A survey of how and why medical students and junior doctors choose a career in ENT surgery.

OBJECTIVE: To ascertain determinants of an interest in a career in ENT surgery through a survey of medical students and junior doctors. METHODS: A survey was administered, comprising Likert scales, forced response and single option questions, and free text responses, at five different courses or events for those interested in a career in ENT. RESULTS: The survey had an 87 per cent response rate; respondents consisted of 43 applicants for national selection, 15 foundation doctors and 23 medical students. The most important factors that encourage ENT as a career included: the variety of operative procedures, work-life balance, inherent interest in this clinical area and inspirational senior role models. Exposure to ENT in undergraduate or post-graduate training is critical in deciding to pursue this specialty. CONCLUSION: It is important to promote those aspects of ENT surgery that attract people to it, and to argue for greater exposure to ENT during undergraduate and post-graduate training.

Significant benefit of a targeted HIV testing module on medical students' knowledge and confidence.

The objective was to evaluate the efficacy of a HIV targeted-testing teaching session in improving knowledge and confidence at a London medical school. A survey assessing knowledge of HIV testing guidelines, confidence to offer testing and outcomes of targeted-testing teaching was developed and distributed to fifth year medical students. Results were compared for students who had completed GU/HIV modules (GU+) and those who had not (GU-) and chi-squared testing was performed; 100 and 119 questionnaires were returned by GU+ and GU- students (response rate of 92.6% and 97.5%), respectively. For the three knowledge-based questions, GU+ students were significantly more likely to provide correct answers for two (p < 0.001). Similarly, they were significantly more likely to feel confident in offering an HIV test (p < 0.001). After targeted-testing teaching 92%, 98% and 62% felt more confident about when to test, how to discuss testing and more knowledgeable about testing, respectively. Most students were happy to offer HIV testing in different medical settings; significantly fewer reported this for an acute admissions unit compared with antenatal clinic (79% vs 96%). Students who had received targeted-testing teaching demonstrated better knowledge and confidence about HIV testing. We hope this study raises awareness of the need to include HIV testing teaching in medical school curricula.

Acceptability, feasibility and costs of universal offer of rapid point of care testing for HIV in an acute admissions unit: results of the RAPID project.

OBJECTIVES: UK guidance recommends that acute medical admissions are offered an HIV test. Our aim was to determine whether a dedicated staff member using a multimedia tool, a model found effective in the USA, is an acceptable, feasible, and cost-effective model when translated to a UK setting. METHODS: Over 4 months in 2010, a health advisor (HA) approached 19-65-year-olds at a central London acute medical admissions unit and offered a rapid HIV point of care test (POCT) with the aid of an educational video. Feasibility and acceptability were assessed through surveys and uptake rates. Costs per case of HIV infection identified were established. RESULTS: Of the 606 eligible people admitted during the pilot, 324 (53.5%) could not be approached or were individuals for whom testing was deemed inappropriate. In total, 23.0% of eligible admissions had an HIV POCT. Of the patients who watched the video and had not recently been tested for HIV, 93.6% (131 of 140) agreed to an HIV test; four further patients had an HIV test but did not watch the video. Three tests (2.2%; three of 135) were reactive and all were confirmed HIV positive on laboratory testing. HIV testing in this setting was felt to be appropriate by 97.5% of individuals. The cost per patient was £21, and the cost per case of HIV identified was £1083. CONCLUSIONS: Universal POCT HIV testing in an acute medical setting, facilitated by an educational video and dedicated staff, appears acceptable, feasible, effective, and low cost. These findings support the recommendation of HIV testing for all medical admissions in high-prevalence settings, although with this model a significant proportion remained untested.

Routine detection and management of neurocognitive impairment in HIV-positive patients in a UK centre.

