Hepatocellular carcinoma (HCC) is the most common form of hepatic malignancy, with high mortality rates recorded globally. Early detection through clinical biomarkers, medical imaging and histological assessment followed by rapid intervention are integral for positive patient outcomes. Although contrast-enhanced computed tomography scans and magnetic resonance imaging are recognised as the reference standard for the diagnosis and staging of HCC in international guidelines, ultrasound (US) examination is recommended as a screening tool for patients at risk. Contrast-enhanced US (CEUS) elevates the standard of an US examination using US contrast agents (UCAs), capable of diagnosing focal liver lesions with high efficacy. Most UCAs are purely intravascular, offering clinicians a dynamic representation of a lesions' arterial phase vascular kinetics, which is seldom seen in such detail during computed tomography or magnetic resonance imaging assessments. Despite its benefits, there is incongruity between international societies on the role of CEUS in the HCC clinical pathway. The transient nature of pure blood-pool agents is suggested to be insufficient to justify CEUS as a primary modality due to the inability to consistently perform whole liver imaging, alongside disputes regarding its capabilities to differentiate HCC from intrahepatic cholangiocarcinoma. A sinusoidal phase UCA affords clinicians the opportunity to perform whole liver imaging through Kupffer cell uptake in addition to visualising lesion vascular kinetics in the arterial and portal venous phases. Therefore, the purpose of this review was to examine the role of CEUS in the HCC clinical pathway in its current practice and observe how a Kupffer cell sinusoidal phase UCA may supplement contemporary diagnostic techniques through a multi-modality, multi-agent approach.

Background and aim Non-contrast computed tomography of kidneys, ureters, and bladder (CT KUB) is the gold standard radiological imaging for nephrolithiasis. It significantly contributes to the total radiation exposure of a population. This is well known to be linked to increased cancer risk over time and as such should be minimized in line with Ionising Radiation (Medical Exposure) Regulations (IR{ME}R). Previous works have explored a number of avenues to reduce the total radiation exposure such as the cranial extent of the scan; however, at present, there are no formalized guidelines. This study aimed to compare the cranial extent of local CT KUB imaging with previously established thresholds and assess whether total radiation can be reduced through local intervention. Results In the first cycle, a total of 102 non-contrast CT KUB scans were included. Of these, 51% (n=52) commenced from the superior border of the T10-T12 vertebral levels, 48% (n=49) commenced above the T10 vertebral level, and only 1% (n=1) started below the T12 vertebral level. In the second cycle, a total of 105 non-contrast CT KUB scans were assessed. Of these, 21.9% (n=23) commenced above the T10 vertebral level, and 75.2% (n=79) commenced from the superior border of T10-T12 vertebrae. A further 2.9% (n=3) commenced below T12 vertebral level. The findings of this study demonstrate that starting the upper extent of the CT KUB at the T10 vertebral level showed a reduction in radiation dose in millisievert (mSv) delivered to patients while maintaining adequate diagnostic utility. Conclusion Limiting the cranial extent of CT KUB imaging to T10 has consistently captured the upper pole of both kidneys across different patient cohorts, including ours, thus making it an effective way of limiting radiation exposure without sacrificing diagnostic accuracy. In order to achieve robust evidence-based guidelines, further studies would be beneficial.

No abstract available

Pain is frequently encountered in dermatology practice, which impairs the activities of daily living, adds to psychological morbidity, and therefore compromises the quality of life. It ranges from mild to severe in intensity across various dermatoses and requires prompt addressal and treatment. Diseases such as extensive pemphigus vulgaris and Stevens-Johnson syndrome are especially painful and require a multidisciplinary approach with the involvement of a pain specialist in their management. The main pathogenic types of pain include visceral nociceptive, somatic nociceptive, and neuropathic types, the latter two being most relevant in dermatological disorders. Somatic nociceptive pain is often seen in patients of Stevens-Johnson syndrome/ Toxic epidermal necrolysis, epidermolysis bullosa, pemphigus vulgaris, erythema nodosum, and hidradenitis suppurativa, while neuropathic pain is part of the disease process in dermatoses like leprosy, herpes zoster, and dysesthesia syndromes. Therapeutic approaches to pain management include the use of non-opioids (acetaminophen, non-steroidal anti-inflammatory agents), opioids, and non-pharmacological therapies, along with appropriate management of the underlying dermatosis. World Health Organisation (WHO) analgesic ladder remains the most commonly employed guideline for the management of pain, although treatment needs individualisation depending on the nature and severity of pain (acute/chronic), type of dermatosis, and patient factors. There is a paucity of literature pertaining to pain management in dermatology and this topic is often neglected due to a lack of awareness and knowledge of the topic. The present review aims to discuss the pain pathway, various painful conditions in the setting of medical dermatology practice, and their management along with relevant pharmacology of the commonly used analgesics.

