Countess of Chester Hospital

Abstract Background Idiopathic granulomatous mastitis (IGM) is a rare, benign breast disease characterised by granulomatous inflammation. Current literature mainly comprises of small-sized retrospective studies with no well-designed clinical trials and limited representation of UK population. With no consensus to guide clinical practice there is a significant risk of delayed diagnosis and variation in management strategies that may adversely affect patient outcomes Methods ENIGMA is a multi-stage programme of work aiming to develop guidelines for the diagnosis and management of IGM in the UK. A scoping review will assess the range and quality of existing evidence, focusing on its relevance to UK practice. Findings from this review will inform a national practice questionnaire (NPQ) to capture current approaches to IGM care across the UK. These data, combined with a modified Delphi process involving experts and stakeholders, will support guideline development and help define priority research questions to advance best practice. Progress The scoping review identified 225 papers, involving 13 062 patients, mostly from Turkey, the USA, and China. Only three studies, covering 25 patients, originated from the UK. Commonly reported ethnic groups were Hispanic and Turkish. Risk factors include smoking and hormonal influences such as oestrogen and prolactin. Reported treatment strategies range from conservative approaches to medical therapies (antibiotics, steroids, immunosuppressants) and surgical interventions (drainage or excision). Preliminary results of the NPQ highlight substantial heterogeneity in UK diagnostic and management practices. Once the NPQ analysis is complete, the working group will initiate the Delphi process to establish consensus and inform guideline development.

Background: Emergency department (ED) visits have increased exponentially in many countries, leading to overcrowding. This overcrowding results in delays in care across most EDs and has been associated with poorer outcomes, including increased morbidity and mortality. Triage algorithms were developed and widely implemented in EDs worldwide to identify patients requiring resources and to allocate those resources appropriately. However, despite the use of algorithms, the care delivery remains highly variable. Machine learning (ML) models have been developed to improve clinicians’ predictive ability to identify high-risk patients and to improve resource allocation in EDs globally. This systematic review and meta-analysis, therefore, outlines the current evidence on the efficacy of artificial intelligence (AI) in predicting patients’ clinical deterioration in the ED. Methodology: A comprehensive literature search was conducted across five electronic databases—ScienceDirect, PubMed, Google Scholar, CENTRAL, and EMBASE—to identify all relevant articles published up to February 2025. Data were extracted from the studies that met the inclusion criteria, and the reported outcomes were pooled using the MedCalc statistical software. Results: A total of 743 articles were identified through the literature search; however, only nine met the inclusion criteria and were thus included in the review. We pooled the area under the receiver operating characteristic curve (AUROC) of ML models for predicting the occurrence of in-hospital cardiac arrest (IHCA) and observed a pooled Area Under the Curve (AUC) of 0.909 (95% CI: 0.889–0.929; p < 0.001). The models showed high predictive ability for the other clinical deterioration outcomes in the ED. However, we were unable to pool the results because only a limited number of studies reported these different outcomes. Conclusion: Our systematic review and meta-analysis found that ML models have a high predictive ability in identifying patients at risk of clinical deterioration in the ED. However, limited data exist on the additional benefits clinicians gain from incorporating AI into routine ED patient care. Moreover, although many models have been developed, further studies are needed to evaluate their clinical utility.

COVID-19 pandemic has impacted every aspect of the health care system, which led to many alterations and modification of the ways of consultations. Likewise, in our unit, shift in the practice of skin cancer management was by addressing all new referrals through virtual telephone consultation with the aid of selfies taken by the patients and emailed to us before their appointment. Assessment of effectiveness of selfie pictures taken by patients for skin cancer management over teleclinics and comparing teleclinical diagnosis with histological diagnosis. A prospective, single-center study conducted from June 2020 to June 2021 at Countess of Chester Hospital, UK, included all new skin lesion referrals. All nonskin lesion referrals are excluded from this review. The number of pictures received and their quality in terms of focus, zoom, site identifiability, and overall satisfaction were noted. Decisions based on the teleconsultation were recorded as listing for surgery, face-to-face clinic (F2FC)/teleclinic (TC), or discharge. This included 939 patients with a mean age of 70.8 years, Of the patients, 90.8% were listed for theater. The study demonstrated how much selfies can help in triaging the skin cancer patients, and it can be used as an effective way of providing care for the patients, which will significantly help avert delay in diagnosis and treatment.

