Patients as ethnographers
I recently spent 2 weeks as an inpatient on a hospital ward. It was not an experience I would have chosen, but I had several advantages by comparison with many of the other patients. I was ambulant for most of the time. As a doctor, I was able to understand many of the technical details of my condition and its treatment. By a strange coincidence, a colleague and friend of mine was also admitted to the same ward a few days after me, so we could support each other. As we are both involved professionally in healthcare education and organisational development, we were able to exchange our reflections on what was going on aroun...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Launer, J. Tags: On reflection Source Type: research

Pleural empyema: a case of failing to see the discharge leading to discharge failure
A 54-year-old heavy smoker was admitted with a 2-week history of pleuritic chest pain, cough, shortness of breath and weight loss. He had not improved despite a course of antibiotics from his general practitioner. He was commenced on intravenous antibiotics for presumed pneumonia based on his chest X-ray, which seemed to show left middle zone opacification (figure 1), and after 2 days, he was discharged with a further oral antibiotic course. Figure 1Posteroanterior chest X-ray showing pleural-based shadowing with cavitation abutting the left lateral chest wall with a characteristic convex ‘D’ shape of...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Ashkir, Z., Tsaknis, G., Jeffrey, A. Tags: Journalology, General practice / family medicine, Drugs: infectious diseases, Pain (neurology), Alcohol-related disorders, Drugs misuse (including addiction), Radiology, Pneumonia (respiratory medicine), Clinical diagnostic tests, Cardiothoracic surgery, Source Type: research

Lead pipe sign in mixed inflammatory bowel disease
A middle-aged female with inflammatory bowel disease (IBD) (with mixed features of ulcerative colitis and Crohn's disease), iron deficiency anaemia and recurrent Clostridium difficile colitis presented to the emergency department with complaints of abdominal pain, haematochezia and diarrhoea. An abdominal plain film obtained during her work-up demonstrated a portion of the distal transverse, descending and sigmoid colon lacking normal haustral patterns (lead pipe sign) (figure 1, arrows). Figure 1Lead pipe sign—abdominal X-ray showing a large burden of stool throughout the colon to the descending colon where the...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Ekeledo, O. J., Scelsi, C., Keshavamurthy, J. H. Tags: Drugs: gastrointestinal system, GI bleeding, Inflammatory bowel disease, Emergency medicine, Journalology, Immunology (including allergy), Pain (neurology), Malnutrition, Connective tissue disease, Dermatology, Ethics, Metabolic disorders Images in medi Source Type: research

Neuroblastoma in a 6-year-old boy
A previously healthy 6-year-old boy presented to the children's Accident and Emergency Department with right-sided abdominal pain. On examination, there was a palpable, non-tender abdominal mass, with no lymphadenopathy. Initial investigations revealed pancytopenia (haemoglobin was 5.7 g/dL, white cell count 3.7 x 109/L, platelets 134 x 109/L) and lactate dehydrogenase 1690 (normal range 240–480) with normal urea and electrolytes/liver function tests. Abdominal ultrasound showed a large central mass extending from the epigastrium to the level of the aortic bifurcation. A chest X-ray showed a ...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Russell-Jones, E., Iliadis, K., Wynne, C. Tags: Emergency medicine, Journalology, Immunology (including allergy), Pain (neurology), Paediatric oncology, Screening (oncology), Radiology, Surgical diagnostic tests, General surgery, Radiology (diagnostics), Ethics Images in medicine Source Type: research

Osborn waves of hypothermia
A 38-year-old patient with paranoid schizophrenia presented to our institution from the crisis response centre for unusual behaviour over the last 24 hours. Rectal temperature measured in the emergency department was 28.9°C (84.2°F) with an ECG (figure 1) showing Osborn waves in leads V1–V5 with reciprocal depression in lead aVR. ‘Shivering artefacts’ can also be seen in leads V1 and V2 (figure 1). His ECG normalised on rewarming (figure 2). Figure 1ECG on presentation at 28.9°C. Figure 2ECG on rewarming. Osborn waves that were definitively described in 1953 are classically see...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Ram, P., George, G. Tags: Journalology, Drugs: cardiovascular system, Psychotic disorders (incl schizophrenia), Ethics, Arrhythmias Images in medicine Source Type: research

