RSS 1.0General Medicine
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Epidemiology and management of pediatric group A streptococcal pneumonia with parapneumonic effusion: an observational studyBackground: During autumn/winter 2022, UK pediatricians reported an unseasonal increase in invasive group A streptococcal infections; a striking proportion presenting with pneumonia with parapneumonic effusion. Methods: Clinicians across the United Kingdom were requested to submit pseudonymized clinical data using a standardized report form for children (<16 years) admitted between September 30, 2022 and February 17, 2023, with microbiologically confirmed group A streptococcal pneumonia with parapneumonic effusion. Results: From 185 cases submitted, the median patient age was 4.4 years, and 163 (88.1%) were previously healthy. Respiratory viral coinfection was detected on admission for 101/153 (66.0%) children using extended respiratory pathogen polymerase chain reaction panel. Molecular testing was the primary method of detecting group A streptococcus on pleural fluid (86/171; 50.3% samples). Primary surgical management was undertaken in 171 (92.4%) children; 153/171 (89.4%) had pleural drain inserted (96 with fibrinolytic agent), 14/171 (8.2%) had video-assisted thoracoscopic surgery. Fever duration after admission was prolonged (median, 12 days; interquartile range, 9-16). Intravenous antibiotic courses varied in length (median, 14 days; interquartile range, 12-21), with many children receiving multiple broad-spectrum antibiotics, although evidence for additional bacterial infection was limited. Conclusions: Most cases occurred with viral coinfection, a previously well-recognized risk with influenza and varicella zoster, highlighting the need to ensure routine vaccination coverage and progress on vaccines for other common viruses (eg, respiratory syncytial virus, human metapneumovirus) and for group A streptococcus. Molecular testing is valuable to detect viral coinfection and confirm invasive group A streptococcal diagnosis, expediting the incorporation of cases into national reporting systems. Range and duration of intravenous antibiotics administered demonstrated the need for research on the optimal duration of antimicrobials and improved stewardship.
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Informed consent in balloon Eustachian tuboplasty: a systematic review of possible complications and preventive measuresObjective: To systematically identify the complications associated with balloon Eustachian tuboplasty and their frequency of occurrence. This study will also highlight the measures that can be employed to avoid these complications and perform this procedure more safely. Methods: Systematically reviewed relevant papers published until January 2023. Each reference was checked and evaluated for any potential manuscripts. There was no registered protocol; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used. Results: Sixty-nine publications were found, from which 14 publications met our inclusion criteria: 2 randomised clinical trials, 5 retrospective studies, 2 systematic reviews, 2 case series and 3 case reports. Studies with balloon Eustachian tuboplasty procedure only were included, regardless of ethnicity, gender and age. All studies were excluded in which more than one procedure was performed. Conclusion: Balloon Eustachian tuboplasty is a relatively safe procedure with an overall complication risk of 1.66 per cent. Major complication rate was 0.43 per cent. Surgical emphysema was the most common, around 0.40 per cent.
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Questionnaire-based study of 392 women in Abbottabad, Pakistan, to evaluate the types of cosmetic products purchased between December 2018 and March 2019 and their associated adverse eventsBACKGROUND Cosmetics are applied topically to enhance appearance and are commonly used by women of all ages. Cosmetics contain many chemical agents, but the incidence of adverse reactions is low, possibly due to underreporting. This questionnaire-based study included 392 women to evaluate information on the types of cosmetics purchased between December 2018 and March 2019, their use by the women surveyed, and their associated adverse events. MATERIAL AND METHODS A cross-sectional study was conducted among 392 women in Abbottabad, Pakistan, using a pre-structured and validated questionnaire to evaluate information on the types of cosmetics, their use, and their associated adverse events. Part 1 of the study collected information about demographics. Part 2 contained a total of 11 items, and collected the frequency of use of cosmetic on skin and hair care products. Part 3 consisted of 4 items and collected information about problems encountered due to the use of cosmetics. RESULTS In the winter season, 47.7% (n=187) of women preferred chemical-based cosmetic products, while 30.9% (n=121) preferred Ayurvedic products. Among commonly used cosmetic products, 26.9% (n=106) of women used foundations. The most frequently used skin care product was face wash 39.5% (n=155). The most prevalent adverse events related to cosmetics were pimples (19.9%, n=78), redness (17.6%, n=69), and eye discomfort (15.8%, n=62). Furthermore, 51.3% (n=201) strongly agreed that cosmetics aid in getting a whiter complexion. CONCLUSIONS The survey concluded that most women preferred cosmetics with a chemical base, which are associated with rashes, redness, and acne. It is important to encourage cosmetovigilance and awareness campaigns among cosmetic product sellers and users.
