Loughborough Hospital

1. A 12 week prospective survey of all patients of any age with confirmed or suspected poisoning presenting to six accident and emergency departments in the North East of England was performed to establish the local incidence and patterns of presentation of poisoning. 2. 945 episodes of poisoning involving 852 patients were recorded representing approximately 1.2% of all A&E presentations and suggesting an annual attendance rate of 2.7 per 1000 persons per year. 3. Attendance rates varied threefold between hospitals and were similar in males and females overall; between the ages of five and 14 attendances were more common in females (1.9 vs 0.6/10(3)/y) while between 0 and 4 y (3.1 vs 2.4) and 25 and 34 y (3.9 vs 2.9/10(3)/y) they were more common in males. 4. The median interval between poisoning and presentation was 2 h (mean 4.1 h) and only 19% of cases presented within 1 h. Presentation was most common between Friday evening and Tuesday morning and in the late afternoon and evening. 5. 6% of the patients presented more than once with poisoning during the study period and 37% had a past history of deliberate self-harm. The most common poisons involved were paracetamol (43%), opioids (15%) and benzodiazepines (15%). 6. The study illustrates the frequency of presentations of poisoning to A&E departments. The high rate of poisoning in young men and the increasing use of paracetamol are particular causes for concern.

The electric strengths of simple hydrocarbons and of transformer oil have been found to be dependent on applied hydrostatic pressure under all conditions investigated, including conditions of extreme cleanliness and for voltage pulses lasting only 1 µsec. A special feature of the investigation is that most of the results are for fresh liquids and electrodes, with which there had been no previous breakdown. It is suggested that electric breakdown is partly governed by dielectric layers on the cathode, which change with successive breakdowns, and that breakdown first takes place in a bubble of gas or vapor.

Veterinary use of the aminoglycoside antibiotics is under increasing scrutiny. This questionnaire-based study aimed to document the use of aminoglycosides with a particular focus on gentamicin. An online questionnaire was delivered to generalist equine veterinary surgeons and specialists in internal medicine to determine the perceived importance, frequency of use and routes of administration of the aminoglycoside antibiotics. A series of hypothetical scenarios were also evaluated regarding gentamicin. Data were compared to evaluate the impact of the level of specialisation on prescribing practices for different antibiotics using Chi-squared and Fischer's exact tests. Data were analysed from 111 responses. Gentamicin was commonly used empirically without culture and susceptibility testing. Generalists were more likely to use gentamicin only after susceptibility testing than specialists in a variety of clinical presentations including respiratory diseases, septic peritonitis, acute febrile diarrhoea, cellulitis and contaminated limb wounds (p < 0.01). Intravenous administration of gentamicin was most common, although inhaled and regional administration of gentamicin and amikacin were also described. Amikacin was most commonly used by intra-articular administration. Gentamicin was more likely to be used in high-risk procedures or contaminated surgeries (86% and 74%, respectively) compared with clean surgery (32%; p < 0.0001). Gentamicin was often used perioperatively in horses undergoing exploratory celiotomy and more commonly used in horses undergoing an enterotomy (90%) than without and enterotomy (79%; p = 0.04). Most respondents (86%) used gentamicin at a dose of 6.6 mg/kg in adults, with few changing their dosing strategies based on the presence of sepsis, although higher doses were more reported in foals (7-15 mg/kg) irrespective of the presence of sepsis. Aminoglycosides are widely used in equine practice and use outside current EU marketing authorisations is common. Stewardship of the aminoglycoside antibiotics could be enhanced in both generalists and specialists through the more frequent use of susceptibility testing, regional administration and dose adjustment, especially in foals.

