With increasing antibiotic resistance, oral chloramphenicol may be utilized more frequently; below we highlight the risk of toxic optic neuropathy.
Although uncommon, bilateral patellar tendon rupture is preposterously debilitating. Ultrasonography is valuable in diagnosing patellar tendinosis and preventing subsequent rupture.
We describe an improved technique for the reconstruction of a neglected patellar tendon rupture, using semitendinosus-gracilis grafts and FiberWire augmentation.
OBJECTIVES:To assess patients' knowledge of their drug therapy for neovascular macular degeneration and to identify which aspects of the drug they considered most important if given the option of switching to an alternative drug.DESIGN:Prospective questionnaire survey.SETTING:Wolverhampton, England.PARTICIPANTS:A total of 126 patients attending our hospital service for intravitreal ranibizumab therapy for neovascular macular degeneration.MAIN OUTCOME MEASURES:Using a questionnaire, patients were asked questions pertaining to aspects of drug therapy in neovascular macular degeneration. Fields covered included drug names, knowledge of alternative drugs, cost of drugs and their views on switching to another drug.RESULTS:Eighty (63.5%) had heard of Lucentis (ranibizumab) and 31 (24.6%) were aware of Avastin (bevacizumab). Of the latter 31 patients, 20 did not have a preference between Avastin and Lucentis. These patients felt that the factors they would consider important for them to consider switching were effectiveness (10, 50%), specialist recommendation (8, 40%), safety (2, 10%) and cost (0).CONCLUSIONS:Introducing a cheaper, off-label alternative in the therapy of macular degeneration in the presence of a licensed option has been extensively debated. Many patients have no knowledge of this controversial issue but it is likely that efficacy and recommendation by clinicians are more important than cost to patients who may consider switching to the off-label Avastin.
OBJECTIVE:To investigate whether measurements of junior doctor on-call workload and performance can clarify the mechanisms underlying the increase in morbidity and mortality seen after junior doctor changeover: the 'August effect'.DESIGN:Quantitative retrospective observational study of routinely collected data on junior doctor workload.SETTING:Two large teaching hospitals in England.PARTICIPANTS:Task level data from a wireless out of hours system (n = 29,885 requests) used by medical staff, nurses, and allied health professionals.MAIN OUTCOME MEASURES:Number and type of tasks requested by nurses, time to completion of tasks by junior doctors.RESULTS:There was no overall change in the number of tasks requested by nurses out of hours around the August changeover (median requests per hour 15 before and 14 after, p = 0.46). However, the number of tasks classified as urgent was greater (p = 0.016) equating to five more urgent tasks per day. After changeover, doctors took less time to complete tasks overall due to a reduction in time taken for routine tasks (median 74 vs. 66 min; p = 3.9 × 10(-9)).CONCLUSION:This study suggests that the 'August effect' is not due to new junior doctors completing tasks more slowly or having a greater workload. Further studies are required to investigate the causes of the increased number of urgent tasks seen, but likely factors are errors, omissions, and poor prioritization. Thus, improved training and quality control has the potential to address this increased duration of unresolved patient risk. The study also highlights the potential of newer technologies to facilitate quantitative study of clinical activity.
Interpreting information on diagnostic accuracy is an area that health professionals struggle with. In this paper, we use the example of Mr Samways, a 45-year-old man with joint symptoms, to illustrate how to apply the results of a diagnostic accuracy study in clinical practice. We consider the various measures used to quantify diagnostic accuracy and discuss their clinical utility. We provide an overview of potential biases to consider when evaluating a diagnostic accuracy study and consider how to determine whether the results can be applied to a particular patient.
Placebo appears to be a real neurobiological phenomenon that has evolved through the selection pressure to be able to heal ourselves. The complex language and social structures of humans means that we can attribute meaning to therapeutic encounters with culturally sanctioned authority figures and we can use our attachment to such figures to generate hope for recovery. Different mechanisms may be involved in the neurobiological aspect of placebo including anxiety, learning, conditioning as well as individual genetic variation. Examination of the published work shows that while some trials do seem to indicate a specific mode of action for homeopathic remedies other trials do not and this is an issue that needs to be addressed at the trial design stage. A clinical trial that includes both a placebo group and a non-participating control arm is the most powerful design for separating the non-specific and polymorphic placebo effect from the specific effects of trial medication. The control variables in a trial of homeopathic medication should also include the process of consultation as this may assume a meaning for the individual that can also be associated with a placebo effect.
We set out to assess the relative age effect (RAE)on UK Nobel laureates in physics, chemistry andphysiology or medicine. The academic year ofthe UK begins in September; therefore, childrenin one classroom may have an entire year’s dif-ference in age (i.e. children born in Septemberand those born in August of different years).This relative age difference could cause a disad-vantage in the younger students compared tothe older students within one classroom.
