JRSM Open最新文献

We want to remind Physicians that unusual conditions can present in unusual ways and to keep an open mind always.

Awareness of the various clinical manifestations and diagnostic pitfalls in patients with atrio-oesophageal fistula is necessary among healthcare professionals.

Objectives: To establish principles informing a new scoring system for the UK's Clinical Impact Awards and pilot a system based on those principles.

Design: A three-round online Delphi process was used to generate consensus from experts on principles a scoring system should follow. We conducted a shadow scoring exercise of 20 anonymised, historic applications using a new scoring system incorporating those principles.

Setting: Assessment of clinical excellence awards for senior doctors and dentists in England and Wales.

Participants: The Delphi panel comprised 45 members including clinical excellence award assessors and representatives of professional bodies. The shadow scoring exercise was completed by 24 current clinical excellence award assessors.

Main outcome measures: The Delphi panel rated the appropriateness of a series of items. In the shadow scoring exercise, a novel scoring system was used with each of five domains rated on a 0-10 scale.

Results: Consensus was achieved around principles that could underpin a future scoring system; in particular, a 0-10 scale with the lowest point on the scale reflecting someone operating below the expectations of their job plan was agreed as appropriate. The shadow scoring exercise showed similar levels of reliability between the novel scoring system and that used historically, but with potentially better distinguishing performance at higher levels of performance.

Conclusions: Clinical excellence awards represent substantial public spending and thus far the deployment of these funds has lacked a strong evidence base. We have developed a new scoring system in a robust manner which shows improvements over current arrangements.

This case highlights the importance of genetic testing over fibroblast testing and presents the first published thromboelastometry data in vascular Ehlers-Danlos syndrome.

Objectives: To examine modern media depictions of the third stage of birth in a selection of UK television representations.

Design: Observational study of a sample of televised fictional and real births, audited against current National Institute of Health and Social Care Excellence (NICE) guidance.

Setting: UK television channels BBC (Call The Midwife and This Is Going To Hurt) and Channel 4 (One Born Every Minute).

Participants: 87 births from 48 episodes, sampled from the three shows.

Main outcome measures: The primary outcome was the number of births where the cord was clamped at more than 1 min after birth. Secondary outcomes included place and type of birth, measures of dignity and paternal involvement.

Results: Overall, the timing of cord clamping was clearly shown in 25/87 (29%) of births, of which only 4/25 (16%) occurred at more than 1 min in screen time. The place of birth and caesarean section (CS) rate changed according to the series perspective and era; graphic explicit images were shown, but these related to CS detail.

Conclusions: UK television shows have accurately depicted changes in place, culture and type of birth over the last century. They provide the public with a view of new rituals but an inaccurate picture of good quality care. Early cord clamping was shown in most births, even those set after 2014. No programme informed viewers about the safety aspects. When showing outdated practices, broadcasters have a public health duty to inform viewers that this is no longer recommended.

Progressive multifocal leukoencephalopathy (PML) is a rare disease of the central nervous system caused by opportunistic infection with JC virus. It presents in patients who are immunocompromised, and diagnosis is made by correlating clinical findings and radiological changes with the detection of JC virus in cerebrospinal fluid. Rarely, a brain biopsy is needed. A 72 year old with high grade B-cell lymphoma developed right arm weakness and limb ataxia shortly after his diagnosis. CNS involvement was excluded with a normal CT head, MRI brain/spine, and CSF examination. A paraneoplastic cause was suspected, and he received 5 cycles of Rituximab-containing chemotherapy to a complete metabolic remission. His neurology evolved during treatment despite serial MRI and CSF examination remaining normal. CSF and serum were both negative for JC virus by PCR. Following completion of chemotherapy, he deteriorated acutely with seizures and personality changes. It was only at this point that a repeat MRI showed new multiple scattered ring enhancing lesions within both cerebral hemispheres. The patient underwent a brain biopsy confirming JC virus positive-PML by immunohistochemistry and passed away one month later. This case illustrates the diagnostic challenges associated with PML and had several atypical features which led to diagnostic delay, specifically the onset of symptoms before starting immunochemotherapy, and the lack of radiological change despite evolving neurology. The eventual MRI abnormalities were not altogether classical for PML which, coupled with the JC-negativity in CSF and serum, meant a brain biopsy was required to reach the diagnosis.

Objectives: To critically appraise the quality of the studies underpinning the Global Burden of Disease (GBD) 2017 estimates for Major Depressive Disorder (MDD) with respect to i) the GBD 2017 inclusion criteria and ii) population coverage.

Design: Systematic critical appraisal.

Setting: Not applicable.

Participants: Not applicable.

Main outcome measures: Each study was critically appraised with respect to the four GBD 2017 inclusion criteria: representativeness, study method and sample, diagnostic criteria and publication from 1980 onwards. Population coverage was calculated.

Results: Less than half of studies (221/467, 47.3%) were nationally representative. Only 262/467 (56.1%) of studies reported specifically on MDD and more than a third did not use DSM or ICD diagnostic criteria: 94/467 (20.1%) did not specify any diagnostic criteria and 68/467 (14.6%) relied on self-reported depression for diagnosis. Only 62/467 (13.3%) of studies were conducted during the period 2011-2017. Only 107/195 (54.9%) of countries had one or more prevalence studies.

Conclusions: GBD 2017 estimates for MDD are based on incomplete country and population coverage. The inclusion of studies with non-representative populations, that do not use diagnostic criteria and the lack of specific data on MDD reduces the reliability of estimates and limits their value for policy making.