Search

Background: The Black Country (BC) is an area of the United Kingdom covering Dudley, Sandwell, Walsall, and Wolverhampton. The area is ethnically, culturally and religiously diverse. One-fifth of the total population is in the lowest socioeconomic quintile, with an uneven distribution of wealth. The area manifests unmet needs and as perceived underserved community groups. Objectives and Methods: To better understand the situation and inform future provision, listening events were organised across the BC to engage with local underserved communities. A mixed-methods design was employed, using collaborative workshops. The workshops enabled stakeholders to explore priorities, perceived barriers and solutions to mental health services' access within the BC. Results: Sixty participants verbally consented and signed in to attend the three workshops. There were nine groups that provided 247 statements on the topic, yielding a total of 12 codes and six themes (priorities). The top identified priorities were inappropriate periodisation of accessible funded healthcare needs (n = 42, 18.03%), barriers to appropriate healthcare (n = 49, 21.03%) and limited resources for training, health promotion, preventative care and support networks (n = 62, 26.61%). Conclusions: Addressing the identified priorities will require location and community-specific solutions to establish those communities' trust and engagement. Cultural stigma should not be viewed as the only barrier to access healthcare but should be considered in combination with the population's reluctance to reach out to healthcare services due to loss of trust between community groups and lack of co-design of culturally and religiously appropriate services for the community.

Background: Diabetic ketoacidosis (DKA) is a life-threatening condition among diabetic patients characterized by metabolic anion gap (AG) acidosis of arterial pH <7.30, glucose >250 mg/dL, and positive ketones. The triggers for DKA can be infection, surgery, and, in reported cases, intraparenchymal hemorrhage (IPH). In rare cases of DKA, despite being in active ketoacidosis, glucose levels may be within normal or accepted range. Such a condition is called euglycemic DKA. It has been recently recognized in association with the use of sodium glucose co-transporter-2 (SGLT-2) inhibitors in the treatment of type 2 diabetes., Case Description: An 83-year-old male taking an SGLT-2 inhibitor (empagliflozin) for type 2 diabetes presented with an IPH. His laboratory studies revealed an elevated AG acidosis, an elevated beta hydroxybutyrate, and serum glucose levels within the acceptable range. Urine studies revealed elevated ketones and glucose. The diagnosis of euglycemic DKA was made, and the patient was treated with insulin and glucose infusions., Conclusion: Like hyperglycemic ketoacidosis, euglycemic DKA requires prompt recognition and immediate aggressive medical therapy, but the diagnosis can be challenging, and the treatment using insulin in the setting of a normal glucose can be counterintuitive. Euglycemic DKA can often be missed in the setting of blood glucose not being elevated. Prompt recognition and treatment are critical for successful management., Competing Interests: There are no conflicts of interest., (Copyright: © 2024 Surgical Neurology International.)

Aim: This survey was conducted to determine the type and frequency of antibiotics (AB) use for the prevention of infections in dental third molar (M3) extraction and implantation procedures (DIP) among UK dentists and the opinions underpinning their practice., Methods and Design: Systematic reviews of the evidence were undertaken alongside this survey of practicing dentists in the United Kingdom to identify the opinions and practices of those undertaking the procedures.With ethical approval, a survey was designed for online delivery and was sent to every dental practitioner in the UK with a publicly available email address or social media contact. The opening page provided the project information sheet and proceeding to complete and submit the questionnaire was considered consent to participate. The online survey was circulated to 900 identified addresses and a total of 145 responses were received. Responses were collated in Microsoft® Excel™ and analyzed using IBM® SPSS™ plus thematic analysis of free text responses., Results: There were 42% of participants (n=61) who discouraged AB prophylactic use in M3 extractions in people with no systemic conditions and who also preferred postoperative AB use when required. Where, 57.9% of respondents (n=84) supported the short-term use of ABs (5-7 days) for M3 extraction and 53% (n=77) in DIP placement in patients with no relevant medical history. As an ad hoc finding, dentists reported on the negative impact of heavy smoking and oral parafunctional behavior on DIP success., Conclusion: The use of antibiotics and broad spectrum antibiotics remains higher than current guidelines would recommend. Further research is required to clarify the specific risks arising from underlying medical conditions to further clarify where prophylaxis is required.

