Postgraduate Medical Journal

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The internet has enabled widespread dissemination of health-related information to global audiences. However, the unfiltered nature of many online sources puts the public at risk of receiving false or misleading information.1 A recent meta-narrative systematic review of 153 cross-sectional studies evaluating 11 785 websites found that the quality of online health information is suboptimal.2 There is a growing concern within the scientific and clinical communities regarding the public health problem that is medical misinformation on the internet.3

The concept of misinformation has evolved over recent years and shares some conceptual overlap with the terms ‘fake news’ and ‘disinformation’.4 The popularised term ‘fake news’ has been defined as ‘fabricated information that mimics news media content in form but not in organizational process or intent’ while ‘disinformation’ has been defined as ‘false information that is purposely spread to deceive people’.4...

Author: Trethewey, S. P., Beck, K. J., Symonds, R. F.
Posted: August 26, 2021, 4:42 am

Medicine and politics are inseparable. This applies from the very beginning of medical training and throughout doctors’ careers. In most countries, the young people selected to go to medical school are predominantly drawn from a social elite. (The state-educated 94per cent of the school population in the United Kingdom, for example, were given fewer than half the offers for medical training in Oxford).1 They will generally share the experiences, assumptions and values of the privileged backgrounds from which most of them come. As they go through training, medical students almost everywhere will receive an intense grounding in the scientific and technological aspects of medicine but vastly less in the social and political determinants of health. They may be exposed to some of this information (such as the difference in life expectancy between the least and most deprived deciles in England of 9.5 years for males and 7.7...

Author: Launer, J.
Posted: August 26, 2021, 4:42 am

People with early-onset dementia have a potential risk of being marginalised with respect to care and social support as a result of the blame and stigma associated with their condition, and because they have reduced access to treatment options and postdiagnostic care. The limited use of community services and the resulting psychological implications are two key issues facing the group and their caregivers. Early diagnosis, behavioural therapies such as talking therapy, meaningful Montessori activities and friendly community services tailored to meet the needs of people with early-onset dementia are relationship-centred care approaches that could be implemented in practice, using the ‘Senses Framework’ to promote an enriched supportive environment of care with zero tolerance for marginalisation and discriminatory tendencies. Support for caregivers is invaluable in controlling behavioural changes in people with early-onset dementia. A combined approach involving pharmacological and behavioural interventions could be used in severe mood and behavioural changes.

Author: Nwadiugwu, M.
Posted: August 26, 2021, 4:42 am
Introduction

Metronidazole is commonly prescribed for intra-abdominal infections. Oral metronidazole has high bioavailability (>95%) and intravenous metronidazole should be reserved for patients not suitable for oral preparations.

Methods and materials

This full cycle audit evaluated the type of metronidazole preparation prescribed in adult emergency surgical patients requiring first-line empirical antimicrobial therapy for intra-abdominal infections. The criterion for audit was the proportion of patients who were prescribed intravenous metronidazole when the oral route was available. The first cycle included all consecutive eligible patients between 20 April and 14 May 2020. After an intervention phase educating prescribers about the similar pharmacokinetic properties of oral and intravenous metronidazole, clinical practice was reaudited between 22 June and 16 July 2020. Data were collected by case note and drug chart review.

Results

A total of 54 patients were included in the first audit cycle. Of these, 11 (20.4%) were prescribed oral metronidazole and 43 (79.6%) were prescribed intravenous metronidazole. In the majority of cases (35/43, 81.4%), intravenous metronidazole was prescribed in the absence of clear contraindications to the oral preparation. Of the 61 patients included in the reaudit cycle, 23 (37.7%) were prescribed oral metronidazole and 38 (62.3%) were prescribed intravenous metronidazole. The proportion of patients prescribed intravenous metronidazole despite being suitable for oral preparation decreased from 81.4% in the first cycle to 34.2% (13/38) in the reaudit cycle (risk ratio 0.42, 95% CI: 0.26 to 0.67, p<0.0001). Prescribing oral metronidazole when suitable saved up to £10.53/day per patient.

Conclusion

This full cycle audit led to a significant improvement in the use of oral metronidazole in suitable patients, as well as a considerable reduction in healthcare costs.

