We present a rare case of allergic bronchopulmonary aspergillosis (ABPA) with endobronchial aspergilloma in a 70-year-old man who presented with acute total collapse of the left lung. Initial imaging raised concern for malignancy, but bronchoscopy revealed a fungal ball obstructing the left main bronchus. Serological markers confirmed ABPA. Treatment with bronchoscopy-guided clearance, oral corticosteroids, and voriconazole led to complete clinical and radiological recovery. This case highlights the importance of considering fungal aetiologies in atypical presentations of lung collapse

Objective:
We conducted a systematic review and meta-analysis to assess the effectiveness of Intensive Community Care and Services (ICCS) compared with treatment as usual (TAU), including inpatient care, and to synthesize common psychosocial interventions used within ICCS.

Method:
We searched 14 databases from Jan 1, 1999, to May 30, 2025, for quantitative studies of ICCS for adolescents predominantly (aged 12-18 years) with mental health problems. We used a random-effects meta-analysis of randomized controlled trials (RCTs) comparing ICCS versus TAU (and inpatient care only), on psychosocial functioning, mental health and cost-effectiveness outcomes. We used a narrative synthesis with an adapted Delphi approach to identify common psychosocial interventions and theoretical mechanisms. The protocol was registered in PROSPERO.

Results:
We included 48 publications on 35 unique ICCS evaluations (N=6917 adolescents; median age 14.5 years) involving admission avoidance/home treatment, assertive outreach and family preservation models. Meta-analysis of 11 unique RCTs (range: 297-1176 participants per outcome) showed that, compared with TAU, ICCS yielded statistically significant improvements in psychosocial functioning (Hedges' g= 0.15, 95% CI=0.04, 0.26; 9 RCTs), reductions in inpatient admission days (-0.48 -0.82, -0.15; 4 RCTs), total emotional and behavioral problems (-0.15, -0.30, -0.01; 5 RCTs), and externalizing symptoms (-0.18, -0.30,-0.06; 6 RCTs) post-treatment. The effect for psychosocial functioning increased and remained significant when comparing ICCS with inpatient care only (0.25, 0.04, 0.46; 5 RCTs). No significant differences were found for internalizing symptoms, family functioning, or total costs. The narrative synthesis showed that psychosocial interventions consistently included enhanced engagement strategies, cognitive behavioral therapy, family systems approaches, and dialectical behavior therapy skills.

Conclusion:
For adolescents with severe mental health problems, ICCS yielded small but significant improvements in psychosocial functioning, reductions in inpatient days and emotional and behavioral symptoms, while achieving comparable effects for other outcomes. Findings support the expansion of ICCS as a viable alternative to inpatient care. Future research should prioritize multisite RCTs and developing and evaluating standardized psychosocial intervention guidelines to enhance treatment fidelity and outcomes

Purpose of review:
Point-of-care ultrasound (POCUS) has transformed emergency medicine by providing a noninvasive, accessible, repeatable, efficient, and cost-effective imaging tool to the bedside. This article is a narrative review of the most impactful POCUS literature over the past 18 months, identifying and highlighting the most common emerging themes.

Recent findings:
We identified five main themes in the recent POCUS literature: ultrasound-guided regional anesthesia, POCUS in resuscitation, diagnostic POCUS, technology and artificial intelligence, and POCUS governance and administration.

Summary:
The recent body of literature strengthens the utility of POCUS in emergency medicine, demonstrating its efficacy, safety, and efficiency across multiple clinical scenarios. The literature continues to expand the scope of POCUS by covering new diagnostic applications and integrating emerging technologies, while continuing to build a robust governance framework. Future research should focus on patient-oriented outcomes, implications of POCUS protocolization and clinical application, and the impact of POCUS at hospital and healthcare systems levels.

No Abstract Available

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.

Fractured and missing teeth within the aesthetic zone have always posed a clinical challenge for the dental team. Management and treatment requires the input from a number of dental specialists to guarantee a high quality result. A case report is presented to demonstrate an effective combined orthodontic/restorative approach that fully restored aesthetics and function. The report is of a 14-year-old girl who traumatized her maxillary central incisors, in a dentition that was already compromised as she had congenital absence of her maxillary left lateral incisor.

Using fixed orthodontic appliances, the fractured teeth were extruded to bring the fracture line above the level of the alveolar bone. This movement allowed an immediate aesthetic improvement, using stainless steel prefabricated posts and composite resin buildups, which also facilitated further orthodontic tooth movement. Teeth, that would otherwise have been extracted, were salvaged and, utilizing a multidisciplinary team approach, a reasonable long-term prognosis has resulted.

CPD/Clinical Relevance: This case report aims to demonstrate how a multidisciplinary team approach in Orthodontics can be utilized for management of severely handicapped dentitions that have sustained dental injury. It is not the aim of this case report to discuss the treatment of dental injuries but to demonstrate and provide an overview of the possible treatment modalities that can be effective in restoring function and aesthetics, with special consideration given to missing teeth and subgingival crown fractures within the aesthetic zone.

BACKGROUND: Cancer of unknown primary is the fourth most common cause of cancer death in the United Kingdom. National guidance in 2010 recommended the establishment of a dedicated unknown primary team to facilitate targeted investigation and symptom control. A service development project was undertaken to identify those affected by malignancy of unknown origin and institute a pathway for coordinating their care led by a palliative physician.
METHOD: In order to describe the patient population and illness trajectory and to assess the effect of the new pathway on the clinical outcomes we used a retrospective and prospective comparative case notes survey to identify the pre- and post-pathway population. This took place in secondary care. Inclusion criteria were patients with metastatic disease with no known primary; exclusion criteria were where the site of metastasis was so suggestive of a primary that it would be managed as per that disease process. 88 patients were included.
RESULTS: Mean age was 72.5 years. The mean survival time from presentation was 81.8 days. There was no difference pre or during pathway implementation in age, performance status or survival time. There was no reduction in the numbers referred for tumour directed therapy. There was a non-statistically significant reduction in the number who died in hospital during the pathway implementation.
CONCLUSIONS: This study suggests having a metastatic malignancy of unknown primary origin service led by a palliative physician does not reduce the number referred for tumour directed therapy. It also adds evidence of the poor prognosis and thus the need for early palliative care input.

Environments that support pre- and post-registration students' and staff learning are vital to ensure the delivery of high quality patient care by knowledgeable and competent healthcare practitioners. A project was undertaken at Chesterfield Royal Hospital NHS Foundation Trust to modernise and enhance preceptorship against a background of national and local drivers. This article describes the development, piloting and evaluation of a new role designed to support and enhance practice learning environments for newly qualified nurses, preceptors, pre-registration nursing students and mentors. The article identifies the factors that affect clinical learning environments and discusses some practical solutions to the challenges associated with learning in practice. Finally, the article offers some recommendations and implications for practice in relation to the pilot outcomes.

Purpose: To describe a hitherto unreported late ocular surface complication of retinal detachment surgery around a radial segment explant.

Methods: A single case report of a 72-year-old white man, with a previous history of right scleral buckling surgery for retinal detachment surgery 25 years ago, presented with right-sided ptosis of 6 months duration.

Results: Ocular surface examination showed a prominent right supero-nasal quadrant radial segment explant, around which there was bulky pink conjunctival mass, extending from the supero-medial fornix down to the medial canthal area and inferior medial fornix with similar changes seen on the upper medial tarsal conjunctiva. The clinical differential diagnosis was either inflammation from an exposed radial explant or lymphoma. Biopsies of the conjunctival mass showed perivascular and interstitial solid eosinophilic deposits of amyloid, with scattered giant cells; the amyloid was of AL type. There was no morphological or immunohistochemical evidence of lymphoma or a plasma cell neoplasm in the specimen.

Conclusion: This is the first report of localized conjunctival amyloid deposition, secondary to a retinal detachment radial explant. It is proposed that the localized amyloid deposit arose from the ocular surface irritative effects of the radial explant.

Esophageal varices are dilated submucosal esophageal veins that connect the portal and systemic circulations. Bleeding esophageal varices is a well-recognized complication of liver cirrhosis.It is known that in active variceal bleeding, treatment needs to be started promptly. Treatments comprise band ligation, sclerotherapy, removable stent placement, balloon tamponade, and transjugular intrahepatic portosystemic shunt (TIPS).We report a case in which hemodynamic stability can be maintained with the use of Purastat to control bleeding

Lifelong learning refers to the systematic acquisition, renewal, updating and completion of knowledge. It is synonymous with the term 'self-directed learning'. This is a new educational strategy meant to consolidate knowledge in a fashion that is reproducible for a lifetime with successful application to both known and unknown clinical exercises. The development of lifelong learning is based on the principles of andragogy (autonomy and independence in one's learning activities), reflection and learning from experience. This paper deals with the development of these theories culminating in the advent of self-directed learning. Evidence to support experiential, reflective and self-directed learning is provided, including the use of rating scales. An example from obstetrics is used to highlight the application of these principles. There are barriers to adopting a new educational paradigm, however, lifelong learning remains an excellent tool for continuous professional development.

Introduction Seroma formation is the most common complication after modified radical mastectomy (MRM). It leads to increased pain and discomfort, potentially prolonging morbidity and treatment. Various treatment modalities are being used to decrease the incidence of seroma formation. The objective of this study was to compare intravenous hydrocortisone injection versus placebo in patients undergoing MRM in terms of frequency of post-operative seroma formation. Methods This randomized, double-blinded, placebo-controlled study was conducted at Surgical Unit-I, Holy Family Hospital, Rawalpindi, Pakistan from January 2021 to December 2021. A total of 152 female patients were randomly assigned to each of the study and placebo groups. Group I patients received 100 mg of hydrocortisone intravenously while group II patients received one ml of 0.9% normal saline intravenously prior to induction of general anesthesia for MRM. The incidence of seroma formation after 10 days of MRM and total drain volume till their removal was measured in all patients. Results The mean age was 48.42±10.15 in Group I, while it was 47.67±10.75 in Group II. Mean drain output till removal was 99.14±31.01 ml in the hydrocortisone group and 177.57±63.37 ml in the placebo group. Forty-eight patients developed seroma (31.58%), of whom nine received intravenous hydrocortisone and 39 received normal saline (P=0.000). Conclusion Intravenous hydrocortisone is effective in terms of frequency of post-operative seroma formation as compared to placebo in patients undergoing MRM.

This article aims to outline the role and training of orthodontic auxiliaries in the UK, including the development of orthodontic therapists (OTs). The limitations and findings from a survey taken to understand the training and scope of orthodontic auxiliaries across Europe are provided and we reflect on the desirability and feasibility of standardized training for OTs, particularly in light of Brexit.

CPD/Clinical Relevance: Orthodontic auxiliaries are important members of the dental team. It is important that the training, role and scope of practice of all team members are understood to allow safe delegation and supervision.

