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Introduction An electronic resuscitation system, implemented in 2015, within electronic patient records (EPR) at King's College Hospital NHS Foundation Trust was studied, aiming to review and improve decision documentation and communication. Method The study (January 2018 -- June 2018) included all gerontology inpatients with electronic do not attempt cardiopulmonary resuscitation (e-DNACPR) decisions. Cases were identified weekly, followed by retrospective analysis of discharges. Amendments to the electronic system and improvements were implemented between cycles. Cycle 1 One-hundred and thirty-three patients were included; 85% had an e-DNACPR form; 86% of all forms had senior doctor involvement; 68% evidenced patient/relative discussion; 13% documented multidisciplinary team (MDT) discussion. Interventions A mandatory 'named nurse' field was added to the form and trust-wide education programme implemented. Cycle 2 One-hundred and twenty-six patients were included; 100% had an e-DNACPR form; 93% evidenced senior doctor involvement; 71% evidenced patient/relative discussion; 57% documented MDT discussion. Conclusion Changes to the process and trust-wide education resulted in more robust documentation and communication. [ABSTRACT FROM AUTHOR]

The protracted form of COVID-19 known as 'long covid' was first described in 2020. Its symptoms, course and prognosis vary widely; some patients have a multi-system, disabling and prolonged illness. In 2021, ring-fenced funding was provided to establish 90 long covid clinics in England; some clinics were also established in Scotland and Wales. The NIHR-funded LOCOMOTION project implemented a UK-wide quality improvement collaborative involving ten of these clinics, which ran from 2021 to 2023. At regular online meetings held approximately 8-weekly, participants prioritised topics, discussed research evidence and guidelines, and presented exemplar case histories and clinic audits. A patient advisory group also held a priority-setting exercise, participated in quality meetings and undertook a service evaluation audit. The goal of successive quality improvement cycles aimed at changing practice to align with evidence was sometimes hard to achieve because definitive evidence did not yet exist in this new condition; many patients had comorbidities; and clinics were practically constrained in various ways. Nevertheless, much progress was made and a series of 'best practice' guides was produced, covering general assessment and management; breathing difficulties; orthostatic tachycardia and other autonomic symptoms; fatigue and cognitive impairment; and vocational rehabilitation. This paper summarises key findings with the frontline clinician in mind. [ABSTRACT FROM AUTHOR]

Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC. The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers. Experts ranked five system-based metrics highest. These focus on optimisation of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples. The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care. [ABSTRACT FROM AUTHOR]

Introduction Encephalitis is typically caused by infection or autoimmunity. Most survivors suffer complex neurological and psychiatric sequelae. Standardised outcome measures are needed for accurate interpretation of observational studies and clinical trials. Step one in this process is understanding the strengths and weaknesses of those in use. Methods We performed a systematic literature review searching six databases. One reviewer screened titles and abstracts, and two reviewers determined if shortlisted full-text articles met inclusion criteria. Key data were extracted from these papers and presented as a narrative summary. Results Thirty-seven outcome measures were used for 3,133 patients across the 35 included papers, of which, only one was developed for encephalitis. The outcome measures used in most patients were the Glasgow Outcome Score used in 1,436 (46%), Barthel Index used in 1,173 (37%), Euro-QoL-5D used in 1,107 (35%) and modified Rankin Scale used in 1,034 (33%). Conclusion Most of the 37 measures assessed a single category of sequelae using 5--8-point scales and were not validated for use in encephalitis. Research is needed to develop a composite outcome measure for use in clinical practice and a core-outcomes set for use in clinical trials. For now, the Liverpool Outcome Score offers a good choice for clinicians. [ABSTRACT FROM AUTHOR]

Background A qualitative fit test using bitter-tasting aerosols is the commonest way to determine filtering face-piece (FFP) mask leakage. This taste test is subjective and biased by placebo. We propose a cheap, quantitative modification of the taste test by measuring the amount of fluorescein stained filter paper behind the mask using image analysis. Methods A bitter-tasting fluorescein solution was aerosolised during mask fit tests, with filter paper placed on masks' inner surfaces. Participants reported whether they could taste bitterness to determine taste test 'pass' or 'fail' results. Filter paper photographs were digitally analysed to quantify total fluorescence (TF). Results Fifty-six healthcare professionals were fit tested; 32 (57%) 'passed' the taste test. TF between the taste test 'pass' and 'fail' groups was significantly different (p<0.001). A cut-off (TF = 5.0 x 106 units) was determined at precision (78%) and recall (84%), resulting in 5/56 participants (9%) reclassified from 'pass' to 'fail' by the fluorescein test. Seven out of 56 (12%) reclassified from 'fail' to 'pass'. Conclusion Fluorescein is detectable and sensitive at identifying FFP mask leaks. These low-cost adaptations can enhance exiting fit testing to determine 'pass' and 'fail' groups, protecting those who 'passed' the taste test but have high fluorescein leak, and reassuring those who 'failed' the taste test despite having little fluorescein leak. [ABSTRACT FROM AUTHOR]

