Medway NHS Foundation Trust

ABSTRACT Background Without a cure for dementia, providing psychosocial support to people living with the condition is imperative. There is a developing evidence base for psychological and therapeutic support for people living with dementia. However, there is little to guide therapists working in this area, in terms of approaches and techniques that are likely to be successful. Methods In the present study, we utilised different methods to engage people with dementia and their family members in discussions around ways in which psychotherapists could improve the delivery and accessibility of person‐centred therapy, to develop core competences for therapists. We brought together evidence from interviews with people with dementia, their families, and psychotherapists, with workshops utilising a World Café approach. Findings We hosted four workshops with 47 participants in total. Using thematic analysis, we identified core themes across the different forms of data. We developed core competences in four areas: knowledge of dementia, therapeutic techniques and skills, therapeutic relationship and scope of practice. Discussion The competences developed present an overview of expectations for those working therapeutically with families affected by dementia. It is hoped that their development leads to increased awareness of the specialist skills needed to engage with people with dementia, valuing of these skills for psychotherapists.

Pain is one of the most distressing symptoms that patients experience as they approach the end of life. Opioids remain the gold standard of care, but the need for alternative options continues to grow, especially in the face of opioid unresponsive pain or opioid side effects. Clonidine, a drug initially known as a nasal decongestant and anti-hypertensive, has shown promise through its depression of the sympathetic nervous system by inhibiting norepinephrine release. It has since shown potential as an analgesic post-operatively, helping to reduce overall opioid use while providing adequate pain relief. This systematic review aimed to collate and analyse the available literature on the use of clonidine as an analgesic for palliative care patients. A comprehensive literature search was performed on CENTRAL, SCOPUS, MEDLINE, EMBASE and ClinicalTrials.gov for studies assessing the use of clonidine as analgesia for patients under palliative care. Twelve studies involving 194 patients were included. All studies were either case reports or case series. Clonidine was used as both monotherapy and as an adjunct through a variety of delivery methods, including intrathecal, perineural, subcutaneous and transdermal. Clonidine has shown initial potential to provide adequate analgesia while reducing overall opioid usage. However, further research is required to form a stronger evidence base and gain further insight into its future role in this field. Further insight is also required into more easily accessible delivery, such as oral, subcutaneous and transdermal routes.

Abstract The integration of artificial intelligence (AI) and machine learning (ML) in waste management has the potential to significantly advance circular economy objectives by enhancing efficiency, reducing waste, and optimizing resource recovery. However, realising these benefits depends on addressing significant technical, economic, and systemic barriers. AI technologies, such as intelligent waste‐sorting systems and predictive models, are transforming how waste is processed and materials are reused. This article critically evaluates the potential and limitations of AI‐driven approaches across the waste management lifecycle through a narrative review of peer‐reviewed literature published between 2015 and 2025. AI offers a revolutionary approach to waste management, resource recovery, and environmental impact reduction by enabling the processing of massive datasets and automating complex decision‐making. However, to fully realize AI's promise, critical issues, including scarce data availability, expensive implementation costs, the requirement for efficient human‐AI cooperation, and ethical considerations regarding algorithmic transparency and workforce impacts, must be systematically addressed. Additionally, ethical concerns related to job displacement and the environmental footprint of AI technologies themselves require careful management. This review identifies significant research gaps, including the need for standardized datasets, explainable AI frameworks, and comprehensive lifecycle assessments of AI‐driven interventions. Looking to the future, decentralized AI systems, AI‐driven global waste trade optimization, blockchain‐integrated tracking systems, and AI‐enhanced product design offer promising avenues for further innovation. As AI continues to develop, its incorporation into waste management systems will be essential to accelerating the world's shift to a circular economy that is more resource‐efficient and sustainable.

Herpes zoster (HZ) or shingles is an acute and self-limiting viral infection caused due to reactivation of varicella zoster virus. The virus remains latent in the ganglionic neurons, and during states of reduced cell-mediated immunity, as in the elderly and immunocompromised, the virus reactivates and travels along the nerve fibres peripherally. The result is a painful vesicular rash, which should typically be localised to a single dermatome and not cross the midline. In some cases, however, the infection may have a varied and atypical presentation, including disseminated HZ, multidermatomal or bilateral HZ, glioma and acute cerebral angiitis. A prompt diagnosis and early initiation of antiviral therapy can prevent the occurrence of postherpetic neuralgia and neurological sequelae, and also enable early disease resolution. We report the case of a 27-year-old man with severe HZ infection of all the divisions of the trigeminal nerve. A robust knowledge of such atypical disease presentations would enable improved patient outcomes.

