Louise Pealing

Subjective memory problems

#### Summary points The National Dementia Strategy for England, published in 2009,1 urges general practitioners to become skilled at recognising dementia at an early stage and to promptly refer those at risk to specialist memory services. The implementation of the strategy includes a public awareness campaign to reduce the stigma of dementia and encourage people to approach their GP if they have concerns about their memory. Subjective memory loss, which is seen as the cardinal symptom of dementia by the public, is likely to be the main problem reported by those who consult their doctor. However, the findings of the Kungsholmen cohort study, which included 1435 people aged 75-95 years without dementia, suggest that only 18% of future cases of dementia will be identified in the preclinical phase by investigating those who screen positive for memory problems.2 What evidence is available to guide GPs in management and referral decisions for patients with subjective memory loss? This clinical review is based on the findings of five systematic reviews, three of which3 4 5 investigated the association between subjective memory …

Outcome reporting across randomised controlled trials evaluating therapeutic interventions for pre‐eclampsia

Standardising outcome collection and reporting in pre‐eclampsia trials requires an appraisal of current outcome reporting.

Inadequate safety reporting in pre-eclampsia trials: a systematic evaluation

Randomised trials and their syntheses in meta‐analyses offer a unique opportunity to assess the frequency and severity of adverse reactions.

A systematic review of primary outcomes and outcome measure reporting in randomized trials evaluating treatments for pre-eclampsia

An evaluation of outcome reporting is required to develop a core outcome set.

Risk Factors for Vascular Occlusive Events and Death Due to Bleeding in Trauma Patients; an Analysis of the CRASH-2 Cohort

Background Vascular occlusive events can complicate recovery following trauma. We examined risk factors for venous and arterial vascular occlusive events in trauma patients and the extent to which the risk of vascular occlusive events varies with the severity of bleeding. Methods and Findings We conducted a cohort analysis using data from a large international, double-blind, randomised, placebo-controlled trial (The CRASH-2 trial) [1]. We studied the association between patient demographic and physiological parameters at hospital admission and the risk of vascular occlusive events. To assess the extent to which risk of vascular occlusive events varies with severity of bleeding, we constructed a prognostic model for the risk of death due to bleeding and assessed the relationship between risk of death due to bleeding and risk of vascular occlusive events. There were 20,127 trauma patients with outcome data including 204 (1.01%) patients with a venous event (pulmonary embolism or deep vein thrombosis) and 200 (0.99%) with an arterial event (myocardial infarction or stroke). There were 81 deaths due to vascular occlusive events. Increasing age, decreasing systolic blood pressure, increased respiratory rates, longer central capillary refill times, higher heart rates and lower Glasgow Coma Scores (all p<0.02) were strong risk factors for venous and arterial vascular occlusive events. Patients with more severe bleeding as assessed by predicted risk of haemorrhage death had a greatly increased risk for all types of vascular occlusive event (all p<0.001). Conclusions Patients with severe traumatic bleeding are at greatly increased risk of venous and arterial vascular occlusive events. Older age and blunt trauma are also risk factors for vascular occlusive events. Effective treatment of bleeding may reduce venous and arterial vascular occlusive complications in trauma patients.

Effects of Ascent to High Altitude on Human Antimycobacterial Immunity

Background Tuberculosis infection, disease and mortality are all less common at high than low altitude and ascent to high altitude was historically recommended for treatment. The immunological and mycobacterial mechanisms underlying the association between altitude and tuberculosis are unclear. We studied the effects of altitude on mycobacteria and antimycobacterial immunity. Methods Antimycobacterial immunity was assayed in 15 healthy adults residing at low altitude before and after they ascended to 3400 meters; and in 47 long-term high-altitude residents. Antimycobacterial immunity was assessed as the extent to which participants’ whole blood supported or restricted growth of genetically modified luminescent Bacille Calmette-Guérin (BCG) mycobacteria during 96 hours incubation. We developed a simplified whole blood assay that could be used by a technician in a low-technology setting. We used this to compare mycobacterial growth in participants’ whole blood versus positive-control culture broth and versus negative-control plasma. Results Measurements of mycobacterial luminescence predicted the number of mycobacterial colonies cultured six weeks later. At low altitude, mycobacteria grew in blood at similar rates to positive-control culture broth whereas ascent to high altitude was associated with restriction (p≤0.002) of mycobacterial growth to be 4-times less than in culture broth. At low altitude, mycobacteria grew in blood 25-times more than negative-control plasma whereas ascent to high altitude was associated with restriction (p≤0.01) of mycobacterial growth to be only 6-times more than in plasma. There was no evidence of differences in antimycobacterial immunity at high altitude between people who had recently ascended to high altitude versus long-term high-altitude residents. Conclusions An assay of luminescent mycobacterial growth in whole blood was adapted and found to be feasible in low-resource settings. This demonstrated that ascent to or residence at high altitude was associated with decreased mycobacterial growth in whole blood relative to controls, consistent with altitude-related augmentation of antimycobacterial cellular immunity.