Background People experiencing homelessness frequently die young, from preventable and treatable conditions. They experience significant barriers to healthcare and are often critically ill when admitted to hospital. A hospital admission is an opportunity to intervene and prevent premature mortality by providing compassionate care and facilitating access to safe onward accommodation and support. Methods To quantify needs, a cross-sectional audit of inpatients experiencing homelessness across 15 acute hospital teams in London, was undertaken in February 2022. Integrated discharge and hospital homelessness teams were interviewed about each patient identified as homeless or vulnerably housed. Data was collected about patients' health, housing, support needs, and reasons for delayed discharges. Results Detailed information was gathered on 86 patients. There was a high level of clinical complexity and multimorbidity. For a safe discharge 60% of individuals were deemed to need accommodation providing high or medium level support and at the time of the audit, half were delayed discharges. Conclusion There is an urgent need for a range of intermediate/step down and longer-term accommodation and support to enable safe appropriate discharge from hospital and start to address the huge inequity in health outcomes of this population. This paper includes recommendations for clinicians and commissioners. [ABSTRACT FROM AUTHOR]

Background During transition from children's to adults' healthcare, young adults with long-term conditions may show delays in psychosocial development compared to their peers without long-term conditions, and deterioration of their conditions' medical control. Methods This paper integrates the findings, already published in 10 separate papers, of a 5-year transition research programme. Implications There is an important role for funders (commissioners) of adults' services to fund transitional healthcare, in addition to funders of children's services who currently take responsibility. It is important that healthcare provider organisations adopt an organisation-wide approach to implementation to ensure that good practice is adopted in children's and adults' services, not just adopted by enthusiasts in some special- ties. This includes provision of 'developmentally appropriate healthcare' which recognises the changing biopsychosocial developmental needs of young people. Three features of transitional healthcare were associated with improved outcomes: appropriate parent involvement, promotion of young people's confidence in managing their health and meeting the adult team before transfer. These should be maintained or introduced as a priority. Child and adult healthcare providers should routinely explore with a young person how they approach transition and personalise their clinical approach thereafter. These implications are relevant for a range of stakeholders, including funders of transitional healthcare, organisations providing transitional healthcare and clinical practitioners. [ABSTRACT FROM AUTHOR]

With the transition of documentation systems, the National Early Warning Score (NEWS) is moving into a digital environment as a part of electronic health records. This paper aims to explore the opportunities and challenges of the digital environment for delivery of NEWS and the impact on safety of deteriorating patients. We make five recommendations to maximise the impact of a change to digital systems for patients, clinicians and healthcare organisations. [ABSTRACT FROM AUTHOR]

Multiple myeloma (MM) is a type of haematological bone marrow malignancy. Cancer Research UK reports that MM is the 18th most common cancer in the UK, accounting for 2% of all new cancer cases, yet, non-haematologists often lack familiarity with the pathology and initial investigations. This paper aims to demonstrate the diagnostic features, relevant investigations and basic management plan for the non-specialist. [ABSTRACT FROM AUTHOR]

Desaturation on exercise has been suggested as a predictive feature for deterioration in COVID-19. The objective of this paper was to determine the feasibility and validity for the 40-steps desaturation test. A prospective observational cohort study was undertaken in patients assessed in hospital prior to discharge. One-hundred and fifty-two participants were screened between November 2020 and February 2021, and 64 were recruited to perform a 40-steps desaturation test. Patients who were able to perform the test were younger and less frail. Four patients were readmitted to hospital and one patient deteriorated within 30 days but no patient died. The majority of patients showed little change in saturations during the test, even with pre-existing respiratory pathology. Change in saturations, respiratory rate, heart rate and breathlessness were not predictive of death or readmission to hospital within 30 days. Of 13 patients who had a desaturation of 3% or more during exercise, none was readmitted to hospital within 30 days. Not enough patients with COVID-19 could be recruited to the study to provide evidence for the safety of the test in this patient group. The 40-steps desaturation test requires further evaluation to assess clinical utility. [ABSTRACT FROM AUTHOR]