Author: Sgro, A., Wu, D. A., Yalamarthi, S.
Posted: August 26, 2021, 4:42 am
Background

The pattern and impact of burnout among the medical staff are not yet well defined. However, the consequences of burnout are not limited to the healthcare providers but also may affect their family, colleagues and patients in a negative manner. We aimed to assess the characteristics and predictors of burnout among health professionals at two large tertiary hospitals.

Methods

We conducted a cross-sectional study during the period from July 2018 to 31 December 2018. Data, via Maslach Burnout Inventory survey, were collected from physicians and other healthcare workers in two hospitals.

Results

A total of 624 responses to questionnaires were analysed. Half of the respondents were physicians, and men constituted the majority. About 10% (95% CI, 7.8 to 12.5) of the respondents satisfied the criteria of burnout. Emotional exhaustion (EE) was observed in 45.7%, depersonalisation (DP) in 26.9% and personal accomplishment (PA) in 41.2% of the respondents. There was a positive correlation between EE and DP (r=0.627, p=0.001), and a weak negative correlation between DP and PA (r=–0.195, p=0.001). Young age, less experience, trauma surgery, lack of habits and getting depressed ≥1 time/week were predictors of burnout.

Conclusions

Burnout affects one-tenth of the health professionals in the tertiary hospitals in Qatar. Physicians are more likely to have higher DP and lower PA, whereas nurses prone to have higher EE. In this study, no gender discrepancy is appreciated and the junior medical staff is at a higher risk of burnout.

Author: El-Menyar, A., Ibrahim, W. H., El Ansari, W., Gomaa, M., Sathian, B., Hssain, A. A., Wahlen, B., Nabir, S., Al-Thani, H.
Posted: August 26, 2021, 4:42 am
Background

During the crucial time of coronavirus pandemic, education is being remodelled: opening the doors of electronic learning (e-learning). The review emphasises on the various e-learning methods that can be used in the current scenario.

Methods

The review was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on databases, namely, PubMed, Google Scholar and Cochrane. Out of 1524 identified articles, after the process of screening and based on the eligibility criteria, 45 full-text articles were reviewed.

Results

Though there are many caveats on the path of successful implementation this is the right time that we step towards e-learning. The article discusses the methods and tools in e-learning that can modify the traditional ways of content delivery, record maintenance, assessment and feedback.

Conclusion

During the period of ‘planet arrest’, when the whole world is locked down with the motive of social distancing, let us stay connected with e-learning.

Author: Deepika, V., Soundariya, K., Karthikeyan, K., Kalaiselvan, G.
Posted: August 26, 2021, 4:42 am
Background

A clinical audit measures specific clinical outcomes or processes against a predefined standard. However, many clinicians are unable to carry out audits given their time constraints. Alternatively, medical students may often wish to complete audits early in their career to strengthen their portfolios. As such, the student clinical audit platform was designed to connect willing supervisors and these medical students.

Methods

Project supervisors were members of a regional trainee-led network. Interested students were familiarised with the various aspects of an audit and allocated to supervisors with similar interests. There was regular communication to track progress and anonymised feedback forms were distributed to all students and supervisors after a year.

Results

A total of 17 responses were received from the 19 students who were involved in a project. Based on a 5-point Likert scale, students displayed a mean improvement in their understanding of a clinical audit (1.18±1.07, p<0.001), the confidence to approach a supervisor (1.29±1.21, p<0.001) and the ability to conduct an audit by themselves in the future (1.77±1.15, p<0.001). Of the seven affiliated supervisors, five provided feedback with 80% indicating they had projects which remained inactive and all happy with the quality of work produced by their students.

Conclusion

Despite limitations to this programme, the platform produced projects which were disseminated both locally and nationally, demonstrating positive collaboration between medical students and clinicians. We present our findings and evaluations to encourage similar audit platforms to be adopted at other locations.

Author: Kumar, P. R., Hashmi, Y., Morad, R., Dewan, V.
Posted: August 26, 2021, 4:42 am
Aim

Primary hyperparathyroidism (PHPT) is much more common than familial hypocalciuric hypercalcaemia (FHH), but there is considerable overlap in biochemical features. Urine calcium indices help with the differential diagnosis, but their reliability in making this distinction is not clear. The aim of this study was to compare urinary calcium values in patients with PHPT and FHH.