Background: Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear.

Methods: We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis.

Results: A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P = 0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients.

Conclusions: In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.).

Objectives: Self-compassion is a positive psychological factor linked to improved physical and psychological outcomes across different chronic illness populations. However, the extent to which self-compassion contributes to reduced distress across different conditions or as a function of participant factors is not clear. The current meta-analysis aimed to quantify the association between self-compassion and psychological distress in different chronic illness populations and evaluate the factors that moderate this association.

Methods: A systematic search of three electronic databases identified research reporting associations between self-compassion and psychological distress in chronic illness. A random effects meta-analysis was conducted to evaluate the association between self-compassion and psychological distress. Moderator analyses were conducted for sample characteristics and distress types. A bespoke tool evaluated study quality.

Results: Searches yielded 51 eligible studies with 57 effect sizes. Meta-analysis revealed that self-compassion was negatively associated with psychological distress (r = -.516; 95% CIs [-.55, -.48]; p = .000). Moderator analyses were significant for distress type and chronic illness group, with effects being largest for stress and neurological conditions. Effects did not vary by sex, age or illness duration.

Conclusions: Findings from this first comprehensive investigation of the link between self-compassion and distress in chronic illness highlight the protective role of self-compassion for chronic illness populations. These results lay the foundation for further research into understanding the processes that link self-compassion to lower psychological distress, and that examine the effectiveness of self-compassion interventions in chronic illness populations, to further advance knowledge and inform practice in this area.

No abstract available

Suprapubic catheterisation (SPC) is a commonly performed urological procedure. Although it is generally safe, SPC-induced bowel injury is a rare but morbid complication. It is described in the literature, but management consensus is lacking. A scoping review was conducted assessing existing literature regarding the management of intestinal injury. The review highlighted that bowel perforation, particularly involving the small bowel and terminal ileum, is the commonest SPC-related bowel injury type. Depending on the severity of the injury and the patients' condition, various management strategies, ranging from exploratory laparotomy to less invasive techniques like laparoscopic intervention, are documented. Despite the introduction of preventive measures, such as ultrasound guidance, intestinal injury occurs. SPC-associated bowel injury is a serious but rare complication despite available preventative measures. Its management varies and depends on the part of the bowel injured and its severity. This review highlights reported management strategies specific to this injury and a literature summary to aid future quality improvement on the topic.

Prostate cancer (PCa) is the most common solid malignancy in men in the UK. Pleomorphic giant cell carcinoma (PGCC) is a rare, aggressive variant of prostate adenocarcinoma. PGCC is associated with a poor prognosis and high Gleason-grade characteristics, often occurring in patients with a history of PCa treatment. This case report details the presentation of a 78-year-old male with a background of PCa, previously treated with radiotherapy and androgen deprivation therapy, who was initially diagnosed with a periurethral abscess. Despite initial treatment, the patient experienced recurrent symptoms, leading to further investigations and surgical intervention. Histopathological analysis of tissue samples revealed PGCC, highlighting the importance of considering this malignancy in cases of recurrent abscesses in patients with a history of PCa. This case underscores the necessity of early suspicion, prompt investigation, and multidisciplinary management in complex cases involving PGCC, emphasizing the need for heightened awareness of this rare pathology in clinical practice.

Frontal view morphing is needed for better preoperative consultation and simulation process in rhinoplasty. Restoration of the correct light-shadow interactions in rhinoplasty demands a firm appreciation of the underlying nasal structures. Chiaroscuro is a painting technique of dark and light contrasts that can be utilized in the morphing process, enabling the surgeon to explain possible results. Patients undergoing surgery in 2019. Encounters were divided into three. First visit: history taking, a list of desires and physical examination, photography. Second visit: photo analysis was presented as well as the hypothesis of correction expressed by morphing (morphing with Adobe Photoshop software). We termed the differences between light and shade of the lateral nasal walls, the dorsum and the brow dome line and nose cheek line as the "Chiaroscuro of the nose." This term is significant in the process of morphing of the frontal view. We used this method of morphing in the simulation process of 126 patients. The age range was 15 to 59 years old. A total of 67% (84) were females and 33% (42) were males. A total of 43% (54) of the cases were revision cases. At the postoperative visits, all patients were more satisfied with their operative result than with their "morphed" simulation. The chiaroscuro concept of the nose is an essential step in the analysis and morphing processes of the frontal view, and a logical tool in creating a realistic surgical game plan. The morphing of the frontal view enables the surgeon and patients to discuss the possible result with more details and refinements. Morphing may be a good option to educate young surgeons in both preoperative consultation and at the operating theater.

