Time to unshackle the medical treatment of obesity in the NHS.

Obesity affects one in four people in the United Kingdom and costs the National Health Service (NHS) ∼£6.5 billion annually. The glucagon-like peptide-1 (GLP-1) receptor analogues, such as once-daily subcutaneous Liraglutide 3.0 mg (Saxenda®) and once-weekly subcutaneous Semaglutide 2.4 mg (Wegovy®), were approved by the National Institute of Health and Care Excellence (NICE) as a treatment for obesity and funded by the NHS for 2 years. Our local data shows that Saxenda is effective at reducing body weight and glycaemia in people with obesity and diabetes; however, the supply issues of GLP-1 receptor analogues have contributed to the unavailability of Saxenda and Wegovy in our service. Our patients are devastated that they cannot access NICE-approved GLP-1 receptor analogues for obesity. The 2-year GLP-1 receptor analogue treatment limit for obesity alongside a lack of funded NHS services and supply issues represent barriers to treatment for people living with obesity who have clear medical indications.

Faecal calprotectin is not necessarily required as a screen for significant bowel disease in primary care.

OBJECTIVE: NICE recommends measurement of faecal haemoglobin (f-Hb) using faecal immunochemical test (FIT) when colorectal cancer is suspected and calprotectin (f-Cal) in the context of inflammatory bowel disease, though neither is disease specific. During the COVID-19 pandemic, f-Hb has been a requirement prior to referral for endoscopy in England; f-Cal is often performed simultaneously. The aim of this study was to investigate test performance of both tests for significant bowel disease in those patients referred. DESIGN: All adult patients with simultaneous measurements of f-Hb and f-Cal between April 2019 and September 2020 were included. For those referred, outcomes were determined from clinical records. RESULTS: 650 patients with simultaneous samples for f-Hb an f-Cal were managed in Primary Care; 319 patients were referred to hospital; SBD was found in 32 (10.0%) (CRC 5, high risk adenomas 5, IBD 22). At a cut-off of 10 µg/g for f-Hb and 200 µg/g for f-Cal, the sensitivity, specificity and negative predictive value for diagnosis of SBD were 84.4%, 58.2% and 96.7% and 68.8%, 89.6% and 95.7%, respectively. Performance of both tests would have enabled diagnosis of two more cases of significant, but non-malignant, bowel disease but required over 4% more referrals for investigation. CONCLUSION: Use of FIT has become established to assist prioritisation of patients for referral from Primary Care. Whilst introduced specifically for CRC, FIT performs well as a rule out for IBD in Primary Care and the use of f-Cal is not required.

Medical training in acute specialties: the acute care common stem training pathway.

In 2007, the acute care common stem pathway changed the delivery of acute specialty training. Acute care common stem is the core training programme for all emergency medicine trainees, 46% of anaesthetic trainees and a cohort of acute medicine trainees with more than 630 places nationally, the third highest of any core training programme. In their first 2 years of core training (CT1-2), trainees rotate through 6-month rotations in emergency medicine, acute medicine, anaesthetics and intensive care to gain core competencies in the assessment and management of acutely unwell patients, before completing 1 year (CT3) in their parent specialty. Acute care common stem trainees benefit from undertaking rotations in allied acute specialties, which is invaluable when treating complex and comorbid patients in an ageing population. Acute care common stem gives trainees core skills in management of acutely unwell patients, which can be built upon in higher specialty training.

A hypercoagulable state leading to venous limb gangrene associated with occult lung adenocarcinoma.

We report a case of lung adenocarcinoma-associated hypercoagulability leading to venous limb gangrene, managed successfully with argatroban and then dabigatran. Use of idarucizumab permitted diagnostic investigations, leading to targeted antineoplastic therapy with crizotinib, surgical resection with curative intent, and continued survival over 2 years after the index event.

The role of hyperglycemia in mechanisms of exacerbated inflammatory responses within the oral cavity.

Immune modulating factors are necessary for pathogen clearance, but also contribute to host tissues damage, as those seen in periodontal diseases. Many of these responses can be exacerbated by host conditions including type 2 diabetes [T2D], where toll-like receptor 4 [TLR4] and the receptor for advanced glycated end products [RAGE] play a significant role. Here we investigate causality associated with the increase in inflammatory markers observed in periodontally diseased patients with T2D using multi-variant correlation analysis. Inflammation associated with periodontal diseases, characterized by elevated pro-inflammatory cytokines, innate immune receptor expression, and cellular infiltrate was exacerbated in patients with T2D. In addition, a feed forward loop regulated by poor glycemic control was associated with a loss of mucosal barrier integrity and accumulation of innate immune receptor ligands resulting in an exacerbation of ongoing inflammation, where RAGE and TLR4 cooperated to induce responses in oral epithelial cells, which were exacerbated by hyperglycemia.

Three cases of subpontic osseous hyperplasia of the mandible: a report.

Subpontic osseous hyperplasia is a relatively uncommon benign submucosal mass of normal bone found beneath a pontic. Three cases of mandibular subpontic osseous hyperplasia are described, adding to the 40 existing cases in the English-language literature. Subpontic osseous hyperplasia may represent a unique reactive osseous metaplasia in the subpontic region, with chronic stimuli and functional or occlusal stress as possible etiologies. This article aims to address the clinical significance, treatment considerations, and radiographic correlation of subpontic osseous hyperplasia.