Introduction: Transition to the medical registrar role often lacks sufficient support, particularly for non-training grade doctors such as speciality and specialist (SAS) and locally employed doctors (LEDs). In the UK, while simulation-based education is well-established in early postgraduate stages for trainees in medicine, opportunities at the registrar transition level are limited for these groups. At Medway NHS Foundation Trust, no ongoing simulation existed for registrars outside formal training, despite the Royal College of Physicians' recommendations advocating equitable educational access for SAS and international medical graduate (IMG) doctors. This study describes a local needs assessment identifying training gaps and evaluates a targeted simulation course designed for SAS medical registrars with non-UK primary medical qualifications.Methods: A three-step quality improvement (QI) approach was undertaken: (1) needs assessment via an anonymised online survey for SAS doctors, internal medicine training (IMT) stage 1 year 2 (IMT2) trainees, LEDs, and registrars, exploring demographics, clinical experience, self-perceived preparedness, and training gaps; (2) a bespoke one-day high-fidelity simulation course for six SAS medical registrars, targeting acute clinical scenarios and human factor skills, with live observation and facilitated debriefs focusing on clinical and non-technical competencies; (3) evaluation applying the Kirkpatrick model, including immediate post-course feedback assessing satisfaction and confidence change, and a one-month follow-up survey measuring behavioural changes, application of learning, and context barriers. Data were analysed quantitatively, and thematic analysis was applied to qualitative feedback.Results: Baseline survey results showed 70.6% (n = 13) of respondents felt unprepared for registrar duties despite most having 1-3 years’ experience in the role, highlighting a significant gap in confidence. All valued simulation training, mentorship, and shadowing, with some SAS/LEDs considering stepping down due to role challenges. Post-simulation, all participants rated scenarios as realistic and relevant, all (n = 6) reported increased confidence in managing acute medical emergencies, and 83.3% (n = 5) described improvements in leadership and communication skills. One participant’s performance concern was identified, prompting targeted support. At one-month follow-up, respondents reported practical application of skills such as leadership, on-call and improved communication, alongside increased reflective practice. Limited peer feedback constrained a comprehensive behavioural change assessment.Conclusions: This QI project demonstrates the feasibility of using high-fidelity simulation to support medical registrars, particularly non-training grade doctors, by enhancing perceived confidence and identifying learning needs. Given the small sample size and reliance on self-reported outcomes, findings should be interpreted as preliminary and reflective of perceived educational value rather than objective competence. Nevertheless, simulation may represent a feasible and locally scalable educational approach to support equitable professional development for SAS and LEDs in line with the Royal College of Physicians' recommendations.

Skeletal tuberculosis remains a great clinical mimicker, often resembling metastatic malignancy on imaging. Prompt and accurate diagnosis is critical to prevent irreversible neurological damage and iatrogenic harm.We describe a diagnostically challenging case involving a 39-year-old previously healthy woman from Zimbabwe who presented with subacute thoracic back pain and bilateral lower limb sensory changes. MRI demonstrated destructive vertebral lesions with spinal cord compression and widespread lymphadenopathy, strongly suggestive of metastatic disease. Further imaging, including contrast-enhanced CT and positron emission tomography (PET)-CT, supported the metastatic pattern but failed to identify a primary malignancy. The patient underwent spinal radiotherapy for presumed metastatic cord compression without clinical improvement.A subsequent CT-guided biopsy revealed caseating granulomatous inflammation and acid-fast bacilli, confirming spinal tuberculosis. Following initiation of standard anti-tubercular therapy, the patient showed marked clinical improvement, including complete resolution of pain and partial neurological recovery. Unfortunately, some sensory impairment persisted due to radiation-induced myelitis - an avoidable complication of premature treatment.This case signifies the importance of maintaining a high index of suspicion for spinal tuberculosis, especially in patients from endemic regions, even in the absence of classic systemic features. It is especially relevant to acute medicine, where clinicians are often the first to assess patients with spinal pain and red flag neurological signs. It highlights the need for histological confirmation before initiating oncologic therapies in uncertain diagnoses. Early tissue diagnosis, guided by WHO and national TB protocols, is essential to avoid misdiagnosis and ensure appropriate management.

