Showing papers in "Journal of the Royal College of Physicians of Edinburgh in 2015"
TL;DR: The principles of grounded theory are outlined, and focus on thematic analysis as the analytical approach used most frequently in grounded theory studies, with the aim of providing clinicians with the skills to critically review studies using this methodology.
Abstract: In today's NHS, qualitative research is increasingly important as a method of assessing and improving quality of care. Grounded theory has developed as an analytical approach to qualitative data over the last 40 years. It is primarily an inductive process whereby theoretical insights are generated from data, in contrast to deductive research where theoretical hypotheses are tested via data collection. Grounded theory has been one of the main contributors to the acceptance of qualitative methods in a wide range of applied social sciences. The influence of grounded theory as an approach is, in part, based on its provision of an explicit framework for analysis and theory generation. Furthermore the stress upon grounding research in the reality of participants has also given it credence in healthcare research. As with all analytical approaches, grounded theory has drawbacks and limitations. It is important to have an understanding of these in order to assess the applicability of this approach to healthcare research. In this review we outline the principles of grounded theory, and focus on thematic analysis as the analytical approach used most frequently in grounded theory studies, with the aim of providing clinicians with the skills to critically review studies using this methodology.
336 citations
TL;DR: Today’s young people are growing up in contexts of rapid urbanisation, increased educational demands, globalisation, and increased access to worldwide information through the internet and social media.
Abstract: www.thelancet.com Vol 379 April 28, 2012 1567 Several factors have contributed to the social construct of adolescence as a distinct period of life, including the rise in education (and with it age segregation), social media, and urbanisation. But adolescence also has a biological basis. Many of the behaviours we associate with the teenage years (eg, risk taking) are evident in other species, and we know that brain maturation in human beings is not complete until about age 25 years. As young people enter adolescence they bring with them resources and vulnerabilities, both biological (genetics, epigenetics, natural endowments) and environmental (national and local policies, as well as community, school, workplace, peers, neighbourhood, and family infl uences). Conse quently, an ecological or life-course framework is crucial to understanding adolescent trajectories (fi gure). In high-income countries and, increasingly, low-income and middle-income countries, birth rates have declined while child survival has increased. Hence, there is a larger cohort of adolescents and young people today (just under 2 billion) than ever before, of whom 86% live in low-income and middle-income countries. This should mean that healthier young people are coming of age and entering the workforce, adding to a nation’s wealth. However, in many low-income and middle-income countries this dividend has yet to be realised. Impeding this realisation are factors that include disparities in access to resources and services by ethnic origin, region of residence, socioeconomic status, and sex. Furthermore, as young people migrate to urban centres seeking often unavailable education and work, there is a growing population of disenfranchised young people adding to, rather than alleviating, the economic and social burdens. Today’s young people are growing up in contexts of rapid urbanisation, increased educational demands, globalisation, and increased access to worldwide information through the internet and social media. Urbanisation is predominantly a feature of low-income and middle-income countries, and disproportionately it is young people who are migrating to urban centres. However, unless there are radical improvements in urban governance and investments, most migrants will Adolescent health in the 21st century
113 citations
TL;DR: A perspective on burnout among doctors is provided, including an overview of symptoms, the scale of the problem, the implications and causes of burnout and, finally, a strategic framework to provide a basis for managing it.
Abstract: Increasing numbers of doctors are experiencing burnout now more than ever before and the worrying part is that what we see is just the tip of the iceberg. Burnout, a state of mental exhaustion caused by the doctor's professional life, is characterised by emotional exhaustion, depersonalisation and a reduced sense of accomplishment or success. Burnout has been largely ignored or under-recognised previously. This paper provides a perspective on burnout among doctors, including an overview of symptoms, the scale of the problem, the implications and causes of burnout and, finally, a strategic framework to provide a basis for managing it. Most importantly, professional bodies are urged to start taking steps to help troubled doctors. Medical Colleges should provide essential assistance, support and guidance as well as ensuring fair management and promotion policies.
