Ninewells Hospital

We present a case report of a 10-year-old girl who sustained significant facial burns after microwaving a frozen stress ball; just one example of a "trend" which quickly gained popularity without disclaiming the harmful risks. The management and outcome of a significant contact burn linked to an uncensored online activity is described, highlighting important considerations of facial burn management and discussing the broader implications for pediatric safety in the ever-evolving digital age.

The investigation of peripheral neurotoxicity associated with systemic anticancer therapy (SACT) agents is often confined to a small range of chemotherapy agents. This study aimed to identify all SACT agents associated with peripheral neurotoxicity and, specifically, peripheral neuropathy, and to provide incidence estimates for the development of each type of neurotoxicity associated with each agent. Antineoplastic agents approved globally for clinical and/or research purposes were identified through triangulation of nine national and global drug product databases. The class of each agent was identified using DrugBank Online. Evidence of peripheral neurotoxicity and, specifically, peripheral neuropathy was obtained by reviewing Micromedex (and, where required, supplemented by data reported in national clinical trials registries). A total of 467 approved antineoplastic agents were identified for clinical and/or research purposes globally. Peripheral neurotoxicity (including neuropathy) was associated with 144 (31%) agents: 49 (45%) classical chemotherapeutic agents; 61 (21%) targeted therapies; 26 (63%) immunotherapies; and 8 (25%) hormone therapies. Peripheral neuropathy, specifically, was associated with 77 (16%) agents: 30 (27%) classical chemotherapeutic agents; 31 (11%) targeted therapies; 16 (39%) immunotherapies; and no hormone therapies. Based on the currently available evidence, this inventory of neurotoxic SACT agents could be considered exhaustive. From clinical and research perspectives, a comprehensive inventory of neurotoxic SACT agents is pivotal to informing drug design and understanding and implementing appropriate drug choice, as well as investigating the mechanisms involved in the neurotoxic effects of agents and identifying neuroprotective strategies for patients undergoing SACT.

To evaluate how UK guidelines for individual health conditions consider coexisting multiple long term conditions and to propose improvements to guideline development processes so that guidelines appropriately account for and consider coexisting multiple long term conditions. Analysis and recommendations from review of single condition guidelines. Clinical guidelines developed by the National Institute for Health and Care Excellence (NICE), UK, 1 January 2013 to 31 December 2024. 56 clinical guidelines developed by NICE covering a broad range of long term conditions. The extent to which guideline recommendations consider multiple long term conditions and coexisting conditions, distinguishing between concordant conditions (those affecting the same organ system as the index condition) and discordant conditions (those affecting different systems). All but one of the NICE guidelines (n=55, 98%) included some advice on managing the index condition in the presence of coexisting conditions, and 50 (89%) guidelines offered general guidance on tailoring care. Only 11 (20%) guidelines, however, explicitly referred to multiple long term conditions, and none included a dedicated section on multiple long term conditions or how care should be adapted in this context. 19 (34%) guidelines featured sections looking at specific coexisting conditions or coexisting conditions generally. Coverage of coexisting conditions varied widely across categories of conditions, with mental health guidelines dealing with the most coexisting conditions (median 10, interquartile range (IQR) 4.5-14.75) in contrast with guidelines on cancer and eye disease covering the fewest conditions (median 3, 1-4.5; median 3, 2.25-2.75, respectively). Of the 397 possible concordant pairings, 120 (30%) were referenced, whereas of the 3859 possible discordant pairings, 259 (7%) were referenced, indicating greater coverage of same system combinations. Data on the composition of guideline committees showed wide variation in size, disciplinary diversity, inclusion of generalist clinicians (eg, general practitioners, general physicians, or others with no single specialty focus), and public contributors, although lived experience of multiple long term conditions was rarely specified. Despite widespread acknowledgement of coexisting or multiple long term conditions, NICE guidelines are predominantly condition specific and offer limited tailored support for the care of multiple long term conditions. Recommendations rarely considered common condition clusters or the cumulative effect of multiple long term conditions. Structured improvements, such as clearer guidance on adapting care, broader cross condition referencing, and more transparent inclusion of lived experience could enhance the relevance and usability of guidelines for clinicians managing patients with multiple long term conditions.

Metformin, a mainstay of treatment for type 2 diabetes, can cause vitamin B12 deficiency. Clinical risk factors have been identified but genetic factors remain undiscovered. Our objective was to identify and validate genetic predisposing factors and establish clinical utility. Individuals with metformin-induced vitamin B12 deficiency (n=487) and metformin-tolerant control individuals (n=6686) were identified in UK Biobank. Genome-wide association analysis was undertaken using logistic regression. Replication was undertaken in three cohorts: a Scottish cohort; the Diabetes Prevention Program Outcomes Study (DPPOS); and a separate cohort from Liverpool. In the Liverpool cohort, plasma metformin levels were also measured. Analysis identified a genome-wide significant non-synonymous SNP in the cubilin gene (CUBN, rs1801222/p.S253F) associated with metformin-induced vitamin B12 deficiency (additive model; adjusted p=1.86×10-10; OR 1.56 [95% CI 1.36, 1.79] for AG vs GG genotype; OR 2.43 [95% CI 1.85, 3.20] for AA vs GG genotype), which was replicated in both the Scottish and the DPPOS cohorts. Vitamin B12 deficiency occurred in 0.84-1.20% of non-metformin-exposed individuals regardless of rs1801222 genotype. However, a large interaction with metformin use was observed, with vitamin B12 deficiency occurring at 6.02% in GG, 7.96% in GA and 12.84% in AA genotype groups. When followed up from metformin initiation, 10% with the AA genotype were vitamin B12 deficient by 11 years vs 21 years for 10% of the GG group. The observed genetic association suggests that the rs180122 genotype should be considered a significant risk factor for metformin-induced vitamin B12 deficiency. While clinical monitoring of serum vitamin B12 levels in patients on metformin is inconsistently done, this finding highlights the potential clinical utility of targeted monitoring for certain subsets of individuals, including those genetically at high risk.

Physical inactivity remains a critical public health concern in the UK, contributing to over one in six deaths and imposing substantial economic costs. Despite strong evidence supporting the effectiveness of physical activity (PA) promotion in healthcare settings, delivery of PA promotion remains inconsistent. This cross-sectional survey, conducted across Scotland and supported by Public Health Scotland, explored the knowledge, attitudes, and training of healthcare professionals (HCPs) across primary and secondary care in relation to PA