Objective Unsuspected idiopathic intracranial hypertension (IIH) is found in a significant minority of patients attending clinics with named headache syndromes, if it is specifically sought out. Chronic fatigue syndrome is frequently associated with headache. Could the same be true of chronic fatigue? Moreover, there are striking similarities between the two conditions. Could they be related? Attempting to answer these questions, we describe the results of a change in clinical practice aimed at capturing patients with chronic fatigue who might have IIH. Design Cross-sectional. Setting Hospital outpatient and radiology departments. Participants Patients attending a specialist clinic with chronic fatigue syndrome and headache who had lumbar puncture to exclude raised intracranial pressure. Main outcome measures Intracranial pressure measured at lumbar puncture and the effect on headache of cerebrospinal fluid drainage. Results Mean cerebrospinal fluid pressure was 19 cm H2O (range 12–41 cm H2O). Four patients fulfilled the criteria for IIH. Thirteen others did not have pressures high enough to diagnose IIH but still reported an improvement in headache after drainage of cerebrospinal fluid. Some patients also volunteered an improvement in other symptoms, including fatigue. No patient had any clinical signs of raised intracranial pressure. Conclusions An unknown, but possibly substantial, minority of patients with chronic fatigue syndrome may actually have IIH. An unknown, but much larger, proportion of patients with chronic fatigue syndrome do not have IIH by current criteria but respond to lumbar puncture in the same way as patients who do. This suggests that the two conditions may be related.
This case report describes Brucellosis initially masquerading as endocarditis. We aim to increase awareness among physicians about the condition in order to aid early investigation and treatment of Brucellosis, which can prevent severe disability.
XRD and EDX analyses confirmed the presence of Ag in all coatings deposited using electrochemical method and silver. The mean thickness coating was noted to be highest in EHA/AG group (102.20 4.20 um) followed by PHA (76.40 2.20 um). Mean coating thicknesses in other groups were: PHA/AgNO3 (76.20 1.29 um); EHA (32.98 2.50 um); EHA/ Ag/2-layers (30.70 2.40 um); EHA/AgNO3 (8.60 0.60 um). The average silver content measured was highest with 6.55% in EHA/Ag/2-layer followed by 3.92% in EHA/AgNO3, 0.38% in EHA/Ag and 0.10% in PHA/AgNO3. The electrochemical technique deposited a uniform coating onto the disc surface with clearly defined microcrystals as compared to the PHA-coated discs where the surface appeared smoother. The EHA coating, however, appeared less dense when compared with the PHA coating. DECLARATIONS
Omental torsion is a rare cause of abdominal pain requiring a high degree of clinical suspicion and often laparoscopy.
A 66-year-old woman presented in October 2011 with bilateral visual failure of subacute onset. She has Rheumatoid Arthritis, treated with methotrexate (since 2002), etanercept (2003–2009). A right knee replacement was revised and underwent 6 washouts for persistent infection. Antibiotics included vancomycin, amoxicillin, and daptomycin. Chloramphenicol 4 g daily was started in June 2011 (14 weeks before visual loss). 10 days after onset of visual loss she had visual acuity of 3/24 (Snellen) bilaterally, hyperaemic optic discs and centrocaecal scotomas. The control Ishihara plate could not be read. Toxic optic neuropathy secondary to chloramphenicol was suspected; chloramphenicol had been stopped on Day 6 of visual symptoms. 4 weeks after stopping chloramphenicol acuity was 6/5 (right), 6/6 (left) and visual fields normal, but Ishihara colour plates impaired at 8/13 bilaterally. At the onset of visual symptoms she developed paraesthesiae of limbs which also improved. Examination showed L5 dermatomal loss to pinprick and abnormal proprioception at the toes. From 1950 to 1988 approximately 40 cases of chloramphenicol optic neuropathy were reported, but only two in the past 12 years. This case highlights the potential pitfalls of older generation antibiotics and unfamiliar adverse effects. This may become more pertinent as antibiotic resistance increase.
Obstruction of the tracheobronchial tree frequently occurs in children due to a lack of adequate dentition and immature swallowing coordination.1,2 This contrasts obstruction in adults which is caused by a failure of airway protection mechanisms due to neurological disorders and trauma.1 Obstruction has three clinical stages: choking and shortness of breath, an asymptomatic phase then a complication stage.2 The composition of the foreign matter determines the stage. Organic materials cause a severe mucosal inflammatory reaction and granulation tissue may develop over several hours. This causes subsequent swelling and partial obstruction warranting immediate clinical intervention. In contrast, inorganic materials can remain asymptomatic for longer periods of time unless the distal airways are compromised. This presents a therapeutic challenge even though two-thirds of objects lodge in main stem bronchi rather than distal bronchi.1,2 Complications of undetected foreign bodies include unresolved pneumonia and abscess formation, fibrosis and bronchiectasis.1 Our case is of a long forgotten toy traffic cone aspirated during childhood that remained undetected for 40 years.
