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doi: 10.4997/jrcpe.2013.402pmid: 24350309
Midway between Africa and South America, on the edge of the ‘roaring 40s’ (37°S 12°W) is an archipelago of five tiny volcanic islands. Tristan, a British Overseas Territory, is the largest – seven miles across and rising 7,000 feet above sea level. There is no airport, no air access except for an occasional ship’s helicopter and no sheltered anchorage. The nearest port is over 1,700 miles away – a week or more by ship and the tiny harbour requires constant repair due to the impact of the relentless South Atlantic. Ship-to-shore travel is hazardous as passengers (and medevacs) are transferred sitting in a box hoisted by crane to a raft or rigid inflatable boat. Tristan has traditionally had a resident ‘ships surgeon’ or ‘island doctor’; although these terms may not have changed, the training and experience to fill these roles have. The island needs a general physician1 with experience of primary care or a general practitioner with experience of secondary care. Additional training is required in surgical and gynaecological emergencies. The two authors between them had appropriate experience in general medicine, general practice, resuscitation and critical care and to be able to worry together is a better prospect than worrying alone – so a joint appointment for six months seemed sensible and was found to be effective.
McCallum, AD; Sutherland, RK; Mackintosh, CL
doi: 10.4997/jrcpe.2013.403pmid: 24350310
Antimicrobial stewardship programmes reduce the risk of hospitalassociated infections (HAI) and antimicrobial resistance, and include early intravenous-to-oral switch (IVOS) as a key stewardship measure. We audited the number of patients on intravenous antimicrobials suitable for oral switch, assessed whether prescribing guidelines were followed and reviewed prescribing documentation in three clinical areas in the Western General Hospital, Edinburgh, in late 2012. Following this, the first cycle results and local guidelines were presented at a local level and at the hospital grand rounds, posters with recommendations were distributed, joint infection consult and antimicrobial rounds commenced and an alert antimicrobial policy was introduced before re-auditing in early 2013. We demonstrate suboptimal prescribing of intravenous antimicrobials, with 43.9% (43/98) of patients eligible for IVOS at the time of auditing. Only 56.1% (55/98) followed empiric prescribing recommendations. Documentation of antimicrobial prescribing was poor with stop dates recorded in 14.3%, indication on prescription charts in 18.4% and in the notes in 90.8%. The commonest reason for deferring IVOS was deteriorating clinical condition or severe sepsis. Further work to encourage prudent antimicrobial prescribing and earlier consideration of IVOS is required.
Oo, MT; Tencheva, A; Khalid, N; Chan, YP; Ho, SF
doi: 10.4997/jrcpe.2013.404pmid: 24350311
Background: Managing acute admission of frail older patients is a challenge in hospitals. Length of inpatient stay, inpatient mortality and the 90-day readmission rate are significant in this group of patients. The Comprehensive Geriatric Assessment (CGA), a multidisciplinary diagnostic and treatment process, is the best approach for identifying medical conditions, mental health, functional capacity and social circumstances in acute geriatric care.Methods: A review of the records of older patients aged 75 and over, acutely admitted to a district general hospital in England from 15 March 2012 to 16 April 2012 was conducted. We developed a frailty assessment tool and applied it to these patients, in order to determine who would be classified as frail. We then established if the patients meeting this criteria were then correctly assessed using the CGA. All patient data were processed and analysed using a statistical package for data analysis.Results: A total of 232 patients with a mean age of 84.25 ± 5.8 years were included. Out of these, 129 patients (55.6%) fulfilled the frailty criteria as determined with our frailty-assessment tool; 80.6% presented with lack of mobility over 24 hours, 69.8% were admitted with falls, 47.3% had known dementia or delirium and 45% were admitted from care homes. Patients aged over 85 years were more likely to have frailty compared with patients aged 75–85 years old (odds ratio [OR]: 4.78, 95% confidence interval [CI]: 2.6–8.6, p value <0.001). Patients assessed by a front door geriatric team were more likely to be reviewed with the CGA than those not seen by this team (adjusted OR 2.8, 95% CI: 1–7.6, p value=0.04).Conclusion: The prevalence of frailty is high in acute admissions of older patients and it is important that they are properly identified and assessed with a CGA in order to ensure effective multidisciplinary care.
