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COVID-19 led to the widespread withdrawal of face-to-face hospital-based clinical placements, with many medical schools switching to online learning. This precipitated concern about potential negative impact on clinical and interprofessional skill acquisition. To overcome this problem, we piloted a 12-week COVID-19 safe face-to-face clinical placement for 16 medical students at the Hospital for Tropical Diseases, London, during the first wave of the COVID-19 pandemic. COVID-19 infection control measures necessitated that students remained in 'social bubbles' for placement duration. This facilitated an apprenticeship-style teaching approach, integrating students into the clinical team for placement duration. Team-based learning was adopted to develop and deliver content. Teaching comprised weekly seminars, experiential ward-based attachments and participation in quality improvement and research projects. The taught content was evaluated through qualitative feedback, reflective practice, and pre-apprenticeship and post-apprenticeship confidence questionnaires across 17 domains. Students' confidence improved in 14 of 17 domains (p<0.05). Reflective practice indicated that students valued the apprenticeship model, preferring the longer clinical attachment to existent shorter, fragmented clinical placements. Students described improved critical thinking, group cohesion, teamwork, self-confidence, self-worth and communication skills. This article describes a framework for the safe and effective delivery of a longer face-to-face apprenticeship-based clinical placement during an infectious disease pandemic. Longer apprenticeship-style attachments have hidden benefits to general professional training, which should be explored by medical schools both during the COVID-19 pandemic and, possibly, for any future clinical placements.
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COVID-19 , Prácticas Clínicas , Competencia Clínica , Educación de Pregrado en Medicina , Enseñanza , COVID-19/epidemiología , COVID-19/prevención & control , Prácticas Clínicas/métodos , Prácticas Clínicas/tendencias , Educación a Distancia , Educación de Pregrado en Medicina/métodos , Educación de Pregrado en Medicina/organización & administración , Hospitales de Enseñanza/organización & administración , Humanos , Control de Infecciones/métodos , Educación Interprofesional , Londres , Mejoramiento de la Calidad , SARS-CoV-2 , Estudiantes de Medicina , Enseñanza/normas , Enseñanza/tendenciasRESUMEN
Background: To report on the implementation and outcomes of a virtual ward established for the management of mpox during the 2022 outbreak, we conducted a 2-center, observational, cross-sectional study over a 3-month period. Methods: All patients aged ≥17 years with laboratory polymerase chain reaction-confirmed monkeypox virus managed between 14 May and 15 August 2022, at the Hospital for Tropical Diseases at University College London Hospitals National Health Service (NHS) Foundation Trust and sexual health services at Central North and West London NHS Foundation Trust, were included. Main outcomes included the proportion of patients managed exclusively on the virtual ward, proportion of patients requiring inpatient admission, proportion of patients with human immunodeficiency virus, and duration of lesion reepithelialization. Results: Among confirmed cases (N = 221), 86% (191/221) were managed exclusively on the virtual ward, while 14% (30/221) required admission. Treatment for concomitant sexually transmitted infections was provided to 25% (55/221) of patients, antibiotics for other infective complications to 16% (35/221), and symptomatic relief to 27% (60/221). The median time from onset to complete lesion reepithelialization and de-isolation was 18 days (range, 8-56 days). Eleven percent (24/221) of individuals disengaged from services within 4 days of testing. Conclusions: The virtual ward model facilitated safe and holistic outpatient management of mpox, while minimizing admissions. This approach could serve as a model for future outbreak responses.
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Many human T-cell responses specific for epitopes in Plasmodium falciparum have been described, but none has yet been shown to be predictive of protection against natural malaria infection. Here we report a peptide-specific T-cell assay that is strongly associated with protection of humans in The Gambia, West Africa, from both malaria infection and disease. The assay detects interferon-gamma-secreting CD4(+) T cells specific for a conserved sequence from the circumsporozoite protein, which binds to many human leukocyte antigen (HLA)-DR types. The correlation was observed using a cultured, rather than an ex vivo, ELISPOT assay that measures central memory-'type T cells rather than activated effector T cells. These findings provide direct evidence for a protective role for CD4(+) T cells in humans, and a precise target for the design of improved vaccines against P. falciparum.
