Pneumomediastinum in patients with COVID-19 undergoing CT pulmonary angiography: a retrospective cohort study.

BACKGROUND: Various complications have been reported in patients with COVID-19 including pneumomediastinum. METHODS: The primary objective of the study was to determine the incidence of pneumomediastinum in COVID-19 positive patients who underwent CT pulmonary angiography (CTPA). The secondary objectives were to analyse if the incidence of pneumomediastinum changed between March and May 2020 (peak of the first wave in the UK) and January 2021 (peak of the second wave in the UK) and to determine the mortality rate in patients with pneumomediastinum. We undertook an observational, retrospective, single-centre, cohort study of patients with COVID-19 admitted to Northwick Park Hospital. RESULTS: 74 patients in the first wave and 220 patients in the second wave met the study criteria. Two patients during the first wave and eleven patients during the second wave developed pneumomediastinum. CONCLUSIONS: The incidence of pneumomediastinum changed from 2.7% during the first wave to 5% during the second wave and this change was not statistically significant (p value 0.4057). The difference in mortality rates of patients with pneumomediastinum in both waves of COVID-19 (69.23%) versus patients without pneumomediastinum in both waves of COVID-19 (25.62%) was statistically significant (p value 0.0005). Many patients with pneumomediastinum were ventilated, which could be a confounding factor. When controlling for ventilation, there was no statistically significant difference in the mortality rates of ventilated patients with pneumomediastinum (81.81%) versus ventilated patients without pneumomediastinum (59.30%) (p value 0.14).

Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors.

PURPOSE: To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade. STUDY DESIGN: We conducted a cross-sectional survey of doctors of different specialities and grades at St. George's Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative. RESULTS: We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005). CONCLUSIONS: Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.

Very Early Brain Damage Leads to Remodeling of the Working Memory System in Adulthood: A Combined fMRI/Tractography Study.

The human brain can adapt to overcome injury even years after an initial insult. One hypothesis states that early brain injury survivors, by taking advantage of critical periods of high plasticity during childhood, should recover more successfully than those who suffer injury later in life. This hypothesis has been challenged by recent studies showing worse cognitive outcome in individuals with early brain injury, compared with individuals with later brain injury, with working memory particularly affected. We invited individuals who suffered perinatal brain injury (PBI) for an fMRI/diffusion MRI tractography study of working memory and hypothesized that, 30 years after the initial injury, working memory deficits in the PBI group would remain, despite compensatory activation in areas outside the typical working memory network. Furthermore we hypothesized that the amount of functional reorganization would be related to the level of injury to the dorsal cingulum tract, which connects medial frontal and parietal working memory structures. We found that adults who suffered PBI did not significantly differ from controls in working memory performance. They exhibited less activation in classic frontoparietal working memory areas and a relative overactivation of bilateral perisylvian cortex compared with controls. Structurally, the dorsal cingulum volume and hindrance-modulated orientational anisotropy was significantly reduced in the PBI group. Furthermore there was uniquely in the PBI group a significant negative correlation between the volume of this tract and activation in the bilateral perisylvian cortex and a positive correlation between this activation and task performance. This provides the first evidence of compensatory plasticity of the working memory network following PBI.

Giant cell arteritis presenting with unilateral sixth nerve palsy.

Giant cell arteritis (GCA) usually presents with headache, scalp tenderness and raised inflammatory markers. GCA presenting with a clinically evident cranial nerve palsy is rare and may result in a delayed or missed diagnosis if not suspected. We present the rare case of a woman in her 70s with histologically confirmed GCA presenting with a unilateral sixth nerve palsy, which responded to treatment with high-dose oral prednisolone.

Rituximab administration during the second trimester of pregnancy for systemic lupus erythematosus: Case report and review of the literature on rheumatic disease.

