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Postgraduate Medical Journal current issue



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Abnormal movements induced by methanol toxicity

2017-11-24T04:04:06-08:00

A 22-year-old man came to our clinic with abnormal movements. Five years earlier, he was admitted to the intensive care unit in a coma due to methanol intoxication after drinking significant amount of home-made liquor. He was discharged 4 months later with binocular blindness, slowing of movements and abnormal limb postures. Treatment with trihexyphenidyl and amantadine induced partial improvement of his abnormal movements. On examination, he was fully oriented, speech was slurred and had low tone, visual acuity was in the range of hand motion and both optic discs were atrophied with dilated non-reactive pupils. He had rigidity, hypokinaesia, severe dystonic posture of upper (more on the left side) and lower extremities (more severe on the right side) (see video 1) and slow gait. Brain MRI showed bilateral putaminal hyperintensities consistent with necrosis and degeneration (figure 1).

Methanol leads to extensive destruction of the nervous system. It...




Palatal tremor with audible click

2017-11-24T04:04:06-08:00

Palatal tremor and myoclonus are the terms used for rhythmic bilateral movements of palate due to excitability of brainstem. It encompasses two types of essential palatal tremor (EPT) and symptomatic palatal tremor (SPT).

The main feature of EPT is an audible click in the ear due to contraction of tensor veli palatini muscle. It usually disappears during sleep.1 In contrast to EPT, SPT lacks audible click and often persists in sleep. Contraction of levator veli palatini muscle is responsible for this type of palatal tremor. Brain MRI is normal in EPT and shows olivary hypertrophy or lesion in dentate–olivary pathway in SPT.2 3

Here, we present a 52-year-old female who suffered from rhythmic movements of the palate for 10 years that was accompanied by audible click (see online ). The clicks would disappear during sleep. The brain MRI was normal. Her symptoms completely improved...




Academic medicine should lead the way on gender equity: but it doesnt

2017-11-24T04:04:06-08:00

Postgraduate Medical Journal (PMJ) includes an interesting article by an eclectic group of authors from the USA, Singapore and the Middle East.1 They studied aspects of gender equity in accredited clinician-educator programmes in Singapore, Qatar and the United Arab Emirates. In short, their conclusions show that the situation regarding gender equity, or the lack of it, is no better in those locations than it is in North America, Europe or Australasia on which much of the previous comparable literature has focused. The study defined clinician educators as ‘physicians whose primary responsibilities are patient care and education, and whose research represents only minor portion (sic) of academic contributions’ and included a high proportion of people whose professional education was from Europe or the USA, that is, introducing international mobility as a feature of the population under study. The most concerning findings were that women were less likely to have an...




Gender and international clinician educators

2017-11-24T04:04:06-08:00

Objectives

To describe gender differences of international clinician educators (CEs) and leaders, and CEs’ perceptions by gender of preparation, roles, rewards and factors affecting job satisfaction and retention in emerging international competency-based residency programmes.

Methods

Cross-sectional surveys of CEs and leadership were conductedJune 2013–June 2014 at institutions that had adopted competency-based graduate medical education and were accredited by the Accreditation Council for Graduate Medical Education-International.

Results

274 (76.3%) of 359 eligible participants responded; 69 (25.2%) were female. Two (18%) of 11 chief executive officers and 1 (9%) of 11 chief medical officers were women. Female CEs were younger, more likely to be single and childless. They were less likely to hold academic appointments, despite no gender differences in length of time at current institution or in current position. A greater proportion of female CEs felt they were ‘never’ rewarded by academic promotion. Satisfaction rates were similar between the genders. Single female CEs were five times as likely to report being ‘extremely likely’ to stay in the country. Female CEs with children <21 were less likely to report high likelihood of staying in academia. Marital status and children were not associated with outcomes for male CEs.

Conclusions

In the international academic medicine programmes studied, there were fewer female CEs in the pipeline and they perceived a gender gap in appointment and advancement. Stakeholders at international programmes need to develop contextualised strategies to expand entry and decrease attrition of women into CE tracks, and promote gender equity.




A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback

2017-11-24T04:04:06-08:00

Purpose

Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.

Design

Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine’s Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.

Results

The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).