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Induction implications: shaping the competence and confidence of junior doctors within complex medical specialtiesIntroduction The newly qualified junior doctors in the United Kingdom face challenges due to their limited experience and unfamiliarity with their rotations. We aim to share the experience of establishing a hepato-pancreato-biliary (HPB) surgery-specific induction program at the University Hospitals of Leicester NHS Trust and assess its impact on doctors' knowledge and experience. Methods A booklet was distributed to new junior doctors, and a two-hour structured teaching session was also conducted, with pre- and post-session assessments using multiple-choice questions and a feedback survey. The survey measured understanding of HPB anatomy, interventions, and satisfaction with the teaching methodology. Results The pre-session questionnaire included 22 participants, while the post-session had 20 participants. Regarding HPB anatomy understanding, in the pre-session, six (28.6%) and 11 (52.4%) participants reported levels 2 and 3, respectively, while levels 4 and 5 were reported by three (13.3%) and one (4.8%) participants. In the post-session, levels 4 and 5 were reported by six (30%) and 13 (65%), with only one (5%) reporting level 3 and none at levels 1 or 2. Similar trends were observed in understanding HPB investigation. In the pre-session, levels 2 and 3 were reported by eight (36.4%) and 11 (50%), while levels 4 and 5 were reported by two (9.1%) and one (4%). In the post-session, eight (40%) and 11 (55%) reported levels 4 and 5, with only one (5%) at level 3 and none at levels 1 or 2. For HPB management methods before teaching, levels 2 and 3 were equally reported by eight (36.4%), level 4 by four (22.7%), and none at level 5. After teaching, nine (45%) and 10 (50%) reported levels 4 and 5, with only one (5%) at level 3 and none at levels 1 or 2. Factual knowledge showed a 38% increase, rising from 49% pre-session to 87% post-session. In post-session feedback, 12 (60%) strongly agreed that the session helped augment their medical practice, and six (30%) agreed, with two (10%) neutral. Feedback on the teaching session's organization was positive, with 13 (65%) strongly agreeing that it was structured coherently, and six (30%) agreeing, with only one (5%) neutral regarding the clarity of the structure and delivery method. Conclusion Specialty-specific induction programs are crucial for providing support and ensuring the development of competent doctors. Efforts should be made to create supportive working environments for junior doctors to alleviate stress and improve their well-being.
