Postgraduate Medical Journal

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Case report

A 38-year-old male patient, farmer by occupation and a known case of diabetes mellitus (uncontrolled, non-compliant on medication), presented with features of right-sided sinus fullness, right-sided cheek swelling and headache for 10 days to an outside hospital. The cheek swelling gradually progressed to involve the right periorbital region as well. On examination, necrotic lesions were found in the oral cavity along with a large palatal perforation (figure 1). Partial ptosis was observed in the right eye but the vision was intact. With a clinical suspicion of mucormycosis, the patient was initiated on liposomal amphotericin B (5 mg/kg) and an extensive debridement was performed. The intraoperative sample showed a field full of aseptate hyphae on KOH mount suggestive of mucormycosis. Amphotericin B had to be discontinued as he developed worsening pancytopenia on therapy. The pancytopenia improved on withdrawal of the drug and re-appeared when amphotericin was...

Author: Gupta, N., Soneja, M.
Posted: September 2, 2020, 9:19 am
Case presentation

A 51-year-old Japanese man with a history of temporal lobe epilepsy, schizophrenia and multiple dental caries was admitted to a hospital with fever and dyspnea. He had a wet cough over the last month. Chest CT showed bilateral, large, thick-walled cavitary lesions that contained air-fluid levels (figure 1A), indicating a complex bronchopleural fistula and associated empyema. Chest tubes were placed, and a large amount of greenish-white pus was drained from both sides (figure 1B). Microbiological culture of the pleural empyema was positive for Fusobacterium nucleatum and Campylobacter rectus, suggesting an aspiration respiratory infection. He was treated with intravenous antibiotics (ampicillin/sulbactam and clindamycin) and thoracic tube drainage. Subsequently, his symptoms improved and he was discharged 6 weeks after admission.

A lung abscess is a subacute infection in which an area of necrosis forms in the lung parenchyma, whereas an empyema is defined as...

Author: Harada, K., Hagiya, H., Otsuka, F.
Posted: September 2, 2020, 9:19 am

Clinical trials are considered the gold-standard method for the evaluation of healthcare interventions. However, randomised control trials are complex to perform and many researchers, especially those in the early stages of their career, can find it challenging to know where to start set up, contribute to or lead a trial. This guide provides an introduction to trials and also practical advice to help potential investigators complete their clinical trial to time and to budget by signposting the pathway through the complex regulatory landscape. The authors draw on their own recent experiences of running clinical trials and provide tips and tricks for troubleshooting common problems encountered including trial design and documentation.

Author: Thomas, R. A. B., Aitken, E. L., Antonelli, J., Marson, L.
Posted: September 2, 2020, 9:19 am
Case Presentation

A 52-year-old Caucasian woman on pembrolizumab maintenance after induction with chemotherapy (carboplatin, pemetrexed) and pembrolizumab for stage 4 non–small cell lung cancer was admitted with increasing weakness. She had presented to emergency with similar complaints 2 weeks earlier, and she was hydrated with normal saline and sent home on antibiotics for urinary tract infection. She reported worsening weakness, anorexia and weight loss of 12 pounds over 3 months. Her other medical problems include chronic pain and depression. Home medications listed at admission were methocarbamol and lorazepam.

Vital signs at admission revealed a blood pressure of 105/63 mm Hg and a pulse of 73/min, and pulse oximetry showed 98% saturation on room air. Physical evaluation was normal other than cachexia.

Investigations

Labs revealed low sodium 117 mmol/L (137–145 mmol/L) and low chloride 85 mmol/L (98–107 mmol/L), but albumin was normal at 4.0 g/dL (3.5–5.0 g/dL). Serum osmolality was low at 241 mOsm/kg...

Author: Desikan, S. P., Varghese, R., Kamoga, R., Desikan, R.
Posted: September 2, 2020, 9:19 am
Introduction

Continuous cardiac monitoring in non-critical care settings is expensive and overutilised. As such, it is an important target of hospital interventions to establish cost-effective, high-quality care. Since inappropriate telemetry use was persistently elevated at our institution, we devised an electronic best practice alert (BPA) and tested it in a randomised controlled fashion.

Methods

Between 4 March 2018 and 5 July 2018 at our 600-bed academic hospital, all non-critical care patients who had at least one telemetry order were randomised to the control or intervention group. The intervention group received daily BPAs if telemetry was active.

Results

275 and 283 patients were randomised to the intervention and control groups, respectively. The intervention group triggered 1042 alerts and trended toward fewer telemetry days (3.8 vs 5.0, p=0.017). The intervention group stopped telemetry 31.7% of the alerted patient-days compared with 23.3% for the control group (OR 1.53, 95% CI 1.24 to 1.88, p<0.001). There were no significant differences in length of stay, rapid responses, code blues, or mortality between the two groups.

