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A previously healthy, 25-year-old man presented with fever, cough and dyspnoea for 1 week. A chest radiograph showed multiple bilateral nodular, mass-like opacities (
Transbronchial biopsy revealed numerous non-caseating epithelioid cell granulomas that were predominantly present within the alveoli (). Gram, acid-fast and Grocott staining of the biopsy specimen and bronchial alveolar lavage fluid (BALF) revealed negative findings. BALF showed a lymphocytic cellular pattern (lymphocyte count was 44%) and negative cultures for bacteria, mycobacteria and fungi. We established a final diagnosis of alveolar sarcoidosis.
After initiating oral prednisolone (30 mg/day), the patient rapidly...
Misperceptions of plastic surgery remain common among medical students and the medical community. This creates barriers in recruitment to specialty and patient referral. Before this study, there was no formal plastic surgery teaching in University of Glasgow undergraduate medical core curriculum. A plastic surgery teaching pilot was implemented for fourth year students. Oncoplastic breast surgery was used as an example of gold standard multidisciplinary reconstructive surgery. Surveys collected data before and after provision of teaching across four parameters; identification of plastic surgery subspecialties, understanding of plastic surgery, opinion of the pilot and curriculum, career preferences and gender. The response rate was 57% (n=160). The most and least recognised subspecialties were burns (48% (n=75)) and perineal and lower limb reconstruction (0% (n=0)), respectively, with more students identifying aesthetic surgery (16% (n=26)) than hand (9% (n=15)) or skin cancer surgery (6% (n=9)). The majority (129 (81%)) thought plastic surgery was poorly represented in their curriculum and wanted further information (98 (61%)). Reported understanding of plastic surgery significantly improved (p≤0.00005). Those interested in surgical careers increased from 39% (n=63) to 41% (n=66) with more males than females reporting interest (p≤0.05). This study introduced plastic and reconstructive surgery into the undergraduate curriculum and led to further increased plastic surgery teaching. It improved student understanding, desire to gain more experience in the specialty and interest in surgical careers. Teaching students about subspecialties is vital to dispel misconceptions, ensure appropriate referrals and ignite interest in those with aptitude for surgical careers.
A previously healthy 22-year-old man presented with acute chest pain and dyspnoea. Chest radiography showed a large right-sided pneumothorax. Primary spontaneous pneumothorax was diagnosed and chest tube drainage was performed (
SHP is associated with 1%–12% of all patients with spontaneous pneumothorax
Patients who repeatedly attend the emergency department (ED) often have underlying complex social, psychological and chronic medical issues which are difficult to address in the emergency/acute medicine environment alone. Their attendances not only present a burden to the ED, but also can be a sign that the patient’s primary issue has been insufficiently addressed. At West Suffolk Hospital, we are trialling an approach to reduce frequency of ED attendances in a specific cohort of patients identified as being frequent attenders. In order to do this, we are using a multi-disciplinary approach including psychiatry services and ED clinicians.
Our cohort of frequent attenders were identified as patients presenting more than 4 times to ED between March 2017 to April 2018. Exclusion criteria was if the patient is under 18 years old, has known long term medical conditions and known safeguarding concerns. With collaborative working by the emergency medicine clinician and liaison psychiatry, a letter was sent to 38 patients in May 2018, identifying them as frequent attenders and inviting them to a tailored multi-disciplinary team meeting. Initially we are assessing the impact of the letter, so 6 months after the letters were sent out, we assessed patient attendances again. 2 patients were excluded due to moving out of area and being in prison. Paired sample for means t-test was used to compare attendances pre- and post-intervention.
There were a wide range of presenting complaints to ED, most of which were psychiatric related – overdose, deliberate self harm, alcohol/drug related. The intervention letter improved the attendance rate the most in this cohort, whereas it had a negligible effect on attendances with physical complaints. The average fall in attendance was 33% in the 6 months post patients receiving the intervention letter. This reached significance level with p=0.039.
Sending frequent attender patients a letter and putting in place a care plan could significantly reduce Emergency Department attendances. However there were a small number of patients, making it difficult to assess the efficacy of our intervention especially when adjusting for patient relocation.