The protracted form of COVID-19 known as ‘long covid’ was first described in 2020. Its symptoms, course and prognosis vary widely; some patients have a multi-system, disabling and prolonged illness. In 2021, ring-fenced funding was provided to establish 90 long covid clinics in England; some clinics were also established in Scotland and Wales. The NIHR-funded LOCOMOTION project implemented a UK-wide quality improvement collaborative involving ten of these clinics, which ran from 2021 to 2023. At regular online meetings held approximately 8-weekly, participants prioritised topics, discussed research evidence and guidelines, and presented exemplar case histories and clinic audits. A patient advisory group also held a priority-setting exercise, participated in quality meetings and undertook a service evaluation audit. The goal of successive quality improvement cycles aimed at changing practice to align with evidence was sometimes hard to achieve because definitive evidence did not yet exist in this new condition; many patients had comorbidities; and clinics were practically constrained in various ways. Nevertheless, much progress was made and a series of ‘best practice’ guides was produced, covering general assessment and management; breathing difficulties; orthostatic tachycardia and other autonomic symptoms; fatigue and cognitive impairment; and vocational rehabilitation. This paper summarises key findings with the frontline clinician in mind.

There is growing recognition of the need for perioperative medicine services for older surgical patients. Comprehensive geriatric assessment and optimisation methodology has been successfully used to improve perioperative outcomes at tertiary centres. This paper describes translation of an established model of geriatrician-led perioperative care to a district general hospital (DGH) setting. Methods A mixed methods quality improvement programme was used and included stakeholder co-design, identification of core components, definition of mechanisms for change, and measurement of impact through qualitative and quantitative approaches. Results Within 18 months, a substantive perioperative service for older people was established at a DGH, funded by the surgical directorate. Key outcomes included reduction in length of stay and 30-day readmission and positive staff and patient experience. Discussion This study is in keeping with improvement science literature demonstrating the importance of a mixed-methods approach in translating an evidenced-based intervention into another setting, maintaining fidelity and replicating results. [ABSTRACT FROM AUTHOR]

Giant cell arteritis (GCA) is a systemic vasculitis with numerous potential complications and societal costs. After the publication of international guidelines, we found a number of deficiencies in the local care pathway of patients suspected to have GCA. These included poor referral and management pathways, and absence of dedicated monitoring and followup. In this paper, we describe a 10-year transformation which led to our service being nominated for a national award. A comprehensive consensus pathway saw referral numbers rise from 19 to 135 from 2012 to 2019. A consensus management pathway has meant that patients are assessed within 2 days of referral and glucocorticoids started at point of referral. All patients with suspected GCA are clerked and managed according to this agreed pathway which is available on the hospital intranet. The introduction of diagnostic ultrasonography has meant that the need for biopsies has dropped by >80% reducing the annual cost of diagnostics by >£140,000. The introduction of a vasculitis specialist nurse has resulted in improving education, contact and speed of access to our service. The improvements in the service resulted in our service becoming a finalist in the Royal College of Physicians Excellence in Patient Care Award in 2020. [ABSTRACT FROM AUTHOR]

Background Perioperative optimisation can improve outcomes for older people having surgery. Integration with primary care could improve quality and reduce variability in access to preoperative optimisation. Aim Our aim was to explore attitudes, beliefs and behaviours of general practitioners (GPs) regarding the perioperative pathway, and evaluate enablers and barriers to GP-led preoperative optimisation. Methods Stakeholder interviews (n=38) informed survey development. A purposive sampling frame was used to target delivery of online and paper surveys. Results were analysed using descriptive statistics. Results We had 231 responses (response rate 32.7%). Enablers included belief among GPs that optimisation improves postoperative outcomes (86%) and that they have a role discussing modifiable risk factors with patients (85%). Barriers included low frequency exposure to older surgical patients, minimal training in perioperative medicine and rare interaction with perioperative services. Conclusion This survey illustrates the importance of interprofessional education, cross-sector training opportunities and collaboration to deliver integrated preoperative optimisation for older people undergoing surgery. [ABSTRACT FROM AUTHOR]

Medically unexplained symptoms or persistent physical symptoms are common, real and are associated with significant distress, loss of functioning and high healthcare costs. History, examination and appropriate investigations are essential to make a diagnosis. Once the diagnosis has been made, exploring the impact of the symptoms helps us to tailor our advice to patients. This paper sets out a practical approach to taking a history, assessment and stepwise management principles. [ABSTRACT FROM AUTHOR]