Conclusions

We successfully implemented a novel high value care curriculum that specifically targets intern physicians.




40-4-40: educational and economic outcomes of a free, international surgical training event

2017-11-24T04:04:06-08:00

Purpose of study

To demonstrate a model for delivery of an international surgical training event, and demonstrate its educational and economic outcomes.

Study design

The Association of Surgeons in Training (ASiT) ran a course series on 16 January 2016 across the UK and Ireland. A mandatory, self-reported, online questionnaire collected delegate feedback, using 5-point Likert Scales, and a NetPromoter feedback tool. Precourse and postcourse matched questionnaires were collected for ‘Foundation Skills in Surgery’ (FSS) courses. Paired economic analysis was performed. Statistical analysis was carried out using RStudio (V.3.1.1 Boston, Massachusetts, USA).

Results

Forty courses were held across the UK and Ireland (65.0% technical, 35.0% non-technical), with 184 faculty members. Of 570 delegates, 529 fully completed the feedback survey (92.8% response rate); 56.5% were male. The median age was 26 years (range: 18–67 years). The mean overall course NetPromoter Score was 8.7 out of 10. On logistic regression high NetPromoter Score was associated with completing a Foundation Skills in Surgery course (R=0.44, OR: 1.49, p=0.025) and having clear learning outcomes (R=0.72, OR: 2.04, p=0.029) but not associated with specialty, course style or teaching style. For Foundation Skills in Surgery courses, delegates reported increased commitment to a career in surgery (p<0.001), confidence with basic surgical skills (p<0.001) and confidence with assisting in theatre (p<0.001). A comparable cost saving of £231,462.37 was calculated across the 40 courses.

Conclusion

The ASiT ‘40-4-40’ event demonstrated the diversity and depth of surgical training, with 40 synchronous technical and non-technical courses, demonstrable educational benefit and a significant cost saving to surgical trainees.




Enhanced recovery after surgery for hip and knee arthroplasty: a systematic review and meta-analysis

2017-11-24T04:04:06-08:00

Objectives

To collect data of randomised controlled trials (RCTs) and clinical controlled trials (CCTs) for evaluating the effects of enhanced recovery after surgery on postoperative recovery of patients who received total hip arthroplasty (THA) or total knee arthroplasty (TKA).

Methods

Relevant, published studies were identified using the following key words: arthroplasty, joint replacement, enhanced recovery after surgery, fast track surgery, multi-mode analgesia, diet management, or steroid hormones. The following databases were used to identify the literature consisting of RCTs or CCTs with a date of search of 31 December 2016: PubMed, Cochrane, Web of knowledge, Ovid SpringerLink and EMBASE. All relevant data were collected from studies meeting the inclusion criteria. The outcome variables were postoperative length of stay (LOS), 30-day readmission rate, and total incidence of complications. RevMan5.2. software was adopted for the meta-analysis.

Results

A total of 10 published studies (9936 cases) met the inclusion criteria. The cumulative data included 4205 cases receiving enhanced recovery after surgery (ERAS), and 5731 cases receiving traditional recovery after surgery (non-ERAS). The meta-analysis showed that LOS was significantly lower in the ERAS group than in the control group (non-ERAS group) (p<0.01), and there were fewer incidences of complications in the ERAS group than in the control group (p=0.03). However, no significant difference was found in the 30-day readmission rate (p=0.18).

Conclusions

ERAS significantly reduces LOS and incidence of complications in patients who have had THA or TKA. However, ERAS does not appear to significantly impact 30-day readmission rates.




Acupuncture for the treatment of obesity in adults: a systematic review and meta-analysis

2017-11-24T04:04:06-08:00

Objective

Meta-analysis was used to assess the clinical efficacy of acupuncture treatment for simple obesity and to provide evidence-based medical data for treating obesity with acupuncture.

Methods

A comprehensive search of studies on MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and Chinese databases (Wan Fang,CNKI and VIP) from 1 January 1915 through 30 November 2015 (MEDLINE search updated through 31 December 2015) was performed. We included only randomised controlled trials (RCTs) that used acupuncture and sham acupuncture to treat simple obesity. The effect of acupuncture on simple obesity was measured using body mass index (BMI), body fat mass (BFM), waist circumference (WC), hip circumference (HC), and body weight (BW). The Jadad scale was used to assess methodological quality. The random effects model was used in the pooled analysis to adjust for the heterogeneity of the included studies, and funnel plots were used to examine publication bias. The differences between treatment groups were reported as mean differences (MD).

