Survey of Patient Knowledge and Awareness of "Sick Day Rules" in Rheumatology Patients on Long Term Glucocorticoid Therapy.

Aims Rheumatic disease (RMD) patients treated with long-term glucocorticoids (GC) are at risk of developing tertiary adrenal insufficiency. With this survey we aimed to assess the knowledge of RMD patients taking long-term glucocorticoid therapy regarding risk of adrenal insufficiency and understanding of the "steroid sick day rules". Methods RMD patients taking ≥2.5 mg prednisolone daily for ≥3 months were recruited from the Rheumatology outpatient department in Beaumont Hospital, Dublin. Patient knowledge and previous counselling of steroid sick day rules was determined using an 8-point questionnaire carried out face-to-face or via phone call. Results 51 RMD patients on GC therapy were recruited. 3/51 (5.9%) of patients reported that they had been counselled on the Sick Day Rules. 2/51 (3.9%) carried a steroid emergency card or MedicAlert bracelet. Few patients would increase their steroid dose appropriately in response to infection, vomiting or peri-procedure [14/51 (27.5%); 9/51 (17.7%) and 5/51 (7.2%), respectively]. Conclusion We demonstrate a significant deficit of patient knowledge around the precautions for long-term GC use in rheumatic diseases. We suspect that our results may be generalisable to many other RMD units. We are currently reviewing our procedures around healthcare professional and patient education, issuing of information leaflets, emergency cards or MedicAlert bracelets etc. to at risk patients.

Effectiveness of an online module: climate-change and sustainability in clinical practice.

BACKGROUND: Climate change has significant implications for health, yet healthcare provision itself contributes significant greenhouse gas emission. Medical students need to be prepared to address impacts of the changing environment and fulfil a key role in climate mitigation. Here we evaluate the effectiveness of an online module on climate-change and sustainability in clinical practice designed to achieve learning objectives adapted from previously established sustainable healthcare priority learning outcomes. METHODS: A multi-media, online module was developed, and 3rd and 4th year medical students at Brighton and Sussex Medical School were invited to enrol. Students completed pre- and post-module questionnaires consisting of Likert scale and white space answer questions. Quantitative and qualitative analysis of responses was performed. RESULTS: Forty students enrolled and 33 students completed the module (83% completion rate). There was a significant increase in reported understanding of key concepts related to climate change and sustainability in clinical practice (p < 0.001), with proportion of students indicating good or excellent understanding increasing from between 2 - 21% students to between 91 - 97% students. The majority (97%) of students completed the module within 90 min. All students reported the module was relevant to their training. Thematic analysis of white space responses found students commonly reported they wanted access to more resources related to health and healthcare sustainability, as well as further guidance on how to make practical steps towards reducing the environmental impact within a clinical setting. CONCLUSION: This is the first study to evaluate learner outcomes of an online module in the field of sustainable health and healthcare. Our results suggest that completion of the module was associated with significant improvement in self-assessed knowledge of key concepts in climate health and sustainability. We hope this approach is followed elsewhere to prepare healthcare staff for impacts of climate change and to support improving the environmental sustainability of healthcare delivery. TRIAL REGISTRATION: Study registered with Brighton and Sussex Medical School Research Governance and Ethics Committee (BSMS RGEC). Reference: ER/BSMS3576/8, Date: 4/3/2020.

Prenatally Diagnosed Fetal Aneuploidy: Natural History and Subsequent Management.

Aims Our aim was to determine the number of cases of aneuploidy which were prenatally diagnosed in our tertiary referral unit from 2005-2015 and to analyse the subsequent outcomes of Trisomies 13, 18 and 21(T13, T18 and T21). Methods This was a retrospective observational study. We firstly determined the total number of prenatally diagnosed aneuploidies. We then analysed their subsequent outcomes including average gestation at miscarriage or IUD, mode of delivery and neonatal outcome. Results 402 cases of T13, T18 or T21 were identified of which 40% opted for expectant management. T18 was the most likely diagnosis to result in miscarriage, IUD or intrapartum death. The highest caesarean delivery rate was in T21. Conclusion With regards to T13 and T18, live birth rates show that some parents may achieve the goal of spending time with their baby in the immediate postpartum period. This information will act as a valuable resource in our counselling.

Investigation of benefits and costs of an ophthalmic outreach clinic in general practice.