Conclusions

Using a randomised controlled design, we show that BPAs significantly reduce telemetry without negatively affecting patient outcomes. They should have a role in promoting high-value telemetry use.

Author: Chin, K.-K., Svec, D., Leung, B., Sharp, C., Shieh, L.
Posted: September 2, 2020, 9:19 am
Introduction

Taster weeks were introduced to give newly qualified doctors (foundation doctors) an opportunity to experience a wider variety of specialties.1 Foundation doctors have the opportunity to experience up to six specialties as part of their 2-year training, with restrictions to include at least one medical specialty, one surgical specialty and one specialty based in the community. As there are over 60 specialties and 30 subspecialties,2 some foundation doctors may not have the opportunity to experience more niche specialties, tertiary hospital care, or even primary care. Additionally, applications to specialist training open a third of the way through foundation year two and this reduces exposure to specialties further.3

This is important as exposure to a specialty has been shown to affect the career decision of doctors.4 Thus, taster weeks are encouraged by the UK Foundation Programme as a part of...

Author: Byrne, M. H. V., Nitiahpapand, R.
Posted: September 2, 2020, 9:19 am

President John F. Kennedy (JFK) had a complex medical history that is now thought to be an autoimmune polyglandular syndrome type 2 with Addison’s disease and hypothyroidism. He also had gastrointestinal symptoms from adolescence, which now fit well with coeliac disease. In addition, he had a chronic back problem, which contributed to a chronic pain syndrome. This review looks at JFK’s various diseases and focusses on the history of coeliac disease, as well as its presentation. JFK’s Irish ancestry supports the hypothesis of a coeliac disease started early in his youth.

Author: Macchia, D., Lippi, D., Bianucci, R., Donell, S.
Posted: September 2, 2020, 9:19 am
Background

Although the concept of medical specialty competitiveness may seem intuitive, there are very little existing empirical data on the determinants of specialty competitiveness in USA. An understanding of the determinants of specialty competitiveness may inform career choices among students and their advisors. Specialty competitiveness correlates with availability and appeal.

Methods

This narrative review examines 2019 National Resident Matching Program (NRMP) data and the existing literature to define the determinants of specialty competitiveness. A statistical analysis of key elements of the 2019 NRMP data was performed.

Results

Using US senior applicant fill rate as a measure of competitiveness, medical specialty competitiveness follows general principles of supply and demand. The demand, or appeal, of a specialty correlates with several factors, including salary, prestige and lifestyle. Salary correlates strongly with US senior fill rate (r=0.78, p=0.001). Relatively few positions are available for the most competitive specialties in the NRMP match. The negative correlation between US senior fill rate and position availability is also strong (r=–0.85; p<0.0001).

Conclusion

A ‘competitive specialty’ correlates strongly with high earnings potential and limited position availability. In an ideal world, a student’s pursuit of a medical specialty should be guided by interest, qualifications and ability to succeed in that field. However, students must contend with the realities of competition created by the residency matching system.

Author: Lefebvre, C., Hartman, N., Tooze, J., Manthey, D.
Posted: September 2, 2020, 9:19 am
Background

The differential diagnosis of malignant effusion remains a clinical challenge. We aim to summarise all relevant literature studies in order to determine the overall clinical value of E-cadherin in the diagnosis of malignant effusion by meta-analysis.

Methods

PubMed, the Cochrane Library Database, Medline (Ovid), Web of Science, CNKI, WANFANG and WEIPU databases are thoroughly searched up to 15 March2018. The calculated pooled sensitivity, specificity, likelihood ratio (LR), diagnostic OR(DOR) and the summary receiver operating characteristic (SROC) curve were plotted.

Results

A total of 15 studies were included in the analysis. The sensitivity and specificity of E-cadherin in the diagnosis of malignant effusion were determined to be high, with a sensitivity of 0.83(95%CI0.79 to 0.87) and a specificity of 0.96(95%CI0.90 to 0.98). The positive LR was determined to be 21.10(95%CI 8.54 to 52.11), the negative LR was determined to be 0.17(95% CI 0.14 to 0.22) and the DOR was determined to be 121.34(95%CI 49.11 to 299.80). The SROC curve exhibited a high overall diagnostic, with the area under the curve measured to be 0.91(95% CI 0.89 to 0.93). Subgroup analysis showed the method (cell blocks or smears), sample size (≥100 or<100), geographical location (Asia, Europe or USA) and impact factor of each article (≥3 or<3) were not the sources of overall heterogeneity.

Conclusion

E-cadherin exhibits very good diagnostic accuracy for the diagnosis for malignant effusion; thus, it can be helpful in the process of clinical decisions.