Driving improvements in patient safety has been a core goal of the Academic Health Science Networks (AHSNs) in England since their inception in 2013. The National Patient Safety Collaborative Programme, nested within the 15 geographically located AHSNs, was established in 2014 in response to the Berwick review. In 2019, the new NHS national patient safety strategy was published, which placed the AHSNs as a key vehicle for delivering its ambitions. This paper explores the achievements of, and opportunities presented by, the collaborative in addressing some of the key patient safety challenges facing physicians and their wider teams. Case studies illustrate the AHSNs' contribution to support national ambitions, including the adoption of the National Early Warning Score (NEWS) 2, and the impact of regionally-led work on patient outcomes, such as reducing mortality from sepsis and acute kidney injury. We set out current activities, opportunities for physician engagement and plans for future work. [ABSTRACT FROM AUTHOR]

The taking of blood for diagnostic purposes is a frequent cause of difficulty for physicians. In patients with intact visible or palpable large veins, such as those often seen in the antecubital fossa, a needle or cannula entering from any direction will usually be rewarded with any quantity of blood. In smaller veins in less convenient locations, such as in the hand, the direction of the needle becomes much more important. Failure to take blood is very commonly because of failure to appreciate the direction of flow of venous blood up the arm, and the ubiquitous presence of valves in the veins, both aspects of the circulation clearly described by William Harvey nearly 4 centuries ago. This paper encourages more frequent success with phlebotomy by remembering Harvey's work and pointing the needle in the right direction; this is not always towards the heart. [ABSTRACT FROM AUTHOR]

In this paper, I discuss the central importance of the clinical consultation to defi ning the potential outcomes for an episode of care. The consultation is also crucial to patient safety. Yet the processes of clinical consultations on ward rounds and outpatients have attracted little attention in terms of ergonomics or research. I propose 10 quality indicators that would be simple to measure and could be used to improve clinical consultations. Better consultations would reduce the possibility of misdiagnosis and also improve patient outcomes, patient experience, patient safety and staff satisfaction. It is high time we improved clinical consultations in hospital settings. [ABSTRACT FROM AUTHOR]

background The novel coronavirus disease (COVID-19) is the most challenging health crisis that we are facing today. Against the backdrop of this pandemic, it becomes imperative to study the effects of this infection on pregnancy outcome and its mode of delivery. Hence, the present study was undertaken to evaluate the effects of COVID-19 infection on pregnancy as well as the outcome. Materials and methods In this retrospective observational analytical study, a total of 150 pregnant women were included in the study, from 1 September 2020 to 1 May 2021, most of them confirmed that positive COVID-19 by PCR, depending on questionaries' paper distributed to the infected pregnant women at that time in Babylon government. Results We observed that young females (<20 years) had the least chance of infection, rural areas were more vulnerable to infection than urban areas, employed pregnant women had a higher chance of infection than unemployed, and that the majority of women were treated at home. Of those infected patients, those who were infected during their third trimester were more likely to present with complications with their pregnancy (rather than COVID-19), such as IUGR and IUD etc. Regarding the mode of delivery, there is a slightly increased rate of caesarian section (CS) when compared with the typical population, after excluding the obstetric indication for CS, such as complete placenta prevea. Conclusion There is no significant effect of COVID-19 infection on maternal and fetal outcomes in pregnancy, despite a slight increase in preterm labor and C/S. [ABSTRACT FROM AUTHOR]

Increasing the number of organ transplants is a priority for most governments. While potential new legislation for donor registration, such as the Welsh Government white paper on establishing an opt-out system for Welsh residents, is the focus of most ethical and legal scrutiny, there are also other approaches to increase the number of patients receiving organ transplants. The then National Institute for Health and Care Excellence (NICE) published guidance on this issue in 2011, but subsequent debate in this journal has suggested that the guidance was presumptuous and might encourage unethical practice. This paper addresses these concerns and concludes that the NICE guidance provides a legal, ethical and clinically relevant way forward in a complex and developing public health issue. [ABSTRACT FROM AUTHOR]

Although often underappreciated, a number of bacterial zoonoses are endemic in Africa. Of these, brucellosis, leptospirosis, Q fever, and rickettsioses are responsible for a substantial proportion of febrile illness among patients seeking hospital care. In this paper, we discuss the aetiology, epidemiology, clinical presentation, diagnosis, treatment and prevention of these bacterial zoonoses. To prevent and control bacterial zoonoses, strategies targeting both animals and humans are crucial. These may lead to better outcomes than strategies based exclusively on treatment of human infections. Such strategies are referred to as the 'One Health' approach; the collaborative effort of multiple disciplines to attain optimal health for people, animals and the environment. [ABSTRACT FROM AUTHOR]