Purpose Burnout continues to be a major concern across the NHS, with increasing evidence that it negatively affects both staff well-being and retention. Psychologists, often involved in developing strategies to reduce workplace stress, are themselves vulnerable to burnout. This pilot project introduced a simple well-being initiative, The Appreciation Station, within a psychology team based in a Forensic Low Secure Service. The purpose of this study is to improve staff well-being and reduce feelings of burnout. Design/methodology/approach Team members completed three standardised measures before (PRE) and approximately six months after (POST) the initiative was introduced: the Maslach Burnout Inventory, the Professional Fulfilment Index and the Warwick–Edinburgh Mental Well-being Scale. The POST measure also included a space for open-ended feedback. Findings The results of this study suggested a significant improvement in staff well-being, although changes in burnout scores were not statistically significant. Even so, a downward trend was observed. Originality/value Early findings are encouraging, and the next step will be to explore whether this initiative can benefit other disciplines across the Low Secure Service.

Ambulance handover between ambulance personnel and emergency department (ED) staff, most often nurses, is a time-critical and complex event that should take place within 15 minutes of the ambulance arriving at the hospital site. However, in recent years there has been an increase in ambulance handover delays, potentially resulting in patient harm. Providing a consistent service to maximise the safety and effectiveness of ambulance handovers is an essential function of all EDs and, increasingly, of acute hospital assessment areas. This article discusses some of the ways in which ambulance handover delays can be addressed, such as using a structured communication tool, and provides an overview of a contemporary standardised approach to initial assessment in the ED that aims to reduce ambulance delays and enhance patient outcomes. The article aims to equip nurses who are responsible for ambulance handovers and initial patient assessments with examples of best practice to support their clinical decision-making and guide clinical practice.

Acute urea cycle disorder (UCD) presentation in patients can be challenging to manage, and the outcome can be deleterious if not promptly detected and urgently managed. This disorder is rare and can either be inherited or acquired. More descriptions of this disorder are noted in the paediatric population. We present a possible clinical scenario of acquired UCD in a middle-aged female with alcohol-related fatty liver disease who had a prolonged critical care admission, which culminated in an acute finding of a severe refractory acute hyperammonemia on her 67th day of critical care stay with a fatal outcome.

Background: The diagnostic process in dermatology often hinges on visual recognition and clinical pattern matching, making it an attractive field for the application of artificial intelligence (AI). Large language models (LLMs) like ChatGPT-4o, Claude 3.7 Sonnet, and Gemini 2.0 Flash offer new possibilities for augmenting diagnostic reasoning, particularly in rare or diagnostically challenging cases. This study evaluates and compares the diagnostic capabilities of these LLMs based solely on clinical presentations extracted from rare dermatological case reports.Methodology: Fifteen published case reports of rare dermatological conditions were retrospectively selected. Key clinical features, excluding laboratory or histopathological findings, were input into each of the three LLMs using standardized prompts. Each model produced a most probable diagnosis and a list of differential diagnoses. The outputs were evaluated for top-match accuracy and whether the correct diagnosis was included in the differential list. Performance was analyzed descriptively, with visual aids (heatmaps, bar charts) illustrating comparative outcomes.Results: ChatGPT-4o and Claude 3.7 Sonnet each correctly identified the top diagnosis in 10 (66.7%) out of 15 cases, compared to 8 (53.3%) out of 15 for Gemini 2.0 Flash. When differential-only matches were included, both ChatGPT-4o and Claude 3.7 achieved a total coverage of 86.7%, while Gemini 2.0 reached 60.0%. Notably, all models failed to identify certain diagnoses, including blastic plasmacytoid dendritic cell neoplasm and amelanotic melanoma, underscoring the potential risks associated with plausible but incorrect outputs.Conclusions: This study demonstrates that ChatGPT-4o and Claude 3.7 Sonnet show promising diagnostic potential in rare dermatologic cases, outperforming Gemini 2.0 Flash in both accuracy and diagnostic breadth. While LLMs may assist in clinical reasoning, particularly in settings with limited dermatology expertise, they should be used as adjunctive tools, not substitutes, for clinician judgment. Further refinement, validation, and integration into clinical workflows are warranted.