Author: Chen, F., Dai, L., An, J., Zeng, N., Chen, L., Shen, Y.
Posted: September 2, 2020, 9:19 am

The aim of this systematic review is to provide an update on the current state of augmented reality (AR) in surgical training and to further report on any described benefits compared with traditional techniques. A PICO (Population, Intervention, Comparison, Outcome) strategy was adopted to formulate an appropriate research question and define strict search terms to be entered into MEDLINE, CENTRAL and Google Scholar. The search was returned on 12/09/2019. All returned results were screened first by title and then abstract. The systematic search returned a total of 236 results, of which 18 were selected for final inclusion. Studies covered the full range of surgical disciplines and reported on outcomes including operative duration, accuracy and postoperative complication rates. Due to the heterogeneity of the collected data, no meta-analysis was possible. Outcome measures of competency, surgical opinion and postoperative complication rate were in favour of AR technology while operative duration appears to increase.

Author: Williams, M. A., McVeigh, J., Handa, A. I., Lee, R.
Posted: September 2, 2020, 9:19 am
Background

It is uncertain how diastolic blood pressure (DBP) may associate with ischaemic stroke in elder patients with hypertension. We aimed to explore this relationship in a Chinese community.

Methods

A total of 3315 participants aged ≥60 years with essential hypertension were enrolled between January 2010 and December 2011, and being followed up until 31 December 2016. DBP levels were categorised into five groups (<60, 60–70, 70–80, 80–90 and ≥90 mm Hg), using 70–80 mm Hg as referent. We performed Cox regression analysis and subgroup analyses to evaluate the relationship between DBP and the incidence of ischaemic stroke.

Results

Among the 3315 participants, 44.49% were men and they were 71.4 years old on average. During a median follow-up period of 5.5 years, there were 206 onset cases of ischaemic stroke. The HRs for the first ischaemic stroke in the fully adjusted model were 1.32 (95% CI 0.73 to 2.40) for DBP <70 mm Hg, 1.50 (95% CI 1.13 to 2.73) for DBP between 80 and 89.9 mm Hg and 2.31 (95% CI 1.14 to 4.68) for DBP ≥90 mm Hg compared with DBP between 70 and 79.9 mm Hg (p=0.020 for trend). Subgroup and interaction analysis showed no significant findings.

Conclusions

DBP had a non-linear association with the risk of ischaemic stroke among Chinese elderly patients with hypertension. DBP between 70 and 80 mm Hg may be an appropriate indicator for a lower stroke risk.

Author: Chen, C.-L., Huang, J.-Y., Liu, L., Yu, Y.-L., Shen, G., Lo, K., Huang, Y.-Q., Tang, S.-t., Feng, Y. Q.
Posted: September 2, 2020, 9:19 am
Background

Sleep deprivation and fatigue from long-shift work impacts doctors’ personal safety, inhibits cognitive performance and risks clinical error. The aim of this study was to assess the sleep quality of surgical trainees participating in European Working Time Directive-compliant training rotations within a UK deanery.

Methods

A trainee cohort numbering 38 (21 core, 17 higher surgical trainees, 29 men and 9 women, median age 31 (25–44 years)) completed a sleep diary over 30 days using the Sleep Time (Azumio) smartphone application and triangulated with on-call rosters to identify shift patterns. The primary outcome measure was sleep quality related to rostered clinical duties.

Results

Consecutive 1152 individual sleep episodes were recorded. The median time asleep (hours:min) was 6:29 (5:27–7:19); the median sleep efficiency was 86% (80%–93%); the median light sleep (hours:min) was 2:50 (1:50–3:49); and the median rapid eye movement (REM) sleep (hours:min) was 3:20 (2:37–4:07). Significant adverse sleep profiles were observed in trainees undertaking emergency on-call duty when compared with elective (non-on-call) duty; the median time asleep (hours:min) 5:49 vs 6:43 (p<0.001); the median sleep efficiency was 85% vs 87% (p<0.001); the median light sleep (hours:min) was 2:16 vs 2:58 (p<0.001); and REM sleep (hours:min) was 2:57 vs 3:27 (p<0.001). Recovery of sleep duration, efficiency and quality necessitated five full days of time.

Conclusion

Surgical emergency on-call duty adversely influences sleep quality. Proper consideration of fail-safe rota design, prioritising sleep hygiene, recovery and well-being, allied to robust patient safety and quality of care should be made a priority.

Author: Brown, C., Abdelrahman, T., Lewis, W., Pollitt, J., Egan,, R., on behalf of the members of the Welsh Surgical Research Initiative, Abdulal, Ahmed, Ahmad, Allen, Ansell, Arnaudov, Barnett, Beamish, Bosanquet, Chan, Chandler, Dewi, Dwalesena, Gardner, Gonzi, Harries, Hopkins, Hopkins, James, Jawad, Jones, Jones, Jones, Luton, Marusza, Measuria, Mehta, Pearce, Petralia, Powell, Powell-Chandler, Reeves, Selwyn, Seymour, Ved
Posted: September 2, 2020, 9:19 am
Background

Transgender medicine is an emergent subfield with clearly identified educational gaps.