<bold>Background:</bold> Spontaneous pneumothorax is classified as primary or secondary with clear guidelines for managing these distinct entities. However, little guidance exists for managing patients with iatrogenic pneumothorax post-CT guided lung biopsy, despite its relative frequency. <bold>Aim:</bold> To investigate the frequency of iatrogenic pneumothorax post-CT guided biopsy, explore risk factors and investigate the optimum management strategy. <bold>Methods:</bold> A single-centre review of patients undergoing CT guided lung biopsy at Countess of Chester Hospital between Jan 2023- Dec 2024. Patient demographics, procedural details, occurrence and timing of pneumothorax, size of pneumothorax and need for (and number of) interventions were analysed. <bold>Results:</bold> 213 patients underwent CT guided biopsy (107 female [50.2%], median age 72 [IQR 64-77], 158 smoking history [74.6%]). Iatrogenic pneumothorax occurred in 48 (22.5%). Median FEV1% pred did not differ between those with pneumothorax and those without (P=0.992). 89.6% would be considered secondary if spontaneous. In those without immediate intervention, 4 measured 1-2cm and 1 >2cm at the hilum. 31 were managed conservatively (64.6%) and 17 (35.4%) underwent intervention (3 aspiration [17.6%],10 Seldinger chest drain [58.8%], 1 surgical chest drain [5.9%]). In those conservatively managed, resolution was confirmed at median 21.5 days (IQR 11-42). <bold>Conclusion:</bold> Iatrogenic pneumothorax post-CT guided biopsy occurs frequently but the majority are small, can be managed conservatively despite being otherwise ‘secondary’ if spontaneous. Further research into risk factors could help mitigate its occurrence and improve patient outcomes.

Abstract Recent evidence has shown a substantial RSV burden in healthy term-born children, but there is less data quantifying the relative burden compared to those with co-morbidity or prematurity. There is also limited primary care and emergency department (ED) data due to the lack of routine pathogen detection. These data are important for the development of RSV immunisation strategies. A prospective surveillance study of children &lt; 3 years old, presenting with lower respiratory infection and a sub-study in primary care of upper respiratory infection was conducted. The primary endpoint was RSV prevalence by healthcare setting. Secondary endpoints included proportion of hospitalisations, level of ventilatory support and admission to higher levels of care. An economic analysis assessing the costs associated with healthcare utilisation was also conducted. The primary analysis revealed RSV prevalence was 50.4% in children admitted to hospital, 36.3% in ED discharges, 36.5% in primary care and 12.8% in primary care children with upper respiratory infection. Healthy term-born children accounted for 73.3% of medically-attended RSV cases and 70.1% of hospitalisations. Risk factors for severe disease included any level of prematurity, age &lt; 3 months and congenital cardiac disease. RSV positive cases incurred a higher mean cost than RSV negative cases (mean = £1,706; incremental = £683) per illness. The findings revealed a substantial burden associated with RSV. Even moderate prematurity was a risk factor for severe disease, and these children may not benefit from the full maternal immune response to vaccination and would not be eligible for Nirsevimab under UK guidance, we therefore recommend broadening eligibility to include these children. What is already known on this topic Recent cohort studies have revealed a substantial healthcare and economic RSV burden from previously healthy term-born children which has supported the implementation of a maternal RSV vaccination programme in the UK, providing protection for infants from birth up to 6 months old. What this study adds We have shown that children born prematurely, including moderately preterm children, are at increased risk of severe RSV disease. These children may not benefit from full protection by maternal RSV vaccination, and may not be eligible for Nirsevimab, the long-acting monoclonal antibody, which is currently reserved for only the most high-risk children in the UK. How this study might affect research, practice or policy This data supports broadening eligibility for Nirsevimab, to include preterm children, who were born before full maternal protection from RSV vaccination may have developed, and to infants born to mothers not receiving maternal vaccination.

Pheochromocytoma is a neuroendocrine tumor of the adrenal gland. It can cause a range of symptoms, but the main ones are palpitations, pallor, headaches, and sweating. Due to its rarity and episodic character, it is frequently misdiagnosed in the initial instance.We report the case of a young woman in her twenties who was misdiagnosed with hypotension, headache, cough, and palpitations, and an echocardiography revealed reduced cardiac function. She was initially diagnosed with Takotsubo cardiomyopathy and then with myocarditis based on clinical and radiological findings, and she was treated for cardiogenic shock. She continued to have a headache, which was diagnosed as a cardiac cephalalgia. Despite receiving topiramate and analgesia, she continued to have headaches and hypotension. She was found to have periodic episodes of hypertension, prompting a pheochromocytoma screening. She had a successful adrenalectomy and recovered well. This case report emphasizes the significance of having a high degree of suspicion for pheochromocytoma in individuals presenting with unexplained cardiac dysfunction.