Methods

This was a case–control study of patients with PHPT who had successful surgery and genetically proven FHH between 2011 and 2016. Due to low FHH numbers, patients from neighbouring hospitals and outside study period (2017–2019) were allowed to improve power. Data on demographics and urinary calcium were obtained from electronic records and compared between the two groups.

Results

During the study period, 250 patients underwent successful PHPT surgery, while in the FHH arm, 19 genetically proven cases were included. The median (IQR) 24-hour urine calcium excretion (UCE) in the PHPT group was 8.3 (5.6–11.2) mmol/24 hours compared with 3.2 (2.1–6.1) mmol/24 hour in the FHH group (p<0.001). Median (IQR) calcium to creatinine clearance ratio (CCCR) in the PHPT and FHH groups was 0.020 (0.013–0.026) and 0.01 (0.002–0.02), respectively (p=0.001). The sensitivity of urinary tests for PHPT was 96% for UCE (cut-off ≥2.5 mmol/24 hour) and 47% for CCCR (cut-off >0.02). The specificity of the urinary tests for FHH was 29.4% for UCE (cut-off <2.5 mmol/24 hour) and 93% for CCCR (cut-off <0.02).

Conclusions

24-hour UCE is more sensitive in diagnosing PHPT; however, it is less specific in ruling out FHH as compared with CCCR, when the cut-offs suggested by the International guidelines from the fourth international workshop are used. A significant proportion of patients with PHPT would have also required genetic studies if the guidelines were followed.

Author: Arshad, M. F., McAllister, J., Merchant, A., Rab, E., Cook, J., Eastell, R., Balasubramanian, S.
Posted: August 26, 2021, 4:42 am
Objectives

Motor neuron disease (MND) is a neurodegenerative disorder leading to functional decline and death. Multidisciplinary MND clinics provide an integrated approach to management and facilitate discussion on advanced care directives (ACDs). The study objectives are to analyse (1) the prevalence of ACD in our MND clinic, (2) the relationship between ACD and patient demographics and (3) the relationship between ACD decision-making and variables such as NIV, PEG, hospital admissions and location of death.

Methods

Using clinic records, all patients who attended the MND clinic in Liverpool Hospital between November 2014 and November 2019 were analysed. Data include MND subtypes, symptom onset to time of diagnosis, time of diagnosis to death, location and reason of death. ACD prevalence, non-invasive ventilation (NIV) and percutaneous endoscopic gastrostomy (PEG) requirements were analysed.

Results

There were 78 patients; M:F=1:1. 44 (56%) patients were limb onset, 28 (36%) bulbar onset, 4 primary lateral sclerosis and 2 flail limb syndrome presentations. 27% patients completed ACDs, while 32% patients declined ACDs. Patients born in Australia or in a majority English-speaking country were more likely to complete ACDs compared to those born in a non-English-speaking country. There was no significant correlation between ACD completion and age, gender, MND subtype, symptom duration, NIV, PEG feeding, location of death.

Conclusion

One-quarter of patients completed ACDs. ACDs did not correlate with patient age, gender, MND subtype and symptom duration or decision-making regarding NIV, PEG feeding or location of death. Further studies are needed to address factors influencing patients’ decisions regarding ACDs.

Author: Phua, C. S., Ng, A., Brooks, C., Harrington, Z., Vedam, H., Huynh, T., Seccombe, D., Aouad, P., Cordato, D.
Posted: August 26, 2021, 4:42 am
Background

Inappropriate antibiotic prescribing practices predispose to resistance emergence. Despite the inclusion of the topic in medical school curricula worldwide, it is uncertain whether newly graduated medical interns have confidence in proper antibiotic prescription.

Objectives

This study aimed to explore the antibiotic prescribing behaviours of the medical interns in Hong Kong and their barriers to appropriate antibiotic prescription.

Methods

Two focus groups were conducted among medical interns with training experiences in different public hospitals. Their prescribing behaviours and barriers were further examined with a questionnaire survey just before completion of internship.

