Hypercalcaemia of malignancy: a case of vitamin-D-mediated hypercalcaemia in lymphoma

Hypercalcaemia of malignancy (HCM) is a paraneoplastic syndrome that often portends a poor prognosis. We present an extremely rare (<1%) case of HCM due to extrarenal calcitriol (1,25-(OH)2D) production in a patient with splenic marginal zone lymphoma. A man in his 80s presented with a 3-week history of fatigue, unsteadiness and abdominal pain, and new findings of anaemia, kidney injury and hypercalcaemia. Laboratory evaluation, bone marrow biopsy and positron emission tomography/computed tomography (PET/CT) confirmed the diagnosis of splenic marginal zone lymphoma which produced calcitriol (1,25-(OH)2D3), causing the patient's hypercalcaemia.

Dapsone-induced methemoglobinemia and hemolysis in a woman without G6PD deficiency presenting with idiopathic urticaria

BACKGROUND

The appearance of bite cells associated with methemoglobinemia can be caused by oxidizing drugs such as dapsone in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency or high drug serum levels. Bite cells are often pathognomonic for oxidant injury in patients with G6PD deficiency and suggest active hemolysis.

CASE PRESENTATION

We report a case of a woman with no prior history of G6PD deficiency who presented with anemia, methemoglobinemia and bite cells on peripheral blood smear after dapsone therapy for new onset idiopathic urticaria. Laboratory tests for G6PD, blood count and liver function were within normal limits prior to initiation of therapy. During the patient's hospital course, moderate methemoglobinemia and anemia were identified despite mildly increased serum G6PD level. These pathologies were reversed upon stopping dapsone therapy.

CONCLUSION

This case highlights the potential for therapeutic levels of dapsone to induce side effects in patients without G6PD deficiency and highlights the importance of routine blood monitoring for anemia and hemolysis during the course of drug therapy.

267 Ascertain Impact of Using Low-Fidelity Simulation Scenarios in Preparation for Practical Surgical Finals

Introduction

Simulation has become the new way of preparing doctors to deal with medical emergencies, we investigate it using in managing ward-based surgical emergencies.

Method

Final year medical students completed pre- and post-session questionnaires related to themes of preparedness, anxiousness, and confidence in management of acute surgical presentations versus post-operative complications.

The intervention was divided into classroom based teaching and common surgical scenarios enacted using Sim-Man.

Results

Preparedness increased by a third following participation in surgical simulation scenarios among participants. Anxiousness related to surgical finals decreased by 9%. Confidence in managing acute patients increased by 25% compared to pre-session results. Moreover, 35% of participants felt more confident in managing post-operative complications after the session. On average, participants scored 8/10 for usefulness of the sessions in highlighting areas to concentrate focus upon during revision.

Conclusions

Simulation is slowly becoming a staple in undergraduate training and our results emphasise positive impact of using this as a revision tool. Kinaesthetic learning is more memorable during simulation which serves as a confidence boost in self-perception of managing both acute and post-operative surgical patients. Anxiety associated with exams and managing real-life emergencies can be dampened by rehearsing scenarios and following a structured approach as championed by medical simulation.

Factors affecting patient flow in a neurosurgery department

INTRODUCTION

Patient flow is the process by which movement of patients and clinical productivity is achieved. The objectives of this study were to implement and evaluate the NHS Improvement SAFER patient flow bundle, evaluate the impact of the Red2Green initiative, and assess the impact of frailty on patient flow.

MATERIALS AND METHODS

All patients admitted to a neurosurgery unit from 1 September to 30 November 2017 were included. Using guidance set out by NHS, data were prospectively collected from daily ward lists and patient notes, including demographics, admission and discharge details, length of stay, anticipated discharge date, red days with reasons and frailty (Rockwood Clinical Frailty Scale). NHS reference costs were used for cost analyses.