This paper describes how difficult it can be to discuss the experience of breathlessness with patients, as identified by respiratory trainees in a psychology-led workshop. The reasons why it is considered an essential role for clinicians to facilitate conversations about patients' breathlessness are outlined within the context of the challenges of respiratory care. The benefits for both patient and clinician are described including rapport building, more focused and targeted consultations, and increasing a patient's receptivity to interventions. The value of preparing a patient to actively engage with their breathlessness management is highlighted. As a way to support clinicians to initiate talk about breathlessness, a 'five-step guide to talking' is presented. [ABSTRACT FROM AUTHOR]

In January 2019, a new nationally commissioned Genomic Medicine Service (GMS) has now commenced in the NHS. Capitalising on the infrastructure developed through the 100,000 Genomes Project, the GMS is underpinned by seven supra-regional Genomic Laboratory Hubs (GLHs) delivering the new inherited rare disease and cancer somatic tissue genetic test directory. This replaces the UKGTN test directory, with the aim of standardising criteria for whole genome sequencing or targeted panel tests where applicable. The new test directory will define who can order specific genetic tests under prescribed eligibility criteria. In keeping with Dame Sally Davies' white paper Generation Genome, this will further democratise genetic testing and, in some situations, avoid the need to refer to clinical genetics to access testing. The aim is to simplify patient pathways and reduce regional or social inequalities. We will discuss the implications of whole genome sequencing and the potential impact of the new nationally commissioned GMS for both patients, their relatives and clinicians. We will also discuss the imminent challenges in implementing genomic medicine into the NHS, and the future impact of novel technologies on service delivery as genomic medicine becomes increasingly integrated into routine healthcare. [ABSTRACT FROM AUTHOR]

St George's Hospital hyperacute neurology service (HANS) is a comprehensive, consultant-delivered service set in a teaching hospital regional neuroscience centre. The service addresses deficiencies in acute neurological care previously highlighted by the Royal College of Physicians and the Association of British Neurologists. HANS adopts a disease-agnostic approach to acute neurology, prioritising the emergency department (ED) management of both stroke and stroke mimics alike alongside proactive daily support to the acute medical unit and acute medical take. Rapid access clinics provide a means to assess ambulatory patients, providing an outlet to reduce the burden of referral from primary care to acute medicine. This paper reports the results from the first year of the service. Admission was avoided in 25% of the cases reviewed in the ED. Compared to historic data, there was a significant improvement in the length of stay for non-stroke disorders while the occupancy of stroke beds by non-stroke cases reduced by 50%. The configuration of this service is replicable in other neuroscience centres and provides a framework to reduce the barriers facing patients who present with acute neurological symptoms. [ABSTRACT FROM AUTHOR]

This paper describes the implementation of an interprofessional patient record (IPPR) at Sheffield Teaching Hospitals NHS Foundation Trust (STHFT). The IPPR was a two year project, commencing in May 2008, aimed at creating a single IPPR to which all staff contribute. Prior to the IPPR, records were profession specific with nursing, medical and therapy staff keeping separate ones. This paper describes the process for the project including the stakeholder engagement plan, the development of IPPR standards, the education and training programme and the key measures used to assess implementation. The staff survey and clinical audit data suggest that the IPPR was successfully implemented with many of the perceived benefits realised. The keys to success of this major change project were: time spent engaging clinical staff, board level support, the appointment of a dedicated project team and the involvement and support of many staff involved in patient records throughout STHFT. [ABSTRACT FROM AUTHOR]

Social determinants of health are responsible for a large proportion of disease which disproportionately affects deprived population groups, resulting in striking disparities in life expectancy and quality of life. Even systems with universal access to healthcare (such as the UK's NHS) can only mitigate some consequences of health inequalities. Instead substantial societal measures are required both to reduce harmful exposures and to improve standards of housing, education, work, nutrition and exercise. The case for such measures is widely accepted among healthcare professionals but, in wider discourse, scepticism has remained about the role of government and society in improving life chances along with the belief that responsibility for health and wellbeing should rest with individuals themselves. The stark inequalities exposed by the coronavirus pandemic could be an opportunity to challenge this thinking. This paper argues that doctors should do more to persuade others of the need to address health inequalities and that to achieve this, it is important to understand the ethical and philosophical perspectives that are sceptical of such measures. An approach to gaining greater support for interventions to address health inequalities is presented along with reflections on effective political advocacy which is consistent with physicians' professional values. [ABSTRACT FROM AUTHOR]

Gender bias and sexism in the health profession in the UK has been highlighted as a major problem. Efforts to reduce this must include medical training and examinations. The Situational Judgment Test (SJT) is an examination that must be passed to work as a foundation doctor in the UK; and is taken by all UK medical students. We analysed gender balance in all 215 scenarios included in the official practice papers for the SJT. We found that senior doctors were more than twice as likely to be men than women, while there was no significant gender difference in representation of foundation year-1 doctors, other health professionals or patients/relatives. This inequality has the potential to reinforce gender biases in healthcare. Medical examinations can, instead, represent an opportunity for prejudices to be challenged. [ABSTRACT FROM AUTHOR]