Abstract Background/Aims Thrombocytopenia is one of the most common haematological abnormalities in SLE and has been noted in 25-50% of the patients with SLE at some point in their disease course. Some of the well known causes of thrombocytopenia in SLE include ITP, Drug induced thrombocytopenia, anti-phospholipid antibody syndrome, thrombotic microangiopathy etc. Here we present an unusual cause of thrombocytopenia in SLE , which if diagnosed early can avoid life threatening complications. Methods This is the case of a 36-year-old lady who was diagnosed with SLE in 2009. She initially presented with skin and musculoskeletal symptoms and was started on methotrexate, hydroxychloroquine and oral steroids. After a year, methotrexate was switched to azathioprine due to intolerance to the former. Over the course of next 10 years, SLE was relatively well controlled with the same. In 2020, the patient presented with fatigue, mild weight loss and a new-onset thrombocytopenia with platelets of 70x109/L. She was on azathioprine 100mg/day, hydroxychloroquine 200mg/day and prednisolone 5mg/day during this time. On evaluation, her investigations showed a WBC of 6.1x109/L,Hb of 120g/L, normal C3 C4, negative urine dip, negative APLA and negative anti-dsDNA. She was treated as a possible flare of SLE with ITP and hence azathioprine was switched to mycophenolate mofetil. However, she was lost to follow up for the next two years and in 2022, she presented with menorrhagia after which was diagnosed with fibroid uterus. Her platelets at this time were 69x109/L. After undergoing hysterectomy, she then had a post-operative infection for which a CT abdomen was carried out. This surprisingly revealed splenomegaly, enlarged splenic and portal veins with normal liver consistent with non cirrhotic portal hypertension. To confirm this, a liver biopsy was carried out, which confirmed subtle nodular regenerative hyperplasia and focal obliterative portal venopathy consistent with porto-sinusoidal vascular disorder aka non-cirrhotic portal hypertension (NCPH). Results The cause of thrombocytopenia in this patient could possibly be due to hypersplenism secondary to NCPH. NCPH has been associated with both SLE and azathioprine as per case reports. Only 22 cases of NCPH associated with SLE have been reported over the past two decades. In terms of management, this patient subsequently underwent variceal banding after confirming oesophageal varices on OGD and was started on carvedilol for the management of portal hypertension. Her platelet counts have remained stable between 50-70x109/L on follow up. Conclusion NCPH should be considered as one of the causes of thrombocytopenia in SLE. Portal venopathy secondary to autoimmune damage is thought to be the mechanism underlying NCPH in SLE. Although early diagnosis can be challenging, this can be decisive in preventing late complications such as variceal bleeding, pulmonary artery hypertension etc. Disclosure A.J. Chandy: None. D. Kapur: None.

ObjectivesElectives offer valuable opportunities for healthcare students to explore clinical care, research, policy, and advocacy within different health systems and settings. Paediatric electives often bring unique and challenging experiences, and if well-supported, can be extremely rewarding. These experiences can help students consolidate clinical knowledge, enable personal and professional development, and establish an interest in global child health. While support for general elective planning and delivery is available, there are limited resources written specifically for paediatrics and child health that take an ethically sensitive and holistic view of the experience.The aim of the ‘Global Child Health Electives Toolkit’ was to develop a resource to support elective planning for healthcare students with a paediatric interest, while promoting engagement in global child health.MethodsThe Toolkit was written by medical students, foundation doctors, and paediatric trainees based in the UK. Further input was provided from recent medical graduates, senior clinicians within the International Child Health Group (ICHG), and representatives from international institutions that have hosted electives for students.ResultsThe Toolkit has three sections: ‘Before’, ‘During’, and ‘After’.The ‘Before’ section contains advice and pre-departure checklists to help students formulate achievable goals and consider the practical logistics of their placement.The ‘During’ section provides tips for history taking and examinations in paediatrics and signposts students to relevant online resources. Various case studies illustrate challenging situations students may encounter to provide support and guidance. These illustrations include ethical dilemmas, resource allocation issues, and dealing with traumatic experiences such as child death during their elective.The ‘After’ section offers recommendations on how to build on the student elective experience from a personal development and career perspective. It focuses on debriefing effectively and offers guidance on how to take part in global child health advocacy.The Toolkit is available to download as an open-access resource on the ICHG website1 and has been disseminated to all UK medical schools. This resource is currently being promoted through social media, the ICHG, and The Electives Network’s workshops. To this date, informal feedback on a national level has been highly positive.ConclusionThe Toolkit is a unique resource for supporting students interested in developing a career in paediatrics and global child health. We plan to collect feedback from students, medical schools, and hosting institutions to keep the toolkit up-to-date and relevant for all stakeholders.Referencehttps://www.internationalchildhealthgroup.org/electivestoolkit