Postgraduate Medical Journal

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There are few doctors in history whose image is recognisable almost everywhere in the world. Dr Ernesto Guevara, known universally as ‘Che’, is one of them. In his most famous photo, he exudes an air of glowering passion and self-conscious ‘machismo’, as if he already knew he would become an enduring icon. (see figure 1) If you ask most people about him, they are likely to describe him as a revolutionary hero, although others may call him a ruthless executioner, depending on their political beliefs. Both accounts are true. His life raises important moral issues, not only for doctors who aspire to be activists, but for anyone interested in bringing about social justice, or in how best to achieve this.

Ernesto Guevara de la Serna was born in 1928, not in Cuba as many assume, but in Argentina. His family were landowners with Spanish and Irish ancestry....

Author: Launer, J.
Posted: January 20, 2022, 11:49 am

A 26-year-old newlywed woman attended our clinic with gigantic breasts associated with neck and back pain, and severe bleeding from breast ulcers. Her breasts had enlarged rapidly within the first 2 months of her first pregnancy, causing approximately 25 kg of weight gain and later, swelling over both the lower limbs. Medical therapy was instituted, but failed to halt breast tissue growth or relieve symptoms. Ultimately, she underwent an abortion at the end of the first trimester of pregnancy, which finally stopped breast enlargement. However, bleeding breast ulcers were problematic. Once, profuse bleeding caused haemorrhagic shock, necessitating multiple blood transfusions.

Examination revealed anaemia, enlarged axillary nodes and engorged subcutaneous veins. Breast tissues were visibly reddish, firm and non-tender on palpation. Sternal notch-to-nipple distances were 62 cm (right) and 60 cm (left), inframammary fold-to-nipple distances were 42 cm (left) and 40 cm (right), with areolar diameters 21 cm bilaterally (figure 1). Multiple ulcerations with...

Author: Saha, S.
Posted: January 20, 2022, 11:49 am
INTRODUCTION

Numerous articles have been written about the decompensation, deconditioning of frail patients awaiting discharge who are medically fit, that is, they do not need to stay in the acute hospital. Their care or further management could be provided in the community. There is a general view that they are stable and hence documentation and clinical input is quite abbreviated. With this article, I want to emphasise that these patients need regular full assessment to prevent any decompensation, deconditioning so that they do not have worse outcomes. This article is mainly geared towards junior doctors under training.

Anyone who is working in the NHS(National Health Service)hospitals will resonate with this word MFFD1—it is the mantra everyone in the NHS hospitals understand. The senior nurse can assess one’s ward round and criticise that there was no plan if one has not mentioned the magic word MFFD (or...

Author: Kumar, A., Sinha, P.
Posted: January 20, 2022, 11:49 am

The primary aim was to systematically review the empirical evidence relating to models and guidance for providing effective feedback in clinical supervision occurring in postgraduate medical education contexts. A secondary aim was to identify the common and differentiating components of models and guidance for providing effective feedback in this context. A systematic review was conducted. Fifty-one records met the inclusion criteria, including 12 empirical studies. Empirical records meeting inclusion criteria were critically appraised. Qualitative content analysis was applied to the guidance on effective and ineffective feedback provision to identify key principles. A composite model was created synthesising the guidance identified for providing effective feedback. The evidence supporting specific models and guidance in postgraduate medical education was limited. However, there is evidence to support all of the commonly identified principles. In addition, a consensus about the principles of effective feedback in clinical supervision in postgraduate medical education was found.

Author: Weallans, J., Roberts, C., Hamilton, S., Parker, S.
Posted: January 20, 2022, 11:49 am

A 63-year-old man presented at emergency for shortness of breath associated with jaundice, oral ulceration, odynophagia and oliguria following accidental ingestion of paraquat 7 days prior. He had no previously known comorbidities. Clinically he had tachycardia (114/min), tachypnoea (34/min), low oxygen saturation (SpO2 66%), icterus and ulceration over the tongue (figure 1). On evaluation, he had acute hepatitis (SGOT 120 U/L, SGPT 252 U/L, bilirubin 18.9 mg/dL), renal failure (urea 224 mg/dL, creatinine 4.4 mg/dL) and acute respiratory distress syndrome (PaO2/FiO2 0.15) with chest X-ray and high-resolution CT scan showing lung infiltration (figure 2). Upper gastrointestinal endoscopy revealed Zargar grade IIA–IIB caustic injury of the oesophagus with hyperaemia in the stomach, for which a nasojejunal tube was placed for nutritional supplementation. He was managed with hydration, antimicrobial, oxygen replacement and renal replacement therapy initiated for persistent oliguria.