Wimalaratna, H; Nandasiri, ASD
doi: 10.4997/jrcpe.2013.406pmid: 24350312
Berardinelli-Seip congenital lipodystrophy (BSCL) is a rare autosomal recessive disorder of generalised lipoatrophy, characterised by the absence of functioning adipocytes, with lipid being stored in muscles, the liver and the pancreas. The usual presentation is in adulthood, with manifestations of insulin resistance, hypertriglyceridaemia and liver steatosis. Cirrhosis as the first presentation of BSCL in a young adult is rare. We describe a patient with BSCL presenting with cirrhosis. To the best of our knowledge this is the first case of BSCL reported in a Sri Lankan patient.
Baqai, MF; Baqai, MT; Kashif, T
doi: 10.4997/jrcpe.2013.408pmid: 24350313
A 19-year-old labourer presented with progressively worsening swelling of both lips. Clinical assessment and investigations led to the diagnosis of granulomatous cheilitis.
Edwards (Chair), N; Gaw, N; Giles, O; Harkness, A; Jack, A; James, S; Leitch, L; Long, J; Lyness, R; McDonald, C; Miller, E; Murdoch, P; Peden, N; Smith, L; Trueland, J; Ward, D
doi: 10.4997/jrcpe.2013.411pmid: 24350316
Social media is everywhere; its use has grown exponentially over recent years. The prevalence of these outlets for communication raises some interesting and potentially risky issues for physicians. On the one hand, some believe that physicians should have a strong social media presence and can benefit greatly from access to a global community of peers and leaders through blogs, online forums, Facebook, Twitter and other communication channels. Dr Anne Marie Cunningham provides a strong case for the advantages of developing networks and figuring out who and what to pay attention to online. On the other hand however, others believe that the use of social media places doctors at a professional and ethical risk and is essentially a waste of time for the already time-pressured physician. Professor DeCamp argues that the risks of social media outweigh their benefits. It makes it more difficult to maintain a distinction between private and professional personas, and as we have seen, one mistyped or inappropriate comment can have potentially negative consequences when taken out of context. With an already time-pressured day, the priority should be patients, not tweets. Whatever your thoughts on the benefits and risks of social media, it is here to stay. Specific guidelines and guidance are needed to ensure that physicians who decide to join an online community reap the benefits of global communication, rather than regret it.
doi: 10.4997/jrcpe.2013.412pmid: 24350317
Acute kidney injury (AKI) represents a medical emergency associated with poor clinical outcomes. The international guideline group Kidney Disease: Improving Global Outcomes (KDIGO) has defined AKI according to rises in serum creatinine and/or reductions in urine output. Any patient who meets the criteria for AKI should be reviewed to ascertain the cause of AKI and the severity of the injury should be staged. Patients with more severe AKI are at greater risk of progression to chronic kidney disease (CKD). The 2009 National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) reported that only 50% of patients who died with a diagnosis with AKI received good care. The mortality from AKI has remained unchanged for the last four decades and there are currently no specific therapies for the majority of cases of AKI. Patients with rarer forms of AKI need urgent renal referral for specific therapy. At present, serum creatinine and urine output remain the best biomarkers for detecting AKI. However, significant kidney damage has usually occurred by the time changes in these biomarkers are manifest and newer biomarkers are under investigation. Management of AKI is based upon general supportive measures, which includes treatment of the underlying cause and the initiation of renal replacement therapy (RRT) in patients with complications refractory to medical management. The optimal choice of intravenous fluid therapy remains controversial. There is currently renewed interest in more specific therapies for AKI secondary to hypoperfusion and/or sepsis, which have been previously unsuccessful. A number of therapeutic strategies are presently being explored in clinical trials.
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doi: 10.4997/jrcpe.2013.410pmid: 24350315