Introduction The COVID-19 pandemic resulted in the suspension of formative Objective Structured Clinical Examinations (OSCEs) at numerous institutions. This resulted in a significant gap in OSCE exposure for junior medical students, including those at our university. Drawing upon our prior experiences with OSCEs, we created a program to evaluate the effectiveness of near-peer teaching (NPT) in preparing third-year medical students to experience and succeed in OSCEs. This program was conducted at the University of Buckingham Medical School (Milton Keynes, GBR) from July to October 2022. Methodology Two final-year medical students, under a medical consultant's supervision, led the program development and implementation. This consisted of 2.5 hours of weekly face-to-face OSCE simulation over 12 weeks. The program was designed to mirror the university's OSCE format but provided the intended benefit of designated feedback and teaching at the end of each station. Each week, five dedicated final-year medical students constructed OSCE stations focused on common clinical presentations and skills. Sixty third-year medical students who had completely missed formative OSCEs due to the COVID-19 pandemic enrolled in the program. Pre- and post-session surveys were administered to assess the effectiveness of the NPT program among students. Results In our study, the paired t-test analysis of data showed a statistically significant improvement after attending our OSCE NPT program in all three domains assessed. Participants reported enhanced preparedness in OSCE (p<0.001), a better awareness of the OSCE structure (p<0.001), and an improved understanding of how General Medical Council (GMC) 'Outcomes for Graduates' themes may be assessed (p<0.001). These findings collectively suggest that the NPT intervention effectively enhanced the participants' clinical competencies and preparedness for OSCEs. Conclusion The peer-led OSCE preparation session, facilitated by senior medical students, effectively augmented third-year medical students' clinical skills and knowledge, enhancing their readiness for the OSCE. These sessions provided a unique opportunity for skill development and practice in a simulated clinical environment, fostering greater confidence and proficiency among participating students. Our findings highlight the crucial role of NPT in preparing students for OSCEs. We recommend using NPT to supplement learning, both during periods when traditional OSCEs are unavailable and as a regular adjunct to medical education.

Aims: The aim of this audit was to assess and improve the completeness and accuracy of the National Joint Registry (NJR) dataset for arthroplasty of the elbow.

Methods: It was performed in two phases. In Phase 1, the completeness was assessed by comparing the NJR elbow dataset with the NHS England Hospital Episode Statistics (HES) data between April 2012 and April 2020. In order to assess the accuracy of the data, the components of each arthroplasty recorded in the NJR were compared to the type of arthroplasty which was recorded. In Phase 2, a national collaborative audit was undertaken to evaluate the reasons for unmatched data, add missing arthroplasties, and evaluate the reasons for the recording of inaccurate arthroplasties and correct them.

Results: Phase 1 identified 5,539 arthroplasties in HES which did not match an arthroplasty on the NJR, and 448 inaccurate arthroplasties from 254 hospitals. Most mismatched procedures (3,960 procedures; 71%) were radial head arthroplasties (RHAs). In Phase 2, 142 NHS hospitals with 3,640 (66%) mismatched and 314 (69%) inaccurate arthroplasties volunteered to assess their records. A large proportion of the unmatched data (3,000 arthroplasties; 82%) were confirmed as being missing from the NJR. The overall rate of completeness of the NJR elbow dataset improved from 63% to 83% following phase 2, and the completeness of total elbow arthroplasty data improved to 93%. Missing RHAs had the biggest impact on the overall completeness, but through the audit the number of RHAs in the NJR nearly doubled and completeness increased from 35% to 70%. The accuracy of data was 94% and improved to 98% after correcting 212 of the 448 inaccurately recorded arthroplasties.

Conclusion: The rate of completeness of the NJR total elbow arthroplasty dataset is currently 93% and the accuracy is 98%. This audit identified challenges of data capture with regard to RHAs. Collaboration with a trauma and orthopaedic trainees through the British Orthopaedic Trainee Association improved the completeness and accuracy of the NJR elbow dataset, which will improve the validity of the reports and of the associated research.