We estimated the burden of HIV-associated neurocognitive disorders (HAND) in a UK clinic. From a random sample, and referrals to specialist services over one year (neurology, clinical psychology, hospital admissions), we determined whether patients were diagnosed with HIV-associated dementia (HAD) and whether they reported symptoms suggesting neurocognitive impairment (NCI). In the first sample, 2/150 (prevalence 1.3%; 95% confidence interval [CI] 0.2-4.7%) had documented HAD. Eleven patients (7.3%; CI 3.7-12.7%) reported recent symptoms suggesting NCI; most of these individuals were diagnosed with a psychiatric or substance-use disorder. Among specialist referrals with symptoms suggesting NCI, 11 were diagnosed with HAD from a clinic population of 3129 individuals (annual incidence 0.4%; CI 0.2-0.6%). No patients with mildly symptomatic or asymptomatic HAND were identified in either sample, suggesting that such patients remain undetected in current clinical practice. Evidence-based screening for HAND in HIV clinics may be needed.

Laparoscopic donor nephrectomy: an increasingly common cause for testicular pain and swelling.

INTRODUCTION: Laparoscopic donor nephrectomy (LDN) is now a well established method for kidney procurement from living donors. In our centre, LDN is currently offered only to donors suitable for left nephrectomy. The aim of this study was to investigate the incidence of testicular pain and swelling following LDN. METHODS: A total of 25 left-sided LDN male patients were assessed in a prospective structured interview together with a control cohort of 25 male patients who had undergone left-sided open donor nephrectomy (ODN). RESULTS: Data were collected on testicular pain, swelling, numbness, urinary symptoms and sexual dysfunction from all 50 patients (100% response rate). Of the 25 LDN patients, 11 (44%) experienced ipsilateral testicular pain and/or swelling. In most instances, pain was of immediate onset, mild to moderate in severity, lasted for a few days to several weeks and was associated with testicular swelling (10 of 11 cases). However, testicular pain and/or swelling were not apparent in ODN patients, with only 2 of 25 (8%) experiencing mild testicular pain, 1 of whom also had swelling. CONCLUSIONS: Testicular pain and swelling following LDN is a common problem. It is underreported in the literature and LDN should be included in the differential diagnoses of testicular pain and swelling. Further investigation is required to confirm our findings.

Prognostic utility of pre-operative circulating osteopontin, carbonic anhydrase IX and CRP in renal cell carcinoma.

BACKGROUND: Objectively measured circulating biomarkers of prognosis complementing existing clinicopathological models are needed in renal cell carcinoma (RCC). METHODS: Blood samples collected from 216 RCC patients in Leeds before nephrectomy (median follow-up 7 years) were analysed for C-reactive protein (CRP), osteopontin (OPN) and carbonic anhydrase IX (CA9) and prognostic significance determined. RESULTS: CA9, OPN and CRP were univariately prognostic for overall survival (OS), cancer-specific survival (CSS) and disease-free survival (DFS) with CRP and CA9 being independently prognostic for OS/CSS and OS, respectively. Including CA9, OPN and CRP with other conventional prognostic factors gave a superior predictive capacity when compared with a previously published pre-operative clinical nomogram (Karakiewicz et al, 2009). Osteopontin outperformed this nomogram and the post-operative SSIGN score for OS but not for CSS, being significantly predictive for non-cancer deaths. Osteopontin, CRP and CA9 outperformed stage (c-index 76% compared with 70% for stage) and OPN or CA9 identified several subsets of poor prognosis patients including in T1 patients, who may benefit from adjuvant therapy and increased surveillance. CONCLUSION: Circulating CA9, OPN and CRP add value to existing clinicopathological prognostic factors/models and support further studies to investigate their potential use in improving the clinical management of RCC.

An unusual cause of fever in an HIV-positive patient.

Patients with HIV frequently present with fever. However, the spectrum of diseases affecting patients with HIV has changed in the era of antiretroviral therapy (ART). Here we present a patient who has an unusual cause for his fever with an eventual diagnosis of adult-onset Still's disease.

A case of oral ulceration and disseminated histoplasmosis in HIV infection.

