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Background Early-life exposure increases health risks throughout an individual's lifetime. Biological aging is influenced by early-life risks as a key process of disease development, but whether early-life risks could accelerate biological aging and elevate late-life mortality and morbidity risks remains unknown. Knowledge is also limited on the potential moderating role of healthy lifestyle. Methods We investigate associations of three early-life risks around birth, breastfeeding, maternal smoking and birth weight, with biological aging of 202 580 UK Biobank participants (54.9 ± 8.1 years old). Biological aging was quantified as KDM-BA, PhenoAge and frailty. Moderate alcohol intake, no current smoking, healthy diet, BMI <30 kg/m2 and regular physical activity were considered as healthy lifestyles. Mortality and morbidity data were retrieved from health records. Results Individual early-life risk factors were robustly associated with accelerated biological aging. A one-unit increase in the 'early-life risk score' integrating the three factors was associated with 0.060 (SE=0.0019) and 0.036-unit (SE = 0.0027) increase in z-scored KDM-BA acceleration and PhenoAge acceleration, respectively, and with 22.3% higher odds (95% CI: 1.185–1.262) of frailty. Increased chronological age and healthy lifestyles could mitigate the accelerations of KDM-BA and PhenoAge, respectively. Associations of early-life risk score with late-life mortality and morbidity were mediated by biological aging (proportions: 5.66–43.12%). KDM-BA and PhenoAge accelerations could significantly mediate the impact on most outcomes except anxiety, and frailty could not mediate the impact on T2D. Conclusion Biological aging could capture and mediate the late-life health risks stemming from the early-life risks, and could be potentially targeted for healthy longevity promotion. [ABSTRACT FROM AUTHOR]

Background Recent work in the UK estimated the prevalence of current cannabinoid-based vaping to be higher than in the USA, a factor previously associated with e-cigarette or vaping-associated lung injury (EVALI). Research in the USA has demonstrated that attendances to emergency departments relating to e-cigarettes began to rise before the EVALI outbreak, suggesting that vapers also experience milder forms of vaping-related illness. Aim Quantify symptom prevalence and healthcare utilization amongst current UK vapers. Design Voluntary online survey of individuals aged 16 and over within the UK. Methods Anonymized data were collected on demographics, vaping/smoking status and vaping substances used. Current vapers were asked about the presence of 10 prevalent symptoms from previous US EVALI case series, healthcare attendances and diagnoses given. Risk-ratios were calculated to compare the likelihood of symptoms and attendances between substances. Results A total of 2477 complete responses were analysed. In all, 397 respondents were current vapers. Symptom prevalence within the previous 12 months ranged from 3.8% to 30.5% (bloody sputum, cough). Healthcare attendances per symptomatic respondent ranged from 0.1 to 1.4 (bloody sputum, shortness of breath). Current vapers of cannabinoid-based products (alone/in combination) had the most attendances per symptomatic respondent for 9/10 symptoms and were more likely to report symptoms aside from 'cough' (nicotine-free e-liquids [risk ratio = 1.7]). Clinicians reportedly never diagnosed vaping-related illness. Conclusions UK vapers experience symptoms previously reported in EVALI cases for which they also seek healthcare. Users of cannabinoid-based products were more likely to report symptoms and accounted for a higher healthcare burden. UK vapers may also experience vaping-related illness that does not meet EVALI case criteria. [ABSTRACT FROM AUTHOR]