Paraquat is a commonly used herbicidal agent in...

Author: Arora, N., Dhibar, D. P.
Posted: January 20, 2022, 11:49 am
Purpose of the study

Burnout is an increasingly recognised phenomenon in acute healthcare specialities and associated with depersonalisation, ill health and training programme attrition. This study aimed to quantify contributory physiological variables that may indicate stress in newly qualified doctors.

Study design

Post Graduate Year 1 doctors (n=13, 7 f, 6 m) were fitted with a VivaLNK wellness device during four prior induction days, followed by their first 14 days work as qualified doctors. Minute-by-minute Heart Rate (HR), Respiratory Rate (RR), and Stress Index (SI) data were correlated with Maslach Burnout Inventories, Short Grit Scales (SGS) and clinical rota duties: Induction vs Normal Working-Day (NWD) versus On-call shift.

Results

In a total 125 recorded shift episodes, on comparing Induction versus NWD versus On-call shift work, no variation was observed in HR above baseline (25.47 vs 27.14 vs 24.34, p=0.240), RR above baseline (2.21 vs 1.86 vs 1.54, p=0.126) or SI (32.98 vs 38.02 vs 35.47, p=0.449). However, analysis of participant-specific temporal SIs correlated with shift-related clinical duties; that is, study participants who were most stressed during a NWD, were also more stressed during Induction (R2 0.442, p=0.026), and also during On-call shifts (R2 0.564, p=0.012). Higher SGS scores were inversely related to lower SIs (coefficient –32.52, 95% CI –45.881 to 19.154, p=0.001).

Conclusion

Stress and burnout stimulus appear to start on day one of induction for susceptible PGY1 doctors, and continues into front-line clinical work irrespective of shift pattern. Short Grit Scale questionnaires appear an effective tool to facilitate targeted stress countermeasures.

Author: Robinson, D. B. T., James, O. P., Hopkins, L., Brown, C., Powell, A., Abdelrahman, T., Egan, R. J., Lewis, W.
Posted: January 20, 2022, 11:49 am

Lower respiratory infections are often caused or precipitated by viruses and are a leading cause of global morbidity and mortality. Mutations in these viral genomes can produce highly infectious strains that transmit across species and have the potential to initiate epidemic, or pandemic, human viral respiratory disease. Transmission between humans primarily occurs via the airborne route and is accelerated by our increasingly interconnected and globalised society. To this date, there have been four major human viral respiratory outbreaks in the 21st century. Healthcare workers (HCWs) are at particular risk during respiratory epidemics or pandemics. This is due to crowded working environments where social distancing, or wearing respiratory personal protective equipment for prolonged periods, might prove difficult, or performing medical procedures that increase exposure to virus-laden aerosols, or bodily fluids. This review aims to summarise the evidence and approaches to occupational risk and protection of HCWs during epidemic or pandemic respiratory viral disease.

Author: Scantling-Birch, Y., Newton, R., Naveed, H., Rajak, S., Bhutta, M. F.
Posted: January 20, 2022, 11:49 am
Objective

The short synacthen test (SST) is widely used across the UK to assess adrenal reserve. The main objective of our study was to determine the morning serum cortisol level that will predict adrenal insufficiency (AI) thus reducing our reliance on SST.

Design

This was a single centre retrospective study of 393 SST tests measuring 0 and 60 min cortisol levels after administration of 250 μg of synacthen (synthetic ACTH).

Patients and methods

All the SST tests for patients suspected of primary or secondary AI between April 2016 and October 2018 were included in this study. We used serum to determine circulating cortisol by a newer generation competitive electrochemiluminescence immunoassay (ECLIA) (Roche Diagnostics). A post-ACTH cortisol response of ≥420 nmol/L at 60 min was considered adequate to rule out AI. The data were analysed to ascertain the relationship between 0 min and 60 min serum cortisol.

Results

A total of 393 SST results were included in this study. Overall, a total of 332 (84.5%) subjects achieved sufficient serum cortisol level at 60 min, while 61 subjects (15.5%) showed insufficient response. Using the logistic regression, we determined that a morning basal serum cortisol level of ≥354 nmol/L was able to predict normal adrenal function with 100% sensitivity. We were unable to find a lower cut-off value below which SST will not be required. By using this proposed cut-off point, approximately 37% of the SSTs tests could be avoided.