We are hoping to disseminate the locally trialed strategy region wide across East Anglia, providing many more data points. We can also implement the model not just in patients with psychiatric background, but also patients with chronic medical problems too with additions to the multi-disciplinary team as per the needs of the patient.
What is the power of human sensation? How does our ability to hear, salivate and taste affect everyday life? It is typical that patients suffering or surviving head and neck diseases continue to be impaired by disabilities and sensory disorders that are often overlooked by clinicians and patients alike. Not least because our senses of hearing and taste are hidden, by virtue of their anatomy. The theme of ‘hidden disability’ came to the project team in their observations of vulnerable patients, in particular the elderly, those suffering dementia, Sjogren Syndrome and survivors of head and neck cancer. Too readily, aspects affecting the quality of life of these patients are not recognised or even ignored.
Hearing and salivation are taken for granted by the public, by patients and even by clinicians. As such the team recognised a need to raise awareness especially amongst clinicians of the hidden nature of hearing loss and dry mouth amongst vulnerable patient groups.
A dry and silent world: living with hidden disabilities sought to encourage a three-way dialogue between patients, clinicians and academics mediated and documented through art.
A dry and silent world: living with hidden disabilities was a collaboration between King’s College London’s Centre for Craniofacial & Regenerative Biology and Emma Barnard. It was supported by the university’s Culture team.
A 1-year-old female child presented with depigmented lesions on her trunk and extremities since birth. Examination revealed multiple, depigmented, atrophic macules in a blashkoidal pattern involving both halves of the trunk and limbs (
FDH or Goltz-Gorlin syndrome is a rare X-linked...
With the introduction of blood ketone testing, it is now possible to quantify the level of ketosis prior to the patient developing life threatening diabetic keto-acidosis (DKA). Administering correction doses of short acting insulin based on ketone level, similar to that for diabetic sick day rules, may avoid critical care admissions, use of variable rate insulin infusions and reduce hospital admissions.
Testing is not without its challenges in particular cost, risk of inappropriate testing in type 2 diabetics (T2DM) and misdiagnosis alternative causes of ketosis. We describe here the experience of introducing ketone testing to A+E and acute wards at a district general hospital.
Blood ketone testing was introduced to A+E, 2 medical wards and 2 surgical wards together with training for ward staff and a written guideline. Ketone testing was triggered if a type 1 diabetic (T1DM) or pancreatitis related diabetic had a BM >14 mmol/L. Based on the ketone level the guideline prompted either no action, correction dose of short acting insulin followed by repeat testing or arterial blood gas analysis. A retrospective analysis was performed after 8 months to investigate compliance with the protocol and effect of the protocol on the incidence of inpatient DKA. Patients were identified through search of the laboratory information management system followed by a review of electronically scanned medical records.
910 ketone tests were carried out representing 116 patients. 395 tests had no patient identifier and were therefore untraceable. Over half of patients (51%) had type 2 diabetes. Of the patients with T1DM/pancreatitis related diabetes 9 patients presented with DKA on admission. Nearly three quarters (73%) resolved with additional subcutaneous insulin as per protocol and 23% were started on a Variable Rate Insulin Infusion. 1 patient developed DKA during an inpatient admission and the protocol had not been followed in this case. The main reasons for deviation from the protocol was lack of documentation and repeat BM testing.
The protocol itself is very effective when used correctly. It clearly helps to identify patients at risk of deteriorating, and clearly outlines what steps should be taken. While the guideline is intended for patients with T1DM and Pancreatic Related Diabetes, there were many occasions where the ketone testing was used inappropriately on patients with T2DM. In response to this the protocol was updated to include additional guidance on management of hyperglycaemia in T2DM. Documentation and lack of patient identification information was another key issue.
Allopurinol is commonly prescribed to treat hyperuricemia. The association between allopurinol use and other comorbidities has been widely explored.
Several previous studies have described a number of benefits of medical students’ involvement in research and scholarly activities.
A paper-form questionnaire was handed out to medical students in their clinical phase (4th and 5th years) at the University of Otago, Christchurch, during their weekly didactic teaching. Out of 210 students, the questionnaire was returned by 65 (corresponding to a response rate of 31%). A total of 23 students were male (35.4%). The median age was 21 years (range 20–39 years). The majority of the students (96.9%) were New Zealand citizens/residents....