Quantification of the risk of liver injury associated with flucloxacillin : a UK population-based cohort study

Background: Flucloxacillin is an established cause of liver injury. Despite this, there are a lack of published data on both the strength of association after adjusting for potential confounders, and the absolute incidence among different subgroups of patients. Objectives: To assess the relative and absolute risks of liver injury following exposure to flucloxacillin and identify subgroups at potentially increased risk. Methods: A cohort study between 1 January 2000 and 1 January 2012 using the UK Clinical Practice Research Datalink, including 1046699 people with a first prescription for flucloxacillin (861962) or oxytetracycline (184737). Absolute risks of experiencing both symptom‐defined (jaundice) and laboratory‐confirmed liver injury within 1–45 and 46–90 days of antibiotic initiation were estimated. Multivariable logistic regression was used to estimate 1–45 day relative effects. Results: There were 183 symptom‐defined cases (160 prescribed flucloxacillin) and 108 laboratory‐confirmed cases (102 flucloxacillin). The 1–45 day adjusted risk ratio for laboratory‐confirmed injury was 5.22 (95% CI 1.64–16.62) comparing flucloxacillin with oxytetracycline use. The 1–45 day risk of laboratory‐confirmed liver injury was 8.47 per 100000 people prescribed flucloxacillin (95% CI 6.64–10.65). People who received consecutive flucloxacillin prescriptions had a 1–45 day risk of jaundice of 39.00 per 100000 (95% CI 26.85–54.77), while those aged >70 receiving consecutive prescriptions had a risk of 110.57 per 100000 (95% CI 70.86–164.48). Conclusions: The short‐term risk of laboratory‐confirmed liver injury was >5‐fold higher after a flucloxacillin prescription than an oxytetracycline prescription. The risk of flucloxacillin‐induced liver injury is particularly high within those aged >70 and those who receive multiple flucloxacillin prescriptions. The stratified risk estimates from this study could help guide clinical care.

A woman with forgetfulness and falls

A 69 year old woman presented to her general practitioner with a six month history of occasional falls and fluctuating forgetfulness and attention. Although she reported no difficulties with names and dates she needed help with taking drugs and preparing meals. She had also had two episodes of apparent visual hallucinations of a woman standing at the foot of her bed. Her sleep behaviour had been poor for many years, with frequent strong physical jerks and motion while sleeping. She had no symptoms of altered or low mood. Her medical history included hypothyroidism, osteoporosis, and cholesteatoma, and she was being investigated for a mixed fibre peripheral sensory neuropathy of unknown cause. Current drugs included levothyroxine, calcitriol, calcium carbonate-colecalciferol, and lansoprazole. She did not drink alcohol and was a non-smoker. On examination she was fully orientated in time and place and her AMTS (abbreviated mental test score) was 10/10 with an MMSE (mini-mental state examination) score of 26/30. Her blood pressure, temperature, and cardiovascular and respiratory examinations were normal. Cranial nerve examination was normal with no primitive reflexes or supranuclear gaze palsy. Tone and power were normal throughout all limbs, as were sensation and reflexes in the upper limbs. The lower limbs showed reduced vibration and pin prick sensation to the mid-shin bilaterally, and joint position sense was limited to large movements. She showed no evidence of bradykinesia or apraxia, but her gait was ataxic in keeping with her peripheral sensory impairment. ### 1 What is the differential diagnosis? #### Short answer Given the patient’s fluctuating forgetfulness and alertness, the differential diagnosis must include causes of delirium and dementia. The most common causes of delirium in this age group are infection, metabolic and nutritional disturbances (including hypoxia and hypoglycaemia), cerebral haematomas caused …

Technology: a help or hindrance to empathic healthcare?

John Preece was the first British general practitioner to use a computer in the consulting room in 1970. Since then, technology in healthcare consultations has advanced tremendously. There has been continuous progression with computerisation of notes, results, imaging and much more. This has allowed information to be in a central place allowing for better preparation and understanding before, during and after the consultation. More recent technological advances include video consultation, smart phone applications and the use of artificially intelligent robot doctors. Due to recent progress in technology, it is unsurprising that many bold claims about its ability to improve healthcare consultations have been made. For example, Alemi et al. have suggested that humanoid robots can alleviate children’s stress and depression, while Crain reported that nurse robots can express empathy to patients. Can we believe these claims? In this instalment of the empathy series, we will focus on the relationship between technology and empathy, and examine whether technology may help or hinder empathic healthcare.

Authors’ reply re: Inadequate safety reporting in pre-eclampsia trials: a systematic evaluation

Narayan Jana, Sukumar Barik, Nalini Arora, & Subhankar Dasgupta a Department of Obstetrics and Gynaecology, Chittaranjan Seva Sadan College of Obstetrics, Gynaecology and Child Health, Kolkata, India b Department of Obstetrics and Gynaecology, ICARE Institute of Medical Sciences and Research, Haldia, India Department of Obstetrics and Gynaecology, ESI Post-Graduate Institute of Medical Sciences & Research, ESIC Medical College, Kolkata, India