Background Vaping of cannabinoid-based products and informal acquisition of vaping products were associated with the outbreak of E-cigarette or vaping associated lung injury (EVALI) in the USA. Current prevalence of cannabinoid-based vaping within the UK is not known and literature regarding the acquisition of vaping products is limited. Aim To estimate the prevalence of nicotine-based, nicotine-free and cannabinoid-based product vaping within the UK and to determine where vaping products are acquired. Design and methods A voluntary online survey of individuals aged 16 and over within the UK was conducted using a convenience sample. Data were collected on respondent demographics, smoking/vaping history and acquisition of e-liquids/products. Results A total of 2478 responses were included. Median age 45 years (interquartile range 35–57). Prevalence of current vaping of nicotine-based e-liquids, nicotine-free e-liquids and cannabinoid-based products was 14.4%, 11.2% and 5.49%, respectively. Current nicotine-based and nicotine-free vaping was most prevalent in 25–34 years olds (22.4% and 19.2% of respondents). Current cannabinoid-based vaping was most prevalent in 16–24 years olds. The most common 'ever' used cannabinoid-based products were cannabidiol oil/cannabigerol oil and cannabis leaves (4.8%). Specialist vaping stores were the most common source of 'ever' acquisition for all products. 36.8% and 40.5% of respondents who had ever vaped nicotine-based and nicotine-free e-liquids reported prior acquisition from informal sources. Conclusion This survey reported a higher prevalence of current cannabinoid-based vaping within the UK (5.5%) than previously reported in the USA (2.0%). In addition to the informal acquisition of vaping products as demonstrated within the survey, these results highlight potential underestimation of the risk of EVALI within the UK. [ABSTRACT FROM AUTHOR]

Objective To determine the proportion of emergency patients treated with immune checkpoint inhibitors (ICIs) that require critical care admission and their requirements. Design Prospective case series. Methods Analysis of acutely unwell patients treated with ICIs attending a tertiary UK cancer hospital between May 2018 and May 2022. The primary outcome measure was the percentage of patients treated with ICI therapy requiring ICU admission. The secondary outcome measure was whether this need was driven by an immune-mediated toxicity. Results Eighteen (1.2%) patients of the 1561 acutely admitted patients treated with ICI therapy required an admission to ICU. Ten (55.5%) patients were admitted due to an immune-mediated toxicity; four due to pneumonitis and four due to myasthenia gravis. Seven of 10 survived their ICU admission with 6 surviving at least 6-month post-ICU discharge. Conclusions Only a small minority of emergency admissions in patients treated with ICIs require admission to ICU. This series adds further evidence that patients with organ failure due to immune-mediated toxicity may achieve good outcomes from ICU admission. [ABSTRACT FROM AUTHOR]

Introduction Stenotrophomonas maltophilia is a bacteria whose role in patients with cystic fibrosis (CF) bronchiectasis has been previously studied; little is known about its role in non-CF bronchiectasis. Materials and methods Aim of our study is to investigate the risk factors for S. maltophilia acquisition and its clinical impact on bronchiectasis patients. A retrospective observational cohort study enrolling patients attending the Bronchiectasis Clinic at the Royal Infirmary of Edinburgh, Scotland, UK. A total of 167 bronchiectasis patients undergoing intravenous (IV) antibiotic therapy were selected and divided according to single or chronic S. maltophilia isolation in sputum. The risk factors and prognostic impact were studied. Results Single isolation was independently associated with lower baseline % predicted forced expiratory volume in 1 s [odds ratio (OR) 0.98; 95% confidence interval (CI) 0.970–1.044; P  = 0.025] and with less radiological involvement (OR 0.379; 95% CI 0.175–0.819; P  = 0.01). Chronic isolation was associated with the number of IV antibiotic courses in the year before and after the first isolation (OR 1.2; 95% CI 1.053–1.398; P  = 0.007) and with the absence of Pseudomonas aeruginosa colonization (OR 0.207; 95% CI 0.056–0.764; P  = 0.02). In the chronic isolation group, there were more exacerbations and more need of IV antibiotics in the year after the first isolation. Conclusions Poor lung function is the main independent risk factor for single isolation of S. maltophilia. For chronic colonization, the main independent risk factor is the number of IV antibiotic courses and the absence of P. aeruginosa chronic colonization. Only when chronically present, S. maltophilia had a clinical impact with more exacerbations. [ABSTRACT FROM AUTHOR]

