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Introduction Antibiotic use drives antibiotic resistance. Reducing antibiotic use through reducing antibiotic course lengths could contribute to the UK national ambition to reduce total antibiotic use. Methods Medical notes were reviewed for patients who had received at least 5 days of antibiotic therapy; had been discharged in January 2019; and were from a 750-bed acute secondary care hospital in England. UK national guidelines were used to determine the excess antibiotic use in common medical infections: community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), pyelonephritis, cellulitis, infective exacerbation of chronic obstructive pulmonary disease (IECOPD) and cholangitis. Results Four-hundred and twenty-three patients met the inclusion criteria. Of these, 307 (73%) patient notes were retrieved and reviewed. One-hundred and seventy-three patients met the study case definitions, of which, 137 met short course criteria. Potential antibiotic reductions (measured in defined daily doses) were identified for five of the six infections: 32% in CAP, 20% in HAP, 14% in IECOPD, 11% in cellulitis and 10% in pyelonephritis. These reductions were estimated to reduce total antibiotic use in medical specialties by 12.4%, which equates to 3.6% of the hospital9s total antibiotic use. Conclusion Clinical application of the evidence-based guidance for shorter antibiotic course lengths appears to be a valid strategy for reducing total antibiotic consumption.

Objective: \ud \ud This review will systematically examine and synthesize the evidence evaluating the effectiveness and safety of interventions that enable non-allergy specialist health care workers to assess allergy risk in patients with reported penicillin allergies and subsequently remove erroneous allergy records.\ud \ud \ud \ud Introduction: \ud \ud The potential benefits of removing erroneous penicillin allergy labels (de-labeling) are wide-ranging. Penicillin allergy assessment and de-labeling is an antibiotic stewardship priority. Delivery of such assessment and de-labeling by non-allergy specialists has been reported in several studies, but the effectiveness and safety have not been formally synthesized. This is a necessary step in the upscaling of penicillin allergy assessment services.\ud \ud \ud \ud Inclusion criteria: \ud \ud This review will consider quantitative studies using appropriate designs. The studies will include adults and pediatric patients who have undergone penicillin allergy assessment and de-labeling by non-allergy specialists in any health care setting.\ud \ud \ud \ud Methods: \ud \ud A range of databases will be searched to identify studies published in English, with no date limit. Unpublished studies and gray literature will also be searched. Title and abstract screening, and assessment of selected full texts against the inclusion criteria will be conducted by at least two independent reviewers. Identified studies will be assessed for methodological quality using standardized critical appraisal instruments. Data will be extracted and categorized using the EPOC taxonomy, and the effectiveness and safety of the intervention will be determined. Where possible, data will be pooled to facilitate meta-analysis. Data from heterogeneous studies will be reported narratively. The GRADE approach for grading the certainty of evidence will be followed.\ud \ud \ud \ud Systematic review registration number: \ud \ud PROSPERO CRD42020219044

Point of care ultrasound (POCUS) has seen steady growth in its use and applications in aiding clinicians in the management of acutely unwell patients. Focused Acute Medicine Ultrasound (FAMUS) is the standard created specifically for Acute Medicine physicians and is endorsed by the Society for Acute Medicine and recognised by the Acute Internal Medicine (AIM) training committee as a specialist skill. In this document we present a curriculum mapping exercise which utilises a ‘knowledge, skills and behaviours’ framework and incorporates the GMC’s ‘Good Medical Practice’ (GMP) domains. We believe this will provide a standard for consideration of integrating focused ultrasound in AIM training programmes, with the aim of ultimately incorporating FAMUS as a core skill for all AIM trainees.

Ultrasound guidance is recommended by the British Thoracic Society when undertaking any procedure on a pleural effusion in order to reduce complications. This chapter outlines the indications for draining a pleural effusion and describes the technique for using ultrasound to identify a safe site for drainage. A detailed description of how to undertake an ultrasound-guided pleural aspiration, thoracocentesis, and insertion of chest drain follows.

This chapter describes the use of ultrasound to assess pleural disease in the intensive care setting. The ultrasound signs of pneumothorax are described and the specificity reviewed, with the pitfalls highlighted. The assessment and quantification of pleural effusions are outlined, together with the limitations and pitfalls.

But what of the concerns of those, like my own family, who have also suffered dispossession as a result of an ailing coal industry on which their lives depend? In an inclusive and progressive envir...