This systematic review compared the efficacy and tolerance of oral antipsychotics (APDs) used in the treatment of schizophrenia following the PRISMA-P© statement ( n = 21). The primary outcomes of interest were clinical response measured with symptoms' improvement, tolerance to side effects and discontinuation reasons. There was better individual patients' response to aripiprazole vs. ziprasidone and quetiapine ((CDSS p = 0.04), BPRS p = 0.02, YMRS p = 0.001) and ziprasidone vs. quetiapine (CGI p = 0.02, CDSS p = 0.02). Aripiprazole was more tolerated than risperidone, ziprasidone and quetiapine ( p < 0.05). Quetiapine was more tolerated than aripiprazole, ziprasidone and risperidone ( p < 0.05). Ziprasidone was more tolerated than quetiapine haloperidol and olanzapine ( p < 0.05). Risperidone was more tolerated than olanzapine ( p = 0.03) and haloperidol was more tolerated than olanzapine and quetiapine ( p < 0.05). Olanzapine caused less discontinuation than quetiapine; quetiapine caused less discontinuation than ziprasidone, aripiprazole and haloperidol; ziprasidone caused less discontinuation than quetiapine, aripiprazole and haloperidol; aripiprazole caused less discontinuation than quetiapine, ziprasidone and olanzapine and olanzapine caused less discontinuation than ziprasidone and haloperidol ( p < 0.05). It was concluded that individual patient clinical response, tolerance to side effects and life-threatening side effects remain the most reliable basis for selecting and continuing the use of APD.

The aim of this survey of psychiatrists from the UK and India was to compare their opinions on antipsychotic medication choice and their experiences of such medications' effectiveness and tolerability in patients who were newly diagnosed with acute schizophrenia. Following ethical approval, a cross-sectional online survey of psychiatrists from the UK and India was conducted. Ninety-five responses were received from each country. The most selected first-line APDs in both countries were olanzapine (47.5%), risperidone (42.8%) and aripiprazole (25.3%). A total of 60% of psychiatrists from India (60%) and 48% from the UK (48%) selected 'medication efficacy' as the main factor in their choice. Reassessment and consideration to switch most often took place within 4-6 weeks (53.7%) and 3-6 months (11.6%). The major reasons for switching antipsychotic medications were poor clinical efficacy (69%) and lack of tolerability (45%). Nonadherence was the most common reason for relapse (90% of UK psychiatrists and 70% of Indian psychiatrists), followed by illicit drug use (27.6%). The most commonly reported side effects that led to nonadherence were weight gain (10.8%), drowsiness (10.4%), erectile dysfunction and movement disorders (equally 8.7%). It was concluded that olanzapine, risperidone and aripiprazole are the most commonly selected as the initial treatment choice by psychiatrists from India and the UK. They are perceived as widely effective and well tolerated.

Background: A limited number of studies have explored patients' experience with home parenteral (injectable) therapy (HPT) in the UK., Aim: To explore the immediate-, short-, and long-term experience of patients with self-management of any home parenteral therapy with the intention for developing a guideline for service development in the United Kingdom., Methods and Design: An interview-based study of patients receiving HPT. Invitations were posted to all patients on the hospital HPT register. The sessions were conducted by telephone for all consenting patients. The interviews were recorded, transcribed, and analysed thematically. Participants completed the 'Health Education Impact Questionnaire' (heiQ) before and after the education session., Results: Of the 640 patients invited to participate in the study, 45 (7%) patients completed the interviews and the education session. An interview analysis revealed that the patients' experiences of HPT were generally positive, but the levels of training and support received showed wide individual variations. The patients had experienced periods of doubt and uncertainty, where they would have appreciated quick access to professional advice to alleviate their concerns. There was a reliable positive change (10.5-18.4%) from before and after the education sessions in six out of the eight domains on the heiQ questionnaire (health-directed behaviour, self-monitoring and insight, constructive attitudes and approaches, skill and technique acquisition, social integration and support, and emotional distress) and moderate change in two domains (5.3% in positive and negative engagement in life, and 2.6% in health services navigation)., Conclusion: Self-administered parenteral therapy at home is a valuable option, but training and preparation standards should be optimised across hospitals and the wider NHS.