Background Loperamide is a mu-opioid receptor agonist that is available as an over-the-counter anti-motility agent in the US and UK; recommended maximum doses of 12-16 mg/day. Anecdotal reports of non-medical use (NMU) have increased over the past decade with supra-therapeutic doses (70-800 mg/day) associated with cardiotoxicity. Little data exists on the prevalence of loperamide NMU. Aim The aim of this study was to determine the prevalence of loperamide NMU in the UK and US and to describe characteristics of non-medical loperamide users. Design The Researched, Abuse, Diversion and Addiction Related Surveillance (RADARS®) Survey of Nonmedical Use of Prescription Drugs (NMURx) was utilized to study NMU of loperamide among the adult population in the UK and US in 2017. The RADARS® NMURx is anonymous and self-administered online. Methods A total of 40,029 completed surveys were included (10,019 from the UK and 30,010 from the US). Respondents were asked questions about medical and NMU of loperamide, frequency of and reasons for NMU, route of use problematic drug use markers, and demographics. Results Prevalence of lifetime loperamide use (95% CI) and lifetime NMU of loperamide were: UK 28.5% (27.67-29.4), and 0.66% (0.5-0.8), respectively; US 33.7% (33.1-34.2), and 5.19% (4.9-5.5), respectively. Problematic drug use markers were elevated in those who reported NMU of loperamide in both the UK and US, however high-risk use was more prevalent in the UK than in the US. Conclusion NMU of loperamide is common. In the current international environment of opioid addiction involving both therapeutic and illicit opioids, awareness of the NMU of loperamide is important. [ABSTRACT FROM AUTHOR]

Background Immunoglobulin-G4-related disease (IgG4-RD) is a recently recognized fibro-inflammatory condition that can affect multiple organs. Despite growing interest in this condition, the natural history and management of IgG4-RD remain poorly understood. Aim To describe the clinical characteristics, treatment and outcomes of IgG4-RD in a multi-ethnic UK cohort, and investigate its possible association with malignancy. Design Retrospective analysis of case-note and electronic data. Methods Cases were identified from sub-specialty cohorts and a systematic search of an NHS trust histopathology database using 'IgG4' or 'inflammatory pseudotumour' as search terms. Electronic records, imaging and histopathology reports were reviewed. Results In total, 66 identified cases of IgG4-RD showed a similar multi-ethnic spread to the local population of North West London. The median age was 59 years and 71% of patients were male. Presenting symptoms relating to mass effect of a lesion were present in 48% of cases and the mean number of organs involved was 2.4. Total of 10 patients had reported malignancies with 6 of these being haematological. 83% of those treated with steroids had good initial response; however, 50% had relapsing-remitting disease. Rituximab was administered in 11 cases and all achieved an initial serological response. Despite this, seven patients subsequently relapsed after a mean duration of 11 months and four progressed despite treatment. Conclusions We report a large UK-based cohort of IgG4-RD that shows no clear ethnic predisposition and a wide range of affected organs. We discuss the use of serum IgG4 concentrations as a disease marker in IgG4-RD, the association with malignant disease and outcomes according to differing treatment regimens. [ABSTRACT FROM AUTHOR]

Background Timely and consistent recognition of a 'clinical crisis', a life threatening condition that demands immediate intervention, is essential to reduce 'failure to rescue' rates in general wards. Aim To determine how different clinical caregivers define a 'clinical crisis' and how they respond to it. Design An international survey. Methods Clinicians working on general wards, intensive care units or emergency departments in the Netherlands, the United Kingdom and Denmark were asked to review ten scenarios based on common real-life cases. Then they were asked to grade the urgency and severity of the scenario, their degree of concern, their estimate for the risk for death and indicate their preferred action for escalation. The primary outcome was the scenarios with a National Early Warning Score (NEWS) ≥7 considered to be a 'clinical crisis'. Secondary outcomes included how often a rapid response system (RRS) was activated, and if this was influenced by the participant's professional role or experience. The data from all participants in all three countries was pooled for analysis. Results A total of 150 clinicians participated in the survey. The highest percentage of clinicians that considered one of the three scenarios with a NEWS ≥7 as a 'clinical crisis' was 52%, while a RRS was activated by <50% of participants. Professional roles and job experience only had a minor influence on the recognition of a 'clinical crisis' and how it should be responded to. Conclusion This international survey indicates that clinicians differ on what they consider to be a 'clinical crisis' and on how it should be managed. Even in cases with a markedly abnormal physiology (i.e. NEWS ≥7) many clinicians do not consider immediate activation of a RRS is required. [ABSTRACT FROM AUTHOR]

