Postgraduate Medical Journal

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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 (figure 1A). Moreover, chest CT revealed multiple bilateral dense consolidations with central-air bronchograms and ill-defined micronodular and ground-glass margins (figure 1B). The bilateral hilar and mediastinal lymph nodes were enlarged (). Blood tests revealed C-reactive protein, ACE and lysozyme levels of 3.98 (normal <0.30) mg/dL, 7.9 (normal <21.4) IU/L and 11.8 (normal <10.2) µg/mL, respectively.

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...

Author: Kawakami, N., Moriya, T., Wakai, Y., Saito, K.
Posted: January 22, 2020, 9:38 am

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.

Author: Higgins, G., Thomson, S. E.
Posted: January 22, 2020, 9:38 am
Case presentation

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 (figure 1A). Four hours later, the patient complained of chest pain and dyspnoea and developed hypotension. Bloody pleural effusion was drawn through the chest tube. Chest radiography showed massive right pleural effusion (figure 1B). Subsequently, spontaneous haemopneumothorax (SHP) was diagnosed. Video-assisted thoracic surgery (VATS) revealed a torn aberrant vessel at the apical parietal pleura and apical bullae, and surgical haemostasis and bullectomy were successfully performed ().

Discussion

SHP is associated with 1%–12% of all patients with spontaneous pneumothorax1 and, due to rapid respiratory collapse and haemorrhagic shock, is a potentially life-threatening condition. The bleeding sources of SHP include torn vascular adhesion between the two layers of the pleurae;...

Author: Kawakami, N., Aoki, H., Ito, M., Moriya, T., Wakai, Y., Saito, K.
Posted: January 22, 2020, 9:38 am
Introduction

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.

Methods

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.

Results

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.

Conclusions

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.

Author: Huang, F., Kiberu, Y., Das, S.
Posted: January 22, 2020, 9:38 am

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.

Author: Barnard, E., Tucker, A., Mozaffari, M., Teshima, T.
Posted: January 22, 2020, 9:38 am

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 (figure 1A). She also had ectrodactyly of her feet with left foot showing ‘lobster claw’ anomaly (figure 1B) and dystrophy and anonychia of finger and toe nails. Another noticeable feature was the presence of multiple, soft swellings on both feet suggestive of subcutaneous fat herniation (figure 1C). Ophthalmological examination revealed bilateral iridochoroidal coloboma (figure 1D). She was born of a non-consanguineous marriage and had a healthy elder sibling. Based on the clinical features, a diagnosis of focal dermal hypoplasia (FDH) or Goltz-Gorlin syndrome was established. The mother was counselled about the disease and referred to a paediatrician for further evaluation.

FDH or Goltz-Gorlin syndrome is a rare X-linked...

Author: Bhattacharjee, R., Tekumalla, S., De, D.
Posted: January 22, 2020, 9:38 am
Introduction

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.

Methods

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.

Results

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.

Conclusions

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.

Author: Amin, O., Cartwright, D., Azharuddin, M.
Posted: January 22, 2020, 9:38 am

Allopurinol is commonly prescribed to treat hyperuricemia. The association between allopurinol use and other comorbidities has been widely explored.1 2 Recently one cohort study revealed that no significant association could be detected between allopurinol use and the risk of prostate cancer (HR=1.03; 95% CI 0.92 to 1.16),3 but another cohort study revealed that long-term use of allopurinol for more than 1 year was associated with a lower risk of prostate cancer in men with gout when compared with non-use (HR=0.64; 95% CI 0.45 to 0.90).4 Some of our ideas were shared with the readers. First, in order to clarify this issue, a preliminary case-control study was conducted using the 2005–2012 database of the Taiwan National Health Insurance programme with 23 million people living in Taiwan.5Table 1 revealed that there was a positive association between prostate cancer and allopurinol use in...

Author: Lai, S.-W., Kuo, Y.-H., Liao, K.-F.
Posted: January 22, 2020, 9:38 am

Several previous studies have described a number of benefits of medical students’ involvement in research and scholarly activities.1 The number of students who actually engage in such activities, however, remains relatively low.1 2 We have previously surveyed preclinical medical students in New Zealand about their interest in research.3 The aim of the present study, therefore, was to assess whether the level of research interest differs in senior medical students.

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.

...
Author: Alamri, Y., Al-Busaidi, I.
Posted: January 22, 2020, 9:38 am

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.

Author: Sharma, S., Pandey, S.
Posted: January 22, 2020, 9:38 am

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.

Author: Ahmad, Z., Parkar, A., Shepherd, J., Rushton, N.
Posted: January 22, 2020, 9:38 am
Background

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.

Materials and methods

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.

Results

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.

Conclusions

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.

Author: Qiu, J., Pan, G., Li, M.
Posted: January 22, 2020, 9:38 am
Background

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.

Methods

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.

Results

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).

Conclusions

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.

Author: Shen, G., Huang, J.-Y., Yu, Y.-L., Liu, L., Chen, C.-L., Zhang, B., Huang, Y.-Q., Feng, Y. Q.
Posted: January 22, 2020, 9:38 am

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.

Methodology

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.

Results

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.

Conclusion

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.