We have examined the feasibility of a telemedicine-enabled screening service for children and adolescents with diabetes in Queensland. There are approximately 1400 young people with diabetes in Queensland and only about two-thirds of them are screened in accordance with international guidelines. A regional retinal screening service was established using a nonmydriatic digital retinal camera. Seven centres volunteered to participate in the study. During a five-month pilot trial, 83 of the young people with diabetes who attend these centres underwent digital retinal screening (3.7%). Retinal images were sent via email to a paediatric ophthalmologist for review and results were returned via email. A copy of each participant's results was forwarded by mail to the referring diabetes doctor and the participant and family. The majority of the image files (96%) were rated as excellent or good. Only one participant was identified as having an abnormal result. Participants and their families expressed satisfaction with the digital retinal screening process.

Onychomycosis prevalence is expected to rise as the population ages and the prevalence of diabetes, peripheral vascular disease, and other significant risk factors rise. Until recently, treatment options were limited due to safety concerns with oral antifungals and low efficacy with available topical agents. Efinaconzole and tavaborole were approved by the FDA in 2014 for onychomycosis treatment and provide additional effective topical treatment options for patients with mild-to-moderate disease. Dermatologists and podiatrists both regularly treat onychomycosis, yet there are striking differences between specialties in approach to diagnosis and treatment. In order to explore these differences a joint dermatology-podiatry roundtable of onychomycosis experts was convened. Although it has little effect on mycologic cure, debridement may be a valuable adjunct to oral or topical antifungal therapy, especially in patients with greater symptom burden. However, few dermatologists incorporate debridement into their treatment plans and referral to podiatry may be appropriate for some of these patients. Furthermore, podiatrists may be better equipped to manage patients with concurrent diabetes or peripheral vascular disease and elderly patients who are unable to maintain proper foot hygiene. Once cure is achieved, lifestyle and hygiene practices, maintenance/prophylactic onychomycosis treatment, and proactive tinea pedis treatment in patients and family members may help to maintain patients' cured status.

Summary A 5‐year‐old Arabian mare was referred for the investigation of recent behavioural change, generalised stiffness, and owner‐reported polyuria and polydipsia. Clinical examination revealed severe pain associated with palpation along the entire length of the suspensory ligament ( SL ) and palmar soft tissues of the pastern regions of both forelimbs. Radiographs of the distal forelimbs demonstrated marked radiopaque striations within the straight sesamoidean ligaments ( SSL s), and less severe but similar changes in the regions of the SL branches. Ultrasonography of both distal forelimbs revealed multifocal, hyperechoic lesions within the SSL s. The SL bodies and branches were enlarged and had mixed echogenicity on ultrasound scan. The horse was subjected to euthanasia at the owner's request and submitted for post‐mortem examination. Relevant gross findings were restricted to the SL s and SSL s of all four limbs, all of which contained severe mineralisation and irregularly arranged fibres. Histological examination revealed severe, multifocal to coalescing, dystrophic mineralisation with cartilaginous and osseous metaplasia, which suggested a primary calcifying desmopathy affecting all four SL s and SSL s. Clinical findings in the case reported here were similar to that of degenerative suspensory ligament desmitis previously reported by many authors, but diagnostic imaging and histopathological findings were significantly different.

Abstract The privatization of public services and utilities is a worldwide phenomenon reflecting trans‐national corporate hegemony and a shift of investment capital from productive to financial sources of profit. In one state, the privatization of mental health services was associated with the destruction of community mental health capacities and inpatient care for the seriously and persistently mentally ill. This was associated with increased rates of violence, homelessness, and imprisonment of psychiatric patients along with the deprofessionalization and demoralization of clinicians. An effective response of political activism and alliance‐building among professionals, unions, patients, and advocacy groups is described.