Background The severity of Tuberous Sclerosis Complex (TSC) can vary among affected individuals. Complications of TSC can be life threatening, with significant impact on patients' quality of life. Management may vary dependent on treating physician, local and national policies, and funding. There are no current UK guidelines. We conducted a Delphi consensus process to reach agreed guidance for the management of patients with TSC in the UK. Methods We performed a literature search and reviewed the 2012/13 international guideline for TSC management. Based on these, a Delphi questionnaire was formed. We invited 86 clinicians and medical researchers to complete an online survey in two rounds. All the people surveyed were based in the UK. Clinicians were identified through the regional TSC clinics, and researchers were identified through publications. In round one, 55 questions were asked. In round two, 18 questions were asked in order to obtain consensus on the outstanding points that had been contentious in round one. The data was analysed by a core committee and subcommittees, which consisted of UK experts in different aspects of TSC. The Tuberous Sclerosis Association was consulted. Results About 51 TSC experts took part in this survey. Two rounds were required to achieve consensus. The responders were neurologists, nephrologists, psychiatrist, psychologists, oncologists, general paediatricians, dermatologist, urologists, radiologists, clinical geneticists, neurosurgeons, respiratory and neurodisability clinicians. Conclusions These new UK guidelines for the management and surveillance of TSC patients provide consensus guidance for delivery of best clinical care to individuals with TSC in the UK. [ABSTRACT FROM AUTHOR]

Background Acute Kidney Injury (AKI) is associated with adverse outcomes; therefore identifying patients who are at risk of developing AKI in hospital may lead to targeted prevention. Aim We undertook a UK-wide study in acute medical units (AMUs) to define those who develop hospital-acquired AKI (hAKI); to determine risk factors associated with hAKI and to assess the feasibility of developing a risk prediction score. Design Prospective multi-centre cohort study across 72 AMUs in the UK. Methods Data collected from all patients who presented over a 24-h period. Chronic dialysis, community-acquired AKI (cAKI) and those with fewer than two creatinine measurements were excluded. Primary outcome was the development of h-AKI. Results Two thousand four hundred and fourty-six individuals were admitted to the seventy-two participating centres. Three hundred and eighty-four patients (16%) sustained AKI of whom two hundred and eighty-seven (75%) were cAKI and ninety-seven (25%) were hAKI. After exclusions, chronic kidney disease [Odds Ratio (OR) 3.08, 95% Confidence Interval (CI) 1.96–4.83], diuretic prescription (OR 2.33, 95% CI 1.5–3.65), a lower haemoglobin concentration and elevated serum bilirubin were independently associated with development of hAKI. Multi-variable model discrimination was only moderate (c-statistic 0.75). Conclusions AKI in AMUs is common and associated with worse outcomes, with the majority of cases community acquired. Only a small proportion of patients develop hAKI. Prognostic risk factor modelling demonstrated only moderate discrimination implying that widespread adoption of such an AKI clinical risk score across all AMU admissions is not currently justified. More targeted risk assessment or automated methods of calculating individual risk may be more appropriate alternatives. [ABSTRACT FROM AUTHOR]

Aim Although socioeconomic background is known to impact on the incidence and progression of chronic kidney disease, its influence of on the presentation and outcome for acute kidney injury is not known and is the subject of this study. Design The Welsh National electronic AKI reporting system was used to identify all cases of AKI in patients >18 years of age between March 2015 and November 2017. Methods Socioeconomic classification of patients was derived from the Welsh Index Multiple Deprivation score (WIMD). Patients were grouped according to the WIMD score by their postcode, and the ranked data were categorized into percentiles and correlated with incidence and measures of AKI severity and outcome. Results Date was collected on a total of 57 654 patients. Increased deprivation was associated with higher AKI incidence rates, more episodes of AKI per patient and more severe AKI at presentation. In contrast 90-day mortality was highest in the most affluent areas. Mortality in affluent areas was driven by increased patient age. Corrected for age 90-day mortality was higher in areas of increased deprivation. Conclusion This study highlights that AKI incidence presentation and outcomes are adversely affected by social deprivation. Further studies are required to understand the extent to which these differences reflect patient related factors or regional differences in provision and access to care. [ABSTRACT FROM AUTHOR]