This article describes the problem of disorientation in students as they become doctors. Disorientation arises because students have a poor or inaccurate understanding of what they are training to become. If they do not know what they are becoming it is hard for them to prioritise and contextualise their learning, to make sense of information about where they are now (assessment and feedback) or to determine the steps they need to take to develop (formative feedback and "feedforward"). It is also a barrier to the early development of professional identity. Using the analogy of a map, the paper describes the idea of a curriculum that is articulated as a developmental journey--a "roadmap curriculum". This is not incompatible with a competency-based curriculum, and certainly requires the same integration of knowledge, skills and attitudes. However, the semantic essence of a roadmap curriculum is fundamentally different; it must describe the pathway or pathways of development toward being a doctor in ways that are both authentic to qualified doctors and meaningful to learners. Examples from within and outside medicine are cited. Potential advantages and implications of this kind of curricular reform are discussed.

No abstract available

INTRODUCTION: "Be Clear on Cancer" (BCOC) was a national campaign to raise awareness of breast cancer in women over seventy years old. Cancer Research UK conducted this campaign from 03 February 2014 to 15 March 2014. This study assesses its impact on breast care services.

METHODS: BCOC campaign guidelines for hospital trusts were used as standard comparator for this retrospective case-control study. All new patients referred to breast clinic over four months from February 2014 were included, and compared to the same period in 2013. Information was recorded for referrals, biopsy rates and pathological diagnoses. Intra & inter-group comparisons were performed.

RESULTS: 1646 patients were included. An increase of 25.2%(n = 184) was observed in referrals in 2014(n = 915) compared to 2013(n = 731). Cancer detection rates went down significantly (P = 0.002,Chi-square) in 2014 (5.1%,n = 47) compared to 2013 (9.0%,n = 66) due to the increase in number of referrals. In the over 70s group, a higher than predicted increase of 64.2%(n = 52) in all referrals, and 8%(n = 44) in two-week wait referrals was observed. The number of biopsies and cancers detected remained stable although the proportions undergoing biopsies (2014-29.3%,n = 39/133 versus 2013-38.3%,n = 31/81) or being diagnosed with cancer (2014-19.5%,n = 26/133 versus 2013-30.9%,n = 25/81) declined significantly (P = 0.001,McNemar) during the campaign due to an inflation in the number of referrals. Despite the overall reduction, cancer detection rate for biopsies performed remained significantly high in the over 70s (66.7%,n = 26/39) when compared with the under 70s (23.9%,n = 21/88) during the campaign.

CONCLUSIONS: Although "Be Clear on Cancer" campaign resulted in a significant increase in breast cancer referrals, it did not translate into an increase in biopsy rates or cancer detection rates. The amount of work generated for the hospital because of this campaign was far greater than the predicted increase from campaign pilots. Therefore, the overall effectiveness of this campaign is questionable.

We previously reported modest clinical 3-year benefit for topical imiquimod compared with surgery for superficial or nodular basal cell carcinoma at low-risk sites in our noninferiority randomized controlled SINS trial. Here we report 5-year data. Participants were randomized to imiquimod 5% cream once daily (superficial basal cell carcinoma, 6 weeks; nodular basal cell carcinoma, 12 weeks) or excisional surgery (4-mm margin). The primary outcome was clinical absence of initial failure or signs of recurrence at the 3-year dermatology review. Five-year success was defined as 3-year success plus absence of recurrences identified through hospital, histopathology, and general practitioner records. Of 501 participants randomized, 401 contributed to the modified intention-to-treat analyses at year 3 (primary outcome), 383 (96%) of whom had data at year 5. Five-year success rates for imiquimod were 82.5% (170/206) compared with 97.7% (173/177) for surgery (relative risk of imiquimod success = 0.84, 95% confidence interval = 0.77-0.91, P < 0.001). These were comparable to year 3 success rates of 83.6% (178/213) and 98.4% (185/188) for imiquimod and surgery, respectively. Most imiquimod treatment failures occurred in year 1. Although surgery is clearly superior to imiquimod, this study shows sustained benefit for lesions that respond early to topical imiquimod.

No abstract available

Records were reviewed (n=1052) for patients admitted to a large general intensive care unit (GICU) and examined for HIV testing criteria published in UK national testing guidelines (UKNG). All actual tests sent from GICU were also examined for comparison. Strict application of the UKNG revealed 30% of patients met criteria for HIV testing on admission to GICU. With pragmatic application, 18% of admissions met criteria for testing. Less than 5% of admissions were actually tested when no testing guideline was adopted.
DISCUSSION: The UKNG can be adopted in a representative GICU to increase HIV testing rate by 4-6-fold.

BACKGROUND: The TheraMon microsensor is the most recent device developed to measure the wear-time of removable appliances. The accuracy has not been validated intraorally.

OBJECTIVES: To determine 1) if the TheraMon microsensor accurately records time when fixed intraorally, and 2) the effect of the intraoral location on the recorded time.

METHODS: A prospective pilot study, using a convenience sample, was carried out in a UK hospital orthodontic department. Five non-patient volunteers wore microsensors positioned palatal to an upper molar, and buccal to a lower molar for 7 days. Differences between actual amount of wear and the wear recorded by each device were calculated. Differences between sites were also examined.

RESULTS: The mean daily wear-time recorded by the upper and lower microsensors combined was 23 hours (95% CI 22.6-23.4), which is a mean under-recording of 4% (CI 2.5-5.8%). The maximum daily under-reporting of wear times was 5.5 hours. Microsensors in the lower buccal sulcus recorded wear-times that were closer to actual wear-times.

CONCLUSIONS: Assumptions made by the TheraMon microsensors software lead to under-reporting of intraoral wear-time, particularly when placed palatally. These discrepancies could be significant in both clinical practice and research. Adjustment of the microsensor software parameters would improve accuracy, irrespective of the intraoral location.

The objective of this review is to assess the diagnostic accuracy of bedside-focused transthoracic echocardiography (TTE) in acute atraumatic thoracic aortic syndrome in adults. We performed a systematic review and meta-analysis of publications that described the use of bedside-focused TTE on adults presenting to the emergency care setting with suspected atraumatic thoracic aortic syndrome. Studies were identified using keyword and Medical Subject Heading searches on databases and grey literature, followed by abstract screening and study selection by two independent reviewers. Sixteen studies over six decades were included in the meta-analysis (n = 4569 patients). The prevalence of Type A thoracic aortic dissection was 11% (range 1.4-45.7%) and Type B dissection was 7% (range 1.8-30.55%). Type A dissection through direct visualisation of an intimal flap on TTE (i.e. direct sign) pooled sensitivity and specificity were 89% [95% confidence interval (CI), 82-94%] and 92% (95% CI, 88-95%) respectively. For Type B dissection, the pooled sensitivity was 65% (95% CI, 45-80%) and specificity was 100% (95% CI, 0.69-100%). TTE indirect signs for dissection showed a pooled sensitivity of 64% (95% CI, 5.2-98.2%) and specificity of 94% (95% CI, 92-96.1%) for aortic valve regurgitation, a pooled sensitivity of 92% (95% CI 54-99.2%) and specificity of 87% (95% CI, 62-97%) for thoracic aortic aneurysm and a pooled sensitivity of 39% (95% CI 33.8-45%) and a specificity of 94% (95% CI, 92-95%) for pericardial effusion. In this systematic review and meta-analysis, bedside-focused TTE has a good specificity for Type A and B dissection, but poor sensitivity for Type B, and unclear for intramural haematoma and penetrating aortic ulcer.

A midline diastema is a part of normal dental development, which, in the mixed dentition, is termed the ‘ugly duckling’ stage. Supernumerary teeth, however, can also be a cause, with the most common type being a mesiodens. Supernumeraries can cause other complications including delayed or failure of eruption of a permanent tooth, displacement of crowns, crowding, root resorption and cyst formation. Treatment options for supernumeraries include immediate or delayed removal or active monitoring. This article advocates for early diagnosis and treatment to reduce the need for future complex treatment.

CPD/Clinical Relevance: This case emphasizes the importance for clinicians to accurately and carefully diagnose the cause of a midline diastema and the presence of supernumerary teeth early in development. Prompt orthodontic referral can reduce the need for later complex surgical and orthodontic treatment.

No abstract available

OBJECTIVES:
To understand the role of preoperative education for patients undergoing colorectal surgery by involving patients, carers and staff in: (1) identifying its perceived value and deficits for enhanced recovery; (2) modifying current education practices to address educational deficits; and (3) evaluating these changes for preparing patients to enhance their recovery.

DESIGN:
Qualitative study of three cycles of action research using mixed methods within a 24-month naturalistic enquiry to identify, implement and evaluate changes through observations, questionnaires, semistructured longitudinal interviews, focus groups and documentation review.

SETTING:
A UK 1200-bed National Health Service (NHS) hospital providing colorectal surgery in a small city in a rural county.

PARTICIPANTS:
Ninety-sevenpatients having colorectal surgery, 19 carers and 22 clinical staff.

RESULTS:
Themes identified were: (1) knowledge and engagement; (2) situated understanding and confidence building; and (3) partnership and proactive involvement in enhancing recovery. All patients articulated needs to prepare mentally and physically to plan for colorectal surgery and rehabilitation. Patients and carers wanted to counter uncertainty about medical procedures: likely bodily changes, recovery timescales and future. They therefore sought as much personalised, relevant information as possible about their disease, planned surgery and recovery. Staff implemented preoperative education to more specifically inform and respond multimodally to individual needs.

CONCLUSIONS:
Patients wanted to be proactively involved in managing their recovery to re-engage with their everyday lives. Preoperative education supported this through developing patients' situated understanding of hospital and bodily processes related to colorectal surgery. Situated understanding was achieved through educational product to give knowledge and processes promoting engagement. Multimodal, comprehensive and timely preoperative education on the whole patient pathway facilitates active engagement. Situated understanding increased patients' confidence to work in partnership with healthcare professionals and proactively self-manage recovery.

No Abstract Available

BACKGROUND: Procedure-based assessment (PBA) is used within most UK surgical training programmes for assessing trainees' procedural skills in the operating theatre. All postgraduate assessment methods require evidence to support their implementation. The aims were to evaluate the validity, reliability and acceptability of PBA.

METHODS:
Eighty-one trainees in six surgical specialties were assessed performing common procedures; 749 PBAs were provided across 348 operations by 57 clinical supervisors and four independent assessors.

RESULTS:
Construct validity was demonstrated by correlation of PBA scores with measures of surgical training and experience. Reliability (G exceeding 0.8) of the adjusted total item score and global summary score for a given procedure was achieved using four and three assessor judgements respectively; assessing a mix of procedures required more cases/assessors because performance is procedure specific. The acceptability of PBA for assessment and feedback within surgical training was predominantly positive among clinical supervisors and trainees.