55 citations
TL;DR: It seems reasonable to consider that healthcare needs reshaping so that care that pursues goals important to patients as well as those suggested by evidence-based medicine can be achieved by using shared decision approaches guided by the expertise of clinicians to deliver optimal care while minimising the burden of treatment on patients, their caregivers, and the healthcare system.
Abstract: Patients with chronic conditions or multimorbidity, and often their caregivers, have to adjust their lives and mobilise their capacity (ability) to respond to the workload (demands) imposed by treatments and the care of their conditions There is a continuous and complex interaction between workload and capacity When capacity proves insufficient to address the treatment workload, creating a burden, patients may place a lower priority on other aspects of their lives, or reduce engagement with healthcare Guidelines usually focus on disease-centred outcomes without consideration of limited capacity or demanding workload (burden) from treatment regimens It seems reasonable to consider that healthcare needs reshaping so that care that pursues goals important to patients as well as those suggested by evidence-based medicine This can be achieved by using shared decision approaches guided by the expertise of clinicians to deliver optimal care while minimising the burden of treatment on patients, their caregivers, and the healthcare system What we need is minimally disruptive medicine
41 citations
TL;DR: Enteral tube feeding is usually a relatively straightforward method of nutritional support, and should be facilitated by a multiprofessional team, but if longer term feeding is required then a gastrostomy is appropriate, usually inserted endoscopically (a percutaneous endoscopic gastroparesis tube).
Abstract: Enteral tube feeding is usually a relatively straightforward method of nutritional support, and should be facilitated by a multiprofessional team. For short-term use (<4 weeks) a fine bore feeding nasogastric tube is indicated but if longer term feeding is required then a gastrostomy is appropriate, usually inserted endoscopically (a percutaneous endoscopic gastrostomy tube). The most common serious complication of a nasogastric tube is not identifying a misplaced tube within the lungs: there are clear recommendations from the National Patient Safety Agency as to how to check tube placement. Nasojejunal tubes are required in patients with gastroparesis. Tube blockage is common and is prevented by careful and regular flushing. Diarrhoea is the most complication of feeding and is often related to other medication. Clinicians need an algorithm for systematically dealing with such a problem. Refeeding syndrome may occur in malnourished patients and is characterised by low levels of potassium, phosphate, and/or magnesium, as well as disorders of water and salt balance. Identifying the at-risk patient with careful monitoring is crucial.
27 citations
TL;DR: A high positive and negative predictive value of arteritis on colour duplex ultrasound indicates that temporal artery biopsy may be unnecessary in suspected giant cell arteritis, particularly where clinical suspicion of giant cellarteritis is high or low.
Abstract: BACKGROUND Establishing a diagnosis of giant cell arteritis, or indeed ruling it out, may be difficult. We describe an evaluation of temporal artery colour duplex ultrasound as first line investigation in patients with suspected giant cell arteritis. METHODS A retrospective cohort study of all patients undergoing colour duplex ultrasound for suspected giant cell arteritis between January 2005 and January 2014 was undertaken at a teaching hospital. A minimum clinical follow-up of three months was required. Patients were classified on the basis of ultrasound reports, using described features such as a halo sign or arterial wall thickening and clinical diagnosis of giant cell arteritis after at least 3 months follow-up, determined by the treating physician. The relationship of colour duplex ultrasound to a final clinical diagnosis of giant cell arteritis was analysed. RESULTS A total of 87 patients underwent colour duplex ultrasound: 36 (41%) had clinically confirmed giant cell arteritis at 3-month follow-up. The positive predictive value of colour duplex ultrasound for a clinical diagnosis at 3 months was 97% (95% confidence interval (CI) 93 to 99%) and negative predictive value 88% (95% CI 76 to 95%). Sensitivity was 81% (95% CI 64 to 92%) and specificity 98% (95% CI 90 to 100%). CONCLUSIONS A high positive and negative predictive value of arteritis on colour duplex ultrasound indicates that temporal artery biopsy may be unnecessary in suspected giant cell arteritis, particularly where clinical suspicion of giant cell arteritis is high or low.