Conclusions

Basal morning serum cortisol can be safely used as a first step in the evaluation of patients with suspected AI. This will enhance the number of patients being screened for this condition.

Author: Kumar, R., Carr, P., Wassif, W.
Posted: January 20, 2022, 11:49 am
Purpose of the study

While opioid overuse is a public health crisis in the USA, opioid analgesics are used suboptimally in Central and Eastern Europe, causing many pain cases to remain untreated or undertreated.

Study design

This questionnaire study aimed to identify the prevalent prescribing patterns and attitudes and the possible internal impediments to optimal opioid use among palliative care physicians and other specialists in Poland.

Results

Tramadol was the most commonly preferred opioid. While palliative care physicians (n=81) used various strong opioids, other physicians (n=87) prescribed mostly buprenorphine, accessible with standard prescription forms. Neither internal prejudices and beliefs nor administrative regulations impede prescribing opioids by palliative care physicians, unlike specialists other than palliative medicine. Special prescription forms for psychoactive medications, fear of drug addiction of their patients and penalties for possible errors on prescriptions affect the latter’s optimal prescribing. They also revealed significant gaps in the knowledge of prescribing opioids and would take part in additional training. Palliative care physicians appeared optimally prepared for cancer pain management and report fewer internal barriers than other specialists.

Conclusions

Continuous medical education on cancer pain treatment should be provided to all specialists to ensure optimal opioid pharmacotherapy and avoid overprescribing or underprescribing opioids. Administrative restrictions are the main barrier to optimal pain treatment.

Author: Dzierzanowski, T., Kozlowski, M.
Posted: January 20, 2022, 11:49 am
Background

Atrial fibrillation (AF) is associated with an increased risk of dementia. Little is known about the relationship of antithrombotic therapy and the risk of dementia in patients with AF without clinical stroke.

Method

This was an observational study based on a hospital AF registry. Patients aged 65–85 years at the time of AF diagnosis were identified via the computerised database of the clinical management system. Patients with prior stroke or known cognitive dysfunction were excluded. The primary outcome was newly diagnosed dementia during the follow-up period.

Results

3284 patients (mean age 76.4±5.3 years, 51.6% male) were included for analysis. The mean CHA2DS2-VASc score was 3.94±1.44. 18.5% patients were prescribed warfarin, 39.8% were prescribed aspirin and 41.7% were prescribed no antithrombotic therapy. After a mean follow-up of 3.6 years, 71 patients (2.2%) developed dementia, giving rise to an incidence of 0.61%/year. The incidence of dementia were 1.04%/year, 0.69%/year and 0.14%/year for patients on no therapy, aspirin and warfarin, respectively. Both univariate and multivariate analyses showed that age ≥75 years, female gender and high CHA2DS2-VASc score were associated with significantly higher risk of dementia; warfarin use was associated with significantly lower risk of dementia (HR: 0.14%, 95% CI 0.05 to 0.36, p<0.001). Patients on warfarin with time in therapeutic range (TTR) ≥65% had a non-significant trend towards a lower risk of dementia compared with those with TTR <65%.

Conclusion

In elderly AF patients, warfarin therapy was associated with a significantly lower risk of new-onset dementia compared those with no therapy or aspirin.

Author: Wong, C. K., Huang, D., Zhou, M., Hai, J., Yue, W. S., Li, W.-h., Yin, L.-X., Zuo, M.-L., Feng, Y. Q., Tan, N., Chen, J. Y., Kwan, J., Siu, C. W.
Posted: January 20, 2022, 11:49 am
Study Purpose

Malignant central airway obstruction (CAO) in non-small cell lung cancer (NSCLC) is associated with high morbidity and requires endobronchial palliative treatment to re-establish a free air passage. We investigate intratumoral therapy combining anti-angiogenic and cytotoxic as a feasible therapeutic modality to treat malignant CAO.

Study Design

Ten NSCLC subjects with symptomatic malignant CAO underwent endobronchial intratumoral cisplatin and Endostar co-injection after tumour debulking next to systemic cisplatin-based chemotherapy. Injection was performed immediately after debulking surgery and was then carried out on day 2, day 6 and day 10 past systemic chemotherapy. Nine subjects of control group constantly received traditional cisplatin-based chemotherapy. Bronchoscopy, CT scanning, histology, FEV1/FVC ratio, Karnofsky performance (KPS) and shortness of breath scores were analysed to assess therapeutic efficacy.