A 51-year-old Malawian woman presented with persistent mouth ulceration and an eight-month history of non-specific respiratory symptoms. Histoplasma capsulatum was diagnosed on gum, gastric and lymph node biopsies. Identification of H. capsulatum prompted HIV testing and the patient tested positive with a CD4 count of 40 cells/mm(3). The diagnosis of histoplasmosis was delayed due to its unusual presentation.

Outcome of HIV-infected patients transferred to a specialist inpatient unit.

The British HIV Association (BHIVA) recommends that specialist clinical networks are involved in care of HIV-positive patients admitted to district general hospitals (DGHs) and that transfer to a specialist HIV treatment centre is considered for each patient. We audited our experience of 29 patients transferred to our specialist inpatient unit over a two year period. Fifteen (52%) patients were known to be HIV-infected before admission to the referring hospital. Ten (71%) of 14 patients with newly diagnosed HIV had an opportunistic infection at transfer. At the referring hospital the time taken to diagnose HIV infection ranged from one to 26 days (median = 3.5). Only five patients (17%) were transferred by 72 hours of admission to the referring hospital. The duration of stay at our centre was 1-212 days (median = 15): seven patients (24%) required admission to the intensive care unit. Seven patients died; of these, three had newly diagnosed HIV infection. This audit demonstrates that sick HIV-infected patients transferred to a specialist HIV unit had a poor outcome and lengthy hospital admissions. Our audit supports roll-out of HIV testing to avoid adverse outcomes associated with late diagnosis and development of clinical networks involving specialist HIV treatment centres in order to support provision of HIV care in DGHs.

Improving the accuracy of pre-operative survival prediction in renal cell carcinoma with C-reactive protein.

BACKGROUND: Validated objective biomarkers are needed for patients with renal cell carcinoma (RCC) to guide patient management and define high-risk populations for follow-up or for therapeutic purposes. METHODS: Patients undergoing nephrectomy for RCC (n=286 all stages, 84% with conventional clear cell type) were included with a median duration follow-up of 5 years. The prognostic significance of pre-operative haematological and biochemical variables, including C-reactive protein (CRP) values were examined and whether they added additional information to a recently published pre-operative scoring system was determined. RESULTS: C-reactive protein was the most significant predictor of overall survival (OS; χ(2)=50.9, P<0.001). Five-year OS for patients with CRP ≤ 15 mg l(-1) vs >15 mg l(-1) was 72% (95% CI 65-78%) and 33% (95% CI 23-44%), respectively. Similar results were seen for cancer-specific survival (CSS) and disease-free survival. On multivariate analysis, CRP remained highly significant for CSS (χ(2)=17.3, P<0.0001) and OS (χ(2)=9.8, P<0.002), in addition to other pre-operative variables including log of neutrophil/lymphocyte ratio, red blood cell count and white cell count. C-reactive protein was significant in addition to the pre-operative nomogram score (χ(2)=12.5, P=0.0004 for OS, χ(2)=16.2, P=0.0001 for CSS and χ(2)=8.6, P=0.003 for DFS) and was still significant when other pre-operative variables were included. CONCLUSION: C-reactive protein and other haematological and biochemical variables have independent prognostic significance in RCC and may enhance pre-operative scoring systems.

Impact of a metabolic stone clinic on management of patients with cystinuria: 5 years follow-up.

