Subungual Exostosis Presenting as a Pyogenic Granuloma-like Lesion with Reactive Myofibroblastic Proliferation in Two Young Women.

Subungual exostosis (SE) is a well-recognised benign proliferation of the distal phalanx most often seen in young adults and affecting the big toe. Possible triggers include previous trauma and chronic irritation or infection. We describe two atypical cases of SE in two young women presenting with pyogenic granuloma-like lesions clinically. Diagnostic biopsies were performed to confirm the diagnosis and excluded amelanotic melanoma. However, histology unexpectedly revealed reactive myofibroblastic proliferations mimicking nodular fasciitis overlying the SE. Given the atypical clinical presentation, the diagnosis was initially missed or not considered in both patients. They highlight two important points; the first is that SEs may present with pyogenic granuloma-like lesions clinically and that histological analysis is then required to exclude malignancy, particularly amelanotic melanoma. Secondly, that the histology will show a reactive myofibroblastic proliferation and if the sample is relatively superficial and pathologists are not aware of this potential reaction pattern, the underlying diagnosis of SE may be missed.

Lessons learnt for digital inclusion in underserved communities from implementing a covid virtual ward.

The factors associated with digital exclusion in the covid virtual ward population at a North West London teaching hospital were assessed in this study. Patients discharged from the covid virtual ward were contacted to give their feedback on their experience. Questions were tailored to whether or not the patient used the Huma app during their time on the virtual ward and were subsequently divided into 'app user' and 'non-app user' cohorts. The non-app user population accounted for 31.5% of the total patients referred to the virtual ward. Four major themes drove digital exclusion in this group: language barriers, access, inadequate information/training, and poor IT skills. In conclusion, incorporating additional languages and improving hospital-setting demonstration and information provision to patients prior to discharge were highlighted as key factors for reducing digital exclusion in the covid virtual ward patients.

Outcomes of Vital Sign Monitoring of an Acute Surgical Cohort With Wearable Sensors and Digital Alerting Systems: A Pragmatically Designed Cohort Study and Propensity-Matched Analysis.

Background: The implementation and efficacy of wearable sensors and alerting systems in acute secondary care have been poorly described. Objectives: to pragmatically test one such system and its influence on clinical outcomes in an acute surgical cohort. Methods: In this pragmatically designed, pre-post implementation trial, participants admitted to the acute surgical unit at our institution were recruited. In the pre-implementation phase (September 2017 to May 2019), the SensiumVitals™ monitoring system, which continuously measures temperature, heart, and respiratory rates, was used for monitoring alongside usual care (intermittent monitoring in accordance with the National Early Warning Score 2 [NEWS 2] protocol) without alerts being generated. In the post-implementation phase (May 2019 to March 2020), alerts were generated when pre-established thresholds for vital parameters were breached, requiring acknowledgement from healthcare staff on provided mobile devices. Hospital length of stay, intensive care use, and 28-days mortality were measured. Balanced cohorts were created with 1:1 'optimal' propensity score logistic regression models. Results: The 1:1 matching method matched the post-implementation group (n = 141) with the same number of subjects from the pre-implementation group (n = 141). The median age of the entire cohort was 52 (range: 18-95) years and the median duration of wearing the sensor was 1.3 (interquartile range: 0.7-2.0) days. The median alert acknowledgement time was 111 (range: 1-2,146) minutes. There were no significant differences in critical care admission (planned or unplanned), hospital length of stay, or mortality. Conclusion: This study offered insight into the implementation of digital health technologies within our institution. Further work is required for optimisation of digital workflows, particularly given their more favourable acceptability in the post pandemic era. Clinical trials registration information: ClinicalTrials.gov Identifier: NCT04638738.

Liver toxicity from vitamin A.

Hepatic toxicity secondary to hypervitaminosis A is extremely rare. We report the case of a 27-year-old Caucasian female who presented for an investigation of abdominal pain, cholestatic liver function tests, and abnormal computerized tomography findings. She had been prescribed isotretinoin for her acne and had subsequently purchased vitamin A online, which she consumed daily for over 18 months.