Supply of immunoglobulin in the UK faces pressures due to increasing demand, cost and variable supply. This paper describes immunoglobulin replacement therapy (IGRT) in primary immunodeficiency (PID) and secondary immunodeficiency (SID) to assist in the ongoing planning of UK immunoglobulin provision. A retrospective analysis of the National Immunoglobulin Database and the UKPID registry was carried out. In total, 3,222 patients are registered as receiving IGRT for immunodeficiencies. Predominately antibody disorders made up the largest diagnostic category (61% of patients). The total cost of IGRT for immunodeficiency for 2015/16 was £40,673,350; an average annual cost of £1,099,254 per centre and £12,124 per PID patient. SCIg accounted for 43.8% and 50.1% of IGRT, with home therapy accounting for 42.7% and 57.5% of place of therapy in the National Immunoglobulin Database and UKPID registry respectively. In 2015/16 use of immunoglobulin in SID increased by 24% over the previous financial year. The overall trends of increasing demand in immunology are mirrored in other specialties, most notably neurology and haematology. These data are the first national overview of IGRT for immunodeficiencies, providing a valuable resource for clinicians and policy makers in the ongoing management of UK immunoglobulin supply. [ABSTRACT FROM AUTHOR]

The brain dysfunction associated with certain medical and neurological conditions can produce essentially any psychiatric symptom. This means there is always a chance that presentations thought to be 'psychiatric' are actually explained by unidentified medical pathology. This paper aims to outline an approach to minimise these missed diagnoses. [ABSTRACT FROM AUTHOR]

Global developmental delay and intellectual disability are phenotypically and genetically heterogeneous and a specific diagnosis is not reached in many cases. This paper outlines a systematic approach to global developmental delay and intellectual disability. [ABSTRACT FROM AUTHOR]

Virtually all medical specialties are impacted by genetic disease. Enhanced understanding of the role of genetics in human disease, coupled with rapid advancement in sequencing technology, is transforming the speed of diagnosis for patients and providing increasing opportunities to tailor management. As set out in the Annual report of the Chief Medical Officer 2016: Generation Genome 1 and the recent NHS England board paper Creating a genomic medicine service to lay the foundations to deliver personalised interventions and treatments, 2 the increasing 'mainstreaming' of genetic testing into routine practice and plans to embed whole genome sequencing in the NHS mean that the profile and importance of genomics is on the rise for many clinicians. This article provides a brief overview of genomics and its current clinical applications, including its contribution to personalised medicine. Physicians will be signposted to key issues that will allow the successful implementation of genomics for rare disease diagnosis and cancer management. [ABSTRACT FROM AUTHOR]

Approximately 13% of people living with HIV in the UK are unaware of their infection. New diagnoses among people ≥50 years is increasing. Unique factors may be associated with testing in this group. This systematic review aims to identify patient and clinician-related barriers/facilitators to HIV testing in people aged ≥50 years. A systematic electronic search was conducted. Papers were assessed for eligibility and data from eligible studies were extracted. Barriers/facilitators were grouped, and the number of times they were reported was noted. Because of considerable heterogeneity, a narrative approach has been undertaken to synthesise data. In total, 17 studies were included. Main barriers to testing were low perceived risk and clinicians' preconceptions about older people. Main facilitators were regular use of healthcare services or being offered/encouraged to test by a healthcare provider. Although being encouraged to test was a common facilitator, clinicians' preconceptions about older people was the biggest barrier. This shows a divide between clinicians' preconceptions and patients' expectations, which may impact on testing rates. This review is an important first step in identifying potential barriers/facilitators for further study or to be addressed in the design of future interventions. [ABSTRACT FROM AUTHOR]

Physicians reading this will have a broad range of in-depth knowledge about their own subspecialty. However, in daily medical practice there are topics of which all physicians should have some knowledge. Those who deal with young people should have some knowledge of the needs of the hearing- impaired population within this group of patients. This article is intended to provide an overview of young people with hearing impairment (HIYP), the challenges they face and what we can do to help them. In this paper, we assume that data published regarding hearing-impaired children apply to HIYP from 13 years (the age at which the transition process begins) to 25 years of age (the age at which 'youth' according to the World health Organization and the Education Health Care Plan ends). [ABSTRACT FROM AUTHOR]