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Linfocitos T CD4-Positivos/inmunología , Epítopos/inmunología , Malaria Falciparum/prevención & control , Proteínas Protozoarias/inmunología , Adolescente , Adulto , Secuencia de Aminoácidos , Secuencia Conservada , Ensayo de Inmunoadsorción Enzimática , Humanos , Memoria Inmunológica , Malaria Falciparum/inmunología , Persona de Mediana Edad , Datos de Secuencia MolecularRESUMEN
In animals, effective immune responses against malignancies and against several infectious pathogens, including malaria, are mediated by T cells. Here we show that a heterologous prime-boost vaccination regime of DNA either intramuscularly or epidermally, followed by intradermal recombinant modified vaccinia virus Ankara (MVA), induces high frequencies of interferon (IFN)-gamma-secreting, antigen-specific T-cell responses in humans to a pre-erythrocytic malaria antigen, thrombospondin-related adhesion protein (TRAP). These responses are five- to tenfold higher than the T-cell responses induced by the DNA vaccine or recombinant MVA vaccine alone, and produce partial protection manifest as delayed parasitemia after sporozoite challenge with a different strain of Plasmodium falciparum. Such heterologous prime-boost immunization approaches may provide a basis for preventative and therapeutic vaccination in humans.
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Inmunización Secundaria , Vacunas contra la Malaria/inmunología , Linfocitos T/inmunología , Vacunas de ADN/inmunología , Vacunas Sintéticas/inmunología , Virus Vaccinia/inmunología , Animales , Antígenos de Protozoos/inmunología , Humanos , Esquemas de Inmunización , Interferón gamma/inmunología , Interferón gamma/metabolismo , Activación de Linfocitos , Malaria Falciparum/prevención & control , Malaria Falciparum/terapia , Péptidos/inmunología , Péptidos/metabolismo , Plásmidos , Plasmodium falciparum/genética , Plasmodium falciparum/inmunología , Proteínas Protozoarias/inmunología , Linfocitos T/metabolismo , Virus Vaccinia/genéticaRESUMEN
BACKGROUND: Simulation training is an effective tool for improving confidence in healthcare workers. During the recent COVID-19 pandemic, large numbers of staff required re-training to manage unfamiliar situations. We present a set of medical student-led clinical simulation sessions and evaluate their effects on (i) confidence among redeployed healthcare workers managing COVID-19 patients and (ii) medical students' confidence as educators. METHODS: Half-day simulation training sessions consisting of three COVID-related clinical scenarios were devised by senior medical students and delivered to a group of approximately 150 healthcare workers over six repeated sessions prior to redeployment to COVID-19 wards. We distributed an anonymous pre- and post-simulation questionnaire to 36 participants in the final group exploring their experiences. The confidence scores were analysed using the Wilcoxon signed-rank test. Following the delivery of teaching, medical students completed a questionnaire assessing their personal experiences of designing and delivering the exercises. RESULTS: Data are available for 35/36 participants approached. Respondents reported being significantly more confident after the training in all aspects of managing COVID-19 patients, including triage, complex discharge, recognising deterioration, initiating basic life support, managing symptoms and advising on visiting policies (p < 0.001); 97% of respondents rated the training as useful. Thematic analysis of medical students' responses demonstrated mutual benefit. DISCUSSION: This study demonstrates the strengths of simulation training in helping to build staff confidence in a rapidly evolving situation and highlights the value of medical students in supporting a hospital's response to an outbreak. We recommend further studies of student-led simulation exercises, including longer-term follow-up.