The majority of medical patients presenting to hospital in the UK are cared for in acute medical units (AMUs). Such units are also increasingly present internationally. Care delivery varies across units: this review aims to examine the evidence for how best to deliver AMU care. Six electronic databases and grey literature were searched. Inclusion criteria comprised interventions applied to undifferentiated patients in AMU settings. All studies were quality assessed. A narrative approach was undertaken. Nine studies, all conducted in the UK or Ireland, evaluated 1.3 million episodes, 3617 patients and 49 staff. There was single study evidence for beneficial effects of: enhanced pharmacy care, a dedicated occupational therapy service, an all-inclusive consultant work pattern, a rapid-access medical clinic and formalized handovers. Two studies found increased consultant presence was associated with reduced mortality; one of these studies found an association with a reduction in 28-day readmissions; and the other found an association with an increased proportion of patients discharged on the day they were admitted. Three studies provide evidence of the beneficial effects of multiple interventions developed from local service reviews. Overall, the quality of the evidence was limited. This review has identified operationally relevant evidence that increased consultant presence is associated with improved outcomes of care; has highlighted the potential to improve outcomes locally through service reviews; and has demonstrated an important knowledge gap of how best to deliver AMU care. These findings have importance given the challenges acute services currently face. [ABSTRACT FROM AUTHOR]

Background: Acute medical units (AMUs) are a central component of the admission pathway for the majority of medical patients presenting to hospital in the United Kingdom and other international settings. Detail on multidisciplinary staffing provision on weekdays and weekends is lacking. Equity of staffing across 7 days is a strategic priority for national health services in the United Kingdom. Aim: To evaluate weekday compared with weekend multidisciplinary staffing in a national set of AMUs. Design: Cross-sectional survey. Methods: Twenty-nine Scottish AMUs were identified and all were included in the study population. Data were collected by semi-structured interviews with nursing, pharmacy, therapy, non-consultant medical and consultant staff. Staffing was quantified in staff hours. A correction factor of 0.5 was applied to non-dedicated staff. The percentage of weekend/ weekday staffing was calculated for each unit and the mean of these percentages was calculated to give a summary measure for each professional group. Results: As a percentage of weekday staffing levels, weekend staffing across the units was 93.8% for nursing staff; 2.2% for pharmacy staff; 13.1% for therapy staff; 69.6% for non-consultant staff and 65.0% for consultant staff. Conclusions: There is a contrast between weekday and weekend staffing on the AMU, with reductions at weekends in total staff hours, the proportion of dedicated vs. undedicated staff and the seniority of nursing staff. The weekday/weekend difference was far more pronounced for allied healthcare professional staff than any other group. These findings have potential implications for patient outcomes, quality of care, hospital flow and workforce planning. [ABSTRACT FROM AUTHOR]

Electronic cigarettes (e-cigarettes) are increasing in popularity with 19% of UK smokers reporting to have used them. The ability to regulate the evaporation temperature in newer electronic nicotine delivery systems (ENDS) facilitates the potential for use of these devices to 'vape' cannabis, novel psychoactive substances (NPS) and other recreational drugs. Vaping cannabis does have the potential to reduce tobacco use and combustible cannabis/tobacco-related disease, but with over one-third of UK adults reporting life-time use of recreational drugs and increasing e-cigarette uptake in adolescent groups the misuse of these devices poses a serious potential public health risk. Further work is therefore urgently required to inform the appropriate treatment and primary prevention strategies for this emerging issue. [ABSTRACT FROM AUTHOR]