RESULTS

A total of 420 patients (55% elective) were included, totalling 3909 bed days. All patients received daily senior reviews before midday, and anticipated discharge dates were set at daily multidisciplinary team meetings. Ten per cent of patients were discharged before midday. There were 21% (837) red days, significantly more (76%) for emergency patients (639 vs 198 elective; P < 0.001); 63% red days were attributed to awaiting a bed in a local hospital; 25% (106) patients were classed as frail (50 elective), which was associated with a significantly longer length of stay (17.3 vs 6; P < 0.01), and more red days (615 vs 222; p<0.01). Considering excess bed charges and lost revenue (with penalties), red days cost over £1 million per year.

CONCLUSIONS

SAFER has identified areas for improvement in patient flow, with obvious cost implications. It has created a platform for discussion within the referral network and identified a role for a geriatric liaison service.

P50 The role of care of the elderly in neurosurgery

Objectives

Assess the volume of frailty in a neurosurgical centre and role of geriatric liaison.

Design

Retrospective Review.

Subjects

All patients admitted to Charing Cross Hospital in Jan 2018.

Methods

We reviewed patient notes to assess frailty score using the Clinical Frailty Scale (Dalhousie University) and differences with emergency vs elective admissions and length of stay (LoS).

Results

More than 50% of patients admitted to the unit were above 65 years old. 30% of all admissions met the criteria for mild to moderate frailty moreover 34% were classed as severely frail. These findings are comparable to acute medical wards. Two third of patients had an average LoS above 10 days, of these 50% were severely frail. Emergency admissions demonstrated a greater burden of frailty and expectedly LoS in severely frail patients was significantly higher 15 vs 40 days in elective and emergency admissions.

Conclusions

Neurosurgery units would benefit from a geriatric liaison service given the burden of frailty is equivalent to medical wards in-order to improve patient care, experience, turnover and LoS.

Micro and Macro Element Composition of Kalanchoe integra Leaves: An Adjuvant Treatment for Hypertension in Ghana

Two samples, water extract and blended whole leaves, of fresh Kalanchoe integra leaves (Crassulaceae), a traditional antihypertensive medicine used in Ghana, were analyzed with Energy Dispersive X-Ray Fluorescence spectroscopy (EDXRF). Analysis revealed 12 macro and 26 micro elements in both extracts. Further quantitative assessment of the results for amounts of elements that are pharmacologically significant revealed that the amounts of calcium, potassium, and magnesium present in the extracts could be correlated to its traditional usage in managing hypertension and arrhythmias. However, heavy metals (lead and inorganic arsenic) detected in the extracts may pose a threat at doses normally used traditionally for the treatment of hypertension.

An audit of the outcome of amblyopia treatment: a retrospective analysis of 322 children

BACKGROUND/AIMS

Little is known about the effectiveness of occlusion therapy in hospital settings. A retrospective analysis was conducted to assess modalities, outcome and hospital costs of children treated for amblyopia with patching in a UK clinic.

METHODS

Notes of 322 children with amblyopia discharged after occlusion treatment were selected consecutively and reviewed. Data collated included age at presentation, amblyopia type, visual acuity (VA; before/after occlusion and at discharge), number of prescribed hours of occlusion, duration of patching treatment, number of glasses prescribed and number of visits attended or failed to attend. Hospital treatment costs were estimated.

RESULTS

Mixed amblyopes were prescribed the longest amount of patching (mean 2815 h over 23 months) followed by strabismic (1984 h) and anisometropic (1238 h) amblyopes. 319 amblyopes received glasses and five atropine treatment. The percentage of patients reaching VA of 6/12 was best in the anisometropic and strabismic groups (>75%) and worse in mixed amblyopia (64%). Average hospital costs were estimated at pound1365.

CONCLUSION

Although the mean duration of treatment was long, involving many hospital visits, the visual outcome was variable, unsatisfactory (<6/9) and more expensive than necessary. As compliance has been identified as a major problem methods to improve amblyopia treatment are needed, possibly by using educational/motivational intervention.