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COVID-19 , Entrenamiento Simulado , Estudiantes de Medicina , COVID-19/diagnóstico , COVID-19/terapia , Humanos , PandemiasRESUMEN
Treatment of acute malaria caused by Plasmodium falciparum may include long-half-life drugs, such as the antifolate combination sulfadoxine-pyrimethamine (SP), to provide posttreatment chemoprophylaxis against parasite recrudescence or delayed emergence from the liver. An unusual case of P. falciparum recrudescence in a returned British traveler who received such a regimen, as well as a series of 44 parasite isolates from the same hospital, was analyzed by PCR and direct DNA sequencing for the presence of markers of parasite resistance to chloroquine and antifolates. The index patient harbored a mixture of wild-type and resistant pfdhfr and pfdhps alleles upon initial presentation. During his second malaria episode, he harbored only resistant parasites, with the haplotypes IRNI (codons 51, 59, 108, and 164) and SGEAA (codons 436, 437, 540, 581, and 613) at these two loci, respectively. Analysis of isolates from 44 other patients showed that the pfdhfr haplotype IRNI was common (found in 81% of cases). The SGEAA haplotype of pfdhps was uncommon (found only in eight cases of East African origin [17%]). A previously undescribed mutation, I431V, was observed for seven cases of Nigerian origin, occurring as one of two haplotypes, VAGKGS or VAGKAA. The presence of this mutation was also confirmed in isolates of Nigerian origin from the United Kingdom Malaria Reference Laboratory. The presence of the pfdhps haplotype SGEAA in P. falciparum parasites of East African origin appears to compromise the efficacy of treatment regimens that include SP as a means to prevent recrudescence. Parasites with novel pfdhps haplotypes are circulating in West Africa. The response of these parasites to chemotherapy needs to be evaluated.
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Dihidropteroato Sintasa/genética , Malaria Falciparum/parasitología , Plasmodium falciparum/enzimología , Plasmodium falciparum/genética , Adulto , Alelos , Secuencia de Aminoácidos , Animales , Antimaláricos/uso terapéutico , Atovacuona/uso terapéutico , Cloroquina/farmacología , Cloroquina/uso terapéutico , Combinación de Medicamentos , Resistencia a Medicamentos/genética , Antagonistas del Ácido Fólico/uso terapéutico , Haplotipos/genética , Humanos , Malaria Falciparum/tratamiento farmacológico , Masculino , Plasmodium falciparum/efectos de los fármacos , Reacción en Cadena de la Polimerasa , Proguanil/uso terapéutico , Pirimetamina/uso terapéutico , Análisis de Secuencia de ADN , Sulfadoxina/uso terapéutico , Tetrahidrofolato Deshidrogenasa/genética , Reino UnidoRESUMEN
Background: Schistosomiasis is rare in western countries, but remains a potentially serious disease. It is known to result in severe urogenital complications; prompt diagnosis can therefore significantly affect outcomes. Case Presentation: We report the case of a 41-year-old male with pleuritic chest pain and visible hematuria who had emigrated from Zimbabwe to the United Kingdom 20 years previously. CT imaging revealed a hydronephrotic right pelvicaliceal system, with a dilated ureter to its distal portion. Preliminary tests for schistosomiasis, including terminal urine microscopy and serology, were negative. An initial ureteroscopy was challenging owing to a tight ureteral stricture such that a retrograde stent insertion and not ureteroscopic visualization or biopsy was carried out. A relook ureteroscopy after 6 weeks revealed a dense distal ureteral stricture, biopsies were taken, the stricture was ablated with LASER, and a retrograde stent was placed. Microscopic examination of the biopsies confirmed Schistosomiasis haematobium. Treatment consisted of a divided dose of praziquantel and a reducing dose of steroids. At a third look ureteroscopy the stricture was ablated with LASER again, and the stent was removed. Subsequent renograms indicated recurrent obstruction despite LASER treatment and a retrograde ureteral stent was replaced. The patient ultimately had a Boari flap ureteral reimplant with good results. Conclusion: This case illustrates the clinical challenges of diagnosing and treating ureteral schistosomiasis. It shows that all the initial tests can be negative, but where the clinical picture points toward schistosomiasis it is worth persevering and a good tissue biopsy may be the only way to verify an otherwise elusive diagnosis.
