North Middlesex University Hospital NHS Trust is an NHS trust which runs North Middlesex University Hospital in Edmonton, London and community services in Enfield. The trust serves more than 350,000 people living in the London boroughs of Enfield and Haringey, as well as the nearby boroughs of Barnet and Waltham Forest. It works closely with the Royal Free London NHS Foundation Trust but the board voted against full membership of the Royal Free London group in October 2018.The trust provides a full range of adult, elderly and children's services across medical and surgical disciplines. Its specialist services include stroke, HIV/AIDS, cardiology (including heart failure care), haematology, diabetes, sleep studies, fertility and orthopaedics. Its sickle cell and thalassaemia department is nationally recognised as a leading centre for these diseases.In May 2018 the trust banned the 444 and 491 buses from the northern perimeter road because cars were following buses through an automatic barrier. The Enfield Transport User Group made a formal complaint about the lack of a risk assessment and the problems caused for patients who rely on public transport.
BACKGROUND:Early warning scores like the National Early Warning Score 2 (NEWS2) identify patient deterioration but do not incorporate clinician-intuitive assessment. Previous research suggests facial expressions can be critical indicators of deterioration risk. OBJECTIVES:The aim of this study was to evaluate whether a prototypical facial expression scoring scale (quick visual early warning score [qVIEWS]) used alongside NEWS2 improves identification of intensive care unit (ICU) admission in hospital ward patients. METHODS:A single-centre observational cohort study of 333 adult ward patients was conducted in a London Acute Hospital, assessed by trained outreach members at the initial (Index) review using both pictographic qVIEWS and NEWS2. The primary outcome was admission to the ICU. Random forest modelling compared NEWS2+qVIEWS versus NEWS2-only prediction and Cox proportional hazards modelling assessed time to ICU admission. The study was approved by the United Kingdom Health Research Authority (Integrated Research Application System 289191, Research Ethics Committee 21/LO/0197). RESULTS:Among 333 patients (ICU admission in 17.4%), higher qVIEWS were associated with a higher Index NEWS2 (p < 0.001), sustained physiological instability to 48 h, increased hospital mortality (risk ratio: 2.62, 95% confidence interval [CI]: 1.39-4.95), and greater ICU admission risk (risk ratio 2.03, 95% CI: 126-3.27). Inter-rater reliability for qVIEWS was 0.98, and qVIEWS moderately correlated with NEWS2 (r = 0.24, p < 0.001). Random forest discrimination for ICU admission was similar between NEWS2+qVIEWS and NEWS2-only models (area under the curve: 0.73 vs 0.74; p = 0.37) with comparable calibration and decision curve net benefit. Permutation importance demonstrated meaningful contribution of qVIEWS, exceeding several NEWS2 components. In exploratory multivariate Cox analysis, qVIEWS was independently associated with earlier ICU admission (high risk: 1.65 per unit increase, 95% CI: 1.02-2.66; p = 0.041) alongside respiratory rate. CONCLUSION:qVIEWS did not improve predictive performance beyond NEWS2 and delivered comparable classification metrics across prespecified thresholds. Exploratory analyses suggested an association between qVIEWS and earlier ICU admission although findings should be interpreted cautiously. While results do not support immediate clinical implementation, they provide proof of concept for facial expression assessment as a novel dimension in acute illness evaluation. Further research, particularly into serial measurements and automatic facial recognition, is warranted.
A multiparous woman presented with a large bulge protruding from the posterior wall of the vagina, initially diagnosed as a rectocele. Imaging revealed a cystic lesion measuring 9 cm × 6 cm × 3.5 cm suspected to be a developmental cyst. The lesion underwent surgical excision with significant improvement in symptoms. Histological analysis reported an aggressive angiomyxoma (AAM); postoperative hormonal therapies were considered and rigorous follow-up initiated. The authors discuss challenges in investigating and managing AAM with proposals made for improving preoperative diagnosis and optimising postoperative management. Correlating tumour size with symptoms, judicious planning of surgery, rigorous postoperative follow-up and involving the patient in all aspects of decision-making will guide clinicians in providing the best care in the rare entity of AAM.
Background:Optimal secondary prevention antithrombotic therapy for patients with antiphospholipid syndrome (APS)-associated ischemic stroke, transient ischemic attack, or other ischemic brain injury is undefined. The standard of care, warfarin or other vitamin K antagonists at standard or high intensity (international normalized ratio (INR) target range 2.0-3.0/3.0-4.0, respectively), has well-recognized limitations. Direct oral anticoagulants have several advantages over warfarin, and the potential role of high-dose direct oral anticoagulants vs high-intensity warfarin in this setting merits investigation. Objectives:The Rivaroxaban for Stroke patients with APS trial (RISAPS) seeks to determine whether high-dose rivaroxaban could represent a safe and effective alternative to high-intensity warfarin in adult patients with APS and previous ischemic stroke, transient ischemic attack, or other ischemic brain manifestations. Methods:This phase IIb prospective, randomized, controlled, noninferiority, open-label, proof-of-principle trial compares rivaroxaban 15 mg twice daily vs warfarin, target INR range 3.0-4.0. The sample size target is 40 participants. Triple antiphospholipid antibody-positive patients are excluded. The primary efficacy outcome is the rate of change in brain white matter hyperintensity volume on magnetic resonance imaging, a surrogate marker of presumed ischemic damage, between baseline and 24 months follow-up. Secondary outcomes include additional neuroradiological and clinical measures of efficacy and safety. Exploratory outcomes include high-dose rivaroxaban pharmacokinetic modeling. Conclusion:Should RISAPS demonstrate noninferior efficacy and safety of high-dose rivaroxaban in this APS subgroup, it could justify larger prospective randomized controlled trials.
Imposter phenomenon (IP) is the internalised experience of self-doubt or mediocracy that leads an individual to believe they do not belong. IP is increasingly recognised across the medical field, from medical school to consultancy, but likely affects different groups to varying extents. The transition in role from medical student to junior doctor can be a time of particularly high stress and insecurities about one's ability can act as a trigger or exacerbator of IP. Foundation doctors can arm themselves against IP by first acknowledging its existence and then actively attempting to dismantle these flawed misconceptions, as well as accessing support and resources available ubiquitously through the foundation programme.