Essential tremor is the most common cause of tremor involving upper limbs, head and voice. The first line of treatment for limb tremor is pharmacotherapy with propranolol or primidone. However, these two drugs reduce the tremor severity by only half. In medication refractory and functionally disabling tremor, alternative forms of therapy need to be considered. Botulinum toxin injections are likely efficacious for limb, voice and head tremor but are associated with side effects. Surgical interventions include deep brain stimulation; magnetic resonance-guided focused ultrasound and thalamotomy for unilateral and deep brain stimulation for bilateral procedures. Recent consensus classification for essential tremor has included a new subgroup, ‘Essential tremor plus’, who have associated subtle neurological ‘soft signs’, such as dystonic posturing of limbs and may require a different treatment approach. In this review, we have addressed the current management of essential tremor with regard to different anatomical locations of tremor as well as different modalities of treatment.
The ultimate cure for the tendon pathology continues to elude current science. Despite great steps in technology, the causation and treatment is still not clear. The number of different theories and treatment modalities in the literature may confuse clinicians and patients. In this paper we outline the definitions, evolution of pathogenesis and treatment for tendinopathy. By highlighting these, the aim of this paper is to guide the practitioner in counselling and treating their patients.
Long non-coding RNAs (LncRNAs) have been recently implicated as having oncogenic and tumour suppressor roles. LncRNA LOC285194 (LOC285194) expression was significantly reduced in a variety of tumour tissues and cell lines, which promotes cell proliferation and migration. The aim of the present study is to examine the expression pattern of LOC285194 and its clinical significance in hepatocellular carcinoma (HCC) patients after curative liver resection.
We examined the expression of LOC285194 in 120 HCC samples and controls from adjacent non-tumour tissues using real-time quantitative reverse transcription-PCR and analysed its correlation with clinical parameters and prognosis in these patients who have undergone curative hepatic resection with a median follow-up of 3.5 years.
The expression level of LOC285194 was significantly lower in tumour tissues and four liver cancer cell lines compared with adjacent normal tissues and normal liver cell line. Furthermore, a low expression of LOC285194 was significantly correlated with advanced tumour stage, microvascular invasion, tumour number and differentiation. Additionally, survival analysis showed that patients with low LOC285194 expression had a significantly worse overall and disease-free survival. Moreover, univariate and multivariate analyses showed that decreased expression of LOC285194 was an independent predictor of long-term survival.
The low expression level of LOC285194 might be a novel candidate biomarker for predicting tumour progression and poor prognosis in HCC patients who have undergone hepatectomy and might be a potential target for gene therapy.
The prognostic value of serum uric acid (SUA) for incident acute coronary syndrome (ACS) in hypertensive subjects is uncertain. Therefore, the present study examined the association between SUA and incident ACS in a large cohort of Chinese hypertensive adults.
This was a retrospective cohort study, which enrolled 5473 Chinese community-dwelling hypertensive patients from 1 January 2012 to 31 December 2012. Study outcomes were ACS events, and patients were followed until 31 December 2016. Cox regression analyses were conducted to determine adjusted HRs and 95% CIs for baseline SUA tertiles (low, middle and high group) and for men and women separately.
A total of 5473 participants were included in the analysis (median follow-up was 4.5 years). Participants were divided into tertiles based on SUA levels. During follow-up, 9 (0.49%), 14 (0.77%) and 25 (1.37%) patients developed ACS in the lowest, middle and highest tertiles, respectively. When compared with the lowest tertile of SUA, the highest tertile of SUA was associated with ACS risk in all subjects and in men and women separately (HR: 2.62, 95% CI 1.14 to 7.01, p=0.0233; 2.15, 95% CI 1.08 to 6.04, p=0.021, and 3.49, 95% CI 1.25 to 7.74, p=0.017, respectively).
Higher SUA levels were independently associated with an elevated risk of ACS incidence. The relationship between SUA levels and ACS in hypertensive patients was J-shaped.
In recent years, the short Synacthen test (SS) has become the most widely used test to assess adrenal reserve. Despite its frequent use, there are still several areas related to the short Synacthen test (SST), which have no consensus including the optimum sampling times, that is, whether a 60 min post-Synacthen administration cortisol is necessary or not.