Mutations in FRMD7, a newly identified member of the FERM family, cause X-linked idiopathic congenital nystagmus

Idiopathic congenital nystagmus is characterized by involuntary, periodic, predominantly horizontal oscillations of both eyes. We identified 22 mutations in FRMD7 in 26 families with X-linked idiopathic congenital nystagmus. Screening of 42 singleton cases of idiopathic congenital nystagmus (28 male, 14 females) yielded three mutations (7%). We found restricted expression of FRMD7 in human embryonic brain and developing neural retina, suggesting a specific role in the control of eye movement and gaze stability.

Why is compliance with occlusion therapy for amblyopia so hard? A qualitative study

OBJECTIVE

To explore parents' perceptions and experiences of occlusion (patching) therapy for treatment of amblyopia in children.

METHODS

Qualitative study involving semistructured interviews with 25 families of a child with amblyopia being treated at a specialist clinic. Interviews were tape recorded and transcribed verbatim. Data analysis was based on the constant comparative method, assisted by qualitative analysis software.

RESULTS

Parents of children prescribed patching treatment found themselves obliged to manage the treatment. This involved dilemmas and tensions, with many parents describing children's distress, particularly in the early stages of patching treatment. Parents were highly sensitive to the credibility of the treatment, but were sometimes confused by information given in the clinic or did not see clinic staff as authoritative. There was evidence that parents were likely to abandon or modify treatment if no improvement could be detected or if the child continued to suffer socially or educationally. Parents described a range of strategies for facilitating patching, including explanation; normalisation; rewards; customising the patch; establishing a routine; and enlisting the help of others. Whatever their practices in relation to patching, parents were keen to defend their behaviour as that of a "good parent".

CONCLUSIONS

Interventions that aim to improve compliance should take account of the difficulties and tensions experienced by parents, rather than simply treating non-compliance as resulting from information deficits. Practical support that builds on strategies described by parents is likely to be of benefit.

Recognized globe perforation during strabismus surgery: incidence, risk factors, and sequelae

BACKGROUND

Inadvertent perforation of the globe is a well-recognized complication of extraocular muscle surgery. We evaluated the incidence, risk factors, and sequelae of this complication at our institution.

METHODS

Medical records of patients who underwent extraocular muscle surgery at King Khaled Eye Specialist Hospital, Saudi Arabia, between September 1983 and April 1997, were reviewed for the occurrence of globe perforation. We documented preoperative visual acuity and refraction, surgical procedure, how the perforation occurred, and immediate management, as well as the sequelae of the perforation, its management, and final outcome.

RESULTS

Recognized perforations occurred in 15 of 4886 procedures, for an overall incidence rate of 3/1000. Perforations were 3 times more common in myopic eyes (>-6.00 D, P =.05) and 2 times more common in eyes with previous extraocular muscle surgery. Perforations occurred during muscle reattachment (5 cases), placement of traction sutures at the limbus (4 cases with transient hyphema), muscle disinsertion (3 cases), and placement of sutures at the muscle insertion before disinsertion (3 cases). One patient had a large scleral laceration with uveal prolapse, necessitating scleral patch graft at the time of surgery, and later had retinal detachment surgery with loss of 2 lines of visual acuity. Endophthalmitis, cataract, glaucoma, and phthisis bulbi were not encountered in our review.

CONCLUSION

The current incidence of globe perforation is low and only rarely associated with serious sequelae.

Regulation of mitochondrial carnitine palmitoyl transferases from liver and extrahepatic tissues

Developments in our understanding of the complex CPT enzyme system over the past ten years have been reviewed. Liver CPT1, which is probably distinct from that in several extrahepatic tissues, is subject to up- or down-regulation of its activity and kinetic properties with changing physiological state. Evidence is now accumulating to support the notion that the catalytic and malonyl-CoA-binding entities of CPT1 are separate polypeptides.