Results

Eleven RCTs were selected after all relevant literature from the electronic databases had been screened. There were 338 and 305 participants in the acupuncture and sham acupuncture groups, respectively. Auricular and electro acupuncture were both able to reduce BMI in obese patients (MD 0.47 kg/m2, 95% CI 0.35 to 0.58, p<0.001; MD 0.50 kg/m2, 95% CI 0.38 to 0.62, p<0.001). BFM change after acupuncture treatment compared with sham treatment was statistically significant (MD 0.66 kg, 95% CI 0.51 to 0.80, p<0.001). There were also significant differences in WC and HC between the acupuncture and sham acupuncture groups (MDwc2.02 cm, 95% CI 0.21 to 3.83, p=0.03; MDHC2.74 cm, 95% CI 1.21 to 4.27, p=0.0004). BW was not statistically significantly different between the acupuncture and sham acupuncture groups (MD 0.60 kg, 95% CI –0.20 to 1.39, p=0.14). Begg’s test and funnel plots showed that the potential publication bias of the included studies was very slight (p>0.05).

Conclusion

Acupuncture for simple obesity appeared to be an effective treatment, but more studies on the safety of acupuncture used to treat simple obesity are required.




Association between the autophagy-related gene ULK1 and ankylosing spondylitis susceptibility in the Chinese Han population: a case-control study

2017-11-24T04:04:06-08:00

Purpose

Ankylosing spondylitis (AS), inflammatory bowel disease and Crohn’s disease (CD) often coexist in the same patient and these diseases have remarkably strong overlaps in genetic association. The association between Unc51like kinase 1 (ULK1) gene polymorphisms and CD has been reported, and the aim of the current study was to investigate whether ULK1 polymorphisms are also associated with susceptibility to AS in the Chinese Han population.

Methods

Five tagging single nucleotide polymorphisms in the ULK1 gene (rs9652059, rs11616018, rs12303764, rs4964879 and rs7300908) were genotyped by the improved multiplex ligase detection reaction method in a cohort of patients with AS (n=649) and controls (n=628). Various genetic models were performed and haplotypes were constructed after linkage disequilibrium analysis.

Results

A statistically significant difference was found in the dominant model of the rs9652059 polymorphism (OR (95% CI) = 0.796 (0.638 to 0.994), 2 = 4.064, p= 0.044). Haplotypes were conducted between rs9652059 and rs11616018, rs11616018 and rs4964879, rs9652059 and rs4964879 based on D' ≥0.9 and r2 ≥ 0.6. Ht5 (rs9652059C-rs4964879G) haplotype was associated with AS (OR (95% CI) = 0.834 (0.706 to 0.985), 2=4.555, p= 0.0328) and other two haplotypes were marginally correlated with AS (ht2 (rs9652059C-rs11616018T): OR (95% CI) = 0.846 (0.717 to 1.000), 2= 3.864, p= 0.0493); ht3 (rs9652059T-rs11616018T): OR (95% CI) = 1.440 (0.999 to 2.076), 2 = 3.849, p = 0.0498).

Conclusions

Our findings suggest that rs9652059 variation (C->T) could increase AS susceptibility and haplotypes of rs9652059C-rs4964879G, rs9652059C-rs11616018T and rs9652059T-rs11616018T may be associatd with AS.




The ID genotype of MDM2 40 bp insertion/deletion polymorphism was associated with lower risk of SLE

2017-11-24T04:04:06-08:00

Background

In patients with systemic lupus erythematosus (SLE), loss of immunological tolerance to self-nuclear antigens and abnormal activation of self-reactive T and B cells lead to self-antibodies and immune complex production. The autoreactive lymphocytes are removed by the apoptotic process in healthy individuals; however, apoptosis disruption could cause accumulation of apoptotic bodies and nuclear debris. Therefore, apoptosis plays a crucial role in the pathogenesis of autoimmune diseases.

Purpose

To investigate the association between two polymorphisms in an apoptotic-related gene, MDM2, and SLE.