Background: The COVID-19 pandemic necessitated rapid change in neurorehabilitation delivery at the Defence Medical Rehabilitation Centre (DMRC), with a reduction in inpatient capacity. Aims and method: An interdisciplinary remote working group developed a novel neurorehabilitation telerehabilitation (TR) model. The plan, do, study, act (PDSA) model was used to develop and monitor activity in the changing pandemic context and to identify clinical outputs, key themes and learning points. Results: Eight PDSA cycles were performed, including video outpatient clinics, multidisciplinary team meetings, virtual ward rounds and TR for patients at home. Ten patients and 21 staff members provided feedback. Qualitative themes emerged including information technology, consultation environment, access to clinical notes and record keeping, clinical considerations, consent, patient and staff feedback, and feasibility. Conclusion: COVID-19 accelerated the implementation of TR at DMRC, allowing maintenance of service during lockdown. TR was acceptable to patients but placed a significant burden on staff. Practical suggestions for establishing a TR service are provided alongside challenges and limitations.

Patient group directions (PGDs) are now an integral feature of walk-in centres (WiCs), enabling nurses to supply and administer drugs to the generalised direction of a doctor rather than by means of a patient-specific prescription. The aims of the study described here were to assess nurses' record-keeping and knowledge with regard to PGDs for antibiotics implemented at a local WiC. The study methods included undertaking a clinical audit of patient records between October 2000 and March 2001 and an assessment of nurses' knowledge using multiple-choice questionnaires, vignettes and shadowing consultations. A total of 1,169 patients was supplied antibiotics, 72% of which were provided by nurses using a PGD. Nearly 100% of patients were supplied antibiotics correctly according to drug and dose; however, in only 63% of cases was there recorded evidence that allergy or contraindications were checked before the antibiotic was supplied. The study found that 51% of the required assessment criteria were recorded on the computer records. Nurses' knowledge at baseline resulted in a median score of 70%, which rose to 79% following educational interventions. The study suggests that nurses are knowledgeable and supply antibiotics judiciously in terms of drug and dose, but that in terms of clinical governance there is room for improvement in record-keeping.

The need to treat chronic pain and the increasing number of patients requiring opioid therapy are among the factors that have led to prescription opioid-related harm. Several professional society guidelines aim to reduce the frequency of opioid-related problems by modifying prescriber behaviour.1, 2 We analysed Monitoring of Drugs of Dependence System (MODDS) data for adult Queensland residents (18 years or older) for whom opioids were dispensed during 1 January 1997 ‒ 31 December 2018. Our aim was to determine the most frequently prescribed doses of opioids, and to examine associations between the mean number of prescribers per patient and the opioid doses dispensed. The database included data for 228 861 opioid prescribers during the study period and 18 798 942 dispensed opioid prescriptions. We undertook multivariate mixed effects Poisson regression, with random intercept by patient identification to account for within-patient correlations and between-patient characteristics. We adjusted for socio-economic status of patient residence (by postcode),3 as an association between lower socio-economic status and greater opioid prescribing has been reported.4 We also adjusted our analysis for duration of opioid use, dose in oral morphine milligram equivalents per day (MME/day), and opioid formulation, as in our previous studies.5, 6 The study was approved by the Royal Brisbane and Women’s Hospital Human Research Ethics Committee (HREC/17/QRBW/669), the University of Queensland Human Research Ethics Committee (2018000623/HREC/QRBW/669), and by the Department of Health under the Public Health Act 2005 (Qld) (RD007970). The number of patients for whom opioids were dispensed increased from 28 299 in 1997 to 322 307 in 2018; the number of Queensland medical practitioners who prescribed opioids increased from 4537 to 20 226 (online Supporting Information, table). The proportion of opioid prescribers who prescribed opioids at doses of 50 to less than 100 MME/day peaked in 2003 (813 of 5530, 14.7%), as did the proportion prescribing 100 MME/day or more (1077, 19.5%), before declining in 2018 to 1294 (6.4%) and 1064 of 22 941 (5.3%) respectively (Box 1, A; Supporting Information, figure). During 1997‒2018, 1 916 842 people (67.8% of people dispensed opioids) were dispensed doses of less than 20 MME/day, 624 114 were dispensed 20 to less than 50 MME/day (22.1%), 159 448 were dispensed 50 to less than 100 MME/day (5.6%), and 127 323 were dispensed 100 MME/day or more (4.5%) (Box 1, B). For modified release opioids, the largest proportions of prescribers and patients were for the 20 to less than 50 MME/day dose category (Box 1, C, D). * Opioids included were morphine, oxycodone, hydromorphone, tapentadol, fentanyl, buprenorphine, and codeine; methadone was excluded because we could not distinguish between prescribing for pain management and opioid replacement therapy. All formulations except lozenges, suppositories and parenteral formulations were included, apart from tablet and sublingual buprenorphine formulations (used to treat gastrointestinal problems and opiate dependence) and fentanyl (approved for palliative care). For complete inclusion and exclusion criteria, see Supplementary Material 3 in reference 6. The mean number of prescribers per patient per year increased with the dose of opioids dispensed (v < 20 MME/day: 20 to < 50 MME/day, incidence rate ratio [IRR], 1.04; 95% confidence interval [CI], 1.03‒1.04; 50 to < 100 MME/day, IRR, 1.09; 95% CI, 1.08‒1.09; ≥ 100 MME/day, IRR, 1.22; 95% CI, 1.21‒1.22) (Box 2). However, the mean number of prescribers per patient per year increased as the duration of opioid dispensing decreased (patients dispensed opioids for one month v for 7‒12 months: IRR, 1.36; 95% CI, 1.35‒1.36). This finding is consistent with a report that people using opioids for shorter periods more frequently visit multiple prescribers.4, 5 Mean prescribers per patient per year (95% CI) Our findings indicate that most Queensland medical practitioners prescribe lower opioid doses, and that the proportion prescribing lower doses has increased since 2004. The proportion of people dispensed doses of opioids associated with increased risk of accidental overdose (from 50 MME/day) was small and has declined over time. No relevant disclosures. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