21 citations
21 citations
TL;DR: The incidence of Lyme borreliosis may be stabilising in Scotland but NHS Highland remains an area of high incidence and should be considered in symptomatic patients that have had exposure to ticks and not just those with a definite tick bite.
Abstract: This study examines the distribution of laboratory-confirmed cases of Lyme borreliosis in Scotland and the clinical spectrum of presentations within NHS Highland. Methods General demographic data (age/sex/referring Health Board) from all cases of Lyme borreliosis serologically confirmed by the National Lyme Borreliosis Testing Laboratory from 1 January 2008 to 31 December 2013 were analysed. Clinical features of confirmed cases were ascertained from questionnaires sent to referring clinicians within NHS Highland during the study period. Results The number of laboratory-confirmed cases of Lyme borreliosis in Scotland peaked at 440 in 2010. From 2008 to 2013 the estimated average annual incidence was 6.8 per 100,000 (44.1 per 100,000 in NHS Highland). Of 594 questionnaires from NHS Highland patients: 76% had clinically confirmed Lyme borreliosis; 48% erythema migrans; 17% rash, 25% joint, 15% neurological and 1% cardiac symptoms. Only 61% could recall a tick bite. Conclusion The incidence of Lyme borreliosis may be stabilising in Scotland but NHS Highland remains an area of high incidence. Lyme borreliosis should be considered in symptomatic patients that have had exposure to ticks and not just those with a definite tick bite.
18 citations
TL;DR: There is a case that service delivery would be well served by recognition that 'care home medicine' is a distinct entity and staff with these competencies need to work in an appropriate service context in order to achieve the best outcomes.
Abstract: This paper makes the case for a specific set of competencies required to adequately care for care home residents. It proposes that staff with these competencies need to work in an appropriate service context in order to achieve the best outcomes. These competencies and contextual factors are not currently recognised or championed by any single constituency within the existing healthcare infrastructure and there is a case that service delivery would be well served by recognition that 'care home medicine' is a distinct entity.
18 citations
TL;DR: The survival of patients with malignant pleural mesothelioma remains poor and typically around 1 year, while patients with a good performance status and few co-morbidities should be encouraged to receive chemotherapy.
Abstract: Background: The prognosis of malignant pleural mesothelioma has traditionally been poor. Whether this remains the case compared to historical data and within a specific geographical location is uncertain. Knowledge of predictive factors for survival with malignant pleural mesothelioma is also inadequate. Methods: We conducted a retrospective local database analysis to determine overall prognosis of patients with malignant pleural mesothelioma and evaluate the influence of demographic characteristics, histological subtype and laboratory parameters. Patients with histological diagnoses of malignant pleural mesothelioma held on the NHS Grampian pathology database between 2002 and 2012 were analysed. Data on baseline demographics, mode of diagnosis, histological sub-type, and survival and serum laboratory parameters, were analysed; time to death was examined using Cox regression analyses. Results: A total of 114 patients with malignant pleural mesothelioma were included in the analysis. The median survival was 345 days (IQR 99–600). Sarcomatoid malignant pleural mesothelioma carried a significantly worse prognosis with median survival of 125 days (IQR 44–289) vs 334 days (IQR 126–715) for biphasic, 412 days (IQR 201–656) for epithelioid and 345 days (IQR 99–600) for those with no definitive typing. Individuals who did not receive chemotherapy experienced a significantly worse prognosis (hazard ratio 2.7; 95%CI 1.5–4.7; p = 0.001), while a low albumin and raised urea at time of diagnosis were also associated with a significantly poorer prognosis. Conclusion: The survival of patients with malignant pleural mesothelioma remains poor and typically around 1 year. The presence of raised urea and low albumin is associated with a poorer prognosis, while patients with a good performance status and few co-morbidities should be encouraged to receive chemotherapy.