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Chest x-ray reporting: a comparative study of specialist nurses and trainee doctors' knowledge in the biologic prescription serviceWith all the challenges facing the NHS at the current time, specialist nurses are fundamental and an important part of an ever-expanding NHS workforce. Furthermore, specialist nurses now possess more diversity and a wide range of advanced skills. In the field of rheumatology in most NHS hospitals, specialist nurses play a key role in biologic services to ensure that patients are promptly started on biological therapy to control their disease. An important element of this workup is the ability to comment on an unreported chest radiograph to facilitate a biological prescription. Some studies have shown that there is limited expertise among non-doctors with the required skills to review unreported chest X-rays confidently. The authors of this paper sought to explore whether this is the case among specialist nurses involved in the biologic prescription service among other clinicians in the same service. An online questionnaire was designed by the authors, which included seven questions and responses collected on a 5-point Likert scale. Trainee doctors, non-trainee grade doctors, and specialist nurses who were involved in the biologic prescribing team from Rheumatology, Dermatology, and Gastroenterology were invited. A total of 56 responses were obtained and analyzed. Descriptive and inferential statistics were obtained from the data. To determine if there was a statistical difference between the responses of trainee doctors and specialist nurses, the Kruskal-Wallis statistical test was used, and a post hoc test using the Dunn-Bonferroni test was used to analyze any statistically significant results. Regarding chest X-ray interpretation prior to starting biological treatment, only 8% of specialist nurses reported being confident, whereas 63% of trainees reported being confident. The Kruskal-Wallis test revealed a significant difference between specialist nurses' and doctors' confidence in interpreting unreported chest radiographs. The P-value is 0.001; thus, with available data, the null hypothesis is rejected. A Dunn-Bonferroni test (post hoc test) showed that, based on the available data, it can be assumed that the two groups had different levels of confidence between Specialist Nurses and trainee doctors. Chest X-ray interpretation skills are vital for specialist nurses in the context of biological therapy prescriptions. Therefore, we recommend access to resources, ongoing formal training, and educational sessions to help specialist nurses maintain their advanced skill sets and broaden their scope of practice to those without the required expertise.
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Effects of blood pressure on brain tissue pulsation amplitude in a phantom modelObjective: The precise mechanism and determinants of brain tissue pulsations (BTPs) are poorly understood, and the impact of blood pressure (BP) on BTPs is relatively unexplored. This study aimed to explore the relationship between BP parameters (mean arterial pressure [MAP] and pulse pressure [PP]) and BTP amplitude, using a transcranial tissue Doppler prototype. Methods: A phantom brain model generating arterial-induced BTPs was developed to observe BP changes in the absence of confounding variables and cerebral autoregulation feedback processes. A regression model was developed to investigate the relationship between bulk BTP amplitude and BP. The separate effects of PP and MAP were evaluated and quantified. Results: The regression model (R2 = 0.978) revealed that bulk BTP amplitude measured from 27 gates significantly increased with PP but not with MAP. Every 1 mm Hg increase in PP resulted in a bulk BTP amplitude increase of 0.29 µm. Conclusion: Increments in BP were significantly associated with increments in bulk BTP amplitude. Further work should aim to confirm the relationship between BP and BTPs in the presence of cerebral autoregulation and explore further physiological factors having an impact on BTP measurements, such as cerebral blood flow volume, tissue distensibility and intracranial pressure.
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Point of care ultrasound: Current and future directions for Acute MedicinePoint of care ultrasound (POCUS) represents an exciting tool for current and future acute care practitioners. POCUS has come a long way in a short space of time and its widespread implementation may well be one of the biggest changes seen in acute medicine across the next decade. This narrative review explores the increasing evidence base for the accuracy of POCUS use in various acute scenarios, whilst also addressing current gaps in the evidence and areas for potential future POCUS development.
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Society for Acute Medicine's Patients: Learning from Experience Report (SAM-PLER) A service evaluation of patient reported experience in Acute Medicine - establishing the feasibility of a quality improvement collaborativePatient reported experience measures (PREMS) are a key part of measured quality. There is no tool currently used in the UK in Acute Medicine. On the 8th of September 2022 10 units based in England, Scotland and Wales collected data for the validated PREM, alongside the EQ-5D and variables from the Society for Acute Medicine's Benchmarking Audit (SAMBA) dataset. 365 patients were screened, 200 were included (55%): 159 patients from AMUs and 41 from SDEC units. Overall experience of patients was rated 8.5/10, patients rated their experience of safety, trust and listening highly. Collection of PREMS was feasible. Further research is required to link experience to clinical outcome and explore tools that capture experience of patients with altered mental status.
