Adult Cerebral Malaria: Acute and Subacute Imaging Findings, Long-term Clinical Consequences.

Cerebral malaria is an important cause of mortality and neurodisability in endemic regions. We show magnetic resonance imaging (MRI) features suggestive of cytotoxic and vasogenic cerebral edema followed by microhemorrhages in 2 adult UK cases, comparing them with an Indian cohort. Long-term follow-up images correlate ongoing changes with residual functional impairment.

Reframing the clinical phenotype and management of cryptococcal meningitis.

Cryptococcal meningitis is an important global health problem, resulting from infection with the yeast Cryptococcus, especially Cryptococcus neoformans and Cryptococcus gattii, which cause a spectrum of disease ranging from pulmonary and skin lesions to life-threatening central nervous system involvement. The diagnosis and management of cryptococcal meningitis have substantially changed in recent years. Cryptococcal meningitis often occurs in people living with advanced HIV infection, though in high-income countries with robust HIV detection and treatment programmes, it increasingly occurs in other groups, notably solid-organ transplant recipients, other immunosuppressed patients and even immunocompetent hosts. This review outlines the clinical presentation, management and prognosis of cryptococcal meningitis, including its salient differences in people living with HIV compared with HIV-negative patients. We discuss the importance of managing raised intracranial pressure and highlight the advantages of improved multidisciplinary team working involving neurologists, infectious disease specialists and neurosurgeons.

COVID-19: lessons for junior doctors redeployed to critical care.

Approximately 4% of patients with coronavirus disease 2019 (COVID-19) will require admission to an intensive care unit (ICU). Governments have cancelled elective procedures, ordered new ventilators and built new hospitals to meet this unprecedented challenge. However, intensive care ultimately relies on human resources. To enhance surge capacity, many junior doctors have been redeployed to ICU despite a relative lack of training and experience. The COVID-19 pandemic poses additional challenges to new ICU recruits, from the practicalities of using personal protective equipment to higher risks of burnout and moral injury. In this article, we describe lessons for junior doctors responsible for managing patients who are critically ill with COVID-19 based on our experiences at an urban teaching hospital.

Quality improvement education for medical students: a near-peer pilot study.

BACKGROUND: Quality improvement (QI) is an essential component of modern clinical practice. Front-line professionals offer valuable perspectives on areas for improvement and are motivated to deliver change. In the UK, all junior doctors are expected to participate in QI in order to advance to the next stage of their training. However, UK undergraduates receive no standardized training in QI methods. This is perpetuated within medical schools by a lack of teaching capacity and competing priorities, and may lead to tokenistic engagement with future QI projects. METHODS: We describe a near-peer teaching programme designed to introduce students to QI methods. This pilot study was conceived and delivered in full by junior doctors and used existing resources to ensure high quality teaching content. 111 fifth-year medical students from the University of Cambridge were taught in interactive, participative workshops that encourage them to develop their own QI change ideas and projects. Core topics included the model for improvement, driver diagrams, stakeholder engagement, measurement for improvement and analysing and presenting data. Students completed surveys before and immediately after this intervention to assess their understanding of and confidence in utilizing QI methods. Questionnaires were also completed by junior doctor tutors. RESULTS: Analysis of questionnaires completed before and immediately after the intervention revealed statistically significant improvements in students' self-reported understanding of QI (p < 0.05) and confidence in applying techniques to their own work (p < 0.05). Students expressed a preference for QI teaching delivered by junior doctors, citing a relaxed learning environment and greater relevance to their stage of training. Tutors reported increased confidence in using QI techniques and a greater willingness to engage with QI in future. CONCLUSIONS: In this single-centre study, near-peer teaching produced significant improvements in students' self-reported understanding of QI and confidence in applying QI methods. Near-peer teaching may constitute a sustainable means of teaching essential QI skills at undergraduate level. Future work must evaluate objective measures of student engagement with and competence in conducting QI.

Protection against ventricular fibrillation via cholinergic receptor stimulation and the generation of nitric oxide.

