Emergency medicine response to the COVID-19 pandemic in England: a phenomenological study.

BACKGROUND: The COVID-19 pandemic has stretched EDs globally, with many regions in England challenged by the number of COVID-19 presentations. In order to rapidly share learning to inform future practice, we undertook a thematic review of ED operational experience within England during the pandemic thus far. METHODS: A rapid phenomenological approach using semistructured telephone interviews with ED clinical leads from across England was undertaken between 16 and 22 April 2020. Participants were recruited through purposeful sampling with sample size determined by data saturation. Departments from a wide range of geographic distribution and COVID-19 experience were included. Themes were identified and included if they met one of three criteria: demonstrating a consistency of experience between EDs, demonstrating a conflict of approach between emergency departments or encapsulating a unique solution to a common barrier. RESULTS: Seven clinical leads from type 1 EDs were interviewed. Thematic redundancy was achieved by the sixth interview, and one further interview was performed to confirm. Themes emerged in five categories: departmental reconfiguration, clinical pathways, governance and communication, workforce and personal protective equipment. CONCLUSION: This paper summarises learning and innovation from a cross-section of EDs during the first UK wave of the COVID-19 pandemic. Common themes centred around the importance of flexibility when reacting to an ever-changing clinical challenge, clear leadership and robust methods of communication. Additionally, experience in managing winter pressures helped inform operational decisions, and ED staff demonstrated incredible resilience in demanding working conditions. Subsequent surges of COVID-19 infections may occur within a more challenging context with no guarantee that there will be an associated reduction in A&E attendance or cessation of elective activity. Future operational planning must therefore take this into consideration.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: The use of corticosteroids in the management of costochondritis.

A short cut review was carried out to establish whether there is any evidence that for the use of corticosteroids in the treatment of costochondritis. No papers were found using the reported search. The clinical bottom line is that further research is needed in this area.

Integrating sustainability into postgraduate medical education.

The delivery of healthcare is a major contributor to the climate crisis, with the NHS being the largest public sector contributor of carbon emissions in the UK. Physicians have an important role to play in the fight against climate change through the practice of sustainable healthcare. This involves maintaining the current and future quality of healthcare through balancing environmental, social and financial constraints. To this end, integrating these skills into medical education is crucial. A large number of medical schools have already embedded planetary health and sustainability theory into their curriculum, however, there is no formal sustainability curriculum in postgraduate education and training. This is vital for enabling clinicians to translate sustainability theory taught at undergraduate level into clinical practice. This article proposes which topics should be included in a postgraduate sustainability curriculum and explores various methods that could be used to incorporate these into the current educational framework.

A comprehensive hospital agile preparedness (CHAPs) tool for pandemic preparedness, based on the COVID-19 experience.

COVID-19 presents an unprecedented challenge to hospitals and the systems in which they operate. The primary exponential surge of COVID-19 cases is arguably the most devastating event a hospital will face. In some countries, these surges during the initial outbreak of the disease have resulted in hospitals suffering from significant resource strain, leading to excess patient mortality and negatively impacting staff wellbeing. As experience builds in managing these surges, it has become evident that agile, tailored planning tools are required. The comprehensive hospital agile preparedness (CHAPs) tool provides clinical planners with six key domains to consider that frequently create resource strain during COVID-19; it also allows local planners to identify issues unique to their hospital, system or region. Although this tool has been developed from COVID-19 experiences, it has potential to be modified for a variety of pandemic scenarios according to transmission modes, rates and critical care resource requirements.

Sympathetic nerve varicosities in close apposition to basolateral membranes of collecting duct epithelial cells of rat kidney.

BACKGROUND: There are reports of sympathetic innervation of the nephron and of P2 purinergic receptors on epithelial cells. Since ATP is a cotransmitter with noradrenaline in sympathetic nerves, the objective of the present study was to re-investigate basolateral innervation of rat renal collecting duct epithelial cells by sympathetic nerves in the context of recent data on the effects of ATP on this nephron segment. METHODS: Kidney sections were processed for electron immunocytochemistry, using tyrosine hydroxylase rabbit polyclonal antibody, with a second layer of biotinylated donkey anti-rabbit antibody and finally extravidin-horseradish peroxidase. Immunoreactivity was visualised with 3,3'-diaminobenzidine and examined with a Philips CM120 transmission electron microscope. RESULTS: Electron microscopic evidence is presented for close apposition of sympathetic nerve varicosities immunolabelled with tyrosine hydroxylase to principal and intercalated type epithelial cells of the collecting duct of the cortical region. CONCLUSIONS: It is suggested that ATP is released as a cotransmitter from sympathetic nerve varicosities to act on basolateral P2 purinoceptors to influence sodium and water (and potentially acid-base) transport, in conjunction with the known (typically inhibitory) actions of autocrine and/or paracrine release of ATP from collecting duct epithelial cells acting via luminal P2 receptors. It is suggested that while luminal responses may dominate under normal physiological conditions, in pathophysiological states, such as stress and dehydration, sympathetic nerves might also be involved in modulating collecting duct fluid and electrolyte transport.

A complementary component to atypical haemolytic uraemic syndrome.

We describe a case of a 22-year-old man who presented with clinical features of atypical haemolytic uraemic syndrome and in whom genetic analysis of complement regulatory proteins demonstrated a CD46 mutation. He was treated with plasma exchange, intermittent haemodialysis and blood transfusions. At 6-month follow-up his haematological parameters and renal function showed complete resolution, and he experienced no further disease recurrence in the subsequent year.

Page kidney in a 17-year-old renal allograft.

Page kidney is a condition where extrinsic renal compression from a haematoma or mass results in hypertension and loss of renal function. Most cases are caused by a subcapsular haematoma following blunt trauma or invasive procedures (eg, renal biopsy). We report a patient who spontaneously developed Page kidney 17 years after renal transplantation. This case represents the oldest renal allograft to develop non-traumatic Page kidney.