Background: Codeine misuse and dependence poses a clinical and public health challenge. However, little is known about dependence and treatment needs in the UK and Ireland. Aim: To characterize codeine use, dependence and help-seeking behaviour. Design: An online cross-sectional survey advertised on Facebook, Twitter, health and drug websites and e-mail circulars. Methods: The survey collected data on demographics and codeine use amongst adults from the UK and Ireland. The Severity of Dependence Scale measured the level of codeine dependence. Results: The sample of 316 respondents had a mean age of 35.3 years (SD¼12.3) and 67% were women. Of the 316 respondents, 54 scored ≥5 on the Severity of Dependence Scale indicating codeine dependence (17.1%). Our study found that codeine dependence is a problemwith both prescribed and 'over-the-counter' codeine. Codeine dependence was associated with daily use of codeine, faking or exaggerating symptoms to get a prescription for codeine and 'pharmacy shopping' (P < 0.01). A higher number of respondents had sought advice on the Internet (12%) rather than from their general medical practitioner (GP) (5.4%). Less than 1% of respondents had sought advice from a pharmacist. Conclusions: Codeine dependent users were more likely to seek help on the Internet to control their use of codeine than from a GP, which may indicate a potential for greater specialized addiction treatment demand through increased identification and referrals in primary care. [ABSTRACT FROM AUTHOR]

Background: The Society for Acute Medicine's Benchmarking Audit (SAMBA) annually examines Clinical Quality Indicators (CQIs) of the care of patients admitted to UK hospitals as medical emergencies. Aim: The aim of this study is to review the impact of consultant specialty on discharge decisions in the SAMBA data-set. Design and methods: Prospective audit of patients admitted to acute medical units (AMUs) on 25 June 2015 to participating hospitals throughout the UK with subgroup analysis. Results: Eighty-three units submitted patient data from 3138 patients. Nearly 1845 (58%, IQR for units 50-69%) of patients were referrals from Emergency Medicine, 1072 (32%, IQR for units 24-44%) were referrals from Primary Care. The mean age was 65 (SD 20). One hundred and forty-one (4.5%) patients were admitted from care homes and 951 (30%) of patients were at least 'mildly frail' and 407 (13%) had signs of physiological instability. The median and the mean time to being seen by a doctor were 1 h 20min and 2h 3 min, respectively. The median and the mean time to being seen by senior specialist were 3h 55min and 5h 56 min, respectively. By 72 h, 29 (1%) patients had died in the AMU, 73 were admitted to critical care units, 1297 (41%) had been discharged to their own home and 60 to nursing or residential homes. For every 100 patients seen specialists in acute medicine discharged 12 more patients than specialists from other disciplines of medicine (P<0.001). The difference remained significant after adjustment for case mix. Conclusion: Specialist in acute care might facilitate discharge in a higher proportion of patients. [ABSTRACT FROM AUTHOR]

Background: Alcohol and substance use in adolescence can be associated with a range of health, emotional, social, behavioural and legal problems. There has been a change in the recreational drugs available to users in recent years; however, little is known about how this impacts the youngest and most vulnerable population of substance users. Aim: To investigate the prevalence of substance use among children aged 15-18 years in London schools. Design: Questionnaire survey. Method: Students aged 15-18 years in three London schools self-completed the questionnaire which collected demographic data (age, gender and ethnicity) and data on frequency of use of alcohol, tobacco and classical recreational drugs and novel psychoactive substances. Results: Completed surveys were available from 533 students (47.8% of those invited to participate). One hundred thirteen (20.4%) students reported lifetime use of at least one recreational drug, cannabis (96, 18.7%) was commonly reported and only 6 (1.1%) reported use of a novel psychoactive substance. A total of 250 (47.8%) reported using alcohol at least once; those from White and Mixed ethnic groups were more likely to report using alcohol than those in other ethnic groups. A total of 382 (74.2%) students reported using tobacco at least once, and students from ethnic minorities were more likely to smoke than their White counterparts. Conclusion: This study supports previous findings that alcohol and drug use are declining in adolescents in UK. There are different patterns of substance use amongst different ethnic groups; this is important to schools and policymakers planning interventions related to substance use in school-aged children. [ABSTRACT FROM AUTHOR]