Results

All 10 subjects benefited from the intratumoral cisplatin and endostar co-injection and systemic chemotherapy combination therapy. Bronchoscopy and CT scanning analyses showed a massive airway widening after treatment. Increased KPS and reduced shortness of breath score were also observed. A substantial improvement of lung function was further confirmed by increased FEV1/FVC ratio. For subjects of control group, the improvement was moderate and obviously not as optimal as the 10 subjects with intratumoral injection.

Conclusions

We have shown that the intratumoral injection of cytotoxic cisplatin plus anti-angiogenic Endostar is an effective and safe adjuvant therapeutic option to treat malignant CAO in clinical practice. This time-staggered local and systemic treatment combination improves quality of life and clinical parameters, thus may provide a feasible therapeutic option for symptomatic CAO.

Author: Jiang, W., Yang, X., Wang, X., Li, Y., Yang, X., Wang, N., Yin, B.
Posted: January 20, 2022, 11:49 am
Background

Characteristics of laboratory findings of COVID-19 patients are of great significance for diagnosis and treatment. Studies that have analysed the variations in hepatic profile in correlation with the inflammatory markers in SARS-CoV-2 are limited.

Methods

We retrospectively analysed liver function tests and inflammatory markers of 170 admitted patients with confirmed COVID-19 in the tertiary care centre, Post Graduate Institute of Medical Education and Research (PGIMER), India, using Roche Cobas Autoanalyzer.

Results

Number of patients with normal liver enzyme levels were 63 (41.5%), while with raised levels of any of the liver enzymes were 89 (58.5%), out of which 43 (48.31%) had liver injury which manifested as increased severity in terms of intensive care unit (ICU) requirement (p=0.0005). Significantly raised levels of liver enzymes and liver injury were observed with age (p<0.0001) and in males (p=0.004). Significantly decreased levels of albumin and total proteins and increased levels of total bilirubin (p<0.0001) were seen in patients with abnormal liver enzyme levels and liver injury as compared to patients with normal levels. Significant increase in the levels of alanine transaminase and gamma-glutamyl transferase was seen on the 7th day, CRP and ferritin (p<0.0001) peaks were observed on 2nd and 3rd day respectively. A significant positive correlation was found between the levels of these inflammatory markers and liver function parameters.

Conclusions

More than half of patients admitted to the hospital with SARS-CoV-2 infection had an abnormal liver function which was found to be associated with raised levels of inflammatory markers. Significantly higher proportions of patients with abnormal liver function were elderly and males and were at higher risk of progressing to severe disease.

Author: Saini, R. K., Saini, N., Ram, S., Soni, S. L., Suri, V., Malhotra, P., Kaur, J., Verma, I., Sharma, S., Zohmangaihi, D.
Posted: January 20, 2022, 11:49 am
Background

Vitamin D has an immunomodulatory role but the effect of therapeutic vitamin D supplementation in SARS-CoV-2 infection is not known.

Aim

Effect of high dose, oral cholecalciferol supplementation on SARS-CoV-2 viral clearance.

Design

Randomised, placebo-controlled.

Participants

Asymptomatic or mildly symptomatic SARS-CoV-2 RNA positive vitamin D deficient (25(OH)D<20 ng/ml) individuals.

Intervention

Participants were randomised to receive daily 60 000 IU of cholecalciferol (oral nano-liquid droplets) for 7 days with therapeutic target 25(OH)D>50 ng/ml (intervention group) or placebo (control group). Patients requiring invasive ventilation or with significant comorbidities were excluded. 25(OH)D levels were assessed at day 7, and cholecalciferol supplementation was continued for those with 25(OH)D <50 ng/ml in the intervention arm. SARS-CoV-2 RNA and inflammatory markers fibrinogen, D-dimer, procalcitonin and (CRP), ferritin were measured periodically.

Outcome measure

Proportion of patients with SARS-CoV-2 RNA negative before day-21 and change in inflammatory markers.

Results

Forty SARS-CoV-2 RNA positive individuals were randomised to intervention (n=16) or control (n=24) group. Baseline serum 25(OH)D was 8.6 (7.1 to 13.1) and 9.54 (8.1 to 12.5) ng/ml (p=0.730), in the intervention and control group, respectively. 10 out of 16 patients could achieve 25(OH)D>50 ng/ml by day-7 and another two by day-14 [day-14 25(OH)D levels 51.7 (48.9 to 59.5) ng/ml and 15.2 (12.7 to 19.5) ng/ml (p<0.001) in intervention and control group, respectively]. 10 (62.5%) participants in the intervention group and 5 (20.8%) participants in the control arm (p<0.018) became SARS-CoV-2 RNA negative. Fibrinogen levels significantly decreased with cholecalciferol supplementation (intergroup difference 0.70 ng/ml; P=0.007) unlike other inflammatory biomarkers.

