The Barts Health NHS Trust COVID-19 cohort: characteristics, outcomes and risk scoring of patients in East London.

BACKGROUND: Barts Health National Health Service Trust (BHNHST) serves a diverse population of 2.5 million people in London, UK. We undertook a health services assessment of factors used to evaluate the risk of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection.METHODS: Patients with confirmed polymerase chain reaction (PCR) test results admitted between 1 March and 1 August 2020 were included, alongwith clinician-diagnosed suspected cases. Prognostic factors from the 4C Mortality score and 4C Deterioration scores were extracted from electronic health records and logistic regression was used to quantify the strength of association with 28-day mortality and clinical deterioration using national death registry linkage.RESULTS: Of 2783 patients, 1621 had a confirmed diagnosis, of whom 61% were male and 54% were from Black and Minority Ethnic groups; 26% died within 28 days of admission. Mortality was strongly associated with older age. The 4C mortality score had good stratification of risk with a calibration slope of 1.14 (95% CI 1.01-1.27). It may have under-estimated mortality risk in those with a high respiratory rate or requiring oxygen.CONCLUSION: Patients in this diverse patient cohort had similar mortality associated with prognostic factors to the 4C score derivation sample, but survival might be poorer in those with respiratory failure.

Patients' attitudes to sickness certification in general practice.

BACKGROUND: In 2010, the sick note was replaced with the fit note, designed to enable return to work. Despite considerable research relating to general practitioners' (GPs') attitudes and practice towards the fit note, little is known regarding the patients' perspective. AIMS: We sought to identify patients' attitudes to and feelings about the process of sickness certification. METHODS: Patients who received fit notes were invited to participate in tape-recorded telephone interviews, which were conducted with a semi-structured approach. Participants described their reason for sickness absence and whether it had been related to work. They were then asked to provide a narrative regarding their experience of the fitness for work process and their feelings about their GP and employer's reaction to sickness absence. RESULTS: Nine patients were interviewed. Four main themes emerged from analysis of the interviews: 'significant stigma', 'a GP who knows me', 'value of work' and 'emotional barriers'. Patients expressed preference for being seen by a familiar GP with a greater perceived understanding of the patient's attitude to sickness and work. CONCLUSIONS: The four emergent themes of stigma, the value of work, a doctor who knows you and emotion suggest that further research should focus on the problems of stigma associated with sickness certification and patients' emotional response to asking for certification.

Hospital social work and community care: the practitioners' view.

This paper presents the findings of an exploratory research study which considers the effect of organisational change on social work practice in hospitals in four local authorities in England. Its aims were (1) to obtain the views of hospital social workers and their managers about the effect of implementing the NHS (National Health Service) and Community Care Act of 1990 and policies for Care in the Community on the practice of social work and (2) to elicit issues of concern to form the basis of a national study. Semi-structured interviews were carried out in hospital social work departments which were providing a service to adults with health needs. Interviews with a representative sample of 85 workers and 36 managers (including Assistant Directors and Principal Training Officers) in 11 hospitals were held between June-December 1993, three months after the introduction of the policies. The interviews were tape-recorded and transcribed. A questionnaire provided some quantitative data, and additional information was obtained through non-participant observation at team meetings. The interviews covered four topic areas: the nature of social work in hospitals; the changes introduced by implementing the legislation; the management of that change; and the effect of the new policies on practice. Results show an increase in the volume of referrals particularly in assessment for nursing home care; and an overwhelming amount of administrative work to process the new procedures for providing community care. Most relates to filling in forms, duplication of assessments and repetitive bureaucracy. Workers struggle to meet their expectation of professional practice with organisational demands. The discussion centres on three issues raised by practitioners; the changing nature of social work due to the alternative models of service being imposed by local authorities; the lack of consultation and involvement by management of the frontline workers in the management of this change; the dissonance felt by hardworking and committed practitioners to whom the increasing paper work is yet another obstacle to user involvement. This may have clear implications for management, for the degree of stress and perceived pressure resulting from these organisational changes is counterproductive to job satisfaction. If the reforms are not to be undermined, they need proactive management. This requires a sensitivity to workers' needs, investment in training and working together to integrate the care management role into social work practice.

Extradigital glomus tumor as a cause of knee pain.

Although there exists much debate in the dermatohistopathologic literature about the exact characterization of the glomus tumor, this case illustrates what should be considered the sine qua non indications of clinically significant glomus tumors, i.e., exquisite pain and complete relief of pain with surgical excision. One should not, therefore, limit the inclusion of glomus tumors to the differential diagnosis of severe localized pain only in the upper extremity.