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Progressive multifocal leukoencephalopathy mimicking a cerebral vasculitis flareWe report a case of a 68-year-old woman with a background of primary cerebral vasculitis, which was diagnosed two years ago. She appeared to have had a recurrence of her symptoms with new onset history of expressive dysphasia, right-sided upper limb weakness, and right-sided facial weakness during a rheumatology clinic visit. The patient was on maintenance azathioprine for her cerebral vasculitis at the time of presentation. She had received a total of 2 g of rituximab through intravenous infusion, with a two-week interval between doses. Additionally, she had undergone intravenous cyclophosphamide treatment (15 mg/kg) following the standard vasculitis regimen for induction remission therapy, which was administered at the time of her diagnosis two years prior. Initial imaging on non-contrast computed tomography head after admission to the emergency department did not show any acute neurological findings. Further imaging studies revealed changes in the right parietotemporal white matter T2 hyperintensity with similar changes on the left frontal and left parietal lobes suggestive of progressive multifocal leukoencephalopathy (PML). A magnetic resonance imaging (MRI) of the brain conducted three months prior was found to be unremarkable. Cerebrospinal fluid (CSF) polymerase chain reaction (PCR) testing confirmed the presence of polyoma John Cunningham (JC) virus deoxyribonucleic acid (DNA). This case highlights that PML should be an important differential to consider in any immunocompromised patient who presents with new stroke-like features.
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The mental health of health care workers in the UK during COVID-19: The prevalence of anxiety, depression, and stressIntroduction: The COVID-19 pandemic had a significant impact on the mental health of health care workers (HCWs). Aim: This study investigated the mental health of HCWs working in Leicester, UK during COVID-19. Settings: Two hospital trusts in Leicester, UK. Methods: An online survey was sent to HCWs in two trusts in July 2020. The Generalized Anxiety Disorder-7 scale (GAD-7) and the Patient Health Questionnaire-9 scale (PHQ-9) were used to measure the prevalence rates of anxiety and depression. The Perceived Stress Scale-14 (PSS-14) was used to measure levels of perceived stress. Other questions were used to identify the prevalence of increased alcohol intake and possible risk factors. Statistical analysis used: Chi-square test, independent sample t-test, ANOVA, and logistic regression. Results: A total of 1009 HCWs completed the survey. Using a cutoff score of 5 (mild symptoms), for both GAD-7 and PHQ-9, 80.2% of participants had at least one condition and 71.5% had both. Using the cutoff score of 10 (moderate/severe symptoms), 27.2% had at least one condition and 27.25% had both conditions. In addition, 37.5% of those who did not report pre-existing mental health conditions now have at least one condition. About 33.6% of participants reported an increase in alcohol consumption. A number of risk factors were identified: having less social support, not feeling supported at work, and poor pre-existing mental health. Conclusions: The pandemic had a significant impact on mental health of HCWs. Health organizations need to monitor and address these emerging effects.
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Review of literature for ethnic minority-led GP practices: impact and experience of CQC regulationBackground/aim: The Care Quality Commissions' (CQC) recent report into the impact and experience of CQC regulation for ethnic minority-led general practitioner (GP) practices found that ethnic minority-led practices are disproportionately situated in areas of deprivation, working single-handedly and without adequate systems of support. These challenges are not always accounted for in CQC's processes or methodology (CQC, 2022).This study summarises a review of literature carried out as part of research by the CQC, which was published in January 2022. Methods: Search terms included 'GP', 'CQC', 'Black and Ethnic Minority GPs' combined with Boolean operators. Grey literature was reviewed, and searches were undertaken of known authors in the field. Backwards and forwards reference harvesting was performed on identified literature. Limitations included the capacity and subjectivity of the reviewer, as well as the availability of studies with a focus on ethnic minority GPs as opposed to doctors whose place of primary medical qualification was outside of the UK. Results: 20 evidence sources were identified and included. The literature review found that many ethnic minority-led GP practices are in complex cycle of inequality, which starts with recruitment and thereafter followed by deprivation, isolation, poor funding and low morale. The symptom of these factors is often poor regulatory outcomes and ratings. When these poor ratings are received, GP providers often struggle to recruit, which serves to perpetuate the cycle of inequality. Conclusion: When CQC rates an ethnic minority-led practice as requires improvement or inadequate, this can perpetuate a cycle of inequality.