This paper presents preliminary analysis of clinicians use of the Tissue Viability Leading Change (TVLC) competency framework launched in November 2015. It is the first UK wide competency framework developed for staff working in a tissue viability service. Total downloads for the framework has been 331 to date. Overall initial feedback has been positive. The majority of respondents have accessed the framework for personal professional development. Respondents were asked to rate each of the TVLC competencies by frequency and ease of use. The first 5 competencies were utilised significantly more than competencies 6–10; the majority of respondents rated most competencies easy to use. Nine respondents (81.8%) reported that they were using, or intended to use, the TVLC as part of their appraisal process. Eleven respondents (84.6%) reported that they had used, or intended to use, the TVLC in validation processes as required by the Nursing and Midwifery Council (NMC).

Carers of stroke victims can experience considerable strain. The treatment of stroke patients in specialist stroke units can have a beneficial effect on recovery. This study looks at whether these benefits were reflected in the health of their principal co-resident carers.

<h3>Aims</h3> Unprecedented winter pressures in 2017–18 led to cancellations of elective activity across the NHS and deteriorating population outcomes. East Midlands Clinical Senate undertook a review of the local planning processes to manage periods of increased demand <h3>Methods</h3> A two-stage approach was adopted: Literature review of national guidance Interviews with four local organisations <h3>Conclusion</h3> 25 papers were identified with guidance falling within 8 key themes: patient flow (n=13), communication and collaboration (13), demand (13), system capacity (12), funding (6), planning (6), patient safety (3) and staff training (3) The interviews revealed that despite similar system and operational challenges, clinical solutions are not being shared between commissioners and providers at scale More collaborative systems leadership approaches from commissioners during winter 2018–19 resulted in improved outcomes across the system The ambulance service is uniquely placed as a provider which interacts daily across local systems and with providers. This enables operational and clinical relationships to be developed and there was evidence of how a strategic approach to learning and responding to this insight had enabled better performance and outcomes following the winter of 2017–18 The importance of looking after workforce and creating the best possible conditions for staff to do their best for patients was highlighted <h3>Recommendations</h3> Better sharing of data and practices across the region Systems embrace and develop innovative ways of working to facilitate holistic care Commissioners should consider acting more as facilitators (enable change to occur and issues to be tackled) rather than regulators (seeking assurances on what has already happened) Develop better relationships with ambulance services to ensure practices are robust and standardised Improvements in rotas and increased investment in staff (both in terms of staffing numbers and improved skillset of each staff member)