KEY POINTS: Animal studies suggest an anti-fibrillatory action of the vagus nerve on the ventricle, although the exact mechanism is controversial. Using a Langendorff perfused rat heart, we show that the acetylcholine analogue carbamylcholine raises ventricular fibrillation threshold (VFT) and flattens the electrical restitution curve. The anti-fibrillatory action of carbamylcholine was prevented by the nicotinic receptor antagonist mecamylamine, inhibitors of neuronal nitric oxide synthase (nNOS) and soluble guanylyl cyclase (sGC), and can be mimicked by the nitric oxide (NO) donor sodium nitroprusside. Carbamylcholine increased NO metabolite content in the coronary effluent and this was prevented by mecamylamine. The anti-fibrillatory action of both carbamylcholine and sodium nitroprusside was ultimately dependent on muscarinic receptor stimulation as all effects were blocked by atropine. These data demonstrate a protective effect of carbamylcholine on VFT that depends upon both muscarinic and nicotinic receptor stimulation, where the generation of NO is likely to be via a neuronal nNOS-sGC dependent pathway. ABSTRACT: Implantable cardiac vagal nerve stimulators are a promising treatment for ventricular arrhythmia in patients with heart failure. Animal studies suggest the anti-fibrillatory effect may be nitric oxide (NO) dependent, although the exact site of action is controversial. We investigated whether a stable analogue of acetylcholine could raise ventricular fibrillation threshold (VFT), and whether this was dependent on NO generation and/or muscarinic/nicotinic receptor stimulation. VFT was determined in Langendorff perfused rat hearts by burst pacing until sustained VF was induced. Carbamylcholine (CCh, 200 nmol l(-1) , n = 9) significantly (P < 0.05) reduced heart rate from 292 ± 8 to 224 ± 6 b.p.m. Independent of this heart rate change, CCh caused a significant increase in VFT (control 1.5 ± 0.3 mA, CCh 2.4 ± 0.4 mA, wash 1.1 ± 0.2 mA) and flattened the restitution curve (n = 6) derived from optically mapped action potentials. The effect of CCh on VFT was abolished by a muscarinic (atropine, 0.1 µmol l(-1) , n = 6) or a nicotinic receptor antagonist (mecamylamine, 10 µmol l(-1) , n = 6). CCh significantly increased NOx content in coronary effluent (n = 8), but not in the presence of mecamylamine (n = 8). The neuronal nitric oxide synthase inhibitor AAAN (N-(4S)-4-amino-5-[aminoethyl]aminopentyl-N'-nitroguanidine; 10 µmol l(-1) , n = 6) or soluble guanylate cyclase (sGC) inhibitor ODQ (1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one; 10 µmol l(-1) , n = 6) prevented the rise in VFT with CCh. The NO donor sodium nitrprusside (10 µmol l(-1) , n = 8) mimicked the action of CCh on VFT, an effect that was also blocked by atropine (n = 10). These data demonstrate a protective effect of CCh on VFT that depends upon both muscarinic and nicotinic receptor stimulation, where the generation of NO is likely to be via a neuronal nNOS/sGC-dependent pathway.

What you need to know about microbiology referrals.

Microbiologists are frequently consulted for guidance on the investigation and management of infection, including antimicrobial prescribing in hospital settings. There is a rising demand for timely microbiology advice in the context of increasing global travel and antibiotic resistance, which give rise to complex cases. However, junior doctors are seldom trained in making effective referrals. Improving confidence in this key skill saves time for both the referring clinician and the specialist, and results in more accurate advice being given. This benefits patients who are more likely to receive appropriate treatment. This article presents guidance, developed in consultation with specialists, to improve the quality of referrals to microbiologists. This includes the information required for a high-quality referral, and signposts referring clinicians to existing resources which are suitable for simpler cases not requiring specialist input.

Social and ethnic group differences in healthcare use by children aged 0-14 years: a population-based cohort study in England from 2007 to 2017.

OBJECTIVE: To describe social and ethnic group differences in children's use of healthcare services in England, from 2007 to 2017. DESIGN: Population-based retrospective cohort study. SETTING/PATIENTS: We performed individual-level linkage of electronic health records from general practices and hospitals in England by creating an open cohort linking data from the Clinical Practice Research Datalink and Hospital Episode Statistics. 1 484 455 children aged 0-14 years were assigned to five composite ethnic groups and five ordered groups based on postcode mapped to index of multiple deprivation. MAIN OUTCOME MEASURES: Age-standardised annual general practitioner (GP) consultation, outpatient attendance, emergency department (ED) visit and emergency and elective hospital admission rates per 1000 child-years. RESULTS: In 2016/2017, children from the most deprived group had fewer GP consultations (1765 vs 1854 per 1000 child-years) and outpatient attendances than children in the least deprived group (705 vs 741 per 1000 child-years). At the end of the study period, children from the most deprived group had more ED visits (447 vs 314 per 1000 child-years) and emergency admissions (100 vs 76 per 1000 child-years) than children from the least deprived group.In 2016/2017, children from black and Asian ethnic groups had more GP consultations than children from white ethnic groups (1961 and 2397 vs 1824 per 1000 child-years, respectively). However, outpatient attendances were lower in children from black ethnic groups than in children from white ethnic groups (732 vs 809 per 1000 child-years). By 2016/2017, there were no differences in outpatient, ED and in-patient activity between children from white and Asian ethnic groups. CONCLUSIONS: Between 2007 and 2017, children living in more deprived areas of England made greater use of emergency services and received less scheduled care than children from affluent neighbourhoods. Children from Asian and black ethnic groups continued to consult GPs more frequently than children from white ethnic groups, though black children had significantly lower outpatient attendance rates than white children across the study period. Our findings suggest substantial levels of unmet need among children living in socioeconomically disadvantaged areas. Further work is needed to determine if healthcare utilisation among children from Asian and black ethnic groups is proportionate to need.

Qualitative evaluation of asthma services for young people: a sequential simulation study.