Background: Pseudomonas aeruginosa is a rare cause of meningitis and ventriculitis but is generally associated with significant morbidity and mortality. Aim: We sought to determine the epidemiology, risk factors and outcome of meningitis and ventriculitis due to P. aeruginosa at our institution in order to inform preventive strategies and treatment guidelines. Methods: Retrospective study of all patients with a positive cerebrospinal fluid (CSF) culture admitted to a tertiary care hospital over 18 years. Clinical details, demographic, microbiological and antibiotic data were obtained from laboratory and medical records. Results: Twenty-four episodes occurred in 21 patients over 18 years. Pyrexia (75%), fluctuating mental status (50%) and headache (41%) were the most frequent presenting symptoms. Nineteen of the 21 patients had previously undergone a neurosurgical procedure and seven had extra-ventricular devices in situ. Twelve (57%) patients had P. aeruginosa isolated from another site prior to their episode. Most (89%) CSF samples demonstrated a neutrophilia; the CSF protein, when measured, was raised in all cases. Gram-negative bacilli were visible on CSF microscopy in only three isolates. There were relatively low rates of resistance to most antimicrobials tested and combination treatment of intravenous with intrathecal antibiotics was often used. No patients died within 28 days. Conclusion: Pseudomonas aeruginosa meningitis and ventriculitis are predominantly nosocomial and related to prior neurosurgery. It can be difficult to diagnose as CSF Gram-film and meningism are insensitive markers. Appropriate empirical treatment, neurosurgical prophylaxis and surveillance can aid in managing this infection. [ABSTRACT FROM AUTHOR]

I would like to comment on those suggestions During the UK-India Telemedicine Project, junior doctors managed the patinets in some satellite Covid-19 centres as their workforce capacity was stretched to the limit by an influx of many patients. These junior doctors presented cases (by maintaining patient confidentiality) to a panel of UK Consultants in a virtual ward round. All the UK clinicians involved in this project are full-time National Health Service (NHS) doctors and they contributed to this project in their free time. [Extracted from the article]

Background: Specialist clinics are recommended for the assessment and follow-up of patients with heart valve disease. We sought to identify the current provision of specialist valve clinics in UK.Methods: A database of all UK National Health Service hospitals was created. An online survey was distributed to each hospital to examine the model of heart valve clinic, patient population, provision of advanced imaging modalities and biochemical markers and provision of patient information services.Results: Valve clinics were run in 48/228 (21%) hospitals, in 27/45 (60%) tertiary centres and 21/183 (11%) district hospitals. The survey was completed by 34 (71%). A consultant cardiologist ran the clinic in 19 (56%), a cardiac sonographer in 8 (24%), a nurse specialist in 3 (9%) and a hybrid model was used in 4 (12%). Patients with native valve disease were seen in 32 (94%), after heart valve surgery in 19 (56%), pre-/post-transcatheter valve intervention in 10 (29%) and with Marfan syndrome in 9(26%). Stress echocardiography, cardiac magnetic resonance imaging, computed tomography and positron emission tomography were available in 21 (62%), 19 (56%), 22 (65%) and 6 (18%) hospitals, respectively.Conclusion: There is an underprovision of specialist heart valve clinics within the UK, and there is a 5-fold difference between cardiac centres and district general hospitals. [ABSTRACT FROM AUTHOR]

Background: There have been few studies on risk factors and treatment outcomes of isoniazid (H)-resistant tuberculosis (TB), and optimal treatment regimens are debated.Aim: To identify risk factors for H-resistant TB, describe treatment regimens and compare these to national guidelines and describe short-term outcomes of H-resistant TB in Birmingham, UK.Design: Retrospective case series.Methods: Cases of H-resistant tuberculosis in Birmingham between January 1999 and December 2010 (n = 89) were compared with drug-susceptible cases (n = 2497). Treatment regimens and outcomes at 12 months from diagnosis were evaluated by case note review.Results: No independent predictors for H-resistant TB were found. For 76/89 (85%) patients with full treatment details available, median treatment duration was 11 months (interquartile range 9–12 months). Only 27/72 (38%) patients with H-monoresistance were treated in line with national guidelines. A further 14/72 (19%) were treated according to other recognized guidelines. Overall treatment success was 75/89 (84%). Treatment failure occurred in 6/89 (7%) patients, all developed multi-drug resistance. Poor adherence was documented in these patients and use of a non-standard regimen in one patient was not thought to have contributed to treatment failure.Conclusions: No discriminating risk factors for early detection of H-resistant TB were found. Treatment regimens in clinical practice were highly varied. H-resistance can drive MDR-TB when there is evidence or suspicion of poor adherence. A low threshold for enhanced case management with directly observed therapy is warranted in this group. [ABSTRACT FROM AUTHOR]

