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Exploring ascites: Its significance, pathogenesis, aetiology, presentation, examinations and management strategies
No full textAscites is characterised by an accumulation of fluid in the peritoneal cavity. While it is commonly associated with liver cirrhosis, it may also result from malignancy, cardiac failure or renal disease. This clinical review explores the pathogenesis, clinical presentation, diagnostic approaches and management strategies for ascites, emphasising its multifaceted nature and clinical implications. The pathophysiology of cirrhotic ascites is largely attributed to splanchnic vasodilation and subsequent sodium and water retention, while non-cirrhotic causes are associated with various underlying mechanisms. Clinical presentations range from abdominal distension and discomfort to systemic signs of underlying diseases. Diagnosis involves imaging, ascitic fluid analysis and advanced laboratory tests to identify the aetiology and guide targeted interventions. Management requires a multidisciplinary approach, integrating sodium restriction, diuretic therapy, paracentesis, albumin infusion and, in some cases, transjugular intrahepatic portosystemic shunts (TIPS). Challenges such as refractory ascites and complications such as spontaneous bacterial peritonitis necessitate a thorough clinical assessment and management. Advanced clinical practitioners and gastroenterology teams play an essential role in optimising outcomes, ensuring patient safety and promoting quality of life.https://www.magonlinelibrary.com/doi/abs/10.12968/gasn.2024.001
A clinician’s guide to neurodivergence : supporting a neuro-affirmative form of practice
No full textAvailable in the library: https://koha.healthlibrariesmidlands.nhs.uk/cgi-bin/koha/opac-detail.pl?biblionumber=161137A Clinician’s Guide to Neurodivergence: Supporting a neuro-affirmative form of practice is a concise handbook which provides a comprehensive and accessible overview of a range of conditions to support clinicians working with individuals with diverse neurocognitive profiles. It provides a practical guide for clinicians to move towards a more neuro-aware and neuro-affirmative way of working. It sets out guidance around diagnosis and access to services whilst giving consideration to the adaptations and accommodations that might be necessary to avoid the inequities that can often be experienced through neuro-normative or heteronormative practices. Topics covered include learning difficulties such as Dyslexia and Dyscalculia, Autism, ADHD, acquired brain injury and various other neurodivergent profiles. The intersection of neurodivergence with factors such as gender and age and comorbidity with mental health and personality profiles are also considered. Drawing on the NICE guidelines, the International Classification of Disease (ICD) system, and the Diagnostical Statistical Manual (DSM), each chapter provides the background to different neuro-cognitive profiles, common indicators that may be observed, screening and diagnostic assessment, clinical recommendations and signposting to relevant resources and services. It is valuable reading for students, researchers, clinicians, therapists, medical and allied professionals who require an introductory text providing in-depth details regarding a range of neurodivergent conditions.https://www.routledge.com/A-Clinicians-Guide-to-Neurodivergence-Supporting-a-Neuro-Affirmative-Form-of-Practice/Ashworth-Watts-Brotherton-Carton/p/book/9781032839783?srsltid=AfmBOoofCfXAtAh3VfZQ11H_f5cxJ_iW9UE6lNg2UMd66zpiERi08Hk
An audit of metabolic monitoring compliance in patients initiated on antipsychotics across general adult wards in the East Midlands
No full textAims: The Lester Tool mandates baseline monitoring parameters for patients starting new antipsychotics or having their current antipsychotic regimen changed. These parameters include blood pressure, haemoglobin A1c (HbA1c)/fasting plasma glucose, lipids, lifestyle review, waist circumference, and weight, along with weekly weight monitoring for six weeks consecutively. This audit was initiated in response to concerns about rapid weight gain observed in many patients after starting certain antipsychotics. It aims to assess compliance with the Lester Tool to address the potential risks of metabolic syndrome in these patients. The audit seeks to understand the pattern of antipsychotic prescriptions as a secondary objective. Method(s): The audit was registered and ethically approved by the local research and audit department. A retrospective review of electronic health records and medication charts was conducted for 38 patients residing in two male and two female inpatient wards in the East Midlands between 17 June 2024 and 26 June 2024. Baseline parameters were audited to determine if they were measured within one week of antipsychotic initiation, and weekly weight checks thereafter. Waist circumference measurement at baseline was excluded due to concerns about its potential impact on patient self-esteem. Result(s): Among baseline monitoring