Dear sir/madam, Point of care ultrasound (POCUS) in the hands of the non-radiologist has seen a steady growth in popularity amongst emergency, intensive care and acute medical physicians. Increased accessibility to portable, purpose-built ultrasound machines has meant that clinicians often have access to a safe and non-invasive tool to enhance their management of the unwell. Focused Acute Medicine Ultrasound (FAMUS) is the point of care ultrasound curriculum created to aid the management of the acutely unwell adult patient. Following a survey of trainees and consultants, it was apparent that there was a strong desire for Acute Medics to be able to use point of care ultrasound to aid their clinical diagnostic skills. The FAMUS committee was set up to develop competencies using the evidence base available. FAMUS stands in contrast to traditional radiology training modules, which focus on carrying out comprehensive assessments of anatomy and pathology. Instead, FAMUS delivers a syndrome-based sonographic assessment with the aim of ruling out gross pathology and interrogating underlying physiology. It serves as a useful adjunct to history and clinical examination by way of providing key information quickly and non-invasively. Furthermore, it provides a feasible way to monitor response to treatment or progression of disease and thereby providing useful dynamic information quickly and safely. The accreditation in FAMUS involves the sonographic assessment of three systems: lung, abdomen and the deep veins of the lower-limb. Accrediting in each one involves theoretical learning, a formal course attendance and achieving a set number of supervised and mentored scans. As well as technical skills, the candidate must demonstrate competence in recognising key pathology and drawing appropriate conclusions about each scan, including when to refer for departmental imaging. FAMUS was met with enthusiasm by trainees and consultants in acute medicine, and its popularity rises as more courses are becoming available for accreditation paired with increasing access to portable ultrasound units. It is envisioned that this will continue to grow and formal ‘train the trainer’ courses have been held in order to increase the pool of available supervisors. Currently, FAMUS is endorsed by the Society for Acute Medicine and recognised by the AIM training committee as a specialist skill that can be undertaken during specialist training. It has been proposed that FAMUS should be considered for integration into the acute internal medicine (AIM) curriculum, which will be re-written for 2022 in line with the GMC’s revised standards for curriculum and assessment. Thus we present in this letter, a curriculum mapping exercise that utilises a ‘knowledge, skills, behaviours’ framework in order to be considered for the AIM curriculum rewrite. We believe this will provide a standard and framework to integrate focused ultrasound in AIM training programmes with the aim of ultimately incorporating FAMUS as a core skill for all AIM trainees.

Sustainable development – improving human well-being across present generations without compromising the ability of future generations to meet their own needs – is a central challenge for the 21st century. Technological innovation can play an important role in moving society toward sustainable development. However, poor, marginalized, and future populations often do not fully benefit from innovation due to their lack of market or political power to influence innovation processes. As a result, current innovation systems fail to contribute as much as they might to meeting sustainable development goals. This paper focuses on how actors and institutions operating in the transnational arena can mitigate such shortfalls. To identify the most important transnational functions required to meet sustainable development needs our analysis undertook three main steps. First, we developed a framework to diagnose blockages in the global innovation system for particular technologies. This framework was built on existing theory and new empirical analysis. On the theory side, we drew from the literatures of systems dynamics; technology and sectoral innovation systems, science and technology studies, the economics of innovation, and global governance. On the empirical front, we conducted eighteen detailed case studies of technology innovation in multiple sectors relevant to sustainable development: water, energy, health, food, and manufactured goods. We use the framework to analyze our case studies in the common language of (1) technology stocks, (2) non-linear flows between stocks substantiated by specific mechanisms, and (3) characteristics of actors and socio-technical conditions (STCs) which mediate the flows between stocks . We identify blockages in the innovation system for each of the cases, diagnosing where in the innovation system flows were hindered and which specific sets of STCs and actor characteristics were associated with these blockages. Figure E.1 displays the components of our framework and how they relate.

The Glasgow Blatchford Score (GBS) is a validated risk assessment tool in primary upper gastrointestinal haemorrhage, which accurately predicts the need for intervention (endoscopic therapy, blood transfusion or surgery) or death.To identify the GBS that predicts lack of intervention or death and to apply this to clinical practice by managing low-risk patients in the community.GBSs prospectively calculated on 232 patients with upper gastrointestinal haemorrhage to identify low-risk score. Patients with low-risk of requiring intervention (GBSor=2, age70 years) from a further 304 patients were considered for management in the community.Fifty-two of 232 patients in the first cohort had a GBSor=2 and were aged less than 70 years: none of these required intervention or died. In the second cohort 104 of 304 (34.2%) patients had a GBSor=2 and were aged less than 70 years, none of whom died or required endoscopic therapy, blood transfusion, surgery or died. Thrity-two of 104 (10.5% of total cohort) were safely managed in the community.Using the criteria of a GBSor=2, aged less than 70 years to define patients at 'low risk' allows 10.5% of patients with primary upper gastrointestinal haemorrhage to be safely managed in the community.