CONCLUSION:
PBA demonstrated good overall validity and acceptability, and exceptionally high reliability. Trainees should be assessed adequately for each given procedure.

This retrospective study covered over two decades, during which an individual head and neck surgeon treated 24 patients with cervicofacial lymphadenitis that was related to both Mycobacterium tuberculosis complex (n=17, made up of M tuberculosis (n=16) and M bovis (n=1)), and non-tuberculous mycobacteria. The seven cases of non-tuberculous mycobacteria were caused by M avium complex (n=3), M malmoense (n=3), and M kansaii (n=1). By using a tailored management approach, at times selective combined surgical and antimycobacterial treatment, he achieved a success rate of 23/24 cases, with only one recurrence and no major complications. The results suggest that patients with tuberculosis confined to the head and neck rarely develop constitutional symptoms, so the absence of such symptoms may not exclude tuberculosis. There was also a good correlation between predictive variables (immune state, inflammatory markers on admission, causative mycobacterium, and the antimycobacterial regimen used) and time spent under follow-up at the head and neck outpatient clinic.

OBJECTIVES: Free-text comments in multi-source feedback are intended to facilitate change in the assessee's practice. This study was designed to utilise a large dataset of free-text comments obtained in a national pilot study in order to investigate how helpful these free-text comments may be to assessees.

METHODS:
We investigated: (i) which areas of performance are usually addressed by free-text comments; (ii) to what extent assessors' (doctors, nurses, allied health professionals and clerical or managerial staff) comments correspond to assessees' (career-grade doctors) self-assessments, and (iii) whether the comments contain specific behavioural evidence and suggestions for change. Initially comments were read through to identify commonly recurring themes. A strong theme was 'respondent-centredness', which refers to the extent to which comments focus on issues that are of value to the assessor rather than to the assessee's personal development. In response to this, the data were re-evaluated against predefined research questions to assess how constructive comments were for the assessee's personal development.

RESULTS:
Of 11,483 assessor forms, 4777 (42%) included free-text comments. A total of 513 forms contained at least one below average score and 286 (56%) of these forms contained the assessor's free-text feedback. Free-text comments were mostly rater-centred and addressed the effect of the assessee on the colleague's working life rather than areas of relevance to the assessee's personal development. A total of 1806 assessor/assessee pairs of comments were compared; most demonstrated clear differences of opinion or interpretation. Reliability and supportiveness were over-represented; clinical performance and personal development were under-represented. The comments were unlikely to provide specific behavioural evidence or to address how change might be initiated.

CONCLUSIONS:
Our data indicate that, in their current form, the overwhelming majority of free-text comments add little to facilitate improvement in assessees' personal development and performance.

Background: Critical care survivors face physical, psychological and socio-economic burdens. Peer support is acknowledged as a way individuals can face, accept and overcome the challenges arising from a stressful event. We sought to examine the provision and benefits of peer support to critical care survivors in the UK.

Method: We distributed a survey, devised by the patients and relatives committee of the Intensive Care Society and ICUsteps, to contacts in 163 UK Trusts/hospitals with critical care departments. The benefit to individuals was assessed by seeking the views of attendees of two support groups.

Results: A response was received from 91 (56%) of the critical care departments. Of these, 46 (48% of respondents) have patient support groups. Our analysis of comments from 30 people is that support groups greatly benefit service users and staff.

Conclusions: Attendees of patient support groups gave highly positive comments about the service yet provision of patient support groups in the UK is not universal.

Recommendations: We make a series of recommendations for consideration by UK health care providers.

No abstract available

Orthodontists are well placed to detect soft-tissue disease of the oral cavity and associated structures because of the frequent repeat examinations of their patients. This review describes the clinical manifestations, pathologic features, and treatment of the soft-tissue pathology most likely to be encountered by the orthodontist and uncommon soft-tissue disease with significant implications for the patient. The recognition of soft-tissue disease will allow reassurance, referral, and early intervention when required.

No abstract available

Purpose: The diagnosis of premature rupture of membranes (PROM) can be difficult in equivocal cases. This study was designed to test the validity of vaginal fluid urea and creatinine in the diagnosis of PROM against the gold standard, the Amnisure ROM test™ METHODS: The study was a prospective observational study. All consenting eligible pregnant women between gestational ages of 28 weeks to 41 weeks + 6 days were recruited from the obstetrics emergency and antenatal clinic of the Federal medical centre, Keffi. Patients with history of drainage of liquor were recruited as the case group, and controls who match for age, parity and gestational age were recruited from the antenatal clinic to constitute the control group. Vaginal fluid aspirated was assessed in the laboratory for urea and creatinine levels and an Amnisure ROM test™ done. The sensitivity, specificity, negative and positive predictive values of vaginal fluid urea and creatinine were assessed in the diagnosis of PROM.

Results: Vaginal fluid urea and creatinine had sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), respectively, of 94%, 82%, 93.18% and 83.93%, and 98%, 90%, 97.82% and 90.74%. The cutoff values for vaginal fluid urea and creatinine were 1.25 mg/dl and 0.23 mg/dl, respectively.

Conclusions: This study has found that vaginal fluid urea and creatinine are very effective tests in diagnosis of PROM. It is a cheaper and more readily available alternative to the Amnisure test. It is especially useful in our environment, especially in cases of equivocal PROM, as a cost-effective means to confirm the diagnosis.

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded on the basis of the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments published in Wilderness & Environmental Medicine 2014;25(1):41-49.

Introduction: Physiological age-related bone loss is common, with 50% of women aged ≥80 having osteoporosis. Bone loss is exacerbated in women receiving aromatase inhibitors (AIs) for early breast cancer (EBC), increasing fracture risk. This study explored the management of bone-health in older women (≥70 years) with EBC and factors influencing clinical decision-making.

Materials and methods: This was a sub-study of a larger United Kingdom multicentre observational study into practice variation and outcomes in older women (≥70) with EBC (Age Gap study). Participants were aged ≥70 years with EBC; data were collected on health status, treatments, and outcomes. This sub-study focused on patients recruited at five hospitals, where more detailed data on bone health and management were collected for women with ER + ve (oestrogen receptor positive) cancers who received adjuvant or primary endocrine therapy treatment. We aimed to determine factors influencing treatment selection and outcomes in this age group.

Results: The main Age Gap study recruited between 2013 and 2018. In this sub-study, 565 patients had ER + ve cancers, of whom 529 (93.6%) received AIs and 26 (4.6%) tamoxifen. The median age of participants was 77 years (70-98 years). A baseline dual energy x-ray absorptiometry (DEXA) scan was performed in only 354/529 (67%) of the AI group. Bisphosphonates were prescribed for 226/529 (43%). Baseline DEXA scans were more likely to be requested if patients were fit for surgery and were < 80 years old. Of those scanned (n = 354), 148 (42%) were osteopenic and 64 (18%) osteoporotic. Bisphosphonate prescription was associated with younger age (<80 years old) (p = 0.02). From recruitment to 2022, fractures were diagnosed in 23% of participants (122/529), of whom only 38% (46/122) had received prior bisphosphonates. Frailty or prefrailty (Rockwood scale) were present in 94% (431/461), but there was no correlation between frailty and baseline hip (r2 = 0.0098) or spine (r2 = 0.00007) T-scores. Rates of DEXA scanning varied between centres from 36% to 76% (p < 0.001) for unknown reasons.

Discussion: Age and general health influenced bone-health management decision-making, but there was considerable variation between centres, highlighting the need for standardised bone-health care for older women with EBC.

Purpose: To describe a hitherto unreported late ocular surface complication of retinal detachment surgery around a radial segment explant.

Methods: A single case report of a 72 year-old white Caucasian male, with a previous history of right scleral buckling surgery for retinal detachment surgery 25 years ago, presented with right-sided ptosis of 6 months duration.

Results: Ocular surface examination showed a prominent right supero-nasal quadrant radial segment explant, around which there was bulky pink conjunctival mass, extending from the supero-medial fornix down to the medial canthal area and inferior medial fornix with similar changes seen on the upper medial tarsal conjunctiva. The clinical differential diagnosis was either inflammation from an exposed radial explant or lymphoma. Biopsies of the conjunctival mass showed perivascular and interstitial solid eosinophilic deposits of amyloid, with scattered giant cells; the amyloid was of AL type. There was no morphological or immunohistochemical evidence of lymphoma or a plasma cell neoplasm in the specimen.

Conclusion: This is the first report of localised conjunctival amyloid deposition, secondary to a retinal detachment radial explant. It is proposed that the localised amyloid deposit arose from the ocular surface irritative effects of the radial explant.

Background: Autoimmune hepatitis (AIH) is a substantial UK health burden, but there is variation in care, facilities and in opinion regarding management. We conducted an audit of service provision and care of patients with AIH in 28 UK hospitals.

Methods: Centres provided information about staffing, infrastructure and patient management (measured against predefined guideline-based standards) via a web-based data collection tool.

Results: Hospitals (14 university hospitals (UHs), 14 district general hospitals (DGHs)) had median (range) of 8 (3-23) gastroenterologists; including 3 (0-10) hepatologists. Eight hospitals (29%, all DGHs) had no hepatologist. In individual hospital departments, there were 50% (18-100) of all consultants managing AIH: in DGH's 92% (20-100) vs 46% (17-100) in UHs. Specialist nurses managed AIH in only 18%. Seventeen (61%) hospitals had a histopathologist with a liver interest, these were more likely to find rosettes than those without (172/795 vs 50/368; p<0.001).Of 999 steroid-treated patients with ≥12 months follow-up, 25% received steroids for <12 months. After 1 year of treatment, 82% of patients achieved normal serum alanine aminotransaminase (ALT); this was higher in UHs than DGHs. Three-monthly liver blood tests were inadequately recorded in 26%. Of potentially eligible patients with liver decompensation, transplantation was apparently not considered in 5% (n=7). The same standards were attained in different types of hospital.

Conclusion: Management of AIH in UK hospitals is often shared between most gastroenterologists. Blood test monitoring and treatment duration are not always in line with recommendations. Some eligible patients with decompensation are not discussed with transplant teams. Care might be improved by expanding specialist input and management by fewer designated consultants.

Patients with severe grades of life-threatening brain injury are commonly characterized as having devastating brain injury (DBI), which we have defined as: 'any neurological condition that is assessed at the time of hospital admission as an immediate threat to life or incompatible with good functional recovery AND where early limitation or withdrawal of therapy is being considered'. The outcome in patients with DBI is often death or severe disability, and as a consequence rapid withdrawal of life sustaining therapies is commonly contemplated or undertaken. However, accurate prognostication in life-threatening brain injury is difficult, particularly at an early stage. Evidence from controlled studies to guide decision-making is limited, and there is a risk of a 'self-fulfilling prophecy', with early prognostication leading to early withdrawal of life sustaining therapies and death. The Joint Professional Standards committee of the Faculty of Intensive Care Medicine and the Intensive Care Society convened a consensus group with representation from stakeholder professional organizations to develop clear professional guidance in this area. It recognized that the weak evidence base makes GRADE guidelines difficult to justify. We have made 12 practical, pragmatic recommendations to help clinicians deliver safe, effective, equitable, and justifiable care within resource constrained healthcare systems. In the situation where patient-centred outcomes are recognized to be unacceptable, regardless of the extent of neurological improvement, then early transition to palliative care is appropriate. These recommendations are intended to apply where the primary pathology is DBI, rather than where DBI has compounded a progressive and irreversible deterioration in other life-threatening comorbidities.