18 citations
TL;DR: Introduction of an enhanced, consultant-led model of working at weekends was associated with reduced in-hospital and 30-day post discharge mortality rates as well as reduced length of stay.
Abstract: Weekend admission is associated with higher in-hospital mortality than weekday admission. Whether providing enhanced weekend staffing for acute medical inpatient services reduces mortality or length of stay is unknown. METHODS: This paper describes a retrospective analysis of in-hospital mortality and length of stay before and after introduction of an enhanced, consultant-led weekend service in acute medicine in November 2012. In-hospital mortality was compared for matching admission calendar months before and after introduction of the new service, adjusted for case volume. Length of stay and 30-day postdischarge mortality were also compared; illness severity of patients admitted was assessed by cross-sectional acuity audits. RESULTS: Admission numbers increased from 6,304 (November 2011-July 2012) to 7,382 (November 2012-July 2013), with no change in acuity score in elderly medical patients but a small fall in younger patients. At the same time, however, a 57% increase in early-warning score triggered calls was seen in 2013 (410 calls vs 262 calls in 2012; p<0.01). Seven-day consultant working was associated with a reduction in in-hospital mortality from 11.4% to 8.8% (p<0.001). Mortality within 30 days of discharge fell from 2.4% to 2.0% (p=0.12). Length of stay fell by 1.9 days (95% CI 1.1-2.7; p=0.004) for elderly medicine wards and by 1.7 days (95% CI 0.8-2.6; p=0.008) for medical wards. Weekend discharges increased from general medical wards (from 13.6% to 18.8%, p<0.001) but did not increase from elderly medicine wards. CONCLUSIONS: Introduction of an enhanced, consultant-led model of working at weekends was associated with reduced in-hospital and 30-day post discharge mortality rates as well as reduced length of stay. These results require confirmation in rigorously designed prospective studies.
TL;DR: A systematic review has identified 25 paintings by five artists in which the presumptive medico-artistic diagnosis of congenital or acquired foot deformity seems to be varyingly present.
Abstract: Although Renaissance artists were skilled in representing normal anatomy, a close look at some paintings reveals anatomical variations in the depiction of the feet of human figures. A systematic review has identified 25 paintings by five artists in which the presumptive medico-artistic diagnosis of congenital or acquired foot deformity seems to be varyingly present. The connection between these five painters and what factors have influenced artists' style in the depiction of such deformities is discussed. The possible iconography and medical-historical meaning of such variations, as well as the possibility of artistic licence and real representation that drove the painters to depict these deformities, is explored and debated.
TL;DR: A roadmap of three strategies toward implementing minimally disruptive medicine in practice is outlined, including large-scale paradigm shifts, mid-level add-ons to existing reform efforts, and a modular strategy using an existing 'toolkit' that is more limited in scope, but can fit into existing healthcare systems.
Abstract: In this second of two papers on minimally disruptive medicine, we use the language of patient workload and patient capacity from the Cumulative Complexity Model to accomplish three tasks. First, we outline the current context in healthcare, comprised of contrasting problems: some people lack access to care and others receive too much care in an overmedicalised system, both of which reflect imbalances between patients' workloads and their capacity. Second, we identify and address five tensions and challenges between minimally disruptive medicine, the existing context, and other approaches to accessible and patient-centred care such as evidence-based medicine and greater patient engagement. Third, we outline a roadmap of three strategies toward implementing minimally disruptive medicine in practice, including large-scale paradigm shifts, mid-level add-ons to existing reform efforts, and a modular strategy using an existing 'toolkit' that is more limited in scope, but can fit into existing healthcare systems.
TL;DR: The need to justify the establishment of diagnostic criteria, that multiple diagnostic criteria for the same disease should be avoided, that diagnostic criteria should be compatible with the disease classification if applicable, and that the scope should be well-delineated with regard to clinical variants are advocated.
