A national clinician survey on the British Society for Dermatological Surgery guidelines on antithrombotic agent use in skin surgery.

Antithrombotic medication is taken by 14-22% patients undergoing skin surgery, with more patients now taking direct oral anticoagulants (DOACs). The latest evidence suggests that the risk of stopping DOACs perioperatively is low in skin surgery, particularly for primary closures, but remains unclear for more complex procedures. The 2016 British Society for Dermatological Surgery (BSDS) guidelines suggest that clinicians could consider stopping DOACs in patients for 24-48 h, based on individual bleeding risk. We surveyed BSDS members to better understand clinical practice and guideline adherence with a view to updating the guidance. The results demonstrated that there is consistency among clinicians in the management of patients on more established antithrombotic agents, such as aspirin, clopidogrel and warfarin. However, there is a higher perceived risk of significant haematomas following higher-risk procedures such as larger flaps or grafts with DOACs vs. other antithrombotics postoperatively. Stopping DOACs perioperatively for 24-48 h for higher-risk procedures can be cautiously considered following an individual risk assessment and informed discussion with the patient.

Why Have Immunization Efforts in Pakistan Failed to Achieve Global Standards of Vaccination Uptake and Infectious Disease Control?

Immunization is one of the most successful public health initiatives in recent times. It is, therefore, worrying to learn the level of under-vaccination in Pakistan. Diseases that have been successfully eliminated through the aid of vaccination in other countries have not been eliminated in Pakistan. The reasons for this vary and show the uniqueness of the economic, healthcare and environmental landscape of Pakistan, through which public health programmes need to be implemented. The "Expanded Programme of Immunization" (EPI) is the main programme through which routine immunization is provided to the public. Within Pakistan, it has encountered many problems since its inception. This includes logistical obstacles, inefficient health worker attitudes, parental and female awareness, and education, the influence of religious community leaders and the complications that accompany conflict. When compared to globally standardised targets for immunization, Pakistan is trailing behind. Not achieving these targets is worrying from both a global perspective and within the national healthcare landscape of Pakistan. Research is necessary to bring together findings on the failings of routine immunization and polio campaigns; there are many intersecting factors that global health bodies and the Department of Health in Pakistan must address in order to relieve the burden of vaccine-preventable diseases (VPDs).

Rare case of paraneoplastic cerebellar degeneration secondary to high-grade serous carcinoma of tubo-ovarian origin.

This case describes a 69-year-old woman, who presented with rapidly progressive cerebellar symptoms and unintentional weight loss. Full neurological assessment excluded space-occupying lesions, vascular accidents and infection. Surprisingly, a chest, abdomen and pelvis CT showed a left hemipelvis mass, which was subsequently biopsied. A high-grade serous carcinoma of tubo-ovarian origin was found, diagnosing paraneoplastic cerebellar degeneration (PCD) secondary to this. The exact mechanism is not known, but is thought to be immune-mediated. In cases of PCD, after cancer treatment, the neurological disability stabilises to a severe level and will unfortunately be lifelong. Our patient continues to make great progress with intensive rehabilitation for her ongoing balance issues. Early recognition of PCD can lead to a prompt diagnosis of the underlying malignancy and hence subsequent management. This can at least limit the extent of the neurological disability of the disease and increase the survival rate from cancer.

The use of an invitational letter to increase the vaccine uptake of patients with coeliac disease.

AIM: We sought to establish the impact on vaccine uptake of sending out a single appointment letter inviting patients to attend a vaccine clinic. BACKGROUND: Coeliac disease is associated with splenic dysfunction and so patients with coeliac disease are at a higher risk of overwhelming infection. Additional vaccinations are recommended for these individuals to provide additional protection against infection. METHODS: We retrospectively identified 54 patients with diagnosed coeliac disease, and all vaccines previously received by these patients. By comparing this to the Green Book [Department of Health (2013) Immunisation of individuals with underlying medical conditions: the green book, chapter 7, London: Department of Health. Retrieved 26 February 2019 from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/566853/Green_Book_Chapter7.pdf], we determined the patients who were due vaccinations and the specific vaccines they were due. An invitation letter was then sent out to patients requiring further vaccinations and vaccine uptake for these patients was re-audited six months later. FINDINGS: Our results show a mild increase in the total uptake of vaccines six months after the letter was sent out, from 38.6% to 49.2%.