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A 67-year-old man presented with unilateral weakness and reduced dexterity four months after autolo- gous peripheral blood stem cell transplantation for multiple myeloma. The weakness progressed over the following months, with accompanying cognitive and sensory symptoms. Brain MRI showed numerous hyper- intense T2 lesions within the subcortical white matter of both cerebral hemispheres suggestive of demy- elination, progressing rapidly on interval imaging. His CSF tested positive for JC virus, diagnostic of PML.This diagnosis was unexpected as the patient did not appear to be significantly immunocompromised and PML is extremely rare in patients with multiple myeloma. Treatment for progressive multifocal leukoen- cephalopathy is via restoring immune function; in our patient no reversible cause of immuno-suppression was present. At the time of our patient’s diagnosis no treatments had been shown to be effective against PML in clinical trials. However, in the last year both pembrolizumab and BK virus specific T-cell therapy have demonstrated efficacy against PML in published clinical trials, offering new hope for patients.Clinicians should consider a diagnosis of PML when assessing patients with neurological symptoms and signs following treatment for multiple myeloma and in other haematological conditions, particularly as efficacious treatments can now be given if PML is diagnosed early.peter.fernandes@ed.ac.uk

Background The application of prior learning within medical curricula to real patient care is challenging. Clinical assistantships support UK medical students making the transition to postgraduate practice as doctors. This paper describes a method of teaching clinical referrals: the process of clinicians contacting colleagues for advice or services. The skills required are key to medical practice, and students should be supported to develop them in order to optimally benefit from their assistantships and prepare for practice. Methods The referrals workshop consisted of five diverse clinical cases that students explored in groups. Each station presented a realistic scenario. Students assimilated written information and made a telephone call to a faculty member in another room with a clinical request. After each 90-minute session students received both personalised and group feedback. Evaluation The workshop was delivered to 108 students over 2 days, and received positive feedback from students and faculty members. Students and faculty members particularly valued the realism of making authentic calls to unseen clinicians, the fidelity of simulated referrals and constructive feedback. They considered this excellent preparation for making referrals in the workplace. Challenges included the moderately large number of faculty members required for each workshop (seven staff) and technical issues with telephone reception. The referrals workshop consisted of five diverse clinical cases that students explored in groups DISCUSSION: These practical, scalable, replicable and well-received learning activities have addressed a key educational need by providing guidance on the integration of prior learning with the performance of core clinical tasks. It has provided valuable preparation for postgraduate practice. Our detailed description should allow others to adapt and evaluate this in their own settings.

Purpose: Competency-based medical education (CBME) seeks to prepare undergraduate and postgraduate trainees for clinical practice. Its major emphasis is on outcomes, but questions about how best to reach these remain. One key issue is the need to integrate what matters most to students when setting educational goals: this is crucial if we are to design curricula that trainees understand and engage with, and that promote successful achievement of competencies. Method: We interviewed medical students in years 4 and 6 of a 6-year medical degree and used thematic analysis to understand their main educational priorities and how these fit with the aims of CBME. Results: Two major themes emerged: features of content and process. For content, students wanted clear guidance on what constitutes competence, finding broad outcome statements abstract and difficult to understand as novices. They also attach critical importance to features of process such as being welcomed, included in clinical teams and being known personally – these promote motivation, understanding, and professional development. Conclusions: We present recommendations for those designing CBME curricula to emphasize the student perspective: what kind of guidance on outcomes is required, and features of process that must not be neglected if competence is to be achieved.

Pyrexia of unknown origin, PUO, is a medical syndrome that is frequently managed by infectious disease teams. The differential diagnoses are vast, and must encompass both infective and non-infective conditions such as malignancy and inflammatory conditions. This chapter will describe a case study along with a discussion of the role of positron emission tomography in elucidating the cause of PUO.

A 53-year-old woman with a history of ventricular ectopic ablation was admitted with weight loss, sweats and low grade fever and was found to have severe aortic incompetence and a dilated left ventricular cavity (6.1 cm) on transthoracic echocardiography (figure 1). No vegetations were seen on transoesophageal echocardiography and sequential blood cultures were negative. Despite extensive investigation she continued to deteriorate clinically and had a persistently elevated C reactive protein and erythrocyte sedimentation rate at 300 mg/l and 108 mm/h respectively. A positron emission tomography (PET)-CT scan with 18F-fluorodeoxyglucose (FDG) …