a melanomas with very low risk and possible eventual reclassification as neoplasms lacking criteria for melanoma. Conclusions and relevance: The implementation of the newly revised MPATH-Dx version 2.0 schema into clinical practice is anticipated to provide a robust tool and adjunct for standardized diagnostic reporting of melanocytic lesions and management of patients to the benefit of both health care practitioners and patients.

Wegener's granulomatosis (WG) also known as granulomatosis with polyangiitis (GPA) is an anti-neutrophil cytoplasmic antibody-positive (ANCA) vasculitis which most commonly affects the upper respiratory tract, lungs and kidneys. It is uncommon for colitis to be the primary reason for the first hospital admission related to WG. This case represents one of the few in the literature where colitis is associated with WG and in particular, where colonic involvement was the presenting symptom. The patient presented to hospital with a 3-day history of bloody diarrhoea and was treated for colitis. The disease progressed and during the second admission renal and pulmonary involvement was found. A renal biopsy showed a crescentic change and a CT-confirmed inflammatory changes in the caecum and ascending colon. A diagnosis of WG was made and appropriate treatment initiated. The patient is now in remission.