This paper outlines the development and evaluation of the utility of workplace-based assessments in higher medical training: case-based discussion (CbD); the acute care assessment tool (ACAT); audit assessment; teaching observation and patient survey (PS). The study population included trainees in higher medical training (ST3+) from physician specialties in the U.K. The pilot consisted of a prospective study of the use of the new assessments using local study coordinators (LSCs) and volunteer trainees. In total, 169 LSCs were recruited and 134 trainees returned at least one assessment. The end-of-pilot questionnaire was returned by 44 assessors and 57 trainees. Questionnaire data and qualitative feedback were used to evaluate the validity, impact and feasibility of the new tools. For adequate reliability (co-efficient 0.7) a total of 12 CbDs; three ACATs and 16 PS raters are required. There was evidence for the validity and positive educational impact of all the tools. There were difficulties with the feasibility of the PS.

OBJECTIVES: To explore the accessibility, usability and relevance of the British Orthodontic Society (BOS) online information resource (OIR), Your Jaw Surgery.
DESIGN: Qualitative, cross-sectional study.
SETTING: 5 UK sites.
PARTICIPANTS: Patients before, during and after treatment for non-cleft skeletal discrepancy.
METHODS: Patients were identified at joint clinics and recruited after having time to view the OIR. Semi-structured interviews were conducted with 17 patients (aged 16-46 years). The interviews were transcribed and thematic analysis was undertaken using a framework approach.
RESULTS: The main themes identified were the overall usefulness, personal relevance and positive perceptions of the OIR. The OIR was seen to be useful for patients considering treatment, and potentially useful for patients undergoing treatment. Participants were looking for a personally relevant resource that would give them the best possible idea of how they would look and feel after surgery. The OIR was perceived as trusted, positive and reassuring.
CONCLUSIONS: Patients at different stages of treatment found the OIR helpful and reassuring. Clinicians may find it useful to direct patients to the OIR to complement a professional consultation, but should be aware that patients may perceive it as presenting a positive image of the long-term benefits of orthognathic surgery.

BACKGROUND: Despite increased understandings that the whole family system is influenced by a family member being diagnosed with an Autism Spectrum Condition (ASC), the experiences of siblings can be overlooked. However, recently understanding of siblings' experiences has begun to develop via qualitative studies.

AIMS:
This review aimed to systematically identify, appraise and review the qualitative literature investigating the lived experience of siblings of autistic people.

METHODS AND PROCEDURES:
Six databases were systematically searched for studies reporting empirical qualitative data on the lived experience of neurotypical siblings of autistic people. Eighteen studies met inclusion criteria and were analysed using Thematic Synthesis.

OUTCOMES AND RESULTS:
Data synthesis revealed four superordinate themes; Roles and responsibilities, different to what may be expected typically; Impact of behaviours, particularly aggressive behaviours; Process of adjustment, including learning and developing empathy and acceptance; Interpersonal experiences with others and between siblings.

CONCLUSIONS AND IMPLICATIONS:
A narrative of love and empathy was present throughout. However, several participants also experienced significant difficulties affecting their mental health. Findings suggest a sense of agency, understanding ASC, time spent alone with parents, supportive environments and the chance to relate to other siblings as protective factors in facilitating positive psychological wellbeing for siblings of autistic people.

This chapter describes the design, methodology and implementation of the study. The Sheffield Surgical Skills Study is evaluating the validity, reliability, feasibility and acceptability of different workplace-based assessment tools for rating surgeons’ technical and non-technical skills in the operating room. Traditionally, surgical training in the United Kingdom (UK) has been based upon an apprenticeship and examination model without formal assessment of technical or non-technical skills. The need for robust methods of assessment for technical and non-technical surgical skills is axiomatic, as they underpin the competency based assessment strategy and curricula for all UK surgical specialties. To successfully recruit a surgical case requires the favourable alignment and accurate timing of many factors which are beyond our control. The study protocol includes the validation of assessment tools which are in use in the workplace for surgical training. The individual surgical specialties have offered different advantages and disadvantages to the study implementation.

The Transfusion 2024 plan outlines key priorities for clinical and laboratory transfusion practice for safe patient care across the NHS for the next 5 years. It is based on the outcomes of a multi-professional symposium held in March 2019, organised by the National Blood Transfusion Committee (NBTC) and NHS Blood and Transplant (NHSBT), attended and supported by Professor Keith Willet and Dame Sue Hill on behalf of NHS England and Improvement. This best practice guidance contained within this publication will facilitate the necessary change in pathway design to meet the transfusion challenges and pressures for the restoration of a cohesive, and functional, healthcare system across the NHS following the COVID-19 pandemic.

No abstract available

The 8th edition of TNM (tumour, node and metastasis) has numerous and important changes compared with the 7th edition. Public Health England and the Royal College of Pathologists, U.K., have adopted the 8th edition of TNM (TNM8) published by the Union for International Cancer Control for skin cancer staging. These changes will have an impact on the management and commissioning of melanoma and nonmelanoma skin cancer (NMSC). The T1-T3 categories for NMSC staging require the clinician to measure the maximum dimension (usually diameter) of every potential invasive cancer. For squamous, basal and adnexal carcinomas, but not Merkel cell carcinoma (MCC), the T1-T3 categories are defined by new 20-mm and 40-mm divisions based on the maximum dimension of the lesion. In addition, new risk factors upstage T1 or T2 to T3. For melanoma, mitotic index no longer influences separation of pathological stage (pT1). There is a new, additional stratification level at 0.8-mm Breslow thickness. Subdivision pT1b, with a negative sentinel lymph node biopsy (SLNB) of pN0, is now stage IA compared with the previous IB. For MCC, SLNB is now included specifically in the pN staging system. The pT1 subdivision requires clinical information as to whether histologically involved nodes were clinically occult or detectable. For both melanoma and MCC the clinician must state whether the lymph nodes are occult or clinically detectable. Eyelid carcinoma continues to have a staging system different from that in general skin and the system is substantially revised in TNM8.

Surgeons are usually not involved in the postdischarge care of patients after uncomplicated laparoscopic cholecystectomy (LC). The aim of this study was to document the the symptomatic recovery of patients following LC, because this has a bearing on the planning of a postoperative care package.
METHODS: Consecutive patients undergoing uncomplicated LC were followed up by a weekly telephone questionnaire survey for 6 weeks.
RESULTS: The study cohort comprised 102 patients who all completed the study. Postoperatively, only 2.9% of all patients had postoperative nausea/vomiting lasting greater than or equal too 2 days. Pain was symptomatic in 11.7% of patients. Port-site wounds were a source of significant symptoms in 70.5% of the patients. Postoperative review by a community nurse and primary-care doctor were necessary in 77.4% and 32% patients, respectively, with a combined average of 3.1 reviews per patient. Less than 4% of patients believed that they would benefit from a surgeon's review 6 weeks after LC. Median time taken to return to routine preoperative activity after surgery was 22 days (IQR, 17 to 34), which was affected by the degree of activity undertaken, wound-related symptoms persisting for greater than or equal to 3, planned follow-up clinic appointment, and discharge as an outpatient.
CONCLUSION: Wound-related symptoms are common after LC, require substantial input from the community health service in their management, and may delay return to preoperative routine.

The use of non-invasive tools in conjunction with artificial intelligence (AI) to detect diseases has the potential to revolutionize healthcare. Near-infrared spectroscopy (NIR) is a technology that can be used to analyze biological samples in a non-invasive manner. This study evaluated the use of NIR spectroscopy in the fingertip to detect neutropenia in solid-tumor oncologic patients. A total of 75 patients were enrolled in the study. Fingertip NIR spectra and complete blood counts were collected from each patient. The NIR spectra were pre-processed using Savitzky-Golay smoothing and outlier detection. The pre-processed data were split into training/validation and test sets using the Kennard-Stone method. A toolbox of supervised machine learning classification algorithms was applied to the training/validation set using a stratified 5-fold cross-validation regimen. The algorithms included linear discriminant analysis (LDA), logistic regression (LR), random forest (RF), multilayer perceptron (MLP), and support vector machines (SVMs). The SVM model performed best in the validation step, with 85% sensitivity, 89% negative predictive value (NPV), and 64% accuracy. The SVM model showed 67% sensitivity, 82% NPV, and 57% accuracy on the test set. These results suggest that NIR spectroscopy in the fingertip, combined with machine learning methods, can be used to detect neutropenia in solid-tumor oncology patients in a non-invasive and timely manner. This approach could help reduce exposure to invasive tests and prevent neutropenic patients from inadvertently undergoing chemotherapy.

Background: A reduction in skeletal muscle performance measured by handgrip strength is common in heart failure. No trial has investigated the role of cardiac resynchronization therapy, which leads to improvements in cardiac performance, on the function of skeletal muscle in patients with heart failure.
Methods: Nineteen patients were recruited, 18 male, age 69 ± 8 years, New York Heart Association class II-IV, QRS duration 173 ± 21 ms and left ventricular ejection fraction 26±8%. Handgrip strength was measured at baseline before, and 6 and 12 months, following cardiac resynchronization therapy. Response was assessed using quality of life questionnaire, 6-minute walk distance, left ventricular enddiastolic volume, and cardiopulmonary exercise testing at the same time points.
Results: Fourteen patients were identified as responders, demonstrating significant improvements in all four markers of response. There was no significant difference at baseline in left or right handgrip strength between responders and non-responders. Compared to baseline, handgrip strength significantly increased in responders during follow-up, left (34.4 ± 11.4 to 40.3 ± 11.3 kgf, P < 0.001) and right (35.7 ± 12.5 to 42.2 ± 11.5 kgf, P < 0.001) at 12 months. No such improvement was seen in non-responders.
Conclusions: This study demonstrates that positive response to cardiac resynchronization therapy is associated with significant gains in handgrip strength, suggesting that cardiac resynchronization therapy may indirectly lead to secondary gains in skeletal muscle function.