Study design

A case–control study was conducted on 200 patients with SLE and 206 healthy volunteers matched for age, sex, and ethnicity. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and PCR methods were used for genotyping.

Results

No association was found between the MDM2 T309G polymorphism (rs2279744) and SLE. The ID genotype of the insertion/deletion (I/D) polymorphism (rs3730485) was significantly lower in patients with SLE, and the ID genotype could be a protective factor for SLE. The DD genotype was not associated with SLE. The frequency of combined TT/ID and GG/ID genotypes of MDM2 T309G and I/D polymorphisms was lower in the patients with SLE and was associated with a lower risk of SLE. The frequency of the TD haplotype of MDM2 T309G and I/D polymorphisms was significantly lower in patients with SLE and could reduce the SLE risk.

Conclusions

The ID genotype of the MDM2 I/D polymorphism was associated with a lower risk of SLE. There was no association between MDM2 T309G polymorphism and SLE.




Cardiac troponin: more than meets the eye

2017-11-24T04:04:06-08:00

Exercise is known to have a vast array of health benefits. It may however confer delirious effects on most body systems, with the cardiovascular system taking particular prominence. Athletes in particular are known to be at a higher risk for sudden cardiac death as a result of several cardiac adaptations which take place. Myocardial damage as a result of extreme exertional activities is thought to play a very important role in this risk. Cardiac troponin I is widely known to be an excellent diagnostic marker which is used in patients suspected of having acute coronary syndrome. Its release during exercise has been routinely studied, with many hypotheses currently being proposed as to its role and potential complications once released. Whether or not it implies that myocardial damage is taking place as a result of exercise is debatable, but its release might have some role in the development of cardiotoxic states which predisposes athletes to significant cardiac risk. This review aims to discuss the proposed mechanisms in exercise-induced troponin release, while also goes into its clinical relevance and potential early and late sequelae.




Uveitis: a sight-threatening disease which can impact all systems

2017-11-24T04:04:06-08:00

Uveitis describes a group of conditions characterised by intraocular inflammation. The term uveitis technically describes inflammation of the uvea which comprises the iris, ciliary body and choroid, however now encompasses inflammation of adjacent intraocular structures such as the retina, vitreous and optic nerve. Uveitis is a significant cause of blindness worldwide, but its impact is generally underappreciated due to a lack of awareness and understanding of the condition among the public and most non-ophthalmic healthcare professionals. In this review, we provide an introduction to uveitis for the non-specialist, outlining the clinical presentations that should raise the suspicion of the disease, the signs that should be looked for and a framework in which to understand the condition. We show how a logical approach to classifying uveitis by aetiology and anatomical focus of disease provides the basis for treatment strategies (drug and route of administration) and clinical presentation and prognosis. We also show why understanding uveitis is helpful to clinicians working in almost every speciality due to the wide-ranging associations with systemic disease.




Severe bradycardia associated with crizotinib

2017-11-24T04:04:06-08:00

Crizotinib is a multitarget tyrosine kinase inhibitor used in treating non-small cell lung cancer (NSCLC) with anaplastic lymphoma kinase (ALK) gene mutation. Common and well-known adverse effects include gastrointestinal disturbance, dizziness, fatigue, liver enzyme elevation and visual disturbance. We describe here a patient with NSCLC who presented with symptomatic bradycardia due to crizotinib.

The patient was a 69-year-old Chinese male with stage IV epidermal growth factor receptor-negative, ALK-rearranged NSCLC. He presented to the emergency department complaining of breathlessness, swollen legs and hiccups. He had type 2 diabetes mellitus but no previous cardiovascular disease. He was taking crizotinib 250 mg twice daily, vildagliptin 50 mg twice daily and gliclazide 160 mg every morning and 80 mg every evening. His heart rate on admission was 36 beats per minute (bpm), with a blood pressure of 128/72 mm Hg and an oxygen saturation of 99% in room air. Cardiac examination revealed symmetrical and regular pulses, normal jugular venous...




Resilience training: no more is needed or desired

2017-11-24T04:04:06-08:00

In their recent report, Halliday et al1 seek to encourage the reader that ‘interventions to improve grit through resilience training should also be examined’. As a matter of concern to myself, this statement and the associated research in the report are likely to give fuel for National Health Service (NHS) employers to dive headlong into further rounds of deeply unpopular ‘resilience training’ for Junior Doctors.