PURPOSE: Cystinuric patients develop new stones and exhibit stone growth despite conservative measures and often require surgical intervention. There have been reports of better outcome both in surgical intervention rates and compliance when patients were referred to dedicated metabolic stone clinics. We wish to report our experience in the running of a metabolic stone disease clinic and to compare our intervention rates to the pre-metabolic stone clinic period in our department. PATIENTS AND METHODS: We reviewed retrospectively our cystinuria patients' database between the years of 1992 and 2008. Patients were divided into two groups. Group A patients (n=28) were treated before the introduction of a dedicated stone clinic (years 1992-2002) and group B patients (n=28) after the establishment of the metabolic stone clinic but every group B patient had a minimum follow up of 5 years. 21 patients were common between the two groups. Main therapy included hyperdiuresis and alkalization. Parameters recorded included the number of clinic visits, whether the patients were stone free or asymptomatic at the time of our review and the nature and frequency of surgical intervention. RESULTS: A total number of 145 procedures were carried out in group A including 89 ESWL, 27 PCNL, 24 ureteroscopy retrograde lithotripsies and 5 open procedures. In group B, a total of 54 procedures were carried out and included 6 ESWL, 5 PCNL and 43 ureteroscopy laser lithotripsies. The average number of surgical interventions per patient per year was 0.74 and 0.34 in group A and B respectively. The number of clinic attendances increased in group B to 279 from 188 in group A. Stone free rates were 46% for group A and 50% for group B patients but all group B patients were asymptomatic at the time of our review. CONCLUSIONS: The introduction of a dedicated cystinuria clinic halved the intervention rate in this complicated group of patients. The majority of surgical procedures shifted towards ureteroscopies (both as inpatients and as day case procedures). We believe that cystine stone patients should be managed in a devoted metabolic stone clinic. With this approach, compliance is better achieved and surgical intervention is less, resulting in better clinical outcome, and less burden both for the patient and the urological services.

A comparison of computed tomography and magnetic resonance brain imaging in HIV-positive patients with neurological symptoms.

We reviewed our practice in order to determine the optimum neuroimaging strategy for HIV-infected patients with acute neurological presentations between April 2007 and August 2008. Overall magnetic resonance imaging (MRI) detected cranial abnormalities in more than twice as many patients as did computed tomography (CT) (74% and 32%, n = 54 and 38, respectively). Replacement of CT by first-line MRI for all patients would have required an additional 16 MRI scans, although at a saving of 38 CT scans. Our study highlights the importance of first-line MRI brain imaging in HIV patients with neurological symptoms and reinforces the need for early transfer of patients from centres that do not have rapid access to (or expert interpretation of) MRI scanning, to an appropriate HIV specialist centre.

Pre-operative urinary cathepsin D is associated with survival in patients with renal cell carcinoma.

BACKGROUND: No circulating markers are routinely used for renal cancer. The objective of this pilot study was to investigate whether conditioned media (CM) from renal cancer cell lines contains potential biomarkers that, when measured in clinical fluids, have diagnostic or prognostic utility. METHODS: Comparative 2D PAGE profiling of CM from renal cell carcinoma (RCC) and normal renal cultures identified cathepsin D that was subsequently validated in urine samples from 239 patients and healthy and benign disease subjects. RESULTS: Urinary cathepsin D was found to be significantly associated with overall (OS) (hazard ratio, HR, 1.33, 95%CI [1.09-1.63], P=0.005) and cancer-specific survival (HR 1.36, 95%CI [1.07-1.74], P=0.013) in RCC patients on univariate analysis. An optimal cut point (211 ng ml(-1) micromolCr(-1)) around which to stratify patients by OS was determined. Five-year OS equal to/above and below this value was 47.0% (95%CI 35.4%, 62.4%) and 60.9% (48.8%, 76.0%), respectively. On multivariable analysis using pre-operative variables, cathepsin D showed some evidence of independent prognostic value for OS (likelihood ratio test P-value=0.056) although requiring further validation in larger patient numbers with sufficient statistical power to determine independent significance. CONCLUSION: These data establish an important proof of principle and show the potential of proteomics-based studies. Cathepsin D may be of value as a pre-operative urinary biomarker for RCC, alone or in combination.

Outcome from treatment of Pneumocystis jirovecii pneumonia with co-trimoxazole.