parameters, blood pressure had the highest compliance at 89.5%, followed by HbA1c/glucose (65.8%), lipids (57.9%), lifestyle review (55.3%), and weight monitoring (36.8%). Weekly weight follow-up compliance was low, with only 5.9% of patients meeting 100% compliance, and 41.2% of patients having no documented weight follow-up within six weeks. Non-compliance reasons were poorly documented. Risperidone was the most prescribed antipsychotic (N=9), followed by olanzapine (N=8), zuclopenthixol (N=7), and quetiapine (N=6). Olanzapine and risperidone were most frequently initiated in male wards, while zuclopenthixol and quetiapine were more common in female wards. Conclusion(s): The audit identified significant gaps in compliance with the Lester Tool, which poses a risk to patients' physical health due to the metabolic side effects of antipsychotic medications. The findings underscore the need for better documentation and communication regarding baseline and follow-up measures. Recommendations include increasing awareness of baseline blood requirements during admission, improving electronic health record functions (e.g. alerts for weekly weight checks and a drop-down to document weight check refusals), and enhancing coordination in monitoring patient weight following planned home leaves. A re-audit is ideal once the recommendations have been implemented.https://www.cambridge.org/core/journals/bjpsych-open/article/an-audit-of-metabolic-monitoring-compliance-in-patients-initiated-on-antipsychotics-across-general-adult-wards-in-the-east-midlands/C2D1094161415D5F8413536CB7EC30D
A case of depersonalization-derealization disorder
No full textAims: Background: Depersonalization-derealization disorder (DPDR), classified under ICD-11 code 6B66, involves persistent or recurrent experiences of depersonalization, derealization, or both. Depersonalization refers to a sense of detachment from one's thoughts, emotions, or body, whereas derealization involves perceiving the external world as unreal or distorted. These symptoms cause significant distress or impairment, are not attributable to other mental disorders, substance use, or medical conditions, and occur while reality testing remains intact. Method(s): Case Report. An 18-year-old female A-level student presented with a two-year history of frequent episodes in which her surroundings, including people and familiar environments, felt unreal. These episodes varied in duration and were highly distressing, particularly during emotional extremes such as heightened happiness or stress. Symptoms were most pronounced in the evenings or when she was unoccupied, leading to emotional breakdowns. Despite these experiences, she remained aware of her own reality, with disturbances centred on external perceptions. Her symptoms began following a nine-month psychiatric hospitalization. Prior to admission, she experienced unexplained gastrointestinal symptoms, and in the absence of an identifiable physical cause, she was diagnosed with conversion disorder. The hospitalization was distressing due to frequent invasive procedures, a perceived sense of blame for her condition, and feelings of entrapment. She subsequently developed post-traumatic stress disorder (PTSD), characterized by flashbacks, nightmares, and avoidance of medical settings. However, DPDR symptoms persisted outside of PTSD-related re-experiencing episodes, causing ongoing distress and impairment. Result(s): Discussion: This case highlights the complex interplay between DPDR and PTSD, particularly following medical trauma. While dissociative symptoms frequently occur in PTSD, ICD-11 differentiates DPDR as a distinct disorder when symptoms persist beyond re-experiencing episodes. In this case, the patient's prolonged hospitalization, combined with perceived invalidation and invasive interventions, likely contributed to the development of DPDR as a maladaptive dissociative response. The exacerbation of symptoms during emotional extremes aligns with research indicating that dissociation may function as an affect regulation mechanism. Trauma-related dissociation has been linked to disruptions in emotional processing, potentially interfering with adaptive coping strategies. This underscores the importance of targeted psychological interventions to reduce distress and improve functional outcomes. Conclusion(s): A trauma-informed, multidisciplinary approach is essential in managing this patient's complex presentation. Psychological interventions such as EMDR or trauma-focused CBT should be integrated with ongoing medical care to address both dissociative symptoms and physical health concerns. Collaborative management between psychiatric and medical teams will be crucial in promoting long-term recovery, enhancing her psychological resilience, and improving overall quality of life.https://www.cambridge.org/core/journals/bjpsych-open/article/case-of-depersonalizationderealization-disorder/C7FD2CAD643CC75A0421D4AAB743452
Revision of total elbow arthroplasty due to humeral loosening with large bone defect using humeral allograft-prosthesis composite: A case report.