Objectives This paper revisits the same cohort of hospital consultants approximately five years after they were first appointed to investigate their reflections on establishing themselves in their role. Design Mixed methods using a short survey and in-depth semistructured interviews. Setting The study was conducted within one Deanery in the North of England. Participants The same 45 hospital consultants who were invited to participate in the study in 2007 were asked to take part in the second stage of the project in February 2011. These 45 consultants started their appointments no earlier than May 2006 within 12 National Health Service (NHS) Trusts in one Deanery. A total of 16 consultants participated. Six consultants who took part in semistructured interviews in 2007–2008 were invited to be interviewed again. Four consented and participated in a further interview in 2011. Main outcome measures Do consultants feel they have completed their transition into their senior clinical posts? Yes, although the ever changing nature of the consultant role means new challenges are always having to be being addressed. What support mechanisms are valued by consultants? Informal support mechanisms are greatly valued by consultants and these are built up over time. Are consultants satisfied that they made the correct specialty choice? Yes, all respondents reported satisfaction in their specialty choice. Results After reflecting on five years in post, all agreed that Specialist training prepared them well for the clinical aspects of their role. Ten (62%) felt they were not prepared for dealing with Trust Management issues and 13 (81%) felt unprepared for financial management. Conclusions consultants learn on the job and eventually fulfil their potential in the role over time. However, the role is regularly changing so informal support mechanisms are valued to help deal with a highly complex role.
A hypocalcaemia case is presented with convulsions, electrocardiogram (ECG) changes and laboratory findings suggestive of osteomalacia. This case constitutes a rare presentation of osteomalacia-induced hypocalcaemia.
As reported in the 2011 World Drug Report, cocaine is likely to be the most problematic drug worldwide in terms of trafficking-related violence and second only to heroin in terms of negative health consequences and drug deaths. Over a period of 60 years, cocaine evolved from the celebrated panacea of the 1860s to outlawed street drug of the 1920s. As demonstrated by the evolution of cocaine use and abuse in the United Kingdom and United States during this time period, cultural attitudes influenced both the acceptance of cocaine into the medical field and the reaction to the harmful effects of cocaine. Our review of articles on cocaine use in the United Kingdom and the United States from 1860 to 1920 reveals an attitude of caution in the United Kingdom compared with an attitude of progressivism in the United States. When the trends in medical literature are viewed in the context of the development of drug regulations, our analysis provides insight into the relationship between cultural attitudes and drug policy, supporting the premise that it is cultural and social factors which shape drug policy, rather than drug regulations changing culture.
This case of a young lady with chronic pancreatitis mimicking pancreatic cancer demonstrates how genetic testing helps surgical management.
Objectives To evaluate the utility of Isabel, an online diagnostic decision support system developed by Isabel Healthcare primarily for secondary medical care, in the general practice setting. Design Focus groups were conducted with clinicians to understand why and how they used the system. A modified online post-use survey asked practitioners about its impact on their decision-making. Normalization process theory (NPT) was used as a theoretical framework to determine whether the system could be incorporated into routine clinical practice. Setting The system was introduced by NHS County Durham and Darlington in the UK in selected general practices as a three-month pilot. Participants General practitioners and nurse practitioners who had access to Isabel as part of the Primary Care Trust's pilot. Main outcome measures General practitioners’ views, experiences and usage of the system. Results Seven general practices agreed to pilot Isabel. Two practices did not subsequently use it. The remaining five practices conducted searches on 16 patients. Post-use surveys ( n = 10) indicated that Isabel had little impact on diagnostic decision-making. Focus group participants stated that, although the diagnoses produced by Isabel in general did not have an impact on their decision-making, they would find the tool useful if it were better tailored to the primary care setting. Our analysis concluded that normalization was not likely to occur in its current form. Conclusions Isabel was of limited utility in this short pilot study and may need further modification for use in general practice.
Summary Objectives We set out to evaluate the impact of Foundation Year (FY) training on the doctors who had been through this training system. Design Doctors in training were surveyed using a structured web-based questionnaire. Setting Postgraduate training in the UK has been the subject of much upheaval in recent years. Participants A total of 1065 doctors in training were surveyed in late 2011 and early 2012, of which 638 were current FY doctors. Main outcome measures The survey was both quantitative and qualitative, focusing on selection, working hours, training quality, training assessments and the regulation of training. Results A majority of current FY trainees worked extra weekly hours with the breakdown being: 5–10 hrs (54%), 10–15 hrs (17%), >15 hrs (9%) and no extra weekly hours (20%). All current FY trainees wanted to work for more than 40 h a week with the following breakdown of desired hours: per week 40–48 (22%), 48–60 (50%) and 60–70 h (19%). The average hours per week spent clerking emergency admissions by current FY trainees were as follows: zero hours (11%), 0–5 h (37%), 5–10 h (30%), 10–15 h (11%) and greater (11%). A large majority (90%) felt that it was possible for incompetent trainees to obtain satisfactory results from assessments and that the FY training program was poor at identifying failing trainees. There were high levels of dissatisfaction with the selection process. Conclusions FY training appears to be failing in several key areas with the lack of emergency exposure a particular area of concern. It is essential that any future reforms of training address these problem areas.
