York Hospital is a National Health Service teaching hospital in York, England. It is managed by the York and Scarborough Teaching Hospitals NHS Foundation Trust, an NHS foundation trust which also runs several other hospitals in North Yorkshire and the East Riding of Yorkshire, including Scarborough Hospital, Bridlington Hospital and Malton Community Hospital.
Background: Introducing haemodialysis (HD) treatment in a phased manner, with lower treatment times at the outset combined with pre-defined increments in treatment over a period of several weeks, reduces the early burden of treatment in patients with kidney failure and may help improve early outcomes. We have evaluated the feasibility of a novel transitional HD regime using a mixed-methods approach. Method: A single-centre cohort design was adopted, where participants were enrolled prospectively into an interventional arm and matched with historical controls. This paper reports on the feasibility of recruitment and retention in the prospective arm. People with kidney failure, starting HD treatment in out-patient settings, were recruited. They started HD on a transitional regime, with four pre-specified incremental steps (Phases 1 to 4), which aimed to establish participants on long-term 3× weekly treatments over 14 weeks. Participants' experiences of starting HD in a phased manner were analysed using semi-structured interviews. Results: We screened 127 people over 18 months: eligible: 54 (43%); enrolled: 25 (46% of eligible). Fifteen started HD within the study timeframe; 14 were retained for 6 months. In 13 participants, the regime was altered (mostly during Phase 2) for clinical or scheduling reasons. Semi-structured interviews (n = 11) found participants overwhelmingly liked the phased HD introduction as an aid to becoming normalised to dialysis routines. Alterations to treatment were not associated with adverse experiences. Participants would highly recommend starting dialysis in this stepped and phased manner. Conclusions: It is feasible to enrol and retain participants in the proposed program of phased start of HD. The regime may be implemented flexibly in future trials. Starting dialysis on a less-than-three-times weekly basis was well received by participants. Trial Registration: Clinicaltrials.gov registration NCT04268264 (registered: 11 February 2020).
A short cut review of the literature was carried out to examine whether there is evidence for the use of intranasal epinephrine in comparison to intramuscular epinephrine to achieve rapid symptom control in patients presenting with anaphylaxis. 113 papers were found of which 8 were directly relevant to the clinical outcome. Seven studies were case series, six of which were published only as conference abstracts and one was an open-label phase III study. 22 studies were also identified, which assessed the pharmacodynamic and pharmacokinetic properties; these were not analysed. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the best papers are tabulated. The clinical bottom line is that, to date, there is insufficient evidence to determine whether intranasal epinephrine is as effective as intramuscular epinephrine in anaphylaxis. Intramuscular epinephrine remains the standard of care.
Introduction Orthopaedic surgeons frequently manipulate and fix fractured bones into place using metal pins known as Kirschner wires (K-wires). The percutaneous placement of these wires makes them susceptible to infection at the pin site. Some surgeons choose to administer antibiotics prophylactically to prevent pin-site infection, while others do not; this variability is due to a lack of conclusive evidence in support of either practice. This study aims to investigate whether prophylactic antibiotics reduce the incidence of pin site infection by comparing those who received prophylaxis with those who did not. Methods A two-centre retrospective cohort study was performed. Records were reviewed for patients who underwent K-wire fixation of either supracondylar humerus or distal radius fractures at Leeds General Infirmary or Bradford Royal Infirmary between 2007 and 2021. Data was collected on antibiotic administration, pin-site infections, fracture location, age, sex, and comorbidities. Results A total of 264 patients met the eligibility criteria and had complete patient records. The overall incidence of K-wire-associated infection was 3.4%. In the group that received antibiotic prophylaxis, there was a higher incidence of infection (3.9% vs 2.4%); however, this result was not significant (OR 1.6, 95% CI 0.33-7.87, p=0.73). Conclusions This study detected no reduction in infection rates when using antibiotic prophylaxis; however, the results did not reach significance. The main study limitation was a small sample size. Due to infection rates being low, the study was underpowered to detect a small effect size. It is recommended that future randomised controlled trials and meta-analyses be carried out to provide significant conclusions and inform future practice.
Abstract Introduction Primary malignant melanoma of the lung (PMML) is extremely rare, accounting for only 0.01% of all lung tumors. [1] Most melanomas found in the lungs represent metastases from other primary sites. Clinical presentation may include cough, hemoptysis, dyspnea, chest pain, and fever, with asymptomatic cases being uncommon. [2] We report a case of PMML that presented as an incidental solitary pulmonary nodule (SPN) detected during preoperative evaluation for coronary artery bypass grafting (CABG). Case Presentation A 77-year-old male, nonsmoker, with significant left main coronary artery stenosis was scheduled for CABG due to non-ST elevation myocardial infarction. A preoperative chest CT revealed an incidental 14 mm SPN in the left lung lingula with mediastinal lymphadenopathy. This prompted navigational bronchoscopy with transbronchial cryobiopsy of the lingular nodule and endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) of the lymph node. Histopathology revealed a malignant neoplasm with epithelioid and spindle cell features. Immunohistochemical staining demonstrated tumor cell positivity for S-100, SOX-10, PRAME, HMB-45, and MART-1, and negativity for TTF-1, p40, Napsin A, CK5, CK7, and CK20, supporting the diagnosis of PMML. A brain MRI and whole-body PET/CT were performed for staging and were negative for any metastasis, effectively ruling out cutaneous, mucosal, and ocular melanoma. The patient denied any personal or family history of melanoma or significant weight loss. Percutaneous coronary intervention (PCI) was favored over CABG due to the aggressive nature of melanoma with nodal involvement. The patient is currently under outpatient oncology follow-up and receiving dual immunotherapy with nivolumab and ipilimumab. Discussion Only about 75 cases of primary malignant melanoma of the lung have been reported in the literature.[2] The clinical and radiologic appearance of PMML closely resembles that of primary lung cancer. Definitive diagnosis requires integration of clinical, radiologic, histopathologic, and immunohistochemical findings, along with exclusion of extrapulmonary primary sites.[3] Although regression of a primary melanoma may occur by the time metastasis is detected in cases of melanoma of unknown primary (MUP), complete regression is exceedingly rare—occurring in only 0.22-0.27% of all melanomas.[4] This diagnostic ambiguity makes differentiation between PMML and MUP particularly challenging, though in this case, PMML remains the most likely diagnosis. Conclusion An asymptomatic SPN in an apparently low-risk patient can, on rare occasions, represent an aggressive malignant lesion. Therefore, differential diagnoses should remain broad when evaluating SPNs, especially in the elderly population. This abstract is funded by: None
Plasmacytoma is a rare malignant tumor originating from plasma cells either located in the bone marrow (known as solitary bone plasmacytoma or SBP) or from outside the bone, usually arising from the mucosa (known as extramedullary plasmacytoma). Extramedullary plasmacytoma (EMP) in the head and neck region is extremely uncommon, and therefore this case involving the paranasal sinuses is reported for its rarity and to demonstrate the importance of imaging in the diagnosis and follow-up of the disease. Both pathologies can progress to multiple myeloma, a much more common manifestation of the continuum of plasma cell neoplasms.