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BACKGROUND: Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services. METHODS: We administered an anonymous questionnaire survey of all presenting patients at an A&E/Walk-In Centre at an inner-city London hospital during a 1 month period. Questions related to nationality, immigration status, time in the UK, registration and use of GP services. We compared differences between groups using two-way tables by Chi-Square and Fisher's exact test. We used logistic regression modelling to quantify associations of explanatory variables and outcomes. RESULTS: 1611 of 3262 patients completed the survey (response rate 49.4%). 720 (44.7%) were overseas born, representing 87 nationalities, of whom 532 (73.9%) were new migrants to the UK (< or =10 years). Overseas born were over-represented in comparison to local estimates (44.7% vs 33.6%; p < 0.001; proportional difference 0.111 [95% CI 0.087-0.136]). Dominant immigration status' were: work permit (24.4%), EU citizens (21.5%), with only 21 (1.3%) political asylum seekers/refugees. 178 (11%) reported nationalities from refugee-generating countries (RGCs), eg, Somalia, who were less likely to speak English. Compared with RGCs, and after adjusting for age and sex, the Australians, New Zealanders, and South Africans (ANS group; OR 0.28 [95% CI 0.11 to 0.71]; p = 0.008) and the Other Migrant (OM) group comprising mainly Europeans (0.13 [0.06 to 0.30]; p = 0.000) were less likely to have GP registration and to have made prior contact with GPs, yet this did not affect mode of access to hospital services across groups nor delay access to care. CONCLUSION: Recently arrived migrants are a diverse and substantial group, of whom migrants from refugee-generating countries and asylum seekers comprise only a minority group. Service reorganisation to ensure improved access to community-based GPs and delivery of more appropriate care may lessen their impact on acute services.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Emigración e Inmigración/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitales Municipales/estadística & datos numéricos , Aceptación de la Atención de Salud/etnología , Salud Urbana/estadística & datos numéricos , Adolescente , Adulto , Niño , Preescolar , Servicio de Urgencia en Hospital/economía , Emigración e Inmigración/tendencias , Medicina Familiar y Comunitaria , Femenino , Necesidades y Demandas de Servicios de Salud , Hospitales Municipales/economía , Humanos , Lactante , Recién Nacido , Londres/epidemiología , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/estadística & datos numéricos , Atención Primaria de Salud , Refugiados/estadística & datos numéricos , Clase Social , Encuestas y Cuestionarios , Migrantes/estadística & datos numéricosRESUMEN
An association between late-stage hepatosplenic schistosomiasis and endomyocardial fibrosis (EMF) has been suggested but not proven. We present the case of a 12-year-old Ugandan boy with striking comorbidities, including advanced periportal fibrosis caused by Schistosoma mansoni infection and right ventricular EMF, and discuss the possible correlation between both diseases.
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Fibrosis Endomiocárdica/complicaciones , Hepatopatías/complicaciones , Schistosoma mansoni/aislamiento & purificación , Esquistosomiasis mansoni/complicaciones , Enfermedades del Bazo/complicaciones , Animales , Antihelmínticos/uso terapéutico , Niño , Fibrosis Endomiocárdica/tratamiento farmacológico , Fibrosis Endomiocárdica/parasitología , Heces/parasitología , Humanos , Hepatopatías/tratamiento farmacológico , Hepatopatías/parasitología , Masculino , Praziquantel/uso terapéutico , Propranolol/uso terapéutico , Esquistosomiasis mansoni/tratamiento farmacológico , Esquistosomiasis mansoni/parasitología , Enfermedades del Bazo/tratamiento farmacológico , Enfermedades del Bazo/parasitología , Uganda , Vasodilatadores/uso terapéuticoAsunto(s)
Disentería Amebiana/diagnóstico , Disentería Amebiana/patología , Entamoeba histolytica/aislamiento & purificación , Parejas Sexuales , Adulto , Antiprotozoarios/administración & dosificación , Disentería Amebiana/tratamiento farmacológico , Entamoeba histolytica/genética , Femenino , Furanos/administración & dosificación , Humanos , Londres , Imagen por Resonancia Magnética , Metronidazol/administración & dosificación , Radiografía Abdominal , Resultado del TratamientoRESUMEN