<h3>Introduction and Objectives</h3> The Optimum Patient Care (OPC) service provides a comprehensive asthma assessment, analysing both GP-recorded and patient-reported outcomes to generate patient-specific management recommendations (based on British guidelines) for considerations by practise staff. This study evaluates the effect of the OPC asthma service evaluation on real-life asthma control outcomes in a UK primary care adult asthma population compared with a control population. <h3>Methods</h3> Routine and patient-reported questionnaire data were collected for 2952 patients with clinician-diagnosed asthma and 1 year outcome data managed in practises across Surrey and Leicester County and Rutland Primary Care Trusts. The effect of the OPC service was evaluated by assessing change in markers of asthma control between initiation and re-assessment: exacerbation frequency (Read code defined acute exacerbations and number of courses of acute oral steroids in previous 12 months) and risk status (high risk: ≥2 annual exacerbations). The number of OPC management suggestions implemented by each practise was also considered. Change in exacerbations over the 12 month period was compared with a control group of patients from UK practises who did not receive OPC management recommendations. Exacerbation rate ratios (RR) for treatment group were produced (relative to control), adjusted for baseline confounders (95%CI). <h3>Results</h3> There were 2952 patients in the study from 22 practises. At time of re-assessment 10% of OPC management suggestions had been implemented and 22% of patients managed at British Thoracic Society (BTS) steps 4/5 had improved their risk status. 17.1% of patients in the control group (n=22,952) suffered from ≥1 exacerbation during the baseline year, increasing to 17.3% of patients after 12 months. For patients receiving the OPC management review, 24.8% had ≥1 exacerbation during baseline, decreasing to 15.3% following review. <h3>Conclusions</h3> OPC’s combined patient-reported and practise data assessment allowed thorough patient assessment and the generation of tailored management recommendations. Although only 10% of recommendations were implemented at 12 months, the OPC service appeared to have a beneficial effect on risk status and exacerbation rates.

![Graphic][1]</img> On 20 December 1952, the British Medical Journal announced the foundation of a college of GPs, now the Royal College of General Practitioners (RCGP).1 The College had a strong vision for general practice. A singular achievement was vocational training.2 Sir James Mackenzie would have been proud of this, as he had himself advocated special training for GPs. There has been immense progress since then. We now have one of the finest systems of general practice in the world: There are also examples of the professionalism of individual GPs up and down the country: the GP who has made that early diagnosis of meningitis in a baby and the GP who deals with the frail older patient with heart failure. ### Concerns about the future There is much to celebrate but we have more work to do. As a practising doctor, I want to do more for my patients. There is much more that we can, and need to do. Take some examples: Mrs Patel is 66, she is distressed, she is crying because she is dying from advanced bladder cancer; her GP failed to diagnose the cancer early enough. Mrs Jones is 86 and has complex multiple medical conditions; her health is declining. She has repeated hospital admissions and multiple referrals without any obvious medical benefit. Actually, she is dying and approaching the end of her life but this goes unrecognised in the health system. People are … [1]: /embed/inline-graphic-1.gif

The MRCGP Recorded Consultation Assessment (RCA) uses recorded consultations, ostensibly to assess three skills: inter-professional; data gathering, technical and assessment; and decision making and clinical management. These are entirely reasonable constructs for an assessment of readiness for safe independent practice. However, the RCA has a hidden fourth construct: candidates must select cases that align with …