Results

Focus group interviews identified a variety of hospital workplace cultures, including inappropriate empirical prescriptions and dosages, interns’ passive roles in prescribing antibiotics and varied guidelines between different departments. Defensive medicine and lack of clinical experience were other barriers encountered. The interns believed that the incorrect practice learnt would perpetuate in their minds and affect their future practice. The top barriers reported by the survey respondents were adaptation to prescription culture of different hospitals (93.5%), lack of experience in antibiotic prescription (88.3%), inadequate knowledge in the choice of antibiotics (85.7%) and compliance with the seniors’ instructions (80.6%). However, some focus group participants perceived weaker barriers in paediatric departments which provided close monitoring of antibiotic use.

Conclusions

Inadequate knowledge and low confidence in antibiotic prescription led to the passive role of medical interns in antibiotic prescription, predisposing to future inappropriate practice. Inconsistent guidelines and prescription cultures between different hospitals and departments might further exacerbate their barriers.

Author: Lam, T. P., Chan, T. H., Sun, K. S., Lam, K. F., Kwok, K. W., Ho, P. L.
Posted: August 26, 2021, 4:42 am
CASE PRESENTATION

A 72-year-old male heavy smoker was diagnosed with stage IV non-small-cell lung cancer (NSCLC) with lung-to-lung metastasis. No druggable driver mutation was found and the tumour proportion score for programmed death (PD)-ligand 1 expression was 100% (Dako 22C3 assay). The result of sputum acid-fast staining, performed 1 month after the diagnosis, was positive. After confirmation by PCR (DR. MTBC ScreenTM IVD Kit), isoniazid, rifampin, ethambutol and pyrazinamide were administered for pulmonary tuberculosis (TB). A viral hepatitis panel performed before the administration of the anti-TB agents was negative for hepatitis B virus and hepatitis C virus infections. The patient’s liver enzyme levels were within the normal ranges before anti-TB agents, during anti-TB treatment and before immune-checkpoint inhibitor (ICI) treatment. Pembrolizumab monotherapy was administered 1 month after the administration of the anti-TB agents and sputum conversion. Unfortunately, the patient was admitted for severe hepatitis 3 weeks later, with...

Author: Sun, C.-Y., Shen, C.-I., Feng, J.-Y., Chiang, C.-L.
Posted: August 26, 2021, 4:42 am

The concept of continuity in medical education reflects the progressive professional and personal development that physicians need in education. The aim of this study is investigating the views of the residents about the adequacy of undergraduate and postgraduate education in the context of preparing them for the next stage and their perceptions about the transition period. This phenomenological study was conducted at Hacettepe University Medical School. The study group consisted of medical and surgical sciences residents in the first year and last year of postgraduate medical education. Four focus group interviews were held with the participation of 21 residents. The participants emphasised that practising with real patients under supervision by taking an active role in healthcare teams was important for their preparation for the next stage in their carrier. However, their educational experiences during undergraduate medical education differed in community-based education, scientific research training, learning in small groups, internship and guidance of clinical educators. The transition period has been expressed with the concepts of identity change, high responsibilities and expectations required by the new identity, adaptation to the healthcare team, institution, and health system, meeting the expectations in an overly busy work environment, and feelings of incompetence. Participants pointed out that curriculum, which was declared and taught, educational environments, assessment approaches, consultancy systems and practices differed between the clinical departments. In line with the principles of competency-based education, practices related to the development and assessment of the competencies with all professional aspects in postgraduate medical education can be strengthened.

Author: Demiroren, M., Atilgan, B., Tasdelen Teker, G., Turan, S.
Posted: August 26, 2021, 4:42 am

Increased economic integration and technological advancements in communication and transportation over the past several decades have spurred growth in cross-national investment, migration and cultural exchange. Nations, economies and people are increasingly interconnected and interdependent; increasingly ‘globalised’. The concept of globalisation entered the mainstream vocabulary in the 1990s, but its history has been fraught with controversy.1 Primarily an economic process involving domestic deregulation, trade liberalisation and privatisation, globalisation can have profound social and cultural ramifications. Proponents highlight the economic benefits and improved standards of living for many communities, while opponents of globalisation focus on the disproportionate channelling of wealth to larger Western nations and the further disempowerment of populations who lack the skills to meaningfully participate in this flow of information and resources.1

Similarly, the globalisation of healthcare has also inspired competing interpretations and perspectives. Historically, the globalisation of health has referred to the cross-border flow...

Author: Ibrahim, H., Abdel-Razig, S.
Posted: August 26, 2021, 4:42 am