BACKGROUND: With the advent of general practitioner fundholding, there has been growth in outreach clinics covering many specialties. The benefits and costs of this model of service provision are unclear. AIM: A pilot study aimed to evaluate an outreach model of ophthalmic care in terms of its impact on general practitioners, their use of secondary ophthalmology services, patients' views, and costs. METHOD: A prospective study, from April 1992 to March 1993, of the introduction of an ophthalmic outreach service in 17 general practices in London was undertaken. An ophthalmic outreach team, comprising an ophthalmic medical practitioner and an ophthalmic nurse, held clinics in the practices once a month. Referral rates to Edgware General Hospital ophthalmology outpatient department over one year from the study practices were compared with those from 17 control practices. General practitioners' assessments of the scheme and its impact on their knowledge and practice of ophthalmology were sought through a postal survey of all partners and interviews with one partner in each practice. Patient surveys were conducted using self-administered structured questionnaires. A costings exercise compared the outreach model with the conventional hospital ophthalmology outpatient clinic. RESULTS: Of 1309 patients seen by the outreach team in the study practices, 480 (37%) were referred to the ophthalmology outpatient department. The annual referral rate to this department from control practices was 9.5 per 10,000 registered patients compared with 3.8 per 10,000 registered patients from study practices. A total of 1187 patients were referred to the outpatient department from control practices. An increase in knowledge of ophthalmology was reported by 18 of 47 general practitioners (38%). Nineteen (40%) of 47 general practitioners took advantage of the opportunity for inservice training with the outreach team; they were more likely to change their routine practice for ophthalmic care or referral criteria for patients with cataracts or diabetes than those who did not attend for inservice training. The outreach scheme was popular with patients, for whom ease of access and familiarity of surroundings were major advantages. The cost per patient seen in the outreach clinics (48.09 pounds) was about three times the cost per patient seen in the outpatient department (15.71 pounds). CONCLUSION: The model of ophthalmic outreach care in this pilot study was popular with patients and general practitioners and appeared to act as an effective filter of demand for care in the hospital setting. However, the educational impact of the scheme was limited. Although the unit costs (per patient) of the outreach scheme compared unfavourably with those of conventional outpatient treatment, potential health gains from this more accessible model of care require further exploration.

Reproductive failure in swine associated with maternal seroconversion for porcine parvovirus.

Reproductive failure occurred in a swine herd in which the epizootiology of enteroviruses and the porcine parvovirus were being studied. Three virgin boars that were seropositive for the parvovirus were mated to seronegative, previously unmated gilts. The 11 gilts that farrowed had small litters, with high perinatal mortality. The remaining 12 gilts were marketed because of infertility, and the reproductive tracts were examined. Pathologic findings included early embryonal death attributed to viral infection. After the reproductive failure, all gifts and boars were seropositive for the parvovirus, suggesting that the reproductive failure was associated with a parvovirus infection.

Ontogeny of the bovine immune response.

The ontogenesis of the bovine immune response was studied in three embryos (<40 days) and 106 fetuses of various ages. In the absence of overt antigenic stimulation, fetuses had lymphoid development of the thymus at 42 days of gestation, the spleen was structurally present at 55 days, and certain peripheral lymph nodes were present at 60 days. Mesenteric lymph nodes were structurally present by 100 days of gestation, and lymphoid tissue of the gastrointestinal tract, particularly the lower ileum, was observed in histologic sections of a 175-day fetus with a bacterial infection. Pyroninophilic cells, plasma cells, and germinal centers were present in lymph node sections of antigenically stimulated fetuses. Lymphoid tissue developed more rapidly in fetuses with bacteria, viral antigens, or apparent maternal red-blood-cell antigens than in the normal fetus. Thymic and splenic indices reached maximal values in the 205- to 220-day fetal age group. Immunoglobulin M (IgM)-containing cells were first observed, by immunofluorescence, in a single fetus at 59 days of gestation. Immunoglobulin G (IgG)-containing cells were observed at 145 days of gestation in one fetus with a bacterial and viral infection. IgM-containing cells were observed in 36 fetuses and IgM and IgG cells were present in seven fetuses. Spleen, lymph nodes, thymus, bone marrow, and liver of one fetus from a dam with lymphosarcoma had immunoglobulin-containing cells. Hemal lymph nodes, blood (buffy coat), Peyer patches, and heart and lung sections from fetuses with immunoglobulin-containing cells in spleen or lymph node did not have immunoglobulin-containing cells. Antigens of the virus of bovine virus diarrhea-mucosal disease (BVD) were detected in one fetus, and antigens of infectious bovine rhinotracheitis (IBR) virus were detected in three fetuses; however, viruses were not isolated in primary bovine embryonic kidney cells. Two of the three fetuses with IBR virus antigens had neutralizing serum antibody titers to IBR virus. Bacteria including Escherichia coli, Lactobacillus sp. and Mima polymorpha var. oxidans were isolated from four fetuses. Antibodies that caused the agglutination of maternal red blood cells were present in 8 of 20 bovine fetal serum samples. The antibodies were 2-mercaptoethanol sensitive and partially heat resistant (56 C for 30 min). The ontogeny of the bovine immune response and human immune response were compared, and it was suggested that the similarities were primarily due to the two species having the same approximate gestation period of 280 days.

Classification of North American porcine enteroviruses: a comparison with European and Japanese strains.

Seventy-two strains of porcine enteroviruses including strains from North America, England, and Japan were compared by cell culture neutralization tests to provide a serological classification of North American strains. From the tests, eight serogroups evolved, with serogroup 8 having a possible three subgroups. There appeared to be some intergroup relationship among certain viruses in groups having the same specific cytopathic effect (CPE) in cell culture. There was no apparent cross-reaction between the group with type II CPE and groups with type I CPE. Antisera produced in nonhost chickens provided a satisfactory antibody source for the tests. It was proposed that satisfactory typing of viruses could be done best by cross-neutralization rather than by one-way neutralization tests. This provided the homologous serum titer as determined in the laboratory conducting the tests which was important where comparisons are made on the basis of per cent of the homologous titer. It was further emphasized that viruses of tissue origin and their antisera have fewer intergroup reactions than viruses of intestinal origin and their antisera. General type strains and specific North American strains were suggested as satisfactory type sera and viruses for seven of the eight groups to facilitate virus identification.