The aim of this study was to follow up a sample of physicians who began core medical training (CMT) in 2009. This paper examines the long-term validity of CMT and GP selection methods in predicting performance in the Membership of Royal College of Physicians (MRCP(UK)) examinations. We performed a longitudinal study, examining the extent to which the GP and CMT selection methods (T1) predict performance in the MRCP(UK) examinations (T2). A total of 2,569 applicants from 2008–09 who completed CMT and GP selection methods were included in the study. Looking at MRCP(UK) part 1, part 2 written and PACES scores, both CMT and GP selection methods show evidence of predictive validity for the outcome variables, and hierarchical regressions show the GP methods add signifi cant value to the CMT selection process. CMT selection methods predict performance in important outcomes and have good evidence of validity; the GP methods may have an additional role alongside the CMT selection methods . [ABSTRACT FROM AUTHOR]

A conference paper on osteoarthritis is presented in which the author describes about prevalent, painful and debilitating conditions. The European League Against Rheumatism (EULAR), Osteoarthritis Research Society International (OARSI) and National Institute for Health and Clinical Excellence (NICE) provide treatment strategies to benefit from risk assessment of patients to obtain optimal therapy. The author suggests that therapies can be improved by identifying patients phenotypes.

It is widely assumed by the general public that if assisted suicide (AS) or euthanasia (VE) were legalised doctors must be essentially involved in the whole process including prescribing the medication and (in euthanasia) administering it. This paper explores some reasons for this assumption and argues that it flatly contradicts what it means to be a doctor. The paper is thus not mainly concerned with the ethics of AS/VE but rather with the concept of a doctor that has evolved since the time of Hippocrates to current professional guidance reflected in healthcare law. The paper argues that the most common recent argument for AS/VE - that patients have a right to control when and how they die - in fact points to the involvement not of doctors but of legal agencies as decision makers plus technicians as agents. [ABSTRACT FROM AUTHOR]

Acute care common stem acute medicine (ACCS AM) training was designed to develop competent multi-skilled acute physicians to manage patients with multimorbidity from 'door to discharge' in an era of increasing acute hospital admissions. Recent surveys by the Royal College of Physicians have suggested that acute medical specialties are proving less attractive to trainees. However, data on the career pathways taken by trainees completing core acute medical training has been lacking. Using London as a region with a 100% fill rate for its ACCS AM training programme, this study showed only 14% of trainees go on to higher specialty training in acute internal medicine and a further 10% to pursue higher medical specialty training with dual accreditation with internal medicine. 16% of trainees switched from ACCS AM to emergency medicine or anaesthetics during core ACCS training, and intensive care medicine proved to be the most popular career choice for ACCS AM trainees (21%). The ACCS AM training programme therefore does not appear to be providing what it was set out to do and this paper discusses the potential causes and effects. [ABSTRACT FROM AUTHOR]

Oxygen is the most commonly used drug in the acute hospital setting. Oxygen can be lifesaving but there is increasing evidence that it can cause harm if it is not given correctly. Prescription of oxygen, according to target saturations, has been advocated since 2008 but compliance remains at low levels. This paper describes a novel approach to improve oxygen prescription and titration in three acute hospital trusts using a colour-coded silicone wristband. The project ran for 3 months and covered more than 2,000 emergency admissions to hospital. Data was collected for oxygen prescription and titration rates for 270 patients during the project period. The wristbands showed an improvement in prescription and titration of oxygen in two out of three sites. The results support a wider controlled study of colour-coded wristbands to improve oxygen safety in secondary care. [ABSTRACT FROM AUTHOR]

There is no national NHS tariff to fund services for patients experiencing long-term bowel and nutritional problems after cancer treatment. In this paper, we report the clinical characteristics and outcomes of patients referred to our service and the estimated cost of a completed episode of care. Patient characteristics, symptom severity, investigations, diagnoses, number of clinic visits and referrals elsewhere were recorded in a prospective cohort study. During 2013-14, 325 patients completed assessment and treatment. The majority of original cancer diagnoses were urological (43%) and gynaecological (21%). A median of six investigations were requested. 62% were found to have three or more new diagnoses including small intestinal bacterial overgrowth (46%), vitamin D deficiency (38%), bile acid malabsorption (28%), gastritis (22%), radiation-induced bleeding (20%), vitamin B12 deficiency (17%), pelvic floor weakness (17%), colorectal polyps (13%) and pancreatic insufficiency (5%). A median of three visits were required and all commonly reported gastrointestinal symptoms improved by discharge. The mean episode of care per patient was costed at £1,563. Effective amelioration of chronic gastrointestinal toxicity after cancer treatment costs substantially less than treating the cancer in the first place and requires an NHS tariff. [ABSTRACT FROM AUTHOR]