Anterior open bite has a multi-factorial aetiology comprising: genetically inherited skeletal pattern, soft tissue effect and digit-sucking habits. To formulate an appropriate treatment plan, accurate diagnosis is essential. Simple open bites may sometimes resolve completely during the transition from mixed to permanent dentition, if the digit-sucking habit is broken. More significant open bites, however, sometimes extending right back to the terminal molars, rarely resolve spontaneously and will often require complex orthodontic treatment, involving active molar intrusion or even major orthognathic surgery. Unfortunately, surgery has associated risks attached, including pain, swelling, bruising, altered nerve sensation and, occasionally, permanent anaesthesia, as well as involving significant costs, as with any major surgical procedure under general anaesthesia. The introduction of Temporary Anchorage Devices (TADs) has expanded the possibilities of orthodontic treatment, beyond traditional limitations of tooth movement. Molar intrusion can be successfully carried out without the need for major surgical intervention, thus avoiding all the attendant risks and disadvantages. This paper provides an overview of anterior open bite and uses an illustrative case where open bite was successfully treated with a combination of fixed appliance therapy and TADs.
CLINICAL RELEVANCE: Anterior open bite is commonly seen in general practice. A knowledge of the possible aetiological factors and their potential management should be understood by general dental practitioners. The increased popularity of TADS allows a new and less invasive approach to management of these cases.

PURPOSE: To identify the frequency of disc hyperfluorescence, and to use optical coherence tomography to look for vitreopapillary traction as a possible underlying cause.
METHODS: Eight patients with presumed Fuchs uveitis syndrome were included. A complete ocular examination, fundus fluorescein angiography, and spectral-domain optical coherence tomography for optic nerve head were performed.
RESULTS: There were 4 males and 4 female patients, and the mean age at diagnosis was 41.7 years. The most common ocular symptom was floaters (5/9). The range of initial visual acuity was 6/5-6/12. The most frequent clinical sign was inflammatory cells in the anterior chamber (9/9). Fundus fluorescein angiography showed disc hyperfluorescence in all but 1 patient. Optical coherence tomography did not show evidence of vitreopapillary traction in all eyes but one eye.
CONCLUSION: We think that the high frequency of disc hyperfluorescence on fundus fluorescein angiography is an indication of an inflammatory process rather than a mechanical one.

Fixed appliance treatment is a popular treatment modality with a burgeoning increase in the numbers of children and adults realizing the benefits that can be gained. Appliance breakage is an unavoidable nuisance which is at best inconvenient, and at worst may result in significant pain or discomfort for the patient. General dental practitioners (GDPs) should have the practical knowledge of how to provide timely and appropriate orthodontic ‘emergency treatment’. This will significantly reduce the sometimes considerable inconvenience and discomfort for both the patient and his/her parents, and the inevitable frustration for the clinician providing ongoing care. This first paper will deal with general orthodontic problems that commonly present, as well as some issues specific to fixed appliances. The second paper will deal with the other orthodontic appliances that may be encountered by GDPs in their daily practice.

Clinical Relevance: Appropriate handling of an orthodontic ‘emergency’ by the general practitioner will, on many occasions, provide immediate relief of pain and distress for the patient. This will in turn allow treatment to continue moving in the right direction, thus allowing more efficient and effective use of valuable resources.

Now recognised as a worldwide public health issue, the significance of promoting and encouraging exclusive breastfeeding (EBF) has been acknowledged by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Documented policies about the importance of facilitating the support of breastfeeding women is currently receiving worldwide recognition (WHO, 2011; WHO and UNICEF, 2003). This literature review will examine provision of support mechanisms for breastfeeding mothers, focusing on peer support in encouraging the starting and maintaining of EBF. Consideration will also be given to any barriers that may prevent higher success rates, as cultural and educational factors may have a significant impact on the starting and maintaining of EBF. These factors must be considered when starting support groups, networks or activities that aim to address this significant public health issue.

No Abstract Available

Gastrointestinal specialist nursing is under threat from workforce reviews and Trust financial deficits. Both the RCN gastrointestinal forum and the Association of Coloproctology (ACPGBI) nurses′ forum have been assessing changes to colorectal and stoma care specialist nursing by asking members to complete and return separate questionnaires. RCN returns (see GIN 2006, 4 (7): 8−9) showed that 38% of the 460 replies felt that they were unable to deliver their service in line with national guidelines. Provisional ACPGBI returns suggest specialist nurses are being asked to work as ward staff nurses and reduce their specialist nurse activity. Others have been downgraded and job descriptions changed from specialist roles to practitioner roles. From the RCN questionnaire 219 (48%) respondents were aware of posts that had been disestablished, downgraded or frozen when vacant. In some areas staff have left and have not been replaced, or have been replaced by a lesser band.

This article describes a retrospective cohort study that investigated whether adult midshaft clavicle fractures possessing the radiological sign of a butterfly vertical fragment demonstrate a higher rate of early and delayed surgical intervention when compared to adult midshaft clavicle fractures with no vertical fragment sign. The radiographs of 134 adult midshaft clavicle fractures were divided into 2 cohorts: those with a vertical fragment radiological sign and those without. Within each cohort, the number of cases that underwent early surgical intervention and that underwent delayed surgical intervention was noted. The vertical fragment group displayed a rate for early surgical intervention, all for skin tenting, of 8.5%, whereas the no vertical fragment group's rate was 1.1%; this proved to be significantly different (P=.0464). Furthermore, the vertical fragment group displayed a rate for delayed surgical intervention for symptomatic nonunion of 12.8%, whereas the no vertical fragment group's rate was 5.7%. Despite being twice as likely for the vertical fragment group to have undergone delayed surgical intervention, this did not prove to be statistically significant (P=.0965). This study revealed that midshaft fractures with the radiological sign of an interfragmentary vertical fragment are significantly more likely to require early surgical intervention due to skin tenting. Furthermore, these fractures are twice as likely to go into symptomatic nonunion, and in this area we may be able to improve current management by considering early surgical intervention.

No abstract available

PURPOSE:
The primary aim of this study was to examine the value of temperature as a diagnostic and prognostic indicator of infection and sepsis in neutropenic patients. A secondary aim was to gain insight into the presenting symptoms reported by these patients at home or on their initial admission assessment.

METHODS:
A cohort study was carried out using a case note review of 220 emergency admissions to a regional cancer centre. All participants were neutropenic and were diagnosed with infection on admission. The main outcome measures were relationships between Early Warning Scores and temperature values at home, on admission and during the hospital stay.

RESULTS:
22% of patients who became acutely unwell did not have a fever. Pearson correlations showed only small associations between highest temperature value at any time point and highest early warning scores (r(202)?=?0.176, P?=?.012). Temperature at home (B?=?0.156, P?=?.336) and temperature on admission (B?=?0.200, P?=?.052) did not predict highest Early Warning Scores.

CONCLUSIONS:
Body temperature is not a consistently reliable diagnostic or prognostic indicator for outcomes in patients with neutropenia and symptoms of infection. It can assist with early presentation and recognition of infection in many neutropenic patients. However, over-reliance on temperature risks missing the opportunity for early detection and treatment.

Traditional approaches to health promotion involve clinicians imparting knowledge to patients and 'telling' patients what changes they should make to benefit their health. This so-called 'fixing reflex' can be counterproductive and ineffective, creating unhelpful discord between clinicians and patients. There is little evidence that this approach is wholly effective in bringing about healthier patient behaviours. In contrast, motivational interviewing (MI) is a patient-centred consultation style aimed at developing patient motivation and commitment for a range of health-related behaviours. It focuses on discovering the values, beliefs and goals of patients and encourages clinicians and patients to work together collaboratively, to bring about change and growth. It is an effective, evidence-based approach, even when used as a 'brief intervention' for a few minutes only. This paper discusses how MI can be applied in dental healthcare settings to enhance general and oral health. The evidence available for its use in dentistry is discussed, along with opportunities for training of the dental team in this skill.

Introduction Currently, there are no agreed-upon investigations and follow-up guidelines for the conservative management of ureteric stones. This study used common themes identified in previous works to investigate whether there is a consensus amongst urology consultants in the United Kingdom. Methods This was a questionnaire-based survey study. An online questionnaire was disseminated nationally to urological consultants practicing in the United Kingdom to explore a range of common factors. The initial sample size was 81 UK-based urological consultants with an interest in endourology and stone surgery. Of the initial 81, 20 participants did not complete the survey and therefore the final sample size was 61. Descriptive analysis was used to analyze the data. Results Our survey found that the main factors influencing the follow-up of conservatively managed ureteric stones were stone size 98% (60), stone location 92% (56), and the degree of altered renal function 79% (48). Regardless of stone size, most participants chose to follow up at 2-4 weeks with asymptomatic patients requiring imaging with discrepancies about the modality. Regarding biochemical markers, most participants only repeated renal function tests if this was deranged on presentation. Calcium and uric acid levels were checked regularly. Diclofenac was the analgesia of choice 93% (55). Regarding the availability of acute ESWL services, over half (59%) were able to offer acute ESWL within the week. The majority offer services at least three or more lists per week. Conclusion Our results demonstrate that there is still no overarching consensus in the follow-up of conservatively managed ureteric stones. Several factors backed by high-level evidence are already consistent across the population of urology consultants and considered "best practice." However, before any all-encompassing national guidelines are formalized, further studies in the form of randomized control trials will be needed to yield high-level evidence.

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.

Introduction: The National Health Service contributes 4%-5% of England and Wales' greenhouse gases and a quarter of all public sector waste. Between 20% and 33% of healthcare waste originates from a hospital's operating room, and up to 90% of waste is sent for costly and unneeded hazardous waste processing. The goal of this study was to quantify the amount and type of waste produced during a selection of common trauma and elective orthopaedic operations, and to calculate the carbon footprint of processing the waste.

Methods: Waste generated for both elective and trauma procedures was separated primarily into clean and contaminated, paper or plastic, and then weighed. The annual carbon footprint for each operation at each site was subsequently calculated.

Results: Elective procedures can generate up to 16.5kg of plastic waste per procedure. Practices such as double-draping the patient contribute to increasing the quantity of waste. Over the procedures analysed, the mean total plastic waste at the hospital sites varied from 6 to 12kg. One hospital site undertook a pilot of switching disposable gowns for reusable ones with a subsequent reduction of 66% in the carbon footprint and a cost saving of £13,483.89.

Conclusions: This study sheds new light on the environmental impact of waste produced during trauma and elective orthopaedic procedures. Mitigating the environmental impact of the operating room requires a collective drive for a culture change to sustainability and social responsibility. Each clinician can have an impact upon the carbon footprint of their operating theatre.

Introduction: Near infrared autofluorescence (NIRAF) is a novel intraoperative technology that has shown promising results in the localisation of parathyroid glands (PGs) over the last decade. This study aimed to assess the potential utility of NIRAF in first time surgery for primary hyperparathyroidism (PHPT).

Methods: An observational study over a period of 3 years in patients who underwent surgery for PHPT was designed. Data on the use of NIRAF and fluorescent patterns in different organs (thyroid and parathyroid) and parathyroid pathology (single versus multi-gland disease) were explored. In addition, cure rates and operating times were compared between the NIRAF and no-NIRAF groups to determine the potential value of NIRAF in this cohort.