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Near-peer-teaching revision series during the COVID-19 recovery phase: An experience from a UK medical schoolBackground The COVID-19 pandemic led to a significant disruption in clinical attachments for final-year medical students which can result in gaps in clinical knowledge and lower confidence levels. We developed a targeted near-peer-teaching (NPT) revision series to bridge this gap. Method A one-week virtual revision series was developed by the postgraduate doctors (PD and AT) and supervised by the final year written paper lead (NS) as per curriculum requirements. The series focused on eight key common clinical presentations. It was delivered via Leicester Medical School's virtual platform by PD and AT a week before the finals. Multiple-choice surveys were sent out prior to the commencement of the series to gauge participation and baseline confidence. Surveys were also sent out before and after each session evaluating teaching, confidence levels, and improvement points. Results This NPT experience was the first comprehensive revision series during the COVID-19 recovery phase. Between 30 and 120 students attended each session. From the pre-series survey (n=63), almost all students indicated that their clinical attachments had been affected by the pandemic and that they (100%) would be interested in participating in the NPT series. From the post-session surveys, 93% of students reported that the session enhanced their confidence in recognizing and managing the clinical presentation, and 100% considered the quality of teaching to be good to excellent. From the post-series survey, a significant improvement was seen in confidence based on the Likert scale (from a combined 35% to 83%, pre, and post-series, respectively). Conclusion The series evaluation demonstrates that students found it a valuable experience and benefited from the social and cognitive congruence afforded by near-peer teachers. Furthermore, the results support the continued use and development of a virtual pre-exam revision series within the medical school curriculum as an adjunct to normal teaching.
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Development of a novel ex vivo porcine hepatic segmental perfusion proof-of-concept model towards more ethical translational researchIntroduction Ex vivo machine perfusion describes the technique where organs are continuously perfused and oxygenated extracorporeally (at physiological conditions) to maintain the organs' viability. To our knowledge, there are currently no reported studies describing ex vivo perfusion of a single hepatic segment. Here, we describe the development of a porcine ex vivo hepatic segmental perfusion model to demonstrate proof of concept and support further research into the ex vivo perfusion of the human liver using discarded tissue. Methods Whole livers were retrieved from abattoir-derived pigs and connected to a normothermic extracorporeal perfusion circuit. Constant segmental perfusion via the common or segmental hepatic artery and portal vein with heparinised autologous blood was established. The viability of the perfused organ was assessed by monitoring perfusion pressures, flow rates and histology samples. Results Following perfusion and optimisation of the model for three hepatic segments, the third perfusion demonstrated viable hepatocytes centrally after 4 h of segmental perfusion. Conclusion Ex vivo hepatic segmental perfusion is technically challenging but its success in a porcine model and the principles learned should facilitate the development of an analogous human model using discarded tissue following formal liver resections. The model would use a healthy liver segment following a major formal resection such as a hemi-hepatectomy and ex vivo perfusion performed via a segmental hepatic artery and portal vein. If successful this model would represent a significant development and enable ethical translation research to assess the response of human livers to a variety of stressors, including toxicity and infection.