A retrospective case-notes audit of 359 HIV-1-infected adult patients with first-episode laboratory-confirmed Pneumocystis jirovecii pneumonia treated with co-trimoxazole (from 1987 adjuvant steroids were used if PaO(2) <9.3 kPa) showed that only 230/359 (64%) patients completed treatment; 104 (29%) patients had treatment-limiting toxicity; rash occurred in 4/60 (6.7%) patients in 1985-1988 and in 15/47 (31.9%) in 2005-2008. Twenty-five patients (7%) failed co-trimoxazole treatment. Overall mortality was 13.6% (49/359); mortality among patients who failed co-trimoxazole treatment was 48% (12/25) and by contrast mortality was 4.8% (5/104) among patients with treatment-limiting toxicity.

Improvements in cheek volume in lipoatrophic individuals switching away from thymidine nucleoside reverse transcriptase inhibitors.

BACKGROUND: Thymidine nucleoside reverse transcriptase inhibitors (NRTIs) are associated with subcutaneous fat loss. Facial changes cannot be assessed by dual-energy X-ray absorptiometry (DEXA) scans. There are limited objective data on the reversibility of facial lipoatrophy. METHODS: We performed a facial volume substudy of a randomized thymidine NRTI replacement study carried out in HIV-infected subjects with moderate to severe lipoatrophy. Facial volume changes were assessed using validated 3D laser imaging. Changes in body composition were measured using DEXA scans. The association between changes in facial volume and body composition parameters at 48 weeks was measured using Spearman's rank correlation. RESULTS: Forty-seven individuals (46 male), 11 receiving zidovudine and 36 receiving stavudine, switched to either tenofovir disoproxil fumarate (DF) (n=23) or abacavir (ABC) (n=24). Thirty-nine of these 47 patients (84.8%) reported facial lipoatrophy at baseline. The median volume increase in both cheeks from baseline was 1857.3 mm(3). These volume changes and increases in limb fat at 48 weeks were similar in the two groups and correlated significantly (Spearman's r=0.41, P=0.004). CONCLUSIONS: Facial volume in lipoatrophic individuals was found to increase after thymidine NRTI replacement. We demonstrated a significant correlation between improvements in facial and limb fat parameters. Switching from thymidine NRTIs in patients with facial lipoatrophy could potentially reduce the need for cosmetic interventions.

Tackling STI epidemics through the HIV clinic: is sex high enough on the agenda?

Sexually transmitted infection (STI) rates among men having sex with men continue to increase. HIV services may operate independently to genitourinary medicine clinics and the sexual health of HIV-positive patients may be of low priority in the context of medical problems related to HIV. A prospective study of HIV-positive gay men was conducted in a London outpatient clinic over a three-month period. Data were available for 90 men. Forty-five percent had STI screens in the preceding six months. These revealed a high rate of infections; 26 infections diagnosed in 14 men in the study period. Fifty-seven percent of the 90 men in the study had more than one partner in the past three months and approximately one-third had unprotected sexual activity. A significant proportion of men were unaware of recent outbreaks of hepatitis C and lymphogranuloma venereum and of HIV postexposure prophylaxis. We therefore recommend that sexual history-taking, STI screens and health promotion should become a routine feature of HIV outpatient consultations in this group.

Immune reconstitution sarcoidosis presenting with hypercalcaemia and renal failure in HIV infection.

An HIV-positive white man developed hypercalcaemia and renal failure 15 months after starting highly active antiretroviral therapy. Investigations showed systemic sarcoidosis affecting parotids, skin and kidneys. This presentation was thought to be a manifestation of immune reconstitution inflammatory syndrome, and the patient was successfully treated with corticosteroid therapy.

Dissemination of Strongyloides stercoralis as an immune restoration phenomenon in an HIV-1-infected man on antiretroviral therapy.

We present a case of Strongyloides stercoralis infection in an HIV-infected man, resulting in Escherichia coli meningitis after initiation of antiretroviral therapy. Recent evidence from studies of strongyloides development supports the concept that strongyloides dissemination in this case is an example of an immune reconstitution inflammatory syndrome.