We performed a retrospective data analysis of 492 SSTs performed on adult patients in a tertiary referral teaching hospital in Ireland. The SSTs were performed in the inpatient and outpatient setting and included patients across all medical disciplines and not exclusively to the endocrinology department.
313 patients had 0, 30 and 60 min samples available for analysis. A total of 270/313 (82%) were deemed to pass the test, that is, cortisol ≥500 nmol/L at both 30 and 60 min. Of the 313 patients, 19 (6%) patients had an indeterminate response, cortisol <500 nmol/L at 30 min, but rising to ≥500 nmol/L on the 60 min sample. Of these 19 patients, only 9/19 patients had a serum cortisol level at 30 min <450 nmol/L, requiring clinical treatment with glucocorticoid replacement. All 24/313 (8%) patients who had insufficient responses at 60 min were also insufficient at 30 min sampling. No individuals passed (≥500 nmol/L) at 30 min and then failed (<500 nmol/L) at 60 min.
Using the 30 min cortisol sample post-Synacthen administration alone identifies clinically relevant adrenal insufficiency in the majority of cases. A small subset of patients have a suboptimal response at 30 min but have a 60 min cortisol concentration above the threshold for a pass. Data regarding the long-term outcomes and management of such patients are lacking and require further study.
A 38-year-old man presented with purple lesions on the skin and oral mucosa that had first appeared several months previously. The lesions had recently increased in size and caused difficulty eating and closing the mouth. Physical examination revealed a bulky lesion on the mucosa of the upper gum (
One study conducted by Saarela et al reported an increased incidence of kidney cancer associated with type 2 diabetes mellitus (standardised incidence ratio = 1.42, 95% CI 1.37 to 1.47).
A young adult patient was brought to the emergency department after a violent motorcycle accident. Neurological examination revealed absent verbal response, eye opening or movements with pain stimulation, and bilateral pupillary miosis. Brain MRI revealed lesions in the corpus callosum, and in the subcortical and periventricular white matter, which were hyperintense on fluid-attenuated inversion recovery sequence (
This is the classical appearance of diffuse axonal injury (DAI), a traumatic brain injury associated with forces of acceleration/deceleration that frequently occur with motor vehicle accidents.
For all musicians there is a need for guidelines to avoid deafness from musical instruments. The author, an amateur musician and Convener of an orchestra was asked to provide guidance. What follows is a superficial and perhaps naïve interim review that should hopefully be of assistance and, more importantly, encourage those with more profound knowledge to issue relevant guidance.
Deafness, decreasing appreciation of loudness, occurs with normal ageing. Counterintuitively ear damage may continue despite this. Indeed there is problem that hearing aids, by amplification of the lost frequencies, may expose ears to greater intensity of vibrations that might have contributed to hearing loss in the first place.
For many years there have been concerns about the hearing of professional musicians exposed to loud music.
If you live in the United States or the United Kingdom and have black or brown skin, your health is likely to be poorer on average than if you have white skin. You are also likely to receive healthcare of a lower standard. The statistics are dismal.
Similar to the United States Medical Licensing Examination steps used in the USA, Mexico has the National Evaluation for Medical Residency Applicants (ENARM, Examen Nacional de Aspirantes a Residencias Medicas), the scores achieved in these assessments represent the entrance door to a specialisation course endorsed by an accredited university. This letter aims to discuss the usefulness of ENARM exam scores obtained by foreign medical graduates (FMG).
The reports of 7 consecutive years (2012–2018) of ENARM scores, were issued by the Interinstitutional Commission for Human Resources Training for Health (Comisión Interinstitucional para la Formación de Recursos Humanos para la Salud) a department of the Undersecretariat of Innovation and Quality of the Mexican Ministry of Health.
Pathological anatomy. Anesthesiology. Audiology,...
Moyamoya disease is a rare chronic progressive cerebrovascular disease characterised by bilateral stenosis or occlusion of arteries around circle of Willis with prominent collateral circulation. The term moyamoya (Japanese for ‘puff of smoke’) refers to the appearance on angiography of abnormal vascular collateral networks that develop adjacent to the stenotic vessels. Moyamoya disease was first described in Japan by Takeuchi and Shimizu in 1957.1 The prevalence and incidence of the disorder there has been reported to be 3.16 cases and 0.35 cases per 100 000 people, respectively. The incidence of moyamoya disease is highest in Japan.2 Moyamoya syndrome has now been observed throughout the world with increasing detection of this disease in American and European populations.3 4
32 years old gentleman with background of Rheumatoid arthritis (In remission) and asthma presented to hospital with confusion and word finding difficulty.