Abstract: We established and validated diagnostic criteria for pityriasis rosea and Gianotti-Crosti syndrome. In this paper, we compare and contrast both diagnostic criteria to formulate a protocol in establishing diagnostic criteria for other dermatological diseases. The diagnostic criteria are similar in employing clear dividing lines and conjunctions ('and/or') to assure high reliability. Both sets of criteria should be applicable for all ethnic groups. Spontaneous remission is not included, so diagnosis is not delayed while waiting for disease remission. Laboratory investigations are not enlisted, so that the criteria can be used in medical care systems in different parts of the world. The diagnostic criteria are different in that pathognomonic clinical manifestations exist for pityriasis rosea, such as the herald patch and the orientation of lesions along the lines of skin cleavages. These features, however, score low for sensitivity. These specific manifestations are not seen in Gianotti-Crosti syndrome. Such differences led to different categorisation of clinical features. Atypical variants are more common for pityriasis rosea. The diagnostic criteria for pityriasis rosea therefore do not include a list of differential diagnoses, while diagnostic criteria for Gianotti-Crosti syndrome do. Using this comparison, we constructed a protocol to establish diagnostic criteria for other skin diseases. We advocate the need to justify the establishment of diagnostic criteria, that multiple diagnostic criteria for the same disease should be avoided, that diagnostic criteria should be compatible with the disease classification if applicable, and that the scope should be well-delineated with regard to clinical variants. We outline the need for validation studies to assess the criteria-related validity, test-retest intra-clinician reliability, and inter-clinician reliability. We emphasise that the establishment of diagnostic criteria should not be a generic process. We also highlight limitations of diagnostic criteria, and emphasise that no diagnostic criteria can replace the bedside experience of clinicians.
TL;DR: There is potential that the process of mentoring can improve an individual's development, and motivate and encourage them to develop the skills needed to achieve their goals, thus having an impact on ultimately improving their ability to deliver an effective patient-centred service.
Abstract: There is increasing evidence of the benefits of having a mentor during the early years as a consultant. Mentoring encourages and provides support to an individual in their professional development. Although there are different forms of mentoring there is recognition that developing a formal mentoring scheme can provide a consistent approach and support within a framework. The Royal College of Physicians of Edinburgh has introduced a mentoring scheme for new consultants that provides a forum for supporting them in their ongoing professional wellbeing. There is potential that the process of mentoring can improve an individual's development, and motivate and encourage them to develop the skills needed to achieve their goals, thus having an impact on ultimately improving their ability to deliver an effective patient-centred service.
TL;DR: This review illustrates how an innovative psychoneuroendocrine approach to endocrine patients may improve their management and introduced in current endocrine care and practice.
Abstract: This review illustrates how an innovative psychoneuroendocrine approach to endocrine patients may improve their management. Important psychological issues pertain to all the different phases of an endocrine disorder. Before disease onset, stressful life events may play a pathogenetic role and, together with chronic stress, may contribute to a cumulative burden also called allostatic load; psychological and psychiatric symptoms are common both in the prodromal and in the active phase of illness; after cure or remission, there could be residual symptoms and impaired quality of life that deserve attention. All these aspects should be taken into consideration and introduced in current endocrine care and practice.
TL;DR: Measurement of plasma B-type natriuretic peptide in a 'real life' setting in primary care had a similar sensitivity, specificity and negative predictive value to that observed in trial populations.