Conclusion

Greater proportion of vitamin D-deficient individuals with SARS-CoV-2 infection turned SARS-CoV-2 RNA negative with a significant decrease in fibrinogen on high-dose cholecalciferol supplementation.

Trial register number

NCT04459247.

Author: Rastogi, A., Bhansali, A., Khare, N., Suri, V., Yaddanapudi, N., Sachdeva, N., Puri, G. D., Malhotra, P.
Posted: January 20, 2022, 11:49 am

Cystic fibrosis transmembrane conductance regulator (CFTR) modulators such as ivacaftor (IVA), elexacaftor (ELX), lumacaftor (LUM) and tezacaftor (TEZ) are recently approved novel therapies for cystic fibrosis (CF) patients who have at least one ‘F508 del’ mutation. This mutation occurs in the majority of cystic fibrosis patients. Clinical trials with ‘triple therapy’ have demonstrated significantly improved lung function, sweat chloride and body mass index, with reduced pulmonary exacerbations.1 2

Our patient is a 24-year-old woman with cystic fibrosis (CF) with homozygous F508 del who received ‘compassionate use’ ELX/TEZ/IVA. She had severe bronchiectasis (forced expiratory volume in one second, FEV1 19%) with chronic Pseudomonas aeruginosa infection and required domiciliary oxygen therapy (2 L/min). She had not yet been listed for lung transplantation, given concerns about low body weight.

She had previously tolerated ‘dual’ cystic fibrosis transmembrane conductance regulator therapies, initially LUM/IVA (Orkambi™) and thereafter TEZ/IVA (Symkevi™). Other CF...

Author: Hu, M. K., Wood, G., Dempsey, O.
Posted: January 20, 2022, 11:49 am

Social and economic factors have a profound impact on patient health. However, education about these factors has been inconsistently incorporated into residency training. Neighbourhood walking tours may help physician-residents learn about the social determinants of health (SDoH). We assessed the impact of a neighbourhood walking tour on physician-residents’ perceptions of SDoH, plans for counselling patients and knowledge of community resources. Using a community-based participatory research approach, in 2017 we implemented a neighbourhood walking tour curriculum for physician-residents in internal medicine, internal medicine/primary care, emergency medicine, paediatrics, combined internal medicine/paediatrics and obstetrics/gynaecology. In both pre-tour and post-tour, we asked participants to (1) rank the importance of individual-level and neighbourhood-level factors affecting patients’ health, (2) describe strategies used to improve health behaviours and (3) describe knowledge of community resources. Eighty-one physician-residents participated in walks (pre-tour surveys (93% participation rate (n=75)), and post-tour surveys (53% participation rate (n=43)). Pre-tour, the factor ranked most frequently affecting patient health was ‘access to primary care’ (67%) compared with post-tour: ‘income’ (44%) and ‘transportation’ (44%). In describing ways to improve diet and exercise, among pre-tour survey respondents, 67% discussed individual-level strategies and 16% discussed neighbourhood-level, while among post-tour survey respondents, 39% of respondents discussed individual-level strategies and 37% discussed neighbourhood-level. Percentage of respondents aware of community resources changed from 5% to 76% (p<0.001). Walking tours helped physician-residents recognise the importance of SDoH and the value of community resources, and may have broadened frameworks for counselling patients on healthy lifestyles.

Author: Cross, J. J., Arora, A., Howell, B., Boatright, D., Vijayakumar, P., Cruz, L., Smart, J., Spell, V., Greene, A., Rosenthal, M.
Posted: January 20, 2022, 11:49 am
Introduction

Facilitating learning has been the focus of extensive research to identify efficient strategies and activities. Solving problems and learning through questions have been widely used to enhance active learning by exposure to inquiry or problem for which answers are needed. The process involves memory retrieval, understanding, application and critical thinking skills. However, writing questions involves all the above learning strategies at a deeper level and broader application. Writing is a commonly known tool of thinking and learning.1 2 Writing questions provides the additional learning skills of analysing, evaluating and creating knowledge.

The educational and learning value of writing questions is well established.3 4 Writing multiple-choice question (MCQ) style was significantly positively correlated with test grades.5 Cognitive strategies of writing questions about study topics result in better comprehension and test results.6 Teaching by encouraging learners to...

Author: Tuma, F.
Posted: January 20, 2022, 11:49 am