BACKGROUND:We provide historical context for the recently discovered University of Glasgow Library records of Archibald Hewan (1832- 1883), the first Black medical doctor known to have served as a missionary in Africa. METHODS:An audit of several different manuscript records of the University of Glasgow's Archives and Special Collections and an analysis of their meaning within the broader historical context of medical libraries during the mid nineteenth century. RESULTS:The records offer insight into what kinds of books were borrowed, how they connected to the curricula of Glasgow's universities, where they were consulted and what kinds of topics caught the attention of students. CONCLUSION:The records of medical libraries offer unique insight into the information sources and learning strategies employed by Hewan and other contemporary university students who later worked in colonial locations.
Cutaneous tuberculosis (TB) is an uncommon condition, the diagnosis of which can be challenging. Biologic disease-modifying anti-rheumatic drugs (bDMARDs) are associated with a higher risk of opportunistic infections, including TB. We present a case of cutaneous TB in a 56-year-old male with psoriatic arthritis on adalimumab. He developed skin lesions on his thumb and axilla, and Mycobacterium tuberculosis was isolated in cultures sent from a skin biopsy. Four months after commencement of TB treatment, he presented with a new onset of seizures. An MRI head showed two tuberculomas, with no further lesions identified in cross-sectional imaging. A tapering course of steroids was started alongside a 12-month course of anti-TB treatment for post-tuberculous treatment paradoxical reaction. In conclusion, although uncommon, cutaneous TB should be considered in patients on bDMARD treatment with atypical skin lesions.
BACKGROUND:Tocilizumab, an interleukin-6 (IL-6) inhibitor, and bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor, have been used in critically ill COVID-19 patients for cytokine storm. We performed a registry-based prospective study to compare the efficacy of these two drugs. METHODS:Virologically confirmed hospitalised patients with severe COVID-19 who received either tocilizumab or bevacizumab have been included. Management details and outcomes were recorded. The primary outcome was in-hospital deaths and secondary outcomes were 30-day deaths, changes in oxygen requirement at 48 h of drug administration and duration of intensive care unit stay. Descriptive statistics are reported. RESULTS:One thousand three hundred forty-five COVID-19 patients were hospitalised during the study period, 87 with severe COVID-19 received tocilizumab (n = 62) or bevacizumab (n = 25). Patients in the tocilizumab group were older (62.6 ± 11 vs 53.2 ± 14, p = 0.001) with more cardiovascular disease and no significant differences in clinical features, laboratory investigations, or radiological and biochemical markers of disease severity. Oxygenation, ventilatory support and proning were similar as were supportive therapies (steroids, remdesivir, anticoagulants; p > 0.05). In-hospital deaths in tocilizumab vs bevacizumab group were 47 (75.8%) vs 12 (48.0%; p = 0.012) with unadjusted hazard ratio (HR) 1.91 (95% confidence interval (CI) 0.99-3.65, p = 0.050) and age-adjusted HR 1.76 (95% CI 0.90-3.44, p = 0.097). Secondary outcome of 30-day death was also more in tocilizumab group: 49 (79.0%) vs 13 (52.0%; p = 0.011). Within-group comparison showed that PaO2:FiO2 at 48-h of drug administration was better in bevacizumab group (p = 0.003) compared to tocilizumab (p = 0.651). CONCLUSION:VEGF inhibitor bevacizumab led to significantly better ventilatory outcomes and lower in-hospital and 30-day deaths compared to IL-6 inhibitor tocilizumab in severely ill COVID-19 patients. Randomised studies are required to confirm these findings.
Autoimmune hepatitis (AIH) is characterised by the presence of circulating auto-antibodies, elevated serum globulin, lymphocytic and plasma cell infiltration on liver biopsy, in the absence of markers of viral hepatitis. Management typically involves use of oral or intravenous corticosteroids in combination with immunosuppressants. We report a rare case of a young patient with a background of AIH that failed to respond to such interventions and was diagnosed to have superadded leptospirosis. In this case report, we describe our challenges in localising the aetiology and management for his acute hepatitis. This report highlights the need to recognise alternative diagnosis in acute hepatitis, especially in AIH patients that fail to respond to conventional management.