Background: Although autologous stem cell transplantation (ASCT) may achieve disease control in severe treatment-resistant Crohn’s disease (CD), relapse is frequent, and there is little information regarding long-term outcomes in terms of response to subsequent treatments and complications of ASCT.Design: Retrospective evaluation of UK patients treated on a compassionate basis from three UK tertiary centres.Methods: We summarize long-term outcomes of six previously unreported patients with severe treatment-resistant CD treated with ASCT according to international guidelines between 2003 and 2009. Median duration of CD before ASCT was 14 (7–22) years. Following stem cell mobilization, patients were treated with high-dose cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulin (7.5 mg/kg) followed by ASCT.Results: All patients tolerated ASCT with routine toxicities and no treatment-related mortality and are alive at 50–123 months post-ASCT. Clinical and endoscopic remissions of CD were confirmed at 3 months post-ASCT in five patients, although median time to next treatment for inflammatory disease was 10 months (range: 3–16 months). Subsequently, disease control was achieved with previously ineffective and newer treatments, with surgery performed predominantly for pre-existing fibrotic strictures. Two patients became independent of home total parenteral nutrition (TPN). Reported late complications of ASCT included hypothyroidism and ovarian failure.Conclusion: Long-term follow-up supports the safety and feasibility of ASCT as a means of achieving short-term control of severe CD whilst potentially re-sensitizing the disease to medical therapy and reducing requirements for surgery and TPN. Given the inevitability of relapse, pre-emptive salvage and/or maintenance treatments post-ASCT should be the focus of future trials. [ABSTRACT FROM AUTHOR]

Background: A recording of ≥30 s is required for diagnosis of paroxysmal atrial fibrillation (AF) when using ambulatory electrocardiography (ECG) monitoring. It is unclear if shorter runs of atrial arrhythmia are relevant with regard to stroke risk.Aim: To assess current management of patients with atrial arrhythmia of <30 s duration detected on ambulatory ECG.Design: Online survey.Methods: An online survey was sent to cardiologists and stroke physicians in the UK, via their national societies.Results: A total of 205 clinicians responded to the survey (130 stroke physicians, 64 cardiologists, 11 other). Regarding diagnosis of AF, 87% of responders would accept a single 12-lead ECG. In contrast, only 45% would accept a single episode lasting <30 s detected on ambulatory monitoring. There was more agreement with regard to the decision to anticoagulate. When asked whether they would anticoagulate eight hypothetical patients with non-diagnostic paroxysms of AF, there was a mean agreement of responses of 78.6%, with up to 94.1% agreement for high-risk patients. There was a trend suggesting that stroke physicians were more likely to accept an atrial arrhythmia of <30 s as ‘AF’ than cardiology specialists [OR 1.63 (95% CI 0.88–3.01), P = 0.12].Conclusions: There is a lack of consensus on the diagnosis and management of patients with brief runs of atrial arrhythmia detected on ambulatory ECG. Further research is needed to clarify the risk of stroke in this unique population of patients. [ABSTRACT FROM AUTHOR]

The second review by Dr Gupta and colleagues of the Institute of Post Graduate Medical Education and Research, West Bengal, India relates to the rarer occurrence of herpes simplex encephalitis in the post-acute COVID-19 infection period. Does anti-viral treatment in acute COVID infection decrease the risk of developing the Long-COVID Syndrome? It was W.B. Yeats, Nobel Laureate and renowned poet who once wrote: Education is not the filling of a pail but the lighting of a fire As the academic home for Translational Medicine, the Association seeks to promote and sustain this lighting of that fire of scientific curiosity. [Extracted from the article]