Abstract: Background and Aims: The utility of B-type natriuretic peptide as a screening test for heart failure has been proven in a number of clinical trials. The aims of this study were to assess the utility of the measurement of B-type natriuretic peptide in a ‘real life’ setting and to estimate the potential costs of implementing its use in primary care in Scotland. Methods and Results: Eight general practitioner practices with a combined population of approximately 62,000 were invited to participate. During the 9-month study period, 82 samples for B-type natriuretic peptide measurement were requested. The negative predictive value for B-type natriuretic peptide was 96.9%. Compared with electrocardiography, B-type natriuretic peptide reduced the need for echocardiography by 308 tests per million population per year. The estimated cost of implementation in Scotland is approximately £220,000 per annum, equating to £64.93 per patient correctly diagnosed with heart failure, with a potential saving in echocardiography of £110,800. Conclusion: In this pilot study, measurement of plasma B-type natriuretic peptide in a ‘real life’ setting in primary care had a similar sensitivity, specificity and negative predictive value to that observed in trial populations. B-type natriuretic peptide aids early diagnosis of heart failure in primary care and may help to facilitate prompt introduction of evidence based therapies to modify patient outcomes. The costs of measuring plasma B-type natriuretic peptide in suspected cases of heart failure are modest, and its use would increase the diagnostic capacity of primary care if supported by local cardiology services.
TL;DR: It is concluded that, although there is no doubt that Fewster did pre-empt Jenner's discovery of vaccination, he did not realise the significance or importance of this momentous medical advance.
Abstract: Edward Jenner is recognised today as the father of vaccination but, as this paper explores, he was not the only Gloucestershire doctor to be linked to this discovery. John Fewster, a local surgeon and apothecary, is also said to have experimented with vaccination, many years before Jenner. This claim is made in a letter addressed to John Coakley Lettsom, written by John Player, a Quaker farmer. Player describes in detail Fewster's realisation that cowpox could be used to protect against smallpox. This letter is frequently cited but has not previously been subjected to critical analysis. We have identified several inconsistencies, including conflicting dates and a possible ulterior motive in that Player's son was to marry Fewster's daughter. We think it unlikely that Player, a devout Quaker, would have consciously fabricated evidence, but argue that the discrepancies in his account undermine the assumption that Fewster carried out vaccination experiments prior to Jenner. We also explore the assertion that Fewster presented a paper in 1765 on the subject of cowpox and its protective effect over smallpox. We conclude that, although there is no doubt that Fewster did pre-empt Jenner's discovery of vaccination, he did not realise the significance or importance of this momentous medical advance.
TL;DR: Pre-hospital notification is associated with earlier stroke physician review, CT imaging and delivery of thrombolysis, and Referral to an out-of-hours thrombalysis service was not associated with additional delay.
Abstract: Intravenous thrombolysis increases disability-free survival after acute ischaemic stroke in a time-dependent fashion. We aimed to determine whether pre-hospital notification, introduction of a CT scanner near to assessment site and introduction of out-of-hours thrombolysis services affect thrombolysis timing. Methods Timings related to thrombolysis were collected between May 2012 and June 2014 at a single hospital site; these included time to stroke physician assessment, time to cranial CT imaging and door to needle time. All thrombolysed ischaemic stroke patients admitted via the emergency department were included. Ambulance services were asked to pre-notify the emergency department of any suspected stroke patient during this period. Results We studied 182 patients (48% female; mean age 74 years; 59% pre-notified). Pre-hospital notification was associated with a significantly higher rate of CT scanning within 25 minutes (60% vs 24%, odds ratio [OR] 4.7, 95% confidence interval [CI] 2.4-9.0; p<0.001), earlier stroke physician assessment (median 6 vs 32 minutes; p<0.001) and receiving thrombolysis within 60 minutes (89% vs 49%, OR 8.0, 95% CI 3.8-16.9; p<0.001). Being treated outside normal working hours did not alter thrombolysis timing. Logistic regression identified the introduction of a near-site CT scanner (OR 4.6 [95% CI 1.7-12.5]) and pre-hospital notification (OR 4.7, [95% CI 2.3-9.6]) as independent predictors of door to CT time less than or equal to 25 minutes, and pre-hospital notification (OR 11.6, [95% CI 4.9-30.3]) and stroke severity (OR 1.15 per point of NIHSS scale, [95% CI 1.08-1.23]) as predictors of door to thrombolysis time less than or equal to 60 minutes. The most common perceived timing delays were radiology-related (33%), the need to acutely lower blood pressure (15%) and obtaining consent (12%). Conclusion Pre-hospital notification is associated with earlier stroke physician review, CT imaging and delivery of thrombolysis. Referral to an out of hours thrombolysis service was not associated with additional delay.