Results: In 230 patients undergoing first time surgery for PHPT, NIRAF was used in 50 patients. Of these 50 patients, NIRAF was considered to aid parathyroid identification in 9 patients (18%). The overall cure rate at 6 months of follow-up was 96.5% (98% in NIRAF and 96.1% without NIRAF; p=1.0). The median (interquartile range) operating time was longer in the NIRAF arm at 102 minutes (74-120 minutes) compared to the no-NIRAF arm at 75 minutes (75-109 minutes); however, this difference was not statistically significant (p=0.542). Although the median parathyroid to thyroid (P/T) auto-fluorescence (AF) ratio was similar between single gland and multi gland disease (2.5 vs to 2.76; p=1.0), the P/T AF ratio correlated negatively with increasing gland weight (p=0.038).

Conclusion: The use of NIRAF resulted in some potential "surgeon-perceived" benefit but did not lead to improvements in cure rates. The negative correlation between fluorescent intensity and gland weight suggests loss of fluorescence with pathology, which needs further investigation. Further studies on larger cohorts of patients, in depth analysis of fluorescence patterns between normal, adenomatous, and hyperplastic glands and evaluation of user experience are needed. Primary hyperparathyroidism, hyperparathyroidism, autofluorescence, near-infrared fluorescence, parathyroid glands, endocrine, surgery.

This study assessed the intra and inter-rater reliability of a modified weight-bearing lunge measure of ankle dorsiflexion range of movement. Thirteen healthy subjects were recruited. Each subject performed 3 repetitions of the lunging method with one rater and 3 more repetitions with a second rater within 30 min. The process was repeated within 3 h. Intra-rater reliability results indicated excellent correlation of measurements (intraclass correlation coefficients (ICCs) of 0.98-0.99). Standard error of measurement (SEM), 95% limits of agreement (LOA) and coefficient of repeatability (CR) calculations indicated suitably low ranges of measurement variance (SEM = 0.4 cm, LOA = �� 1.28 to �� 1.47 cm and CR = 1.21-1.35 cm). Inter-rater reliability was also deemed excellent (ICC = 0.99, SEM = 0.3 cm, LOA = �� 0.83 to �� 1.47 cm, CR = 1.44 cm). The modified lunge technique therefore demonstrates excellent intra and inter-rater reliability.

Objectives: To describe the health-related quality of life (HRQoL) of patients in a prospective 12-month observational cohort study of new bladder cancer diagnoses and compare with national cancer and general population surveys.

Patients and methods: A prospective UK study in patients with new bladder cancer diagnoses at 13 NHS Trusts. The HRQoL data were collected at 3, 6, 9 and 12 months. Questionnaires used included: the EuroQoL five Dimensions (EQ-5D), European Organisation for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ)-30-item core, EORTC QLQ-24-item non-muscle-invasive bladder cancer, and EORTC QLQ-30-item muscle-invasive bladder cancer. Results were compared with the Cancer Quality of Life Survey and Health Survey for England.

Results: A total of 349 patients were recruited, 296 (85%) completed the first (baseline) and 233 (67%) the final survey. The patients underwent transurethral resection of bladder tumour (TURBT) ± intravesical therapy (238 patients, 80%), radical cystectomy/radiotherapy (51, 17%) or palliation (seven, 2%). At baseline, patients needing radical treatment reported worse HRQoL including lower social function (74.2 vs 83.8, P = 0.002), increased fatigue (31.5 vs 26.1, P = 0.03) and more future worries (39.2 vs 29.4, P = 0.005) than patients who underwent TURBT. Post-treatment surveys showed no change/improvements for patients who underwent TURBT but deterioration for the radically treated cohort. At final survey, reports were similar to baseline, regardless of treatment. Radically treated patients continued to report poorer HRQoL including issues with body image (23.4 vs 12.5, P = 0.007) and male sexual function (75.8 vs 40.4, P < 0.001) compared to those who underwent TURBT. Radically treated patients reported lower EQ-5D utility scores and more problems with usual activities than the general population.

Discussion: Patients undergoing TURBT can be reassured regarding HRQoL following treatment. However, those requiring radical treatment report greater changes in HRQoL with the need for appropriate clinical and supportive care to minimise the impact of treatments.

India, a country with the second largest population in the world, does not have a national newborn screening programme as part of its health policy. With funding support from the Grand Challenges Canada, a pilot newborn screening programme was implemented for the Udupi district of South India to study the need and viability of a national programme in India. Six disorders were selected for the study based on the availability of funding and recommendation from pediatricians in the district. Here, we report the observed incidence during the study. A cost-effectiveness analysis of implementing newborn screening in India was performed. It is evident from our analysis that the financial loss for the nation due to these preventable diseases is much higher than the overall expenditure for screening, diagnosis, and treatment. This cost-effectiveness analysis justifies the need for a national newborn screening programme in India.

Background: People with dementia (PwD) and their carers often consider maintaining good quality of life (QoL) more important than improvements in cognition or other symptoms of dementia. There is a clinical need for identifying interventions that can improve QoL of PwD. There are currently no evidence-based guidelines to help clinicians, patients and policy makers to make informed decisions regarding QoL in dementia.

Aims: To conduct the first comprehensive systematic review of all studies that investigated efficacy of any pharmacological or non-pharmacological intervention for improving QoL of PwD.

Method: Our review team identified eligible studies by comprehensively searching nine databases. We completed quality assessment, extracted relevant data and performed GRADE assessment of eligible studies. We conducted meta-analyses when three or more studies investigated an intervention for improving QoL of PwD.

Results: We screened 14 389 abstracts and included 324 eligible studies. Our meta-analysis confirmed level 1 evidence supporting the use of group cognitive stimulation therapy for improving QoL (standardised mean difference 0.25; P = 0.003) of PwD. Our narrative data synthesis revealed level 2 evidence supporting 42 non-pharmacological interventions, including those based on cognitive rehabilitation, reminiscence, occupational therapy, robots, exercise or music therapy. Current evidence supporting the use of any pharmacological intervention for improving QoL in dementia is limited.

Conclusions: Current evidence highlights the importance of non-pharmacological interventions and multidisciplinary care for supporting QoL of PwD. QoL should be prioritised when agreeing care plans. Further research focusing on QoL outcomes and investigating combined pharmacological and non-pharmacological interventions is urgently needed.

Rationale: Research indicates that breast pain as the sole symptom has no association with breast cancer. However, patients with breast pain only are often referred onto urgent breast cancer diagnostic pathways, leading to unnecessary anxiety and overutilisation of secondary health care services. The novel community breast pain clinic (CBPC) service in the UK aims to improve patient care while providing system-wide improvements for patients with breast pain, patients who have 'red flag' symptoms, as well as being cost-effective.

Aim and objectives: This study seeks to evaluate and assess the impact of the CBPC on patient care, experience, and healthcare system improvements.

Methods: Quantitative and qualitative analysis of CBPC was undertaken using data from CBPC based on a core data set designed by the programme team, secondary care follow-up data, Patient Reported Outcomes Measure (PROMs) data and family history data.

Results: The CBPC was well-received by patients with 98.5% recommending the service. Additionally, health economic analysis indicated a cost benefit ratio of 1.23 in year 1, indicating a positive return on investment. Breast cancer incidence within the cohort was estimated at 3.2 per 1000, in line with population estimates in the literature. For those with a breast cancer diagnosis, there is no evidence of care delays or missed diagnoses via the service.

Conclusion: The CBPC offers significant benefits in patient experience and value for money, with no evidence of reducing patient safety. The impacts of the clinics appear to be reproducible across all five centres in the East Midlands (a population of 5.5 million). Recommendations on further assessment on optimal staff mix and clinic cost mechanisms should be considered to maximise benefits.

Attenuated Total Reflectance-Fourier transform infrared (ATR-FTIR) spectroscopy is an emerging technology in the medical field. Blood D-dimer was initially studied as a marker of the activation of coagulation and fibrinolysis. It is mainly used as a potential diagnosis screening test for pulmonary embolism or deep vein thrombosis but was recently associated with COVID-19 severity. This study aimed to evaluate the use of ATR-FTIR spectroscopy with machine learning to classify plasma D-dimer concentrations. The plasma ATR-FTIR spectra from 100 patients were studied through principal component analysis (PCA) and two supervised approaches: genetic algorithm with linear discriminant analysis (GA-LDA) and partial least squares with linear discriminant (PLS-DA). The spectra were truncated to the fingerprint region (1800-1000 cm-1). The GA-LDA method effectively classified patients according to D-dimer cutoff (≤0.5 μg/mL and >0.5 μg/mL) with 87.5 % specificity and 100 % sensitivity on the training set, and 85.7 % specificity, and 95.6 % sensitivity on the test set. Thus, we demonstrate that ATR-FTIR spectroscopy might be an important additional tool for classifying patients according to D-dimer values. ATR-FTIR spectral analyses associated with clinical evidence can contribute to a faster and more accurate medical diagnosis, reduce patient morbidity, and save resources and demand for professionals

The transition from student to newly qualified nurse can be challenging. A period of preceptorship is recommended to support newly qualified nurses in their new work environment, and to give them time to adapt and gain confidence. Researchers have developed a toolkit based on previous research that contains several resources that nurse managers, teams and organisations can use to develop and improve preceptorship for newly qualified nurses. The toolkit includes an organisational support tool, a managerial support framework, a supernumerary time tool and a local culture of support tool. This article describes these resources and gives an example of how the toolkit can be adapted locally.

Background: Coeliac disease affects 1% of the population. Despite this high prevalence, the majority of individuals are undetected. Many patients present with subtle symptoms which may also contribute to under diagnosis. Our aim was to determine the relative importance of different presenting characteristics.

Methods: Unselected gastroenterology patients referred to 4 hospitals in South Yorkshire were investigated for coeliac disease. Diagnosis was based on positive serology and the presence of villous atrophy. Odds ratios were calculated for presenting characteristics and multivariate analysis performed to identify independent risk factors.

Results: 4089 patients were assessed (41.5% male, mean age 55.8 ± 18.2 years); 129 had coeliac disease (3.2%, 95% CI 2.6-3.7%). Multivariate analysis of patients referred to secondary care showed family history of coeliac disease (OR 1.26, p < 0.0001), anaemia (OR 1.03, p < 0.0001) and osteoporosis (OR 1.1, p = 0.006) were independent risk factors for diagnosis of coeliac disease. When compared to population controls, diarrhoea (OR 4.1, p < 0.0001), weight loss (OR 2.7, p = 0.02), irritable bowel syndrome symptoms (OR 3.2, p = 0.005) thyroid disease (OR 4.4, p = 0.01) and diabetes (OR 3.0, p = 0.05) were also associated with increased coeliac disease risk.