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Hyperkalaemia and potassium binders: Retrospective observational analysis looking at the efficacy and cost effectiveness of calcium polystyrene sulfonate and sodium zirconium cyclosilicateWhat is known and objective: Hyperkalaemia is a common medical emergency in patients admitted to hospital. There is a limited evidence base supporting some of the commonly applied treatment strategies. Although, NICE has recommended the use of sodium zirconium cyclosilicate (SZC) (TA599) and patiromer (TA623) in both acute and chronic hyperkalaemia, there is a limited evidence base for their use in acute hyperkalaemia in the hospital setting, particularly when compared to the present standard of care calcium polystyrene sulfonate (CPS). Methods: A retrospective review of the electronic patient record system across our hospital over a 6-month period identified 138 patients who received either SZC (65 patients) or CPS (73 patients) to manage hyperkalaemia, investigating their efficacy and cost effectiveness. Results were analysed using simple descriptive statistics. Based on the results a naïve cost comparison between the two drugs was made. Results and discussion: CPS and SZC both effectively reduced plasm potassium concentrations in patients with hyperkalaemia (6.07 and 6.03 mmol/L respectively) by 1.17 mmol/L and 1.24 mmol/L taking a similar amount of time to work (2.97 days vs. 3 days). The principle causes of hyperkalaemia identified were acute kidney injury, medication, and chronic kidney disease. Cost comparison analysis which took into account raw product price and time needed to dispense medications revealed that CPS has slightly better cost effectiveness compared to SZC albeit at a cost of increased staff input. What is new and conclusion: Both CPS and SZC were equally effective at lowering acutely raised potassium concentrations. The cost difference between the two products appears to be small. Claims regarding the benefits of newer agents over older established medications need to be properly explored in randomized trials rather than being based on small scale non-comparative studies.
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Managing surgical demand when needs outstrip resource: qualitative investigation of colorectal cancer surgery provision in the first wave of the COVID-19 pandemicBackground: At the onset of the COVID-19 pandemic, elective surgical provision was severely affected by the need for hospital reorganization to care for critically ill patients. In response, National Health Service (NHS) England issued national guidance proposing acceptable time intervals for postponing different types of surgical procedure. This study reports healthcare professionals' private accounts of the strategies adopted to manage the imbalance of demand and resource, using colorectal cancer surgery as a case study. Methods: Twenty-seven semistructured interviews were conducted with healthcare professionals between June and November 2020. A key informant sampling approach was used, followed by snowballing to achieve maximum regional variation across the UK. Data were analysed thematically using the constant comparison approach. Results: In the context of considerable resource constraint, surgical teams overcame challenges to continue elective cancer provision. They achieved this by pursuing a combination of strategies: relocating surgical services; prioritizing patients within and across surgical specialties; adapting patient treatment plans; and introducing changes to surgical team working practices. Despite national guidance, prioritization decisions were framed as complex, and the most challenging of the strategies to implement, both practically and emotionally. Conclusion: There is a need to better support surgeons tasked with prioritizing patients when capacity exceeds demand.
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Datura poisoning in Trinidad: A case reportDatura, a wild-growing annual plant, common in the American Southwest and the Caribbean, has many uses, including medicinal or pharmaceutical, ornamental, religious, and social. In the Caribbean, this white trumpet-shaped flower has been used for many cultural aspects and has also been found to be used as a potent psychological stimulant. Despite its many purposes, its inappropriate misuse can result in mild-to-severe toxicity, leading to severe anticholinergic effects and even death in some cases. The purpose of this report is to highlight the toxic effects of this plant when misused and the subsequent management as it relates to the spectrum of anticholinergic poisoning, a common complication of drug overdose. We describe a case of datura poisoning presenting in Trinidad, West Indies, which was not described previously in the literature.
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Management of idiopathic pulmonary arterial hypertension in a patient in Trinidad: A case reportAbnormal elevation in pulmonary arterial blood pressure without secondary causes is Idiopathic Pulmonary Arterial Hypertension (IPAH). It is imperative to establish this diagnosis because IPAH often progresses to right heart failure (RHF) and death without treatment. Right heart catheterization is the standard gold test for diagnosing pulmonary hypertension (PH); however, echocardiography is a susceptible sensitive test and the best non-invasive test. The overall management of IPAH involves supportive measures, conventional therapy, and, pending availability, PAH-targeted therapy. Upon review of the literature, there were no published case reports on IPAH in Trinidad and Tobago. We describe a case of IPAH presented at Apley Medical Centre Limited, Trinidad and Tobago, in the West Indies, emphasizing contemporary management, including using the Implantable Delivery Systems (IDS) for Remodulin injection.