BACKGROUND:Resident doctors require professional development through conference attendance yet there are major challenges to the ways in which attendance is impacted. The COVID-19 pandemic created a shift in education delivery, including medical conferences moving towards online setting. The aim of the study was to explore the factors influencing conference attendance and the post-COVID-19 implications for the future of conference delivery and professional development. METHODS:A mixed-methods approach comprising of an online questionnaire and semi-structured interviews was used. Theoretical sampling was performed to invite UK-based resident doctors to complete the questionnaire. Individuals were then invited to a semi-structured interview to explore their experiences further. Content analysis was performed for questionnaire data and thematic analysis for interview data. RESULTS:Seventy-four doctors completed the questionnaire, of these 15 participated in semi-structured interviews. During the COVID-19 pandemic most trainees attended online events, but with the abolition of travel restrictions all were keen to return to the face-to-face format. Motivational learning promoted the drive for conference attendance. Other factors included networking and the attainment of continuous professional development points. DISCUSSION:The findings demonstrate how professional development can be successfully enacted through changes to the delivery of conferences. Virtual conferences promote inclusivity and accessibility for doctors in training. However, the lack of opportunities to network is their main drawback. Whilst face-to-face conferences are considered the most attractive; concerns regarding cost, leave, sustainability and work-life balance affect motivation to attend. The findings have implications for educators, resident doctors and conference organisers.
A 92 year old female with multiple co-morbidities was admitted following a fall at home. She was found to be suffering from ongoing loose stool with intermittent rectal bleeding during hospitalisation. An inpatient flexible sigmoidoscopy identified a large well-demarcated, superficial, non-bleeding ulcer in the rectum. Histology of biopsies of the rectal ulcer showed inflammation and ulceration with crypt distortions in the ulcer base. Immunohistochemistry for cytomegalovirus (CMV) confirmed presence of inclusion bodies which was suggestive of CMV proctitis. Her CMV IgG serology was positive with a high DNA level of 15,861 IU/mL. Oral valganciclovir was started and patient responded well to the anti-viral treatment with resolving bowel symptoms.
Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis (LCH) marked by systemic involvement and diverse clinical manifestations. We report a 35-year-old man with yellowish-brown periorbital lesions initially diagnosed as xanthelasma, which later recurred. The patient developed neurological symptoms, including proximal lower limb weakness and cranial nerve palsies, which improved with corticosteroids. Imaging revealed retro-orbital masses, pan-rhinosinusitis and extensive sclerosis of the sinonasal cavity, along with systemic organ involvement, including the kidneys and spine. Histopathology demonstrated foamy histiocyte infiltration, positive for CD163 and CD68 but negative for S100. The BRAF V600E (B-raf proto-oncogene valine-to-glutamic acid substitution at position 600) mutation was absent. A multidisciplinary team initiated the LCH III protocol, leading to partial regression of cutaneous lesions and stabilisation of neurological symptoms. This case highlights the importance of recognising atypical ECD presentations and suggests the LCH III protocol may benefit BRAF-negative cases. Multidisciplinary management is critical given the disease's progressive, multisystem nature.
Primary mediastinal seminoma is an important diagnostic consideration for an anterior mediastinal mass in a young man. Occasionally, seminomas can elicit a florid granulomatous reaction that can obscure the underlying tumour on a small biopsy like the one obtained with a core needle from an anterior mediastinal mass. Herein, we illustrate such a scenario, which can lead to diagnostic confusion if this association is not recognised.
Cupriavidus pauculus is a rare opportunistic pathogen primarily affecting immunocompromised hosts. We present a case of bloodstream infection caused by C. pauculus in a 52-year-old male with end-stage renal disease on maintenance haemodialysis. This report describes the clinical presentation, microbiological findings and treatment approach, accompanied by a comprehensive literature review and systematic analysis of all reported cases to provide insights into the management of this uncommon pathogen.
The Hippocratic Oath, written by the father of medicine, Hippocrates in 430 BCE has been sworn for millennia across the world by new doctors. Its nine articles outline how a doctor must treat their patients effectively, abiding by the core ethical principles that underscore Good Medical Practice today, including a focus on beneficence and non-maleficence. Today, the Gods of Olympus are no longer routinely worshipped, and we benefit from vast medical and technological advances, so the question arises whether the principles of Hippocratic medicine are still relevant? On the island of Kos, Hippocrates' birthplace, there continues the tradition of an annual 'oath swearing' ceremony for students that have completed medical school both from Greece and across the world. Whilst this event can be used to celebrate the achievements of the new doctors in training, is there still a need for them to retrace the routes of the profession? This article aims to explore the core principles of the Oath and Hippocratic medicine and determine their relevance in today's modern society.