No full textINTRODUCTION AND IMPORTANCE: Revision of total elbow arthroplasty is a challenging procedure, especially when associated with humeral bone deficiency. The purpose of this case report is to highlight the successful management of humeral-sided loosening due to bone defects, using an allograft-prosthesis composite with a humeral bone allograft. PRESENTATION OF CASE: A 70-year-old female patient under medication for rheumatoid arthritis underwent revision of left total elbow arthroplasty due to major bone defect and loosening on the humeral side. The allograft-prosthesis composite method was used to address the bone defect and loosening of the humeral side by using humeral allograft as well as plating the host humeral bone. CLINICAL DISCUSSION: There were no post-operative complications. The radiographic assessment at her latest follow-up was unremarkable, along with a significant improvement on the functional scores and range of motion. CONCLUSION: The use of a humeral allograft is a valuable option for the management of loosened total elbow arthroplasty with significant bone loss. However, more studies need to be conducted to determine the long-term outcomes of revision surgery of total elbow arthroplasty with humeral bone loss
Real-world clinical outcomes of patients with moderate-to-severe rheumatoid arthritis initiating upadacitinib in the United Kingdom: final analysis from a prospective observational cohort study (ENDEAVOUR)
No full textObjective Upadacitinib is recommended by National Institute for Health and Care Excellence in the UK in adults with moderate-to-severe rheumatoid arthritis (RA). This observational study assessed real-world clinical outcomes and patient-reported outcomes (PROs) in patients receiving upadacitinib for 6 months in the UK. Methods Patients from 14 centres in whom the decision to initiate upadacitinib had already been made were enrolled. Baseline data were retrospectively collected from patient records. Clinician-reported data were collected at routine clinic visits 3 and 6 months after upadacitinib initiation. Patient-reported data were collected directly from patients using an app (electronic PROs, ePROs). The primary end-point was proportion of patients achieving clinical remission (DAS28 CRP <2.6) after 6 months of upadacitinib. Results Data are available for 63 patients at all three datapoints and for 53 patients for the primary end-point. At 6 months, 40% (21/53) of patients achieved clinical remission and 21% (11/53) achieved low disease activity. Response was seen at 3 months for all efficacy end-points. ePROs allowed the capture of early patient-reported data which demonstrated clinically important improvements in pain and fatigue within 10 days and other PROs within 2 months. Improvements were also seen in metrics of activity, work and quality of life (QOL). Conclusion Patients in ENDEAVOUR showed similar early effectiveness with upadacitinib to that observed in clinical trials. Use of ePROs demonstrated rapid onset of action and meaningful improvements in QOL providing a potential opportunity to reduce outpatient visits for early responders, thus reducing the burden on rheumatology services.https://www.tandfonline.com/doi/full/10.1080/03007995.2025.251528
Advanced vascular ultrasound prior to radial artery cannulation on the intensive care unit: a feasibility service evaluation
No full textBackground: Radial arterial catheters are frequently used for monitoring and blood sampling in critical care patients. Ischaemic complications are rare but can cause significant morbidity. The use of vascular ultrasound in critical care is becoming increasingly commonplace. This service evaluation aims to assess the feasibility of training novices in advanced vascular ultrasound assessment, prior to radial arterial cannulation. Methods: Over a 4-month period, data was collected from patients admitted to the intensive care unit at the William Harvey Hospital, Ashford, Kent. Ultrasound was used to assess for the presence, size and flow of the radial and ulnar arteries. The assessments were performed by two novice residents in intensive care, who were trained in advanced ultrasound assessment of the radial and ulnar arteries, by an intensive care consultant with expertise in vascular ultrasound. Results: One hundred and five limbs were assessed in 53 patients. Novices were deemed to be sufficiently competent, after performing scans on 15 patients over a 2-week period. Satisfactory images were acquired in 100% of patients. The most common finding was a small diameter ulnar artery, present in 30 limbs (29%), while only 1 patient (1%) was found to have an absent ulnar artery. Thirty-two limbs had a radial arterial catheter in-situ. There were no ischaemic complications. Conclusion: This service evaluation demonstrates that the training of novices in advanced ultrasound assessment of the radial and ulnar arteries by an intensive care consultant, is feasible. Moreover, this modality may identify patients at risk of critical limb ischaemia. This particular investigation may be considered for incorporation into existing vascular ultrasound assessments.https://journals.sagepub.com/doi/10.1177/1751143725135095
Expression of programmed cell death Ligand 1 and mismatch repair status in ovarian carcinomas
No full textBackground: Ovarian carcinoma is the third most common gynecological malignancy among women in India, with a poor prognosis despite advancements in treatment modalities. Immunotherapy, particularly the use of programd cell death ligand 1 (PD-L1) checkpoint inhibitors, has emerged as a promising approach. This study investigates the relationship between PD-L1 expression, mismatch repair (MMR) status, and clinicopathological features in epithelial ovarian carcinoma (EOC). Materials and Methods: A cohort of 50 EOC cases was analyzed for PD-L1 expression in tumor cells and tumor-infiltrating lymphocytes (TILs) using immunohistochemistry (IHC). MMR status was also assessed through IHC. Statistical correlations between PD-L1 expression, MMR deficiency (dMMR), and clinicopathological parameters were evaluated. Results: PD-L1 expression in tumor cells and TILs was observed in 20% and 14% of cases, respectively. PD-L1 expression in tumor cells was absent in most advanced-stage tumors (stages III and IV) and cases with extraovarian spread. dMMR was identified in 30% (n = 15) of cases, predominantly in higher-stage tumors with extraovarian spread and significant TIL presence (P = 0.007). However, PD-L1 expression in tumor cells and TILs was absent in 86.7% and 80% of dMMR cases, respectively. No significant association was found between dMMR status and PD-L1 expression in EOC. Conclusion: PD-L1 expression in tumor cells is predominantly observed in early-stage EOC, suggesting its potential as a prognostic marker and therapeutic target. Although dMMR status correlates with advanced-stage disease and TIL presence, it does not significantly influence PD-L1 expression in EOC. These findings highlight the importance of routinely assessing PD-L1 and MMR status to guide immunotherapeutic strategies in ovarian carcinoma.https://journals.lww.com/jomh/fulltext/2025/07000/expression_of_programmed_cell_death_ligand_1_and.11.asp
Ten-Year Survival after Postmastectomy Chest-Wall Irradiation in Breast Cancer.