TL;DR: Scottish neurologists' use of the 2010 McDonald criteria for diagnosis of multiple sclerosis varies from practitioners' perception of their use of these criteria.
Abstract: Background: The diagnostic criteria for multiple sclerosis have evolved over time and currently the 2010 McDonald criteria are the most widely accepted. These criteria allow the diagnosis of multiple sclerosis to be made at the clinically isolated syndrome stage provided certain criteria are met on a single magnetic resonance brain scan. Our hypothesis was that neurologists in Scotland did not use these criteria routinely. Method: We sent a SurveyMonkey questionnaire to all Scottish neurologists (consultants and trainees) regarding the diagnosis of multiple sclerosis. Results: Our questionnaire response rate was 65/99 (66%). Most Scottish neurologists were aware of the criteria and 31/58 (53%) felt that they were using these routinely. However, in a clinical vignette designed to test the application of these criteria, only 5/57 (9%) of neurologists appeared to use them. Conclusion: Scottish neurologists’ use of the 2010 McDonald criteria for diagnosis of multiple sclerosis varies from practitioners’ perception of their use of these criteria.
TL;DR: The patient presented with acute confusion, muscle cramps and myoclonic jerks 5 weeks after treatment, demonstrating the need to be aware of adverse effects of denosumab in mild-moderate renal impairment and theneed to monitor calcium levels pre- and post-treatment.
Abstract: Denosumab is an emerging new treatment for osteoporosis in postmenopausal women and men with non-metastatic prostate cancer It is largely used by specialists as an alternative treatment in patients with contraindications to traditional, more commonly used drugs such as bisphosphonates One important side effect is hypocalcaemia, which may be life threatening The risk of this is increased in renal impairment, mainly if eGFR < 30 ml/min/173m(2), and is exacerbated by vitamin D insufficiency This is a case study of prolonged symptomatic hypocalcaemia after a single dose of denosumab in a patient with non-metastatic prostate cancer and moderate renal impairment (eGFR 40 ml/min/173m(2)) The patient presented with acute confusion, muscle cramps and myoclonic jerks 5 weeks after treatment This case demonstrates the need to be aware of adverse effects of denosumab in mild-moderate renal impairment and the need to monitor calcium levels pre- and post-treatment
TL;DR: Intracranial dural arteriovenous fistula merits consideration in any patient with subacute cognitive decline, and should be included in the differential diagnosis of sporadic Creutzfeldt-Jakob disease.
Abstract: A patient with rapidly progressive cognitive decline over an approximately four month period was suspected to have sporadic Creutzfeldt-Jakob disease. Features thought to support this diagnosis included psychiatric symptoms (anxiety and depression), visual hallucinations and a visual field defect. However, the finding of papilloedema broadened the differential diagnosis. Although standard brain imaging and electroencephalography had shown only non-specific abnormalities, subsequent cerebral angiography disclosed an intracranial dural arteriovenous fistula. Following embolisation, the patient made a good functional recovery. Intracranial dural arteriovenous fistula merits consideration in any patient with subacute cognitive decline, and should be included in the differential diagnosis of sporadic Creutzfeldt-Jakob disease.
TL;DR: A patient with features of Alström syndrome is described and a clinical picture suggestive of a recurrent, severe, steroid responsive myopathy which, to the best of the authors' knowledge, has not been reported so far is described.