Aims

This manuscript evaluates a gender-affirming healthcare curriculum for second-year medical (M2) students.

Methods

Students received a survey assessing Gender Identity Competency in terms of skills, knowledge and attitudes regarding transgender and gender non-conforming (TGNC) issues. The authors administered the survey before and after the delivery of the curriculum. The curriculum included five online modules, a quiz, a 3-hour case-based workshop and a 2-hour interactive patient-provider panel.

Results

Approximately 60% of M2 students (n=77) completed both preassessments and postassessments. The following showed a statistically significant improvement from preassessment to postassessment: student Gender Identity Competency, t(76) = –11.07, p<0.001; skills, t(76) = –15.22, p<0.001; and self-reported knowledge, t(76) = –4.36, p<0.001. Negative attitudes did not differ (p=0.378). Interest in TGNC issues beyond healthcare settings did not change (p=0.334). M2 students reported a significant change in experience role-playing chosen pronouns in a clinical setting, t(76) = –8.95, p<0.001.

Conclusions

The curriculum improved students’ gender-affirming medical competency, knowledge and skills. The development of a sustained, longitudinal curriculum is recommended in addition to the continuing education of faculty to reinforce this expanding knowledge and skills base and to address discomfort working with this population.

Author: Thompson, H., Coleman, J. A., Iyengar, R. M., Phillips, S., Kent, P. M., Sheth, N.
Posted: September 2, 2020, 9:19 am

We reported a case of eosinophilic oesophagitis (EoE) treated with short-term 6-food-group elimination diet and reintroduction therapy.1 Elimination diet and reintroduction therapies for EoE are usually performed for 6 to 8 weeks and a 2-week observation period, respectively.2 Our method was implemented in 5 days each.

A 12-year-old girl was referred with a history of epigastric pain of 3-year duration. Eesophagogastroduodenoscopy (EGD) revealed linear furrows, esophageal rings, white exudates and pallor throughout the esophagus (figure 1A); finally, EoE was diagnosed as a result of marked eosinophil infiltration for only esophagus (figure 1B). Abdominal pain has disappeared completely with a short-term elimination diet for 5 days. After a short-term reintroduction therapy for 5 days, eggs and peanuts were identified as causative food antigens. From two-food restriction, the abdominal symptoms never recurred. The findings of EoE almost disappeared in EGD after 12 months...

Author: Kakiuchi, T., Nakayama, A., Matsuo, M.
Posted: September 2, 2020, 9:19 am

Hydroxychloroquine and chloroquine are medications that have been used for a long time. Their most common use is for the treatment and prophylaxis of malaria. However, these antimalarial drugs are known to also have anti-inflammatory and antiviral effects and are used for several chronic diseases such as systemic lupus erythematosus with low adverse effects. The antiviral action of hydroxychloroquine and chloroquine has been a point of interest to different researchers due to its mechanism of action. Several in vitro studies have proven their effectiveness on severe acute respiratory syndrome virus and currently both in vitro and in vivo studies have been conducted on 2019 novel coronavirus (covid-19). The purpose of this article is to review the history and mechanism of actions of these drugs and the potential use they can have on the current covid-19 pandemic.

Author: Sinha, N., Balayla, G.
Posted: September 2, 2020, 9:19 am

Although you would not have realised at the time, you probably understood the idea of a trade-off before the age of 5. Perhaps you longed for a toy or other precious item belonging to a friend, but knew it was wrong to steal it, or feared being caught if you did. So you calculated what you could offer that might tempt the other person—something you were willing to part with, but still held value in your own eyes. Intuitively, you realised that when you desire two or more things you may have to seek a compromise. Around the same age you would also have discovered that the principle applies to experiences as well as objects: for instance, you cannot watch television and play table tennis at the same time. You have to choose which of these you prefer at any given moment.

Trade-offs are not only a...

Author: Launer, J.
Posted: September 2, 2020, 9:19 am

In 2003, severe acute respiratory syndrome (SARS) spread through 26 countries, infecting at least 8098 and causing at least 774 deaths (a case fatality rate of 9.6%). Middle East respiratory syndrome (MERS) by January 2020 caused 2519 cases and 866 deaths (a case fatality rate of 34%). SARS and MERS are coronaviruses and both are not as easily transmitted as COVID-19 because they require close contact with those infected (or also with camels in the case of MERS), and infected humans tend not to transmit before they have symptoms. Transmission of both mostly occurred within healthcare settings and could be controlled by improving infection control in hospitals.

In 2015, Bill Gates in a TED lecture warned that we were more at risk of a global pandemic (he thought it would be influenza) than we were from nuclear war.

COVID-19 probably first entered the human population in China in November...

Author: Welsby, P. D.
Posted: September 2, 2020, 9:19 am