Background: Asthma is the most common chronic disease of childhood and an important preventable cause of mortality in children and young people (CYP). Few studies have brought together CYP and health professionals to understand the patient perspective of routine asthma care. We sought to explore how young people engage with routine asthma care in North West London through sequential simulation. Method: We designed a sequential simulation focusing on routine asthma management in young people aged 12-18. A 20 min simulation was developed with four young people to depict typical interactions with school nurses and primary care services. This was performed to a mixed audience of young people, general practitioners (GPs), paediatricians, school nurses and commissioners. Young people were invited to attend by their GPs and through social media channels. Attendees participated in audio-recorded, facilitated discussions exploring the themes arising from the simulation. Recordings were transcribed and subjected to thematic analysis. Results: 37 people attended the sequential simulation. Themes arising from postsimulation discussions included recognition of chaotic family lifestyles as a key barrier to accessing care; the importance of strong communication between multidisciplinary team professionals and recognition of the role school nurses can play in delivering routine asthma care. Conclusion: Sequential simulation allows healthcare providers to understand routine asthma care for CYP from the patient perspective. We propose improved integration of school nurses into routine asthma care and regular multidisciplinary team meetings to reduce fragmentation, promote interprofessional education and address the widespread professional complacency towards this lethal condition.

Changes in Emergency Department Activity and the First COVID-19 Lockdown: A Cross-sectional Study.

INTRODUCTION: Emergency department (ED) attendances fell across the UK after the 'lockdown' introduced on 23rd March 2020 to limit the spread of coronavirus disease 2019 (COVID-19). We hypothesised that reductions would vary by patient age and disease type. We examined pre- and in-lockdown ED attendances for two COVID-19 unrelated diagnoses: one likely to be affected by lockdown measures (gastroenteritis), and one likely to be unaffected (appendicitis). METHODS: We conducted a retrospective cross-sectional study across two EDs in one London hospital Trust. We compared all adult and paediatric ED attendances, before (January 2020) and during lockdown (March/April 2020). Key patient demographics, method of arrival, and discharge location were compared. We used Systemised Nomenclature of Medicine codes to define attendances for gastroenteritis and appendicitis. RESULTS: ED attendances fell from 1129 per day before lockdown to 584 in lockdown, 51.7% of pre-lockdown rates. In-lockdown attendances were lowest for under-18s (16.0% of pre-lockdown). The proportion of patients admitted to hospital increased from 17.3% to 24.0%, and the proportion admitted to intensive care increased fourfold. Attendances for gastroenteritis fell from 511 to 103, 20.2% of pre-lockdown rates. Attendances for appendicitis also decreased, from 144 to 41, 28.5% of pre-lockdown rates. CONCLUSION: ED attendances fell substantially following lockdown implementation. The biggest reduction was for under-18s. We observed reductions in attendances for gastroenteritis and appendicitis. This may reflect lower rates of infectious disease transmission, although the fall in appendicitis-related attendances suggests that behavioural factors were also important. Larger studies are urgently needed to understand changing patterns of ED use and access to emergency care during the coronavirus 2019 pandemic.

Respiratory samples to diagnose tuberculosis in the absence of chest x-ray abnormalities.

BACKGROUND: The World Health Organisation states that the chest x-ray (CXR) has a 'high sensitivity for pulmonary tuberculosis (TB)' [1] and as such, is relied on worldwide as the cornerstone of screening for active pulmonary TB (pTB). METHOD: This is a retrospective analysis of plain chest radiographs and microbiological yield in all patients who were diagnosed with pTB or intra-thoracic nodal tuberculosis (ITLN) in two London NHS Trusts. RESULTS: Between 2011 and 2017 8% of those diagnosed with pTB and 32% with ITLN TB had normal CXR appearances in the 6 weeks preceding diagnosis. DISCUSSION: Pulmomary TB was diagnosed in an additional 51 people based on CT scan and 43 people based on respiratory samples. ITLN TB was also diagnosed in a further 20 people using CT but only an extra 3 people from standard respiratory sampling. Our data suggests that CT imaging and respiratory samples should be sent on all suspected cases of pTB and ITLN TB even if the CXR is normal.

The 'National Finals Revision Day' Teaching Strategy: A Cost-Effective Way to Pass Medical School 'Finals' and Upskill Junior Doctors.

Courses to help medical students pass 'Finals' already exist but are typically expensive or can only be attended by a limited number of students. We describe the success of 'The National Finals Revision Day' (NFRD) course, which we believe is sustainable and unique in terms of its combined scale and cost (£10 per person). The course was organised and taught by 12 junior doctors. In total, 300 students attended from 55% of UK medical schools. Attendees found the course both relevant (96.4%) and cost-effective (97%), whilst the 11 medical and surgical talks were of a high standard (90.1%). The organising committee felt confident to organise their own teaching course in the future with 100% having already run a course themselves since the NFRD course. The NFRD course was also used by 11/12 (91.7%) of the organising committee to achieve their Annual Review of Competency Progression (ARCP) and 12/12 (100%) of the organising committee to obtain jobs on training programmes in the UK. We provide guidance about how to organise similar large-scale events for those interested. Moving forward, the teaching course will be run at: (i) multiple times; (ii) multiple UK venues; (iii) run over two days to cover more medical and surgical topics; and (iv) include the option of attending via video link.