Author: Dineen, R., Mohamed, A., Gunness, A., Rakovac, A., Cullen, E., Barnwell, N., Neary, C., Behan, L.-A., Boran, G., Gibney, J., Sherlock, M.
Posted: January 22, 2020, 9:38 am

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 (figure 1A). Analysis of a biopsy specimen revealed Kaposi’s sarcoma. The result of the HIV test was positive (CD4 lymphocyte count, 167 cells/mm3; HIV viral load, 10 093 copies/mm3). Combination antiretroviral therapy was started immediately with raltegravir and emtricitabine/tenofovir disoproxil fumarate. Given the large number of skin lesions and the bulky lesion on the oral mucosa, liposomal doxorubicin was administered every 3 weeks. The oral mucosal lesion decreased in size by half during the first 4 weeks (figure 1B). After 3 months of treatment, the lesion had disappeared (figure 1C), HIV viral load was undetectable,...

Author: Troya, J., Matarranz, M.
Posted: January 22, 2020, 9:38 am

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).1 Some of our ideas are shared with the readers. First, cancer usually has a prodromal phase, but it may be vague or non-specific, and it cannot easily be self-diagnosed by patients. Additionally, haematuria is an early feature of kidney cancer,2 but initially it may only be microhaematuria or non-visible haematuria. It is difficult to be self-diagnosed by patients. Only when it becomes visible haematuria, can it be discerned by patients.3 Clinically, it is not practical to perform urine analysis every day just for detecting haematuria. Thus, we cannot be sure of the onset date of haematuria. Second, hyperglycaemia always precedes the confirmed diagnosis of diabetes mellitus. Diabetes mellitus is a chronic condition with a long-term clinical...

Author: Lai, S.-W., Lin, C.-L., Liao, K.-F.
Posted: January 22, 2020, 9:38 am

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 (figure 1A), and showed restricted diffusion on diffusion-weighted imaging (figure 1B). Subcortical microhaemorrhages were detected on T2* gradient echo sequence (figure 1C).

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.1 DAI frequently affects cerebral white matter and grey-white matter junction, corpus callosum, and dorsal upper brainstem and cerebellum.2 Given its availability, brain CT is usually the first imaging modality in an emergency setting; however, this...

Author: Quintas-Neves, M., Soares-Fernandes, J. P., Mendes, V.
Posted: January 22, 2020, 9:38 am

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.1 Loudness is subjective and reflects, in a non-linear fashion, how much energy an instrument creates (amplitude usually refers to a scientifically measured value...

Author: Welsby, P. D.
Posted: January 22, 2020, 9:38 am

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.1 Between 1991 and 2011, for example, Pakistani and Bangladeshi women in the UK had mortality rates 10% higher than white women. Long-term illness in men over 65 was reported by 69% of Pakistani men and 64% of Bangladeshi men, compared with 50% of white men. Women of the same ethnic groups reported even higher rates of long-term illness compared with white women. Black Caribbean men also had higher rates of long-term illness than white men. Similarly, a report from Public Health England in 2017 showed that children in black ethnic groups have higher than average levels of infant mortality. The...

Author: Launer, J.
Posted: January 22, 2020, 9:38 am

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).

Logistics of the ENARM exam

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.1 The ENARM exam uses a minimum and maximum scores to show the performance in 27 medical specialties with direct entry:

  • Pathological anatomy.

  • Anesthesiology.

  • Audiology,...

  • Author: Mendoza-Aguilar, A. N., Salazar-Ruiz, S. Y., Cardiel-Marmolejo, L. E., Roldan-Valadez, E.
    Posted: January 22, 2020, 9:38 am
    Background and aims

    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

    Methods

    32 years old gentleman with background of Rheumatoid arthritis (In remission) and asthma presented to hospital with confusion and word finding difficulty.

    Results

    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.

    Conclusion

    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.

    Author: Ali, A., Abbas, M., Saeed, U.
    Posted: January 22, 2020, 9:38 am

    Dr Launer provides significant insight into the challenges faced by doctors in his article ‘Managing the threat to reflective writing’.1 In particular, attention has been focused on the approaches to sustain reflective practice in postgraduate education.

    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.2 My task was then to provide feedback to students on reflective writing pieces through the year and award an overall score. But can we—or should we—grade reflective writing?

    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...

    Author: Young, A.
    Posted: January 22, 2020, 9:38 am

    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?

    Author: Barnard, E., French, W.
    Posted: January 22, 2020, 9:38 am

    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 (figure 1). There was no rash prior to the onset of hypopigmented lesions, no lesions over the palms and soles, and no history of ulcer in the genital region both in our index case and her spouse. Investigations revealed positive venereal disease research laboratory titre of 1:32 and Treponemapallidum haemagglutination assay titre of 1:1280, and negative lesion potassium hydroxide mount, while HIV serology was negative. A diagnosis of leucoderma syphiliticum (LS) was made and the patient was given a single dose of benzathine penicillin 2.4 million unit intramuscular injection, and the hypochromic lesions regressed in 3 weeks.

    A well-recognised, but rarely reported manifestation of secondary syphilis is LS, a condition first described as syphilide pigmentaire by Alfred...

    Author: Pathania, Y. S., Budania, A.
    Posted: January 22, 2020, 9:38 am

    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

    Posted: January 22, 2020, 9:38 am
    Background

    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.1 Vapes are battery-operated devices that work by heating certain liquid compounds to produce vapours. Nicotine-containing liquids are mostly based on glycerine and/or propylene glycol to create dense fumes resembling cigarette smoke; however, cannabinoids are vaped in oil form (no fumes produced). The vapours are delivered to the lungs by inhalation, similar to smoking cigarette. Vaping devices are very different in terms...

    Author: Xantus, G. Z.
    Posted: January 22, 2020, 9:38 am