Objective: Interstitial lung disease (ILD) is relatively common in patients with lung cancer with an incidence of 7.5%. Historically pre-existing ILD was a contraindication to radical radiotherapy owing to increased radiation pneumonitis rates, worsened fibrosis and poorer survival compared with non-ILD cohorts. Herein, the clinical and radiological toxicity outcomes of a contemporaneous cohort are described., Methods: Patients with ILD treated with radical radiotherapy for lung cancer at a regional cancer centre were collected prospectively. Radiotherapy planning, tumour characteristics, and pre- and post-treatment functional and radiological parameters were recorded. Cross-sectional images were independently assessed by two Consultant Thoracic Radiologists., Results: Twenty-seven patients with co-existing ILD received radical radiotherapy from February 2009 to April 2019, with predominance of usual interstitial pneumonia subtype (52%). According to ILD-GAP scores, most patients were Stage I. After radiotherapy, localised (41%) or extensive (41%) progressive interstitial changes were noted for most patients yet dyspnoea scores ( n = 15 available) and spirometry ( n = 10 available) were stable. One-third of patients with ILD went on to receive long-term oxygen therapy, which was significantly more than the non-ILD cohort. Median survival trended towards being worse compared with non-ILD cases (17.8 vs 24.0 months, p = 0.834)., Conclusion: Radiological progression of ILD and reduced survival were observed post-radiotherapy in this small cohort receiving lung cancer radiotherapy, although a matched functional decline was frequently absent. Although there is an excess of early deaths, long-term disease control is achievable., Advances in Knowledge: For selected patients with ILD, long-term lung cancer control without severely impacting respiratory function may be possible with radical radiotherapy, albeit with a slightly higher risk of death., (© 2023 The Authors. Published by the British Institute of Radiology.)

Background and Objectives : This project was developed from anecdotal evidence of varied practices around antibiotic prescribing in dental procedures. The aim of the study was to ascertain if there is evidence to support whether antibiotic (AB) use can effectively reduce postoperative infections after dental implant placements (DIPs). Materials and Methods : Following PRISMA-P© methodology, a systematic review of randomised controlled clinical trials was designed and registered on the PROSPERO© database. Searches were performed using PubMed ® , Science Direct ® and the Cochrane© Database, plus the bibliographies of studies identified. The efficacy of prophylactic antibiotics, independent of the regimen used, versus a placebo, control or no therapy based on implant failure due to infection was the primary measured outcome. Secondary outcomes were other post-surgical complications due to infection and AB adverse events. Results : Twelve RCTs were identified and analysed. Antibiotic use was reported to be statistically significant in preventing infection ( p < 001). The prevention of complications was not statistically significant ( p = 0.96), and the NNT was >5 (14 and 2523 respectively), which indicates that the intervention was not sufficiently effective to justify its use. The occurrence of side effects was not statistically significant ( p = 0.63). NNH was 528 indicating that possible harm caused by the use of ABs is very small and does not negate the AB use when indicated. Conclusion : The routine use of prophylactic antibiotics to prevent infection in dental implant placement was found to be not sufficiently effective to justify routine use. Clear clinical assessment pathways, such as those used for medical conditions, based on the patients' age, dental risk factors, such as oral health and bone health, physical risk factors, such as chronic or long-term conditions and modifiable health determinants, such as smoking, are required to prevent the unnecessary use of antibiotics.

Background and Objectives : Anecdotal evidence suggested variation in practices for antibiotic prescribing around dental procedures including route of administration of antibiotics, timing of the course prescribed (before, after or both), length of course prescribed, narrow vs. broad spectrum agents prescribed, use of single or combination of antibiotics, and the use of loading doses. This review aims to investigate this disparity of practices and the absence of global and local recent consensus on the most appropriate antibiotic interventions around invasive dental procedures. Material and methods : Following PRISMA-P © methodology, a systematic review of randomised controlled clinical trials was designed, reviewed, and entered on the PROSPERO © website prior to commencement. Ethics approval was gained from the University of Wolverhampton Committee. Searches were performed using PubMed © , Science Direct™, and the Cochrane Database, plus the bibliographies of studies identified. They investigated studies examining the efficacy and safety of any antibiotic regimen tested, independent of regimen used, versus a placebo, control, or no therapy, on outcomes in post third molar extraction. Results : The primary outcome of interest was postoperative infection and secondary outcomes were other post-surgical related complications of infectious nature and antibiotic adverse events. Sixteen RCTs were identified that met the selection criteria. Antibiotic use was reported to be safe, causing few adverse events. Meta-analysis of infection events showed antibiotics reduced the risk of an infection by 69%, but routine use for prophylaxis in uncomplicated procedures was not supported, and their role in patients with comorbidities or impaired immunity remains controversial. The effect on the incidence of dry socket showed no difference based upon regimen used. No significant benefit was found with respect to reduction of intraoral inflammation, wound dehiscence, haematoma, and lymphadenopathy. Conclusion : The effect on postoperative pain reduction was inconclusive. Routine use of antibiotics around M3 extraction procedures is not supported, but their use in the presence of co-morbidities and or immunosuppression remains controversial to be confirmed by future studies.