Advising residents on how to present an article in a journal club
Introduction Reading and appreciating medical literature is an important aspect of continuing medical education.1 Residents need to learn this important aspect during their training period.2–4 Evidence-based medicine involves updating, critiquing and using the evidence for patient care. It is the explicit use of the best available evidence combined with intuition of the clinician and the intentions of patients in a given clinical situation.5 To practice evidence-based medicine, it is important to analyse the literature critically. Journal club is an effective way to teach critical appraisal skills to residents.6 Use ...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Prakash, S., Soundrarajan, J. Tags: Letter Source Type: research

Why diets fail: a hypothesis for discussion
Weight regulation depends on the difference between weights of absorbed and metabolised carbon and excretion of the end products of metabolism, calories and carbon dioxide, which can be independently and variably excreted. Calories can be variably excreted as heat by vasoconstriction or vasodilation and carbon dioxide can be excreted variably as exhaled carbon dioxide (the major route of carbon excretion). Unless there are changes in ventilatory carbon excretion, ‘metabolism,’ ‘genetic factors,’ ‘hormones’ or ‘exercise’ do not provide complete explanatory mechanisms for weigh...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Welsby, P. D. Tags: Original article Source Type: research

Lower limb immobilisation and venous thromboembolism risk: combined case-control studies
Background Evidence from randomised controlled trials shows that low-molecular-weight heparin is effective in reducing the risk of venous thromboembolism (VTE) in the clinical setting of temporary lower limb immobilisation. Despite this, international guidelines are non-committal in advocating the use of anticoagulation in this clinical scenario. We determined the risk of VTE associated with lower limb immobilisation and the proportion of VTE events associated with lower limb immobilisation by undertaking a secondary analysis of two case–control studies that had used a similar methodology. Methods We undertook logis...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Braithwaite, I., Healy, B., Cameron, L., Weatherall, M., Beasley, R. Tags: Drugs: cardiovascular system, Stroke, Venous thromboembolism, Pulmonary embolism, Epidemiology Original article Source Type: research

Interhospital transfer neurological deterioration in patients with spontaneous intracerebral haemorrhage: incidence and risk factors
Objective To explore the incidence and risk factors for interhospital transfer neurological deterioration (IHTND) in patients with spontaneous intracerebral haemorrhage (SICH). Methods Consecutive adult patients with first-ever SICH referred to our emergency department (ED) and transported by ambulance from July 2011 through June 2015 were eligible for this prospective observational study. Enrolled patients had SICH with elapsed time
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Fan, J.-S., Chen, Y.-C., Huang, H.-H., Yen, D. H.-T., How, C.-K., Huang, M.-S. Tags: Nursing, Hypertension Original article Source Type: research

Association and interaction analysis of diabetes mellitus and SCN10A for cardiovascular autonomic neuropathy in a Chinese population
Conclusions Our findings suggest that there are interaction effects of DM and SCN10A (rs7375036) that influence the development of CAN. Trial registration number NCT02461342 (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Lv, Y., Zhou, L., Tang, Z., Dong, J. Tags: Diabetes, Metabolic disorders Original article Source Type: research

High prevalence of antithyroid peroxidase and antiparietal cell antibodies among patients with type 1 diabetes mellitus attending a tertiary diabetes centre in South Africa
Conclusions Among patients with T1DM in this study, there was a high prevalence of coexistent AITD and gastric autoimmunity. Screening for hypothyroidism and thyroid autoimmunity should be undertaken in all patients at initial presentation. However, to assess the feasibility and optimal timing of subsequent testing in the African setting with limited resources, more collaborative research with longitudinal studies is required. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Paruk, I. M., Ganie, Y., Maharaj, S., Pirie, F. J., Naidoo, V. G., Nkwanyana, N. M., Dinnematin, H. L., Ramdial, P. K., Motala, A. A. Tags: Immunology (including allergy), Drugs: CNS (not psychiatric), Malnutrition, Ophthalmology, Epidemiology, Diabetes, Metabolic disorders, Thyroid disease Original article Source Type: research