No full textBACKGROUND: The role of postmastectomy chest-wall irradiation in patients with breast cancer classified as pN1 (with involvement of one to three axillary nodes) or pN0 (pathologically node negative) with additional risk factors is uncertain. METHODS: In this international, phase 3, randomized trial, we evaluated the omission of chest-wall irradiation in women with "intermediate-risk" breast cancer - defined as cancer that was stage pT1N1, pT2N1, or pT3N0 or stage pT2N0 with a histologic grade of 3, lymphovascular invasion, or both (tumor size: T1, ≤2 cm; T2, >2 cm to 5 cm; or T3, >5 cm) - that was treated with mastectomy, an axillary procedure, and systemic therapy. Patients were assigned to undergo chest-wall irradiation (40 to 50 Gy; the irradiation group) or not to undergo chest-wall irradiation (the no-irradiation group). The primary end point was overall survival, with 10 years of follow-up. Chest-wall recurrence, regional recurrence, disease-free survival, distant metastasis-free survival, causes of death, and radiation-related adverse events were also assessed. RESULTS: The intention-to-treat population included 808 patients in the irradiation group and 799 in the no-irradiation group. The median follow up was 9.6 years. Overall survival was 81.4% with chest-wall irradiation and 81.9% with no chest-wall irradiation according to 10-year Kaplan-Meier estimates (hazard ratio for death, 1.04; 95% confidence interval [CI], 0.82 to 1.30; P = 0.80). A total of 29 patients had a chest-wall recurrence - 9 (1.1%) in the irradiation group and 20 (2.5%) in the no-irradiation group (between-group difference, <2 percentage points; hazard ratio, 0.45; 95% CI, 0.20 to 0.99). Disease-free survival was 76.2% in the irradiation group and 75.5% in the no-irradiation group (hazard ratio for recurrence or death, 0.97; 95% CI, 0.79 to 1.18), and distant metastasis-free survival was 78.2% and 79.2%, respectively (hazard ratio for distant metastasis or death, 1.06; 95% CI, 0.86 to 1.31). CONCLUSIONS: In this trial, chest-wall irradiation did not result in higher overall survival than no chest-wall irradiation among patients with intermediate-risk, early breast cancer treated with mastectomy and contemporary adjuvant systemic therapy. (Funded by the Medical Research Council and others; SUPREMO ISRCTN Clinical Study Registry number, 61145589.)
Operative Versus Nonoperative Outcomes: A Cohort Study on Distal Biceps Tendon Rupture.
Get PDFBackground Distal biceps tendon ruptures typically occur in middle-aged men following eccentric loading activities. While surgical repair is common, comparative data on operative versus nonoperative outcomes remain limited. We conducted a retrospective study to compare the outcomes of operative versus nonoperative management in Queen's Hospital Burton. Methods We reviewed the records of 72 patients (52 operative, 20 nonoperative) treated during the period of 2016-2023 for complete distal biceps tendon ruptures. All diagnoses were confirmed clinically and radiologically. Operative management was via a single anterior incision or a modified two-incision technique using cortical button fixation. Complications, range of motion, and return to activity were abstracted from clinical records documented at the time of care. Validated outcome measures, such as the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Mayo Elbow Performance Score (MEPS), were not collected as part of routine care. Results Operative management was associated with a higher rate of complications, including nerve injuries and wound issues, though most patients ultimately regained a full range of motion and function. Nonoperative management resulted in minimal complications, with patients reporting return to their previous activity levels and only minor subjective strength deficits. Overall, operative repair offered greater strength recovery, particularly in supination, but at the cost of increased morbidity, whereas nonoperative management provided excellent functional outcomes with lower risk. Conclusion Nonoperative management appeared to be a reasonable option for selected patients in this cohort. Operative repair is effective but associated with a higher complication rate. Treatment should be individualised, balancing patient activity level, expectations, and risk profile