Conclusions: Coeliac disease accounts for 1 in 31 referrals in secondary care to unselected gastroenterology clinics. A low threshold for coeliac disease testing should be adopted.

No Abstract Available

BACKGROUND: Mortality from acute myocardial infarction is influenced by the speed at which reperfusion therapy is delivered. In the U.K., prehospital thrombolysis (PHT), administered by paramedics, has been developed to improve call to needle (CTN) times. Recently, it has been shown in randomised trials that mortality can be further reduced by primary percutaneous coronary intervention (PPCI). This project was developed to assess current ST-elevation myocardial infarction practice in a district general hospital and to prepare paramedics for PPCI.
METHODS: Data were collected prospectively over a 12-month period for all patients who received thrombolysis for a presumed myocardial infarct. The primary outcome measures for each case were who delivered the thrombolysis, either the paramedic crew or the hospital, and if the patient did not receive PHT the reason why not. Secondary outcome measures included the CTN time.
RESULTS: 153 patients received thrombolysis over the time period (99 men, 54 women, mean age 66 �� 15 years). Of this group, 55 patients received PHT (35.9%) with a median CTN time of 36 min (inter-quartile range (IQR) 30-42 min). The commonest reason for exclusion from receiving PHT was that the patient's history did not fit the eligibility criteria (25% of cases).
CONCLUSIONS: Paramedics are able to deliver PHT promptly and safely. With the focus now on PPCI, it is anticipated that not only will paramedics be able to select patients for delivery to a heart attack centre for PPCI, they will be selecting many more patients for this treatment than have up to now received PHT.

BACKGROUND: The UK Department of Health is considering a single, generic multi-source feedback (MSF) questionnaire to inform revalidation.

METHOD:
Evaluation of an implementation pilot, reporting: response rates, assessor mix, question redundancy and participants' perceptions. Reliability was estimated using Generalisability theory.

RESULTS:
A total of 12,540 responses were received on 977 doctors. The mean time taken to complete an MSF exercise was 68.2 days. The mean number of responses received per doctor was 12.0 (range 1-17) with no significant difference between specialties. Individual question response rates and participants' comments about questions indicate that some questions are less appropriate for some specialities. There was a significant difference in the mean score between specialities. Despite guidance, there were significant differences in the mix of assessors across specialties. More favourable scores were given by progressively more junior doctors. Nurses gave the most reliable scores.

CONCLUSIONS:
It is feasible to electronically administer a generic questionnaire to a large population of doctors. Generic content is appropriate for most but not all specialties. The differences in mean scores and the reliability of the MSF between specialties may be in part due to the specialty differences in assessor mix. Therefore the number and assessor mix should be standardised at specialty level and scores should not be compared across specialties.

No Abstract Available

This is a literature search about the clinical use of temporary anchorage devices (TADs) as a means of providing effective orthodontic anchorage. It takes the reader through a journey from the initial description of the technique to the enormous popularity TADs are currently experiencing in clinical practice. This paper aims to present good quality clinical information to allow the clinician and the patient to make an informed decision.

Clinical Relevance: The purpose of this literature review is to provide readers with an overview of the current available literature on this subject and encourage general dental practitioners to adopt a more evidence-based approach to this aspect of orthodontic care.

BACKGROUND: Obesity in all age groups of children has become an increasing concern in recent years. Children looked after by the Local Authority (LA) should be protected from health problems while being accommodated. These studies assess the effect on weight of looked after children (LAC) in the care of a Midlands County Council. They assess the frequency of obesity or overweight problems in looked after children following receipt into care and review changes in body mass index (BMI) while in the care of the LA.
METHOD: The height and weight measurements of all 106 children who had statutory health assessments while in the care of the LA between 1 January 2004 and 30 December 2004 were used to calculate their BMI. The data were plotted onto standard Growth Foundation charts and the International Obesity Task Force Paediatric cut-offs were determined to distinguish overweight and obese children and young people. The date that the child had come into the care system and the number of moves of placement was obtained for each child from the social care. This was related to the total group and the overweight group of looked after children.
RESULT: Looked after children are more likely to be overweight and obese compared with standard norms, and there are a number of children (35%) whose BMI increases once in care.
OUTCOME: Looked after care did not protect a child from the national problem of increasing weight gain and obesity.

No abstract available

Orthodontic mini-implants (OMIs) represent a new form of anchorage provision and appear to provide a variety of benefits for both anchorage-demanding and complex orthodontic cases. This paper reports the latest perspectives on OMIs in terms of the emerging clinical evidence base coupled with their varied clinical applications.

Designing nasal prostheses can be challenging because of the unpaired nature of the facial feature, especially in patients lacking preoperative information. Various nose model databases have been developed as a helpful starting point for the computer-aided design of nasal prostheses, but these do not appear to be readily accessible. Therefore, an open-access digital database of nose models has been generated based on a 3-dimensional (3D) morphable face model approach. This article describes the generation of the database, highlights steps for designing a nasal prosthesis, and points readers to the database for future clinical application and research.

Case reports form an invaluable source of learning and discussion material. The aim of this article is to provide some guidance to help authors who are thinking of submitting reports for future publication. Some common pitfalls are highlighted, as well as useful hints to increase the authors' chances of publication.

No abstract available

Validated competency assessment tools and the data supporting milestone development during gastroscopy training are lacking. We aimed to assess the validity of the formative direct observation of procedural skills (DOPS) assessment tool in diagnostic gastroscopy and study competency development using DOPS.

METHODS:
This was a prospective multicentre (N?=?275) analysis of formative gastroscopy DOPS assessments. Internal structure validity was tested using exploratory factor analysis and reliability estimated using generalisability theory. Item and global DOPS scores were stratified by lifetime procedure count to define learning curves, using a threshold determined from receiver operator characteristics (ROC) analysis. Multivariable binary logistic regression analysis was performed to identify independent predictors of DOPS competence.

RESULTS:
In total, 10086 DOPS were submitted for 987 trainees. Exploratory factor analysis identified three distinct item groupings, representing 'pre-procedure', 'technical', and 'post-procedure non-technical' skills. From generalisability analyses, sources of variance in overall DOPS scores included trainee ability (31%), assessor stringency (8%), assessor subjectivity (18%), and trainee case-to-case variation (43%). The combination of three assessments from three assessors was sufficient to achieve the reliability threshold of 0.70. On ROC analysis, a mean score of 3.9 provided optimal sensitivity and specificity for determining competency. This threshold was attained in the order of 'pre-procedure' (100-124 procedures), 'technical' (150-174 procedures), 'post-procedure non-technical' skills (200-224 procedures), and global competency (225-249 procedures). Higher lifetime procedure count, DOPS count, surgical trainees and assessors, higher trainee seniority, and lower case difficulty were significant multivariable predictors of DOPS competence.

CONCLUSION:
This study establishes milestones for competency acquisition during gastroscopy training and provides validity and reliability evidence to support gastroscopy DOPS as a competency assessment tool.

The adaptor protein-2 sigma subunit (AP2؟2) is pivotal for clathrin-mediated endocytosis of plasma membrane constituents such as the calcium-sensing receptor (CaSR). Mutations of the AP2؟2 Arg15 residue result in familial hypocalciuric hypercalcaemia type 3 (FHH3), a disorder of extracellular calcium (Ca(2+) o) homeostasis. To elucidate the role of AP2؟2 in Ca(2+) o regulation, we investigated 65 FHH probands, without other FHH-associated mutations, for AP2؟2 mutations, characterized their functional consequences and investigated the genetic mechanisms leading to FHH3. AP2؟2 mutations were identified in 17 probands, comprising 5 Arg15Cys, 4 Arg15His and 8 Arg15Leu mutations. A genotype-phenotype correlation was observed with the Arg15Leu mutation leading to marked hypercalcaemia. FHH3 probands harboured additional phenotypes such as cognitive dysfunction. All three FHH3-causing AP2؟2 mutations impaired CaSR signal transduction in a dominant-negative manner. Mutational bias was observed at the AP2؟2 Arg15 residue as other predicted missense substitutions (Arg15Gly, Arg15Pro and Arg15Ser), which also caused CaSR loss-of-function, were not detected in FHH probands, and these mutations were found to reduce the numbers of CaSR-expressing cells. FHH3 probands had significantly greater serum calcium (sCa) and magnesium (sMg) concentrations with reduced urinary calcium to creatinine clearance ratios (CCCR) in comparison with FHH1 probands with CaSR mutations, and a calculated index of sCa x sMg/100 x CCCR, which was ≥ 5.0, had a diagnostic sensitivity and specificity of 83 and 86%, respectively, for FHH3. Thus, our studies demonstrate AP2؟2 mutations to result in a more severe FHH phenotype with genotype-phenotype correlations, and a dominant-negative mechanism of action with mutational bias at the Arg15 residue.

No Abstract Available

No abstract available

No Abstract Available

A 48-year-old woman was seen in a surgical outpatient clinic with a 2 year history of progressive dysphagia with occasional regurgitation, partially controlled with a proton pump inhibitor. Primary investigations of pH testing and gastroscopy were normal, although a barium swallow study revealed significant hold-up at the aortic arch impression and a posterior right-sided oesophageal impression suggestive of a right-sided aortic arch. A follow-up computed tomography angiogram discovered a vascular ring encircling the trachea and oesophagus, formed by a right-sided aortic arch with aberrant aortic branches, and a Kommerell's diverticulum. It was deemed that the patient's symptoms were related to this vascular ring. The patient underwent stage-one surgery - an extra-anatomic bypass of the double aortic arch and right subclavian artery - and 4 months later a stent graft insertion over the origin of the diverticulum with the aim of complete symptomatic relief. This case presents a common symptom familiar to any clinician (dysphagia), which has been caused by a rare pathology. It is even more unusual that this should present itself in adulthood.

Patients with a cleft lip and palate (CLP) deformity require the highest standard of care that can be provided and this requires multidisciplinary care from teams located in regional cleft centres. Care of these cases is from birth to adulthood and requires several phases of intervention, corresponding to the stages of facial and dental development. Management ideally starts pre-natally, following the initial diagnosis, and occasionally pre-surgical appliances are prescribed. The lip is ideally repaired within three months, followed by palate closure between 12 and 18 months. Careful monitoring is required in the first few years and ENT referral, where necessary, will diagnose middle ear infection, which commonly affects CLP patients. Speech therapy is an integral part of the ongoing care. Excellent oral hygiene is essential and preventive dietary advice must be given and regularly reinforced. Orthodontic expansion is often needed at 9 years of age in preparation for a bone graft and, once the permanent dentition erupts, definitive orthodontic treatment will be required. Maxillary forward growth may have been constrained by scarring from previous surgery, so orthognathic correction may be required on growth completion. Final orthodontic alignment and high quality restorative care will allow the patients to have a pleasing aesthetic result. CLP patients and their families will need continuing support from medical and dental consultants, specialist nurses, health visitors, speech and language specialists and, perhaps, psychologists. These two articles outline the principles of care for the CLP patient and, secondly, illustrate this with a case report, documenting one patient's journey from birth to 21 years of age.
CLINICAL RELEVANCE: A successful outcome for CLP patients requires a sound dentition.The general dental practitioner role is vital to establish and maintain excellent oral hygiene, a healthy diet and good routine preventive and restorative care. Understanding the total needs of CLP patients can help the dentist to provide high quality care as part of the multidisciplinary management.