Vaccination practices in patients with inflammatory bowel disease among general internal medicine physicians in the USA
Conclusions Current knowledge and degree of comfort among PCPs in the USA in preventing opportunistic infections in IBD population remain low. Management of patients with IBD requires structured approach to their healthcare maintenance in everyday practice, including enhanced educational policy aimed at primary care physicians. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Gurvits, G. E., Lan, G., Tan, A., Weissman, A. Tags: Inflammatory bowel disease, Patients, General practice / family medicine, Immunology (including allergy), Drugs: infectious diseases, Epidemiology Original article Source Type: research

Common toxidromes in movement disorder neurology
Conclusion There are several toxidromes that have the potential to become a serious life-threatening emergency if there is a delay in recognition of key clinical features and instituting the appropriate treatment at the earliest is crucial. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Malek, N., Baker, M. R. Tags: Emergency medicine, Drugs: CNS (not psychiatric), Drugs: psychiatry, Drugs: musculoskeletal and joint diseases, Epidemiology, Internet, Occupational and environmental medicine Original article Source Type: research

Associations with resident physicians' early adoption of electronic cigarettes for smoking cessation
Conclusions Few residents report recommending electronic cigarettes to patients who smoke. These residents consider the electronic cigarette less addicting than traditional cigarettes, supporting harm reduction strategies over strict abstinence. Most residents require further evidence-based education on efficacy and long-term safety of electronic cigarettes before recommending to their patients. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Egnot, E., Jordan, K., Elliott, J. O. Tags: Journalology Original article Source Type: research

Who to handover: a case-control study of a novel scoring system to prioritise handover of internal medicine inpatients
Conclusions The iHAND score had moderate ability to predict which patients required assessment overnight, while MEWS score and current gestalt approach correlated poorly, suggesting the iHAND score may help prioritisation of patients likely to be seen overnight for handover. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Bittman, J., Tam, P., Little, C., Khan, N. Tags: Patients, Epidemiology Original article Source Type: research

The anticoagulation choices of internal medicine residents for stroke prevention in non-valvular atrial fibrillation
Conclusions Canadian internal medicine residents favoured warfarin over NOACs for patients with NVAF, which is in discordance with the evidence-based CCS guidelines. This finding persisted throughout the 3 years of core internal medicine training. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Moulson, N., McIntyre, W. F., Oqab, Z., Yazdan-Ashoori, P., Quinn, K. L., van Oosten, E., Hopman, W. M., Baranchuk, A. Tags: Drugs: cardiovascular system, Stroke, Arrhythmias Original article Source Type: research

Palliative care series: an overview
"The only certainty is that every one of us will die. Nothing else in healthcare in the UK applies to 100% of our population." So stated Baroness Professor Finlay of Llandaff when she introduced the Access to Palliative Care Bill in the House of Lords.1 This was an apt reminder of the importance of good end-of-life care for every dying person and their loved ones, no matter where they die or which healthcare professionals are caring for them at the end of their life. Palliative care is defined by the WHO2 as ‘an approach that improves the quality of life of patients and their families facing the problems as...
Source: Postgraduate Medical Journal - May 25, 2017 Category: General Medicine Authors: Whitburn, T., Selman, L. E. Tags: Editorials Source Type: research

Faith and loss: masterpieces from the Middlesex Hospital
Hospitals originated as religious institutions. In both the Islamic and Christian worlds, they were built alongside places of worship and made no distinction between physical and spiritual healing. Many of the world’s great hospitals still bear evidence of this, and some still have beautiful ancient chapels within their precincts. Although medicine and nursing gradually became secularised in Europe from the Renaissance onwards, religious faith and regular attendance at services remained the norm, and hospitals continued to provide for these until well into the 20th century. One of the last traditional hospital chapel...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Launer, J. Tags: On reflection Source Type: research

Inadvertent transfer of surgical skin marking could potentiate wrong site surgery
Wrong site surgery (WSS) is a preventable but serious error. It is well accepted that preoperative marking is a fundamental part of the preoperative verification process to prevent devastating incident of WSS.1 For this purpose, WHO guidelines for safe surgery recommend that the site of surgery should be marked with permanent felt-tip marker prior to surgery.2 However, a correct initial surgical mark that is displaced could also potentially lead to WSS. In our recent experience, at preoperative cataract ward round we noticed that a surgical mark was inadvertently transferred from one patient's forehead (figure 1A) onto the...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Ng, J. Y., Stirling, R. Tags: Journalology, Ophthalmology, Ethics Images in medicine Source Type: research