Medical education podcasts are increasingly popular, providing high-quality, asynchronous education to listeners. Here, we describe our experience developing the Royal College of Physicians of Edinburgh (RCPE)'s trainee-led podcasts, Clinical Conversations and Career Conversations. Both podcasts have been designed by resident doctors for resident doctors and are in high demand, approaching one-quarter of a million plays and international listenership. In this article, we explore the myriad benefits for resident doctor hosts, guest speakers and staff involved in podcast production, as well as reflecting on the challenges faced. Providing free, high-quality medical education is a core purpose of RCPE to benefit patients, physicians and healthcare systems around the world, and podcasts play a key role in this. By openly sharing our achievements, challenges and lessons learnt during our journey, we hope we may inspire others to engage in creating high-quality, accessible medical education.
A 39-year-old woman with a 4-year history of limited cutaneous systemic sclerosis (lcSSc) and no prior exposure to D-penicillamine presented with bilateral fluctuating ptosis of 1 week duration. On evaluation, she was found to have elevated acetylcholine receptor antibody levels and a positive neostigmine test confirming the diagnosis of ocular myasthenia gravis (MG). The patient was treated with oral prednisolone and pyridostigmine resulting in significant improvement within 2 weeks. The co-occurrence of systemic sclerosis (SSc) and MG is rare and when such an association is seen, it is usually seen in the background of D-Penicillamine therapy for SSc. The presence of fluctuating ptosis in SSc is a valuable clinical clue to suspect co-existence of neuromuscular junction disorder like MG.
BACKGROUND:Frailty is a multidimensional syndrome characterised by reduced physiological reserve and increased vulnerability to adverse health outcomes. While traditional frailty models focus primarily on physical decline, emerging evidence supports the integration of cognitive domains for a more comprehensive assessment. We wished to develop and preliminarily validate a cognitive-physical frailty index using data from a large, prospective population-based cohort of older adults in central Spain. METHODS:We constructed a frailty index based on 12 variables spanning physical, cognitive, subjective, and functional domains. These were selected from the Neurological Disorders in Central Spain (NEDICES) study using criteria based on feasibility, clinical relevance, and prior evidence of mortality prediction. Frailty distributions and transitions were analysed between two time points (1994-1995 and 1997-1998), and mortality risk was assessed using Cox proportional hazards models. RESULTS:Among the 5,278 participants, the frailty distribution shifted to the right over the 3-year follow-up period, reflecting an increasing vulnerability. The frailty index demonstrated a strong association with all-cause mortality (hazard ratio = 28.05; 95% CI: 16.37-48.06). Quartile-based stratification illustrated clearly within-sample progression. The index showed high goodness-of-fit under a gamma distribution, supporting its internal coherence. CONCLUSION:This brief, multidimensional frailty index offers a feasible tool for capturing early cognitive and physical decline and predicting short-term mortality in ageing populations. Although preliminary, these findings underscore the value of integrating cognitive indicators into frailty assessment. Future validation in other cohorts and with long-term data is warranted.
Critical appraisal of evidence involves carefully evaluating a study's validity, reliability, applicability and generalisability. It is essential for all clinicians and those involved in academic publishing. A manuscript must adhere to two sets of standards. First, reporting guidelines ensure uniformity, transparency and clarity. Then, critical appraisal tools or criteria assess the study's methodological robustness. The manuscript may undergo a preliminary screening before we initiate the critical appraisal process. The foremost criterion is evaluating the journal's quality, assessing the study topic, design and sample size, and checking if the study objectives and outcome measures have been clearly stated. An original study is typically presented in the standard 'IMRaD' format, with each section addressing a specific set of questions. The primary purpose of the 'Introduction' section is to justify the study's objective. The 'Methods' section is crucial to the manuscript. It aids in assessing the validity of the research, describes the critical parameters in a study protocol and ensures the study's replicability. The main components covered in the 'Methods' section include the study question, design, population, sample size, outcome measures, statistical analysis and details of ethics approval. The 'Results' section should discuss the study's findings, which are outlined in the objectives. The 'Discussion' section covers the implications of the study, which should be balanced, and the interpretation in this section should align with the reported results. The validity of a study is nothing but its closeness to the truth, that is, the extent to which the results are accurate and free from bias. Hence, minimising this chance of bias in a study makes it more valid. Internal validity generally reflects a study's methodological robustness, and external validity reflects the generalisability or applicability. In this era of evidence-based medicine, critical appraisal becomes necessary as people always discuss practising it in their daily clinical practice.