On interrogation of the data presented in their report,1 specifically referring to Junior trainees (FY1-CT2): for ‘Grit versus Exhaustion’ in this group, the correlation is moderately negative (–0.391) with a p value of only 0.02. For ‘Grit versus Burnout’, the correlation is weakly negative (–0.254) with a borderline p value of only 0.03. For ‘Grit versus Disengagement’, the negative correlation is weak (–0.222) and not even statistically significant (p value=0.09). As mentioned by the authors, these data are seemingly in line with other such...




Physicians and blocking: can we tear down this wall?

2017-11-24T04:04:06-08:00

Patient case

A patient was brought to the emergency department (ED) by family complaining of chronic headaches and a question of new neurological abnormalities. A week prior, this patient had been hospitalised at a nearby institution and diagnosed with a large intracranial tumour with associated bleeding, with plans for neurosurgery follow-up after discharge. Imaging in the ED confirmed the haemorrhaging brain tumour; images from the prior hospitalisation were not available for comparison. The neurosurgery service was paged for admission but deemed that emergent surgery was not indicated and thus declined to admit the patient to their team, though offered to serve as a consultant. However, they also did not recommend discharge. The neurology service was then paged for admission but after evaluation declined because of the haemorrhage associated with the brain tumour. The oncology service was then called to admit, but per policy deemed it inappropriate to admit...




An unusual but classic cause of hand numbness: Pancoast tumour

2017-11-24T04:04:06-08:00

A 56-year-old man with a 42-pack year smoking history presented with complaints of acute-onset left shoulder pain, weakness and numbness of the left hand. A chest X-ray examination revealed a large apical opacity with complete destruction of first, second and third left ribs (figure 1), which was then confirmed with a chest CT scan (figure 2), which showed a large apical 9 cm heterogeneous mass together with destruction of left first to third ribs and subclavian artery involvement. Transthoracic needle biopsy was then performed which showed poorly differentiated squamous cell carcinoma of the lung. The patient was discharged to follow-up with oncology to initiate chemoradiation therapy.

Pancoast tumours, first described by Henry K Pancoast in 1924, are a rare subtype of apical lung tumours at the superior thoracic outlet and comprise <5% of all lung cancers. The clinical constellation of shoulder and arm pain, along the distribution of the eighth cervical nerve trunk...




The vanishing lung

2017-11-24T04:04:06-08:00

Case report

A 48-year-old woman with medical history significant for 20 pack-years of smoking presented with decreased exercise tolerance for the last year. On examination, her respiratory rate was 18 and oxygen saturation was 96% on room air with absent breath sounds within the left lung field. Alpha-1 antitrypsin levels were normal. Chest radiograph revealed giant emphysematous bulla with concern for concurrent pneumothorax (figure 1). CT scan of the chest revealed a massive bulla without a ‘double wall sign’ making superimposed pneumothorax unlikely (figure 2). Chest tube insertion was deferred and patient underwent bullectomy. Prior to surgery, her exercise tolerance was 1–2 blocks which improved to 7–8 blocks 2 months postsurgery.

Discussion

Giant bullous emphysema or vanishing lung syndrome (VLS) is defined as a large bulla occupying at least one-third of hemithorax leading to displacement of adjacent lung tissue. VLS is often complicated by...




Socratic questions and frozen shoulders: teaching without telling

2017-11-24T04:04:06-08:00

Not long ago, I was asked to teach Socratic questioning to some doctors specialising in accident and emergency medicine. This might seem like a strange piece of work to take on. Doctors in emergency medicine commonly work fast and under great pressure. They have to recall and apply factual knowledge at speed, and to teach their trainees to do the same. Socratic questioning, by contrast, is a way of teaching that depends on slowing things down. Named after the Greek philosopher Socrates, the method rests on the assumption that people gain a fuller understanding of a problem if they work out each stage of the answer for themselves.1 Teachers therefore avoid asking any leading questions, offering direct information, or confronting students openly with their ignorance. Instead, they use a progression of open questions to help students think about any problem logically. A typical series of Socratic questions...