Systemic examination was unremarkable except patient mentioned that he had difficulty in texting on his mobile phone. Blood tests showed raised inflammatory markers. Patient was treated on lines of meningoencephalitis. CT brain showed hypodensity in left temporal, parietal and occipital lobe. MRI brain with contrast showed confirmed these changes to be acute infarcts along with post contrast meningeal enhancement. CSF results came back normal including viral PCR.Patient referred to neurology who advised to continue treating as viral encephalitis. Vasculitic screen weakly positive P-ANCA. Stroke team was involved who organised MRA which showed generalised narrowing of left carotid siphon and left middle cerebral artery and its branches. It also showed loss of definition of M1 segment of right MCA and its branches. Changes initially though to be secondary to vasculitis and patient started on steroids. Patient seen by rheumatology team and possibility of vasculitis was ruled out. Neuroimaging was discussed in neuroradiology MDT after doing DSA and outcome was that changes on brain imaging were suggestive of moyamoya disease with extensive disease bilaterally with more on left side. Patient was seen in neurosurgery clinic and offered revascularisation surgery which patient refused. Patient is under surveillance by neurosurgical team.
Moyamoya is a rare cause of stroke which is diagnosed on basis of clinical and radiographic findings and patients can be offered revascularisation surgery which is the only recommended treatment.
Dr Launer provides significant insight into the challenges faced by doctors in his article ‘Managing the threat to reflective writing’.
As a junior doctor, I volunteered to become a reflective writing tutor for medical students in first year clinical training. Students were given constructive guidance for these assignments, including examples of the different models used in reflective practice; the Gibbs’ cycle (description, feelings, evaluation, analysis, conclusions and actions) was highlighted as an exemplar framework.
The relative content of reflection, for example, if a piece of writing contains mostly descriptive or analytical elements, arguably can be assessed. With an ever-increasing emphasis on...
A project is being developed between artists and researchers to identify how to reduce loneliness and isolation in the older woman which could be a model for health and well-being clinics to adapt.
Regular sessions with artists and wordsmiths can help to minimise the stress caused by the menopause (add (1 or 2) reference(s) if available). Fears, anxieties and depression are symptoms often experienced with this life stage. Mid-life crisis is an expression that can be an unhelpful way to describe the natural aging of a woman’s body. Negative concepts and poor jokes can add to a woman feeling diminished around the natural process of aging. A regular group might talk and explore these feelings with an artist ready to translate words into pictures, and create with the group a positive collage of loss in this respect. We would see whether looking at poems written by women who have gone through the menopause, finding how to identify with others and their loss, and exploring whether the experiences of others help the individual to feel better about themselves. Would this collaborative approach with women help them to feel more positive about the next life stage and therefore enable them to live a healthier life?
A 32-year-old woman at 31 weeks’ gestation with a history of premature rupture of membranes presented with asymptomatic hypopigmented macules on her upper back and neck region of 2 months’ duration (
A well-recognised, but rarely reported manifestation of secondary syphilis is LS, a condition first described as syphilide pigmentaire by Alfred...
Abbas Munzar, 119
Ali Asem, 119
Amin Omar, 119
Azharuddin Mohammed, 119
Barnard Emma, 120
Barnard Emma, 120
Cartwright Douglas, 119
Das Sreejib, 119
French Wendy, 120
Huang Fiona, 119
Kiberu Yusef, 119
Mozaffari Mona, 120
Saeed Umer, 119
Teshima Tathyane, 120
Tucker Abigail, 120
More than 1400 respiratory cases have been linked to vaping at the Center for Disease Control and Prevention (CDC), one of the most prestigious epidemiological organisation in the world. So far, 33 patients succumbed to vaping-associated lung injury (VALI), a new syndrome characterised by respiratory distress with bilateral (sometimes haemorrhagic) infiltrates within 3 months of using e-cigarettes. VALI patients (mostly male young college or high school students) predominantly have presented with shortness of breath and gastrointestinal symptoms: majority needed hospital, often critical care admission.