This article highlights the aspects of treatment that the GDP needs to be conversant with when referring patients for orthognathic surgery. An overview of the management pathway is also outlined

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.).

Patients with a cleft lip and palate (CLP) deformity require the highest standard of care that the NHS can provide and this requires multidisciplinary care from teams located in regional cleft centres.

Care of these cases is from birth to adulthood and requires several phases of intervention, corresponding to the stages of facial and dental development. Management ideally starts pre-natally, following the initial diagnosis, and occasionally pre-surgical appliances are prescribed. The lip is ideally repaired within three months, followed by palate closure between 12 and 18 months. Careful monitoring is required in the first few years and ENT referral, where necessary, will diagnose middle ear infection, which commonly affects CLP patients. Speech therapy is an integral part of the ongoing care. Excellent oral hygiene is essential and preventive dietary advice must be given and regularly reinforced. Orthodontic expansion is often needed at 9 years of age in preparation for a bone graft and, once the permanent dentition erupts, definitive orthodontic treatment will be required.

Maxillary forward growth may have been constrained by scarring from previous surgery, so orthognathic correction may be required on growth completion. Final orthodontic alignment and high quality restorative care will allow the patients to have a pleasing aesthetic result.

CLP patients and their families will need continuing support from medical and dental consultants, specialist nurses, health visitors, speech and language specialists and, perhaps, psychologists. The first article in this series of two outlined the principles of care for the CLP patient and this second part illustrates this with a case report, documenting one patient's journey from birth to 21 years of age.

Clinical Relevance: A successful outcome for CLP patients requires a sound dentition. The general dental practitioner role is vital to establish and maintain excellent oral hygiene, a healthy diet and good routine preventive and restorative care. Understanding the total needs of CLP patients can help the dentist to provide high quality care as part of the multidisciplinary management.

Background: Delayed or inconsistent administration of N-acetylcysteine (NAC) for paracetamol overdose in the emergency department (ED) poses a risk to patient safety, with current Royal College of Emergency Medicine (RCEM) standards often not being met. The traditional 21-hour NAC regimen is associated with adverse drug reactions, medication errors and prolonged admissions. The Scottish and Newcastle Acetylcysteine Protocol (SNAP) was introduced as a simpler alternative with comparable efficacy. This quality improvement project (QIP) aimed to improve compliance with RCEM standards by implementing targeted interventions while also reducing the length of inpatient stay and maintaining patient safety.

Method: This QIP was conducted at Royal Derby Hospital using a multidisciplinary, systematic approach based on Plan-Do-Study-Act cycles. Baseline data were collected from 100 randomly selected patients (November 2021-May 2022) and compared with outcomes during a 52-week intervention period (September 2023-August 2024). Interventions included educational sessions, quick reference materials and enhanced prescribing tools. Data were analysed for compliance with RCEM standards, adverse events (liver function derangement and anaphylactoid reactions) and system-level measures, such as length of inpatient stay and timing of paracetamol plasma levels.

Results: A total of 214 patients were included. Compliance with RCEM standard 1 improved from 36% to 43%. No change was noted for standards 2 and 3. Median inpatient stay decreased from 35 hours to 30.5 hours. No significant differences were found in adverse events. Special cause variation was identified in paracetamol plasma level timing, attributed to early sampling in some cases.

Conclusion: This QIP addressed problems of delayed or inconsistent NAC administration in the ED by improving compliance with RCEM standard 1 and reducing inpatient stay while maintaining patient safety. Although standards 2 and 3 did not improve, the interventions proved cost-effective, feasible and scalable. Future work should focus on sustaining improvements and exploring patient-centred outcomes across diverse healthcare settings.

Objectives: We surveyed healthcare staff working with older people to understand current practice in nutrition screening, initial management and referral for older people with sarcopenia and frailty.

Methods: We conducted a UK-wide web-based survey of staff working with older people in both hospital and community settings. Surveys were distributed through professional organisation e-mail lists and social media channels. Descriptive data were generated from categorical responses and inductive thematic analysis was applied to free-text responses.

Results: Data were analysed from 169 respondents (110 hospital, 59 community), representing 99 healthcare organisations. 91 (83%) hospital respondents and 24 (41%) community respondents reported that nutrition screening was performed on all patients with sarcopenia or frailty. The Malnutrition Universal Screening Tool was most commonly used to trigger referral to dietetics teams, but there was considerable variation in management before referral, referral thresholds and referral pathways. Themes derived from free-text responses included the need for training, issues of responsibility and ownership, inadequate resources (time, staff and equipment) and ineffective or inefficient processes for referral and management.

Conclusions: Current UK nutritional care for older people with sarcopenia and frailty is heterogeneous. There are opportunities for better tools, processes, training and resources to improve current practice and pathways.

As foundation doctors, we have often found ourselves informing patients that a certain aspect of their medical information cannot be immediately found, either because it is on an electronic system we cannot access, or it is in a hospital that is unlinked to our own. Unsurprisingly, this frequently leaves patients flabbergasted and confused. We started to wonder: if patients' data are entered onto an electronic system: where do those data go? If medical data are searched for, where do those data come from? Why are there so many hidden sources of information that clinicians cannot access? In an ever-increasing digital sphere, electronic data will be the future of holistic health and social care planning, impacting every clinician's day-to-day role. From electronic healthcare records to the use of artificial intelligence solutions, this article will serve as an introduction to how data flows in modern healthcare systems.

INTRODUCTION: A survey of the members of the Angle Society of Europe showed that 60% of orthodontists took their own clinical photographs, 35% assigned the task to an auxiliary, and 5% hired professional clinical photographers. It is always useful to ensure that orthodontists' time is used to maximum effect. Clinical photography could be delegated to auxiliary staff. In this study, we assessed the quality of photographs taken by orthodontists to see whether those taken by orthodontic auxiliaries and clinical photographers are of comparable quality.
METHODS: Fifty sets of orthodontic photographs were collected from each of 3 types of photographers: orthodontists, orthodontic auxiliaries, and professional clinical photographers. Four assessors scored each set for quality and detailed errors. The results were compared to determine whether there were differences between the quality of the photographs taken by the different groups.
RESULTS AND CONCLUSIONS: Most of the photos taken by the 3 groups of photographers were judged to be good or acceptable. The results for extraoral photographs showed no statistically significant differences between the 3 groups for good (P = 0.398) and acceptable (P = 0.398) images. The results for intraoral photographs did not differ significantly for acceptable and unacceptable photographs, but orthodontists produced significantly more good-quality intraoral photographs (P = 0.046).

Purpose: Clinical trials have demonstrated efficacy of vedolizumab in ulcerative colitis (UC) and Crohn's disease (CD). Further real-world data is needed to inform clinical practice. The primary outcome was to assess corticosteroid-free and clinical remission after vedolizumab initiation. Secondary outcomes included effect on disease activity scores, biochemical markers, concomitant drug use, endoscopic remission, surgical intervention, hospital admissions and adverse events.

Materials and methods: A multi-centre retrospective observational study was conducted with patients initiated on vedolizumab across seven UK hospitals 1/11/14-30/11/16. Clinical disease activity was assessed using the partial Mayo Scores (pMS) and Harvey Bradshaw Index (HBI). Clinical remission was defined as HBI ≤4 or pMS <2 with a combined stool frequency and rectal bleeding sub score of ≤1. Clinical response was defined as ≥2-point decrease from baseline in pMS and ≥3-point decrease from baseline in HBI.

Results: One hundred ninety-two patients were included in the final analysis. 45% of UC and 10% of CD patients were anti-TNF naive. Over the observation period corticosteroid-free remission rates for UC and CD were 46% and 45%, while clinical remission rates were 52% and 44%, respectively. Time to corticosteroid free remission for UC and CD was 17.6 [IQR: 8.7-29.6] and 14.1 [QR: 6.0-21.7] weeks, respectively. Time to clinical response for UC was 9.4 [IQR: 5.7-15.4] and CD was 9.5 [IQR: 6.1-18.2] weeks. There was a substantial decrease in the concomitant use of immunomodulators and a similar decrease in concomitant corticosteroid use over the study period.

Conclusions: Results in this predominately anti-TNF experienced population mirror other published real-world data, demonstrating good clinical effectiveness and a comparable safety profile.

No Abstract Available

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.

Acute gastrointestinal bleeding (GIB) is a major medical emergency with high morbidity and mortality. Endoscopy remains the first-line diagnostic and therapeutic approach, but radiological imaging has become increasingly important, particularly when endoscopy is inconclusive or unavailable. This review outlines the evolving role of radiological techniques, including computed tomography angiography (CTA), catheter-based angiography, radionuclide scintigraphy, magnetic resonance imaging (MRI), and ultrasound (US), in the detection, localization, and management of acute GIB. CTA is now the preferred imaging modality because of its speed, noninvasive nature, and superior anatomical detail. Catheter angiography not only enables precise diagnosis but also provides therapeutic options through embolization. Nuclear medicine techniques offer high sensitivity for intermittent or low-rate bleeding, while MRI and US contribute complementary insights in select patient groups. An integrated approach that combines radiological, endoscopic, and surgical strategies improves decision-making, shortens time to intervention, and enhances patient outcomes. Recent advances, including dual-energy CT, AI-assisted imaging, and novel embolic agents, are expected to further strengthen both diagnostic accuracy and therapeutic potential. Understanding the strengths, limitations, and sequencing of these modalities is key to optimizing care for patients with acute GIB.

A 56-year-old smoker presented with a 3-day history of intermittent chest pain. Cardiovascular examination on admission was normal. ECG showed minimal (<1 mm) ST elevation in lead III, and right-sided leads revealed similar mild ST-elevation. Troponin I was elevated at 10.91. He was managed as a delayed-presentation ST-elevation myocardial infarction case. 12 h following admission, he developed oxygen-resistant hypoxia and hypotension. There were no clinical or radiological signs of pulmonary congestion. CT pulmonary angiogram revealed no pulmonary embolus. A bubble-contrast echocardiogram confirmed an active interatrial right-to-left shunt without Valsalva provocation. His hypoxia steadily improved over the following 24 h and he did not require any shunt closure. A repeat bubble contrast echocardiogram showed that the shunt was now only active following a Valsalva manoeuvre. Transoesophageal echocardiography confirmed a patent foramen ovale. This is a rare but important cause of resistant hypoxia following a right-heart infarct.