Hypoglycemia in a diabetes nurse care coordinator.

A 26-yr-old registered nurse who is employed as a diabetes nurse care coordinator had episodes of symptomatic fasting hypoglycemia associated with hyperinsulinemia and a relatively suppressed plasma C-peptide concentration, arousing the suspicion of self-induced illness. However, using a species-specific radioimmunoassay, the species of insulin during an episode of hypoglycemia was determined to be human in origin. Once the patient's illness was attributed to endogenous insulin hypersecretion, prompt surgical intervention and the diagnosis of nesidioblastosis in an adult was made.

Excisional breast biopsy and roentgenographic examination for mammographically detected microcalcification.

Sixty-two women had excisional breast biopsy for areas of microcalcification detected by mammography with no associated palpable mass. Carcinoma was discovered in 20 patients (32 percent). These cancers ranged in size from 0.6 to 14 mm in greatest diameter. Six patients had multicentric carcinoma, including one synchronous bilateral lobular carcinoma. Axillary metastasis was present in three patients (15 percent), each with multicentric lesions. Chronic cystic mastopathy (55 percent) was the most common finding associated with microcalcification. In six patients (30 percent) with carcinoma, the microcalcification was present only in adjacent tissue and ducts. Generous excisional biopsy, verification of excision of the site of microcalcification by roentgenographic examination of the specimen, and thorough histologic examination by paraffin section are mandatory to detect these early and potentially curable breast carcinomas.

Benign spindle cell breast tumor.

A distinctive, benign, spindle cell tumor of the breast is described. Three patients were men, the fourth a woman. Histologically, each tumor displayed islands of spindle or stellate cells embedded in a collagenous matrix. Within the female breast, the lesion was within the stroma, displacing but not including the epithelial elements. Ultrastructural study of two tumors revealed diverse populations composed of fibroblasts, myofibroblasts, smooth muscle cells, and undifferentiated mesenchymal cells. The relationship of these tumors to spindle cell lipomas is discussed. The lesions have all been clinically benign, and their recognition as such is important.

Legionnaires' disease pneumonia: histopathologic features and comparison with microbial and chemical pneumonias.

The histopathologic findings in lung tissue are reported from five cases of Philadelphia Legionnaire's Disease and the results are compared to pneumonias caused by other microbial and chemical agents. Histopathology of lung tissue was similar in all cases, despite the fact that death occurred between the fourth and 14th day of clinical illness. The inflammatory response was almost totally limited to the lower respiratory tract and primarily involved respiratory bronchioles, alveolar ducts and alveoli. Major bronchial branches and pulmonary interstices showed little or no involvement. There was considerable variation in the extent and nature of the consolidation, but the overall reaction pattern was highly characteristic of diffuse alveolar damage. Most involved areas showed intra-alveolar, fibrinocellular mononuclear cell predominant exudates, associated with pneumonocytic hyperplasia and slough. These findings plus the presence of erythroleucophagocytosis by macrophages and paucity of polymorphonuclear leucocytes are commonly associated with psittacine pneumonia, and much less so with classic patterns of bacterial, viral, fungal or rickettsial pneumonias. Of the toxic inhalants, nickel carbonyl, phosgene, nitrous oxide, cadmium oxide and some halogenated hydrocarbons have been associated with this tissue reaction pattern. Bacteria were notably absent in lung tissue stained by methods used to demonstrate the Legionnaires' Disease agent.

Receptor for the Fc portion of IgG on the plasma membrane of the hepatocyte.

Applying the immune rosette assay to suspensions of isolated liver cells, 30 to 50 % of hepatocytes obtained from rabbit liver from rosettes with sheep erythrocytes sensitized with IgG. Rosette formation can be inhibited by preincubation of the hepatocytes with aggregated IgG. The interaction between hepatocytes and IgG is not species-specific. Pretreatment of hepatocytes with F(ab')2 fragments of antibody with anti-IgG activity does not interfer with rosette formation. No binding occurs with erythrocytes coated with F(ab')2 fragments, IgM or IgM + complement. These membrane receptors for Fc gamma share many properties with those recognized on macrophagic cells and B lymphocytes; it seems however that on liver cell surface their density and/or their affinity for IgG are inferior to those of mesodermderived cells.

Elastic cartilage choristoma of the neck.

Two cases of elastic cartilage choristoma in the skin and subcutaneous tissues of the lower midline of the neck are reported.