Abstract: Alstrom syndrome is a rare ciliopathy affecting about 1 in 1,000,000 individuals. It is characterised by cone-rod dystrophy, insulin resistance, diabetes mellitus, cardiomyopathy, renal failure and hypogonadism. Progressive multi-organ dysfunction eventually leads to death. Only about 800 patients with this disorder have been identified so far. The diagnosis of Alstrom syndrome is critical as it can easily be overlooked because of the many features it shares with metabolic syndrome. The gene affected in this autosomal recessive disease is ALMS1, the protein product of which is involved in intracellular trafficking and ciliary function. Alstrom syndrome is being studied as a model which would potentially shed light on the pathophysiology of diabetes mellitus. In this report, we describe a patient with features of Alstrom syndrome and a clinical picture suggestive of a recurrent, severe, steroid responsive myopathy which, to the best of our knowledge, has not been reported so far.
TL;DR: The haemorrhage after thrombolysis score uses the least variables and has the best predictive value for symptomatic intracerebral haem orrhage.
Abstract: Symptomatic intracerebral haemorrhage following thrombolysis for ischaemic stroke causes significant morbidity and mortality. This study assessed which of four risk scores (SEDAN, HAT, GRASPS and SITS) best predicts symptomatic intracerebral haemorrhage. Methods: Data from 431 patients treated at Aberdeen Royal Infirmary (2003- 2013) were extracted from a thrombolysis database. Score performance was compared using area under the curve. Results: Any intracerebral haemorrhage occurred in 12% of patients (53/413); 11% fulfilling the SITS-MOST symptomatic intracerebral haemorrhage definition (6/53), 34% the ECASS II definition (18/53), and 43% the National Institute of Neurological Disorder and Stroke definition (23/53). Stroke severity, as defined by the National Institutes of Health Stroke Scale, significantly improved after 24 hours in patients without intracerebral haemorrhage, but not in those with. Significant symptomatic intracerebral haemorrhage predictors were age, glucose, stroke severity, hyperdense middle cerebral artery on CT scan, ASPECTS score and anti-platelet therapy. The haemorrhage after thrombolysis score performed best at predicting symptomatic intracerebral haemorrhage (area under the curve 0.67-0.78, p < 0.001). Conclusion: The haemorrhage after thrombolysis score uses the least variables and has the best predictive value for symptomatic intracerebral haemorrhage. Using predictive scores for clinical decision making depends on estimation of overall benefits as well as risk.
TL;DR: In 1899, the Greek ophthalmologist Alexios Trantas was the first to visualise the angle in vivo and coined the term ‘gonioscopy'.
Abstract: Gonioscopy is a technique used to examine structures in the anterior chamber angle (the fluid filled space inside the eye between the iris and the innermost layer of the cornea, the endothelium). It is an essential tool in ophthalmic practice, particularly in the diagnosis of glaucoma. In 1899, the Greek ophthalmologist Alexios Trantas was the first to visualise the angle in vivo and coined the term 'gonioscopy'. He made a number of other important contributions to ophthalmology.
TL;DR: Significant points in the history of stress hyperglycaemia, from antiquity through to the present day, as well as the challenges faced in translating research into clinical benefit for patients are illustrated.
Abstract: Stress hyperglycaemia, is a common phenomenon, frequently associated with adverse outcomes in a number of prevalent conditions including myocardial infarction and stroke. Knowledge on stress hyperglycaemia evolved in tandem with knowledge relating to homeostasis, stress and disease and involved some of the world's most eminent thinkers. Despite this, it still remains under-recognised. This paper illustrates significant points in the history of stress hyperglycaemia, from antiquity through to the present day, as well as the challenges faced in translating research into clinical benefit for patients. Profiles of significant protagonists including Claude Bernard, Walter Cannon and Hans Seyle are presented, as well their roles in the emergence of modern-day terminology and pathophysiological models. Major themes such as 'fight or flight' and homeostasis are central to this discussion. Closer to the present day, the role of stress hyperglycaemia in a number of common medical conditions is explored in more detail. Contention around evidence for treatment and the future risk of diabetes mellitus are also discussed.