Irregularities of vitamin levels are being increasingly identified associated with skin conditions, and systemic and topical therapies have shown promising improvements. There have been some remarkable improvements achieved, but large variations in outcomes suggest that these conditions are not simply related to a single deficiency or solved by providing a single supplement. Cyanocobalamin, pyridoxine (B6) and riboflavin (B2) supplementation were linked with exacerbating existing acne. There were also reports of allergic reactions to parenteral cobalamin including acne, rosacea, allergic site reactions or anaphylaxis with cobalamin injections. This was also reported in patients who had allergic contact dermatitis to cobalt, where cobalamin therapy resulted in cutaneous manifestations such as chronic vesicular hand dermatitis, cheilitis and stomatitis. The use of niacinamide in acne vulgaris as an alternative to clindamycin or adjunct is also notable, as well as its application for hyperpigmentation. Vitamin B3 also has promise in chemoprevention in particular nonmelanoma skin cancer prophylaxis. Folic acid has a developing role in psoriasis. The data for vitiligo remains inconclusive. Assessment for potential vitamin deficiency, particularly B vitamins, should form part of the normal work-up for a wide range of skin conditions., Competing Interests: Conflict of interest: The authors declare no potential conflict of interest., (©Copyright: the Author(s).)

Zinc is a trace nutrient essential for the normal growth and development of human body. The main aim was to evaluate the significant association between measured zinc status in relation to different skin disorders and their severity. PubMed®, Google® Scholar™ and Cochrane© Reviews databases were searched for studies from January 2017 to June 2021, using the terms; zinc serum levels, zinc plasma levels and different dermatosis in the review, only human studies in English language were reviewed and the studies designs were controlled, cross sectional, observational and analytic types. A total of forty-eight research studies were included in this review. All studies have evaluated serum zinc in skin diseases including psoriasis, atopic dermatitis, pityriasis alba, androgenetic alopecia areata, telogen effluvium, vitiligo, melasma, acne, seborrheic dermatitis and hidradenitis suppuritiva. It was found that 33 studies had validated statistically significant differences in serum zinc levels between patients and controls. There is a predominance of low serum zinc levels in all the dermatoses reviewed. The clinical significance of this finding highlights the possible value, and need to investigate, the use of Zinc supplementation as an adjuvant therapy in the management of chronic inflammatory and autoimmune skin diseases proven to manifest altered zinc levels., Competing Interests: Conflict of interest: The authors declare no conflict of interest., (©Copyright: the Author(s).)

Background Context: Spinal epidural abscess (SEA) is an uncommon yet serious infection, associated with significant morbidity and mortality. Patients diagnosed with SEA often require surgical interventions or critical care services that are not available at community hospitals and are therefore transferred to tertiary care centers. Little is known about the effects of interhospital transfer on acute outcomes for patients with SEA., Purpose: To study the effects of interhospital transfer on acute outcomes for patients with SEA., Study Design: Cross sectional analysis using the 2009 to 2017 National Inpatient Sample (NIS)., Patient Sample: Using the 2009 to 2017 NIS, we identified cases of SEA using ICD, Ninth, or Tenth Revision diagnosis codes 324.1 & G06.1., Outcome Measures: Our primary endpoint was in hospital mortality., Methods: The association between interhospital transfer and inpatient mortality was assessed using multivariable logistic regression to adjust for potential covariates. Patient and hospital factors associated with interhospital transfer were assessed in a secondary analysis., Results: A total of 21.5% of patient with SEA were treated after transfer from another hospital. After adjusting for covariates, those who presented after transfer had higher odds of death during hospitalization (OR: 1.51, 95% CI 1.27-1.78, p<.001). Transferred patients were significantly more likely to live in rural communities (11.4 % vs. 5.3 % for nontransferred patients)., Conclusions: Interhospital transfer, which occurred more frequently in patients from rural hospitals, was associated with death even after controlling for disease severity. Addressing healthcare delivery disparities across the US, including across the rural-urban spectrum, will require better understanding of the observed increased mortality of interhospital transfer as a preventable source of in-hospital mortality for SEA., (Copyright © 2022 Elsevier Inc. All rights reserved.)