Written knowledge assessments for physicians in training typically involve multiple-choice questions that use a clinical scenario in a single-best-answer format. The Royal College of Physicians Part 1 MRCP(UK) examination includes basic sciences themes that are challenging to assess through a clinical scenario. A realistic clinical setting based on everyday clinical practice and integral to the question is the clearest demonstration that the knowledge being assessed is clinically relevant. However, without special attention to detail, the scenario in a clinical science question can appear redundant or artificial. Reading unnecessary material frustrates candidates and threatens the reputation of the assessment. In this paper we discuss why a clinical scenario is important for basic science questions and offer advice on setting realistic and plausible clinical scenarios for such questions. [ABSTRACT FROM AUTHOR]

Primary HIV infection (PHI) refers to the first six months following HIV acquisition and represents a unique opportunity for expedited diagnosis, and consideration of rapid antiretroviral therapy (ART) initiation to improve immune function, reduce the size of the viral reservoir and limit the risk of onward viral transmission. Failure to diagnose and rapidly treat individuals with PHI has significant individual and public health implications. The Strategic Timing of AntiRetroviral Treatment trial recently identified a clinical benefit of immediate ART over deferral of treatment according to CD4 count threshold, and has led to rapid changes in World Health Organization and specialist national guidelines. For all individuals living with HIV, the offer of immediate therapy irrespective of CD4 count is now recommended. This paper summarises the presentation and management of PHI, incorporating current research and guideline changes and discusses the role of PHI in onward transmission. [ABSTRACT FROM AUTHOR]

The term 'Black Wednesday' has been used to describe the August national changeover day, a day when a new cohort of inexperienced doctors start work, many of whom are absent from patient care to attend organisational induction and mandatory training. In this paper, we report on the development and implementation of a novel, interactive e-learning programme for induction and mandatory training for junior doctors in a district general hospital in south-west England from August 2013. This comprehensive mandatory-training programme with summative assessment saved 19.5 hours of trust time per trainee. Since the programme's inception, the completion rate has been 100% (n = 370). Subgroup analysis of starters from August 2013 (n = 141) showed that 85.7% completed by day 1 (mean time of completion 3.0 days before day 1, standard deviation 14.2 days). Importantly, 90 minutes of induction was freed on Black Wednesday, enabling earlier, ward-based clinical orientation, thereby enhancing patient safety. We believe that this is the first programme to combine induction with fully assessed, comprehensive mandatory training in a single package. Such an approach is suitable for widespread application and is to be implemented regionally. [ABSTRACT FROM AUTHOR]

It is widely recognised that developmentally appropriate services for adolescents and young people improve both healthcare experience and health outcomes. However, there is limited evidence of using young people's expertise to evaluate services, or of young people participating in service developments or design to meet their healthcare needs. This report covers both the process and outcomes of a collaborative project with a group of young people (aged 17-25 years) who are 'experts by experience'. We used qualitative mixed methodology to derive themes from narrative accounts of these young people's healthcare experiences to develop an assessment framework that they identified as being relevant to evaluating services. Informing young people about other assessment measures currently in use (including the Department of Health's You're Welcome quality criteria) enabled the group to further develop their views and refine their proposed assessment framework. This paper is co-authored with young people, enabling them to directly voice their views about healthcare services. Reflections on this process and recommendations for working more collaboratively with young people to evaluate healthcare services are also given. [ABSTRACT FROM AUTHOR]

There is little in the literature describing hospital specialist palliative care units (PCUs) within the NHS. This paper describes how specialist PCUs can be set up within and be entirely funded by the NHS, and outlines some of the challenges and successes of the units. Having PCUs within hospitals has offered patients increased choice over their place of care and death; perhaps not surprisingly leading to a reduced death rate in the acute hospital. However, since the opening of the PCUs there has also been an increased home death rate. The PCUs are well received by patients, families and other staff within the hospital. We believe they offer a model for excellence in cost-effective inpatient specialist palliative care within the NHS. [ABSTRACT FROM AUTHOR]

Radiotherapy is an effective treatment modality and an essential tool in the management of cancer. As the incidence of malignant disease rises it is inevitable that physicians will increasingly encounter patients who have presented acutely and require radiotherapy or with a complication from irradiation. This paper explores the basic principles of radiotherapy tailored to the perspective of the acute medical physician and how to manage acute complications. We also discuss the role of radiotherapy in the acutely ill patient and define the need for radiotherapy pathways to ensure that patients receive treatment in a timely manner. [ABSTRACT FROM AUTHOR]