OBJECTIVES: To establish the clinical reasons for inpatient admissions among injecting drug users. To determine the frequency of behavioural issues during their care and to estimate the financial implications of injecting drug use to the health service. METHODS: Retrospective cohort study at University College London Hospital. Clinical, laboratory and financial data were extracted from case notes and electronic records. The cost of each admission was compared to the income received for the period of care. RESULTS: 124 injecting drug users required 191 admissions between 2005 and 2009. Skin and soft tissue infections (58%) and pneumonia (18%) were the commonest reasons for admission. Bacteraemia at admission was often not accompanied by an inflammatory response. Exposure to HIV (4%), hepatitis B (49%) and C (84%) was common. Drug misuse (16%) during admission was frequent. The cost to the NHS of treating soft tissue infections in drug users was approximately £77 million per annum. After a median follow-up of 40 months, 10 patients (8%) had died. All deaths were attributable to drug use. CONCLUSIONS: Bacterial and viral infections are largely responsible for the significant mortality and morbidity of injecting drug users presenting to secondary care. The financial burden to the NHS is substantial.
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Lesiones por Pinchazo de Aguja/diagnóstico , Lesiones por Pinchazo de Aguja/economía , Abuso de Sustancias por Vía Intravenosa/diagnóstico , Abuso de Sustancias por Vía Intravenosa/economía , Adulto , Distribución de Chi-Cuadrado , Femenino , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Hospitales de Enseñanza/economía , Hospitales de Enseñanza/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Londres , Masculino , Lesiones por Pinchazo de Aguja/microbiología , Estudios Retrospectivos , Sepsis/etiología , Sepsis/microbiología , Enfermedades Cutáneas Infecciosas/etiología , Enfermedades Cutáneas Infecciosas/microbiología , Infecciones de los Tejidos Blandos/etiología , Infecciones de los Tejidos Blandos/microbiología , Abuso de Sustancias por Vía Intravenosa/microbiologíaRESUMEN
OBJECTIVES: To quantify geographical concentration of falciparum malaria cases in the UK at a hospital level. To assess potential delay-to-treatment associated with hub-and-spoke distribution of artesunate in severe cases. DESIGN: Observational study using national and hospital data. SETTING AND PARTICIPANTS: 3520 patients notified to the Malaria Reference Laboratory 2008-2010, 34 patients treated with intravenous artesunate from a tropical diseases centre 2002-2010. MAIN OUTCOME MEASURES: Geographical location of falciparum cases notified in the UK. Diagnosis-to-treatment times for intravenous artesunate. RESULTS: Eight centres accounted for 43.9% of the UK's total cases; notifications from 107 centres accounted for 10.2% of cases; 51.5% of hospitals seeing malaria notified 5 or fewer cases in 3 years. Centres that saw <10 cases/year treat 26.3% of malaria cases; 6.1% of cases are treated in hospitals seeing <2 cases/year. Concentration of falciparum malaria was highest in Greater London (1925, 54.7%), South East (515, 14.6%), East of England (402, 11.4%) and North West (192, 5.4%). The North East and Northern Ireland each notified 5 or fewer cases per year. Median diagnosis-to-treatment time was 1 h (range 0.5-5) for patients receiving artesunate in the specialist centre; 7.5 h (range 4-26) for patients receiving it in referring hospitals via the hub-and-spoke system (p=0.02); 25 h (range 9-45) for patients receiving it on transfer to the regional centre from a referring hospital (p=0.002). CONCLUSIONS: Most UK hospitals see few cases of falciparum malaria and geographical distances are significant. Over 25% of cases are seen in hospitals where malaria is rare, although 60% are seen in hospitals seeing over 50 cases over 3 years. A hub-and-spoke system minimises drug wastage and ensures availability in centres seeing most cases but is associated with treatment delays elsewhere. As with all observational studies, there are limitations, which are discussed.