Vanishing bone disease: a manifestation of diabetic Charcot's neuropathic osteoarthropathy
A 50-year-old man with type 2 diabetes mellitus for 13 years presented with painless swelling of the left foot over the previous 18 weeks. He had earlier received multiple courses of antibiotics without improvement. There was no history of trauma, foot ulceration, rheumatoid arthritis or inflammatory arthropathy. His HbA1c was 7.6%, erythrocyte sedimentation rate 19 mm/hour, white blood cell count 9600/mm3 and uric acid 4.3 mg/dL. Examination revealed a swollen, erythematous, deformed left foot with rocker bottom deformity and loss of longitudinal, transverse arch (figure 1A). He had distal symmetric sensori...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Rastogi, A., Bhansali, A. Tags: Journalology, General practice / family medicine, Genetics, Immunology (including allergy), Drugs: infectious diseases, Drugs: cardiovascular system, Orthopaedics, Connective tissue disease, Rheumatoid arthritis, Dermatology, Orthopaedic and trauma surger Source Type: research

Behind the (bilateral) fungus ball
A 54-year-old man with AIDS and a history of Pneumocystis jirovecii pneumonia presented with chronic cough and weight loss for 1 year. There was no haemoptysis. He had normal vital signs and was afebrile. Lung auscultation was normal. Laboratory evaluation was unremarkable. Chest radiography revealed bilateral upper lobe cavities with internal densities (figure 1). CT of the chest demonstrated these apical cavities to contain material consistent with a mycetoma (fungus ball). Adjacent pleural thickening and areas of consolidation and fibrosis were also present (figure 2). A CT scan performed 2 years previously showed ...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Epelbaum, O., Rashidfarokhi, M., Patel, G. Tags: Immunology (including allergy), Drugs: infectious diseases, Radiology, Adult intensive care, Pneumonia (respiratory medicine), Dermatology, Clinical diagnostic tests, Radiology (diagnostics) Images in medicine Source Type: research

Diabetes insipidus induced by suspected eosinophilic granulomatous with polyangiitis
A 54-year-old man with a history of allergic rhinitis, chronic productive cough and shortness of breath presented with symptoms of ophthalmalgia, polydipsia, polyuria, ≥8 L daily urine output and 5 kg weight loss within 2 months. Physical examination revealed a haemorrhage under the sclera on the temporal side of the left eye (figure 1). The results of the fluid deprivation–vasopressin test showed central diabetes insipidus. Laboratory investigations showed circulating eosinophilia: 560x106/L (normal 50–300x106/L ), 5% (normal 0.5–5%); plasma antineutrophil cytoplasm antibodies (ANCA) an...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Xie, Y., Shao, H., Dai, C., Ma, Z. Tags: Urology, Journalology, Immunology (including allergy), Drugs: CNS (not psychiatric), Ophthalmology, Radiology, Surgical diagnostic tests, General surgery, Ethics, Diabetes, Metabolic disorders, Pituitary disorders Images in medicine Source Type: research

Obesity and recurrent vulvovaginal bacterial infections in women of reproductive age
This study was conducted at the gynaecology clinics at Texas Tech University Health Sciences... (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Ventolini, G., Khandelwal, N., Hutton, K., Lugo, J., Gygax, S. E., Schlabritz-Loutsevitch, N. Tags: Open access Letter Source Type: research

A rare cause of thyrotoxic periodic paralysis: liquorice consumption
We describe another case who presented with hypokalaemia, hyperthyroid state and paralysis after the habitual... (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Sayiner, Z. A., Abiyev, A., Eraydin, A., Ozkaya, M. Tags: Adverse drug reactions Source Type: research

Skin autofluorescence, a non-invasive marker of advanced glycation end products: clinical relevance and limitations
Advanced glycation end products (AGEs) are protein-bound compounds derived from glycaemic and oxidative stress that contain fluorescent properties, which can be non-invasively measured as skin autofluorescence (SAF) by the AGE Reader. SAF has been demonstrated to be a biomarker of cumulative skin AGEs and potentially may be a better predictor for the development of chronic complications and mortality in diabetes than glycated haemoglobin A1c. However, there are several confounding factors that should be assessed prior to its broader application: these include presence of other fluorescent compounds in the skin that might b...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Da Moura Semedo, C., Webb, M., Waller, H., Khunti, K., Davies, M. Tags: Reviews Source Type: research