Rituximab (RTX) is an anti-CD20 monoclonal antibody that is used in the treatment of many rheumatic diseases, for both licensed and unlicensed indications. Due to concerns regarding foetal B cell depletion and possible infection, there is conflicting advice about whether the drug should be administered during pregnancy, with some organisations advising administration if the potential benefit to the mother outweighs the risk to the foetus and some advising stopping RTX 6 months prior to conception. Caution in particular is advised about administering RTX in later trimesters when maternal immunoglobulin G (IgG) is transported across the placenta. There have been few literatures thus far examining the safety of administering RTX from the second trimester onwards in rheumatic diseases. We present a case where RTX was used during the second trimester for the treatment of refractory systemic lupus erythematosus, without adverse effect on the neonate.

Osteolytic lesions as the sole presenting feature of secondary syphilis.

We present the case of a 48-year-old man with a background of well-controlled HIV who presented with bony pain in multiple regions and raised inflammatory markers. After an investigative process, the patient was newly diagnosed with secondary syphilis. Bony pain, secondary to osteolytic lesions and demonstrated on plain radiography, CT and nuclear medicine imaging, was the sole presenting feature. The patient was successfully treated with penicillin G and his symptoms improved. Rheumatologists are often tasked with diagnosing the cause of a patient's pain. However, in this case, a multidisciplinary approach was needed and the contribution of a specialist in Genitourinary Medicine/HIV was required to help diagnose this rare cause of bony pain.

A case of enteropathic arthritis complicated by superimposed bilateral septic arthritis of the hips.

Polyarticular septic arthritis is an underappreciated clinical entity. Pre-existing joint diseases, such as osteoarthritis and rheumatoid arthritis have been shown to be risk factors for septic arthritis. However, there is a paucity of data in the literature regarding the risk of septic arthritis in those patients with enteropathic arthritis. Here, we describe the case of a 47-year-old female with a background history of ulcerative colitis who presented with difficulty mobilising and pain in the hips associated with lethargy, fever and a significant inflammatory response. After an investigative process, she was newly diagnosed with enteropathic arthritis, complicated at presentation, by bilateral septic arthritis of the hips, based on progressive radiological destruction and a joint aspirate that grew Staphylococcus aureus. After treatment with antibiotics and steroids, her pain and mobility significantly improved, and she was discharged with a plan for an elective hip replacement and to commence disease-modifying therapy with sulfasalazine. This case reminds us that we must have a high index of suspicion to diagnose septic arthritis in those who present feverish and unwell with joint pain, even in those who present with multiple joint involvement. Furthermore, it describes a rare occurrence of bilateral septic arthritis of the hips occurring in a patient with enteropathic arthritis, which unlike osteoarthritis and rheumatoid arthritis, is not well described in the literature as a risk factor for septic arthritis.

A comparison of the academic impact of plastic surgery units in the United Kingdom and Ireland using bibliometric analysis.

Academic output is just one aspect of a successful career as a plastic surgeon. However, for those with a strong interest in academia, the academic output of a department will likely be a key factor when deciding how to rank jobs. The aim of this study was to quantify and rank the academic output of plastic surgery units across the UK and Ireland. The Institute for Scientific Information (ISI) Web of Science Bibliometric analysis tool was used to collate cumulative (1950-2016), 10 year (2006-2016) and 3 years (2013-2015) research output data for plastic surgery units in the UK and Ireland. Sixty-six plastic surgery units were identified. Departments were ranked for each time period according to the number of papers produced, number of citations (Nc) and h-index (a measure of the impact of scientific output). The top 3 departments for number of papers in the last 10 years were The Royal Free Hospital, London (226) Broomfield Hospital, Chelmsford (218), and Morriston Hospital and Swansea (188). The top 3 for h-number were The Royal Free Hospital (21) Wythenshawe Hospital, Manchester (18) and Morriston Hospital (17). Academic output varies across plastic surgery units in the UK and Ireland. A number of departments have consistently maintained high academic outputs across the years and will be of interest to surgeons hoping to pursue a career in academia.