A Versailles Project on Advanced Materials and Standards round robin test (RRT) has been conducted to evaluate the linearity of the instrumental intensity scale and correction method using an approximation intermediate extended dead time model with parameters derived from two different isotope depth profiles. Nine organizations in five countries participated. An arsenic‐implanted silicon wafer and a film of BN diffused into a Si wafer were supplied by the National Institute of Advanced Industrial Science and Technology along with instructions for the RRT. The instruments used to analyze 103 (AsSi) − and 105 (AsSi) − from arsenic‐implanted samples were five quadrupole‐type SIMS and four magnetic‐sector type SIMS. The instruments used to analyze 10 B + and 11 B + from the BN‐diffused samples were three quadrupole‐type SIMS, four magnetic‐sector type SIMS, and one time‐of‐flight type SIMS. We validated the usefulness of the approximation intermediate extended dead time model to correct saturated intensities for all SIMS in this RRT. The optimum extension parameter ρ tends to be affected by the ratio of the maximum reliable intensity to the maximum intensity in raw profiles. From the ratio, ρ may be predicted when the intensity reaches full saturation. On the other hand, ρ is also affected by lateral non‐uniformity of intensity. In practice, because the maximum intensity does not reach full saturation and the intensity is not laterally uniform, ρ is likely to be smaller than its predicted value. Copyright © 2015 John Wiley &amp; Sons, Ltd.

<h3>Introduction and Objectives</h3> Previous studies have shown that overall asthma care can vary greatly between practises. In this study we evaluate the recorded asthma prevalence and characterize asthma control and risk profiles of real-life asthma patients from 210 practises managed within UK primary care. <h3>Methods</h3> Electronic practise data was extracted from patients with asthma from 210 practises across the UK Patients included in the analysis were ≥18 years, had clinician-diagnosed asthma (defined as a diagnostic Read code compatible with the UK Quality and Outcomes Framework [QoF] for asthma) and were receiving current asthma therapy (≥1 asthma prescriptions within the last 2 years). Eligible patients were sent asthma management questionnaires to capture patient-reported outcomes. Pooled practise and patient data were used to characterize patients in terms of their control status (as classified by the Global INitiative for Asthma [GINA] and Royal College of Physician three questions [RCP3]) and risk status (stratified according to exacerbation frequency [Read code defined acute exacerbations and number of courses of acute oral steroids in previous 12 months], with high risk defined as ≥2 exacerbations annually). <h3>Results</h3> From 210 practises across the UK there was an asthma prevalence of 5.9%, comprising 80280 adult patients and comparing to a UK QoF-assessed prevalence of 5.8%. The percentage of patients per practise with uncontrolled asthma (Median [IQR]) was 18.8% (9.1, 26.7) while the percentage per practise with no recorded RCP3 data was 18.9 (12.4, 45.9). 3.2% (n=2594) of the patients were classified as being high risk. <h3>Conclusions</h3> A high proportion of patients managed in routine UK primary care have sub-optimal asthma control. More patients at BTS management stages 4 and 5 have uncontrolled asthma and suffer from a greater number of exacerbations. RCP3 recording varies between practises, and can be poorly recorded.

The principles of the more important fuel cells are described and their current state of development assessed. Reference is made to the suitability of various fuels for fuel cell power systems applied to locomotive traction. The overall scheme for a 300-kW power unit using a low-temperature fuel battery is described. While technically possible, such a system is unlikely to be economically viable. It is suggested that fuel cell traction for locomotives will have to await the development of an improved fuel cell, such as one using a solid oxide electrolyte.

SummaryUterine artery embolisation (UAE) is becoming increasingly popular as a treatment for symptomatic fibroids We present a series of three patients out of a total of 333 cases who developed bilateral transient buttock pain after UAE. The features of this pain suggest that it IS not due to misembolisation, but to referred pain from the infarcted fibroids and the ensuing inflammatory response.