Transcatheter aortic valve implantation: new hope in the management of valvular heart disease
Severe calcific aortic stenosis is relatively common, and unless treated with valve replacement it carries an adverse prognosis. A large number of patients, however, are denied surgery due to their advanced age or coexistent medical conditions that increase perioperative cardiovascular risks. Transcatheter aortic valve implantation (TAVI), a technique in which a bioprosthetic valve is inserted via a catheter and implanted within the diseased native aortic valve, is a new therapeutic modality for treatment of older patients with severe symptomatic aortic stenosis and other comorbidities, who have an inherently high surgical...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Metaxa, S., Ioannou, A., Missouris, C. G. Tags: Editor's choice Reviews Source Type: research

A survey on internet usage and online learning behaviour among medical undergraduates
Aim To determine the magnitude and pattern of internet usage by undergraduate medical students to retrieve medical information. Materials and methods A pretested questionnaire-based survey was conducted among undergraduate medical students who were willing to participate. The institute ethics committee approved the study. The responses of students to the questionnaire were analysed using VassarStats online statistical programme. Categorical variables were expressed as proportions. To determine the significance of the difference between proportions, the 2 test or Fisher's exact test was used. Log-linear analysis was perfor...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Venkatesh, S., Chandrasekaran, V., Dhandapany, G., Palanisamy, S., Sadagopan, S. Tags: Continuous professional development, Postgraduate Original article Source Type: research

Alterations in the echocardiographic variables of the right ventricle in asymptomatic patients with breast cancer during anthracycline chemotherapy
Background Anthracycline-induced cardiotoxicity can reach an irreversible phase; therefore great efforts are made to diagnose it early. As the right ventricle (RV) is smaller than the left, the right side of the heart is probably influenced by anthracycline to a greater extent and in a shorter time. The purpose of the present study was to investigate the early effects of chemotherapy on the right side of the heart. Methods This cross-sectional study was performed in Isfahan University hospitals from August 2014 to December 2015. Subjects were 67 patients with breast cancer who were planned to receive anthracycline for the...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Abdar Esfahani, M., Mokarian, F., Karimipanah, M. Tags: Echocardiography, Hypertension, Breast cancer, Screening (oncology), Radiology, Clinical diagnostic tests, Radiology (diagnostics), Epidemiology Original article Source Type: research

Patients perceptions and views of surgery and radioiodine ablation in the definitive management of Graves disease
This study aimed to evaluate their concerns, experiences and satisfaction following definitive treatment. Methods A postal survey of patients who had treatment with surgery or RIA between January 2011 and June 2013 for Graves' disease was conducted. Results Of 214 patients, 136 (64%) responded. The majority of patients felt actively involved in decision making (83.8%) and were satisfied (84.9%) with their treatment. Compared with RIA, patients who underwent surgery were more satisfied with their treatment (p=0.008). Discussion with the doctor was the most useful aid to decision making. Feeling involved in decision-making...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Hookham, J., Truran, P., Allahabadia, A., Balasubramanian, S. P. Tags: Immunology (including allergy), Ophthalmology, Radiology, Clinical diagnostic tests, Thyroid disease Original article Source Type: research

Decreased flow-mediated dilatation in patients with rheumatoid arthritis: a meta-analysis
Objectives To derive a more precise comparison of flow-mediated dilatation (FMD%) of the brachial artery between patients with rheumatoid arthritis (RA) and normal controls by performing a meta-analysis of appropriate studies. Methods PubMed and EMBASE databases were searched for all relevant articles. STATA (V.12.0) software was used to perform the meta-analysis. Quality estimation of all appropriate studies was evaluated according to the Newcastle-Ottawa Scale (NOS). Standardised mean difference (SMD) with 95% CIs were calculated with a random-effects model. The Cochrane Q test and I2 statistic were used to evaluate the...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Xu, S.-Z., Wang, P., Guan, S.-Y., Li, H.-M., Leng, R.-X., Pan, H.-F., Ye, D.-Q. Tags: Immunology (including allergy), Drugs: cardiovascular system, Connective tissue disease, Rheumatoid arthritis, Internet Original article Source Type: research

Application of visually based, computerised diagnostic decision support system in dermatological medical education: a pilot study
Background Medical education has shifted from memory-based practice to evidence-based decisions. The question arises: how can we ensure that all students get correct and systematic information? Visually based, computerised diagnostic decision support system (VCDDSS, VisualDx) may just fit our needs. A pilot study was conducted to investigate its role in medical education and clinical practice. Methods This was a prospective study, including one consultant dermatologist, 51 medical students and 13 dermatology residents, conducted in the dermatology teaching clinic at China Medical University Hospital from 30 December 2014 ...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Chou, W.-Y., Tien, P.-T., Lin, F.-Y., Chiu, P.-C. Tags: Patients, Clinical diagnostic tests Original article Source Type: research

Emergency medicine educational resource use in Cape Town: modern or traditional?
Conclusions The use of modern and electronic resources is relatively common, but traditional educational resources are still preferred. This study illustrates an opportunity for greater integration of online resources and social media in educational activities to enhance multimodal and self-directed learning. Specific training in the use of these resources and how to appraise them may further improve their utility. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Kleynhans, A. C., Oosthuizen, A. H., van Hoving, D. J. Tags: Emergency medicine, Adult intensive care Original article Source Type: research

Prognostic indicators and generation of novel risk equations for estimation of 10-year and 20-year mortality following acute coronary syndrome
Conclusions Novel risk equations for all-cause, cardiovascular and cardiac mortality at 10 and 20 years were generated using follow-up data in a large patient population. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Magri, C. J., Debono, R., Calleja, N., Galea, J., Fava, S. Tags: Original article Source Type: research

Timeliness of referral of children with new onset type 1 diabetes
Conclusions Our study has identified a modifiable reason for delayed referrals of children with TID. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Iyer, D., Choudhary, D., Agwu, J. C. Tags: Original article Source Type: research

Clinical examination in the OSCE era: are we maintaining the balance between OS and CE?
After more than three decades of assessment of clinical competence through Objective Structured Clinical Examinations (OSCEs), are medical trainees viewing clinical examination through the lens of an assessment method? Has the structure (the OS) become more important than the skill itself (the CE)? For many students, the standards required by OSCEs are the skills expected for clinical competence. Most recent textbooks on clinical examination are based on the structure needed to succeed in an OSCE, but OSCEs were not designed to teach an ideal framework for performing a clinical examination and most medical encounters requi...
Source: Postgraduate Medical Journal - April 26, 2017 Category: Journals (General) Authors: Lafleur, A., Leppink, J., Cote, L. Tags: Editorials Source Type: research

Reducing futile attempts at resuscitation
A recent review in the BMJ has drawn attention to major concerns about ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) forms.1 One of these concerns is with the distressing number of deaths that are surrounded by futile attempts at cardio-pulmonary resuscitation (CPR). Such attempts occur for a number of reasons. Some patients with terminal illnesses, or who are elderly and frail, do not have a form, perhaps because their doctors were too busy or never got round to raising the issue. Other patients may have deteriorated very soon after admission, or more quickly than anyone expected, so that no-one had...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Launer, J. Tags: On reflection Source Type: research

Dural ectasia as an incidental finding on MRI in a patient with Marfan syndrome
A 48-year-old female with a history of Marfan syndrome and type A aortic dissection repaired with valve-sparing aortic root replacement and stable residual type B aortic dissection presented for surveillance MR angiography. At that time, dural ectasia was appreciated as an incidental finding with MRI showing high T2-weighted multilobar cerebrospinal fluid (CSF) spaces within the lower sacrum (figures 1 and 2). Anteroposterior diameter of the thecal sac was greater at the S1 level than at the L4 level, a defining feature of dural ectasia.1 Figure 1Axial T2-weighted MRI showing dural ectasia as indicated by arrow. Figu...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Laney, D. F., Keshavamurthy, J. H., Agarwal, S. Tags: Urology, Journalology, Genetics, Pain (neurology), Interventional cardiology, Radiology, Connective tissue disease, Clinical diagnostic tests, Radiology (diagnostics), Ethics, Calcium and bone Images in medicine Source Type: research

Erratum: 'Normal serum sodium concentration among in-patients over 65 admitted to hospital: an observational study
McKee M, Exall S, Stuckler D, et al. ‘Normal’ serum sodium concentration among inpatients over 65 admitted to hospital: an observational study. Postgrad Med J 2016;92:21–6. doi:10.1136/postgradmedj-2015-133482. Funder was omitted from this paper. David Stuckler was also funded by ERC HRES 313590. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Tags: Correction Source Type: research

A case of coarctation of the abdominal aorta and renal artery stenosis due to neurofibromatosis type 1
We report a case of an adolescent female with history of neurofibromatosis type 1 (NF1) found to have incidental hypertension. She was hypertensive in all four extremities with medical treatment. CT angiogram confirmed narrowing of the abdominal aorta above the bifurcation and atrophic left kidney (figures 1–3). Treatment with a graft to bypass the stenotic segment was performed (figure 4). Figure 1Axial CT with contrast showing superior mesenteric artery (red arrow) enlarged as compared with descending abdominal aorta. Figure 2Coronal CT maximum intensity projection view of narrowed segment of descending ...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Veean, S., Thakkar, N., Gupta, S., Keshavamurthy, J. Tags: Urology, Journalology, Genetics, Hypertension, Histopathology, Radiology, Clinical diagnostic tests, Urological surgery, Ethics Images in medicine Source Type: research

Retinal nerve fibre myelination
A 50-year-old man, who was newly diagnosed with diabetes, was referred for a routine eye evaluation which was unremarkable except for the observation of a flat white patch located in the inferior temporal arcade of the retina of the right eye (figure 1). A closer look at this structure revealed striation following the distribution of the nerve fibres and feathery borders, virtually diagnostic of nerve fibre myelination (figure 2). This ectopic white matter, present in less than 1% of the population,1 2 is usually found on or in the vicinity of the disc and in the arcades, and represents a failure, of unknown aetiology, of ...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Viso, E. Tags: Journalology, Immunology (including allergy), Drugs: CNS (not psychiatric), Multiple sclerosis, Ophthalmology, Ethics Images in medicine Source Type: research

IgG4-related disease: a new entity sometimes needs a retrospective diagnosis
A 60-year-old male patient presented with a 4-year history of retroperitoneal fibrosis (RF) compressing the aorta, inferior vena cava, left renal vein and left ureter, with ipsilateral renal atrophy. At the time of RF diagnosis, positron emission tomography (PET) scan had shown an expansive retroperitoneal lesion involving large vessels (figure 1). He had also presented a high C-reactive protein (CRP), reduced glomerular filtration rate, polyclonal peak in serum gamma globulins and retroperitoneal biopsy had shown fibrosis and lymphoid infiltration. Figure 1Positron emission tomography scan showing retroperitoneal les...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Böhlke, M., Santos, G. Tags: Pancreas and biliary tract, Journalology, Pancreatitis, Immunology (including allergy), Histopathology, Radiology, Surgical diagnostic tests, General surgery, Radiology (diagnostics), Epidemiology, Ethics, Thyroid disease Images in medicine Source Type: research

Scholarly gender gap extends to medical students: the case of Australasia
This report aims to shed light on the situation in Australian and New... (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Alamri, Y. Tags: Letter Source Type: research

Non-alcoholic fatty pancreas disease
Obesity is a growing problem worldwide and disorders associated with excess body fat including the metabolic syndrome, type 2 diabetes mellitus (T2DM), cardiovascular disease and malignant neoplasms are becoming a major cause of morbidity and mortality. Over the past decade, a vast amount of research has furthered our understanding of non-alcoholic fatty liver disease; however, only recently pancreatic fat infiltration is coming to the forefront of investigation. Termed non-alcoholic fatty pancreas disease (NAFPD), it is becoming evident that it has important associations with other diseases of obesity. It appears to arise...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Alempijevic, T., Dragasevic, S., Zec, S., Popovic, D., Milosavljevic, T. Tags: Reviews Source Type: research

Management of bleeding in patients receiving non-vitamin K antagonists
Anticoagulation with non-vitamin K antagonists (Non vitamin K oral anticoagulant (NOACs)) including dabigatran, rivaroxaban, apixaban and edoxaban is at least as effective as warfarin, has fewer drug and food interactions and does not require monthly monitoring. Although major bleeding with NOACs is infrequent, there remains concern about the ability to effectively treat episodes of major bleeding. New agents have been developed that are capable of providing rapid reversal of the anticoagulation effect of NOACs. Idarucizumab normalises the dilute thrombin time and the ecarin clotting time, both of which are elevated with d...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Balla, S., Koerber, S., Flaker, G. Tags: Editor's choice Reviews Source Type: research

High-risk periodontal pathogens contribute to the pathogenesis of atherosclerosis
Periodontal disease (PD) is generated by microorganisms. These microbes can enter the general circulation causing a bacteraemia. The result can be adverse systemic effects, which could promote conditions such as cardiovascular disease. Level A evidence supports that PD is independently associated with arterial disease. PD is a common chronic condition affecting the majority of Americans 30 years of age and older. Atherosclerosis remains the largest cause of death and disability. Studies indicate that the adverse cardiovascular effects from PD are due to a few putative or high-risk bacteria: Aggregatibacter actinomycet...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Bale, B. F., Doneen, A. L., Vigerust, D. J. Tags: Open access Reviews Source Type: research

Influence of cytokine gene polymorphisms on proinflammatory/anti-inflammatory cytokine imbalance in premature coronary artery disease
Conclusions The association of the selected SNPs with differential serum cytokine levels especially the cytokine imbalance points towards their potential causal role in the immune inflammatory pathogenic pathway of PCAD. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Ansari, W. M., Humphries, S. E., Naveed, A. K., Khan, O. J., Khan, D. A. Tags: Genetics, Immunology (including allergy), Drugs: cardiovascular system, Screening (oncology), Ischaemic heart disease, Radiology, Clinical diagnostic tests, Radiology (diagnostics), Epidemiology, Drugs: endocrine system Original article Source Type: research

A study in high-risk, maximally pretreated patients to determine the potential use of PCSK9 inhibitors at various thresholds of total and LDL cholesterol levels
Conclusions We determined that the proportion of patients eligible for a PCSK9 inhibitor at various TC and LDL-c levels is modest. This may reflect the use of all available statins in UK lipid clinics often at non-daily frequency. We suggest that cost-effective use of PCSK9 inhibitors requires prescribing being restricted to clinicians working in specialised lipid clinics. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Groves, C., Shetty, C., Strange, R. C., Waldron, J., Ramachandran, S. Tags: Original article Source Type: research

Variation in the use of definitive treatment options in the management of Graves' disease: a UK clinician survey
Background Graves' disease can be treated with antithyroid drugs (ATDs), radioiodine or surgery. Use of definitive treatments (radioiodine or surgery) varies widely across centres. Specific clinical circumstances, local facilities, patient and clinician preferences and perceptions will affect the choice of treatment. Detailed understanding of UK clinicians' views and their rationale for different treatments is lacking. Aims To study the preferences and perceptions of UK clinicians on the role of surgery and radioiodine in the management of Graves' disease. Methods ‘British Thyroid Association’ (BTA), ‘S...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Hookham, J., Collins, E. E., Allahabadia, A., Balasubramanian, S. P. Tags: Original article Source Type: research

Improving value-add work and satisfaction in medical residents training: a resident-led quality improvement project employing the lean method to improve hospital supply usage
Purpose Our hospital has a Housestaff Quality Council that fosters education and mentorship of medical residents for quality improvement methodologies. Medical residents on our council identified non-standardised storage rooms as a source of medical resident inefficiency and dissatisfaction. To improve value-add work, medical residents implemented and evaluated a quality improvement project of storage room supplies using the lean method. Methods Using 5S principle and lean methodology, we designed and implemented a standardised supply cart with physician specific supplies. Between April 2014 and April 2015, 40 random obse...
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Yang, J. X., Hunt, T. D., Ting, H. H., Henderson, D., Finkelstein, J., Davidson, K. W. Tags: Original article Source Type: research

Clinicopathological and prognostic significance of survivin expression in renal cancer patients: a meta-analysis
Conclusions Our results indicate that survivin is of prognostic significance in patients with RCC. (Source: Postgraduate Medical Journal)
Source: Postgraduate Medical Journal - March 22, 2017 Category: Journals (General) Authors: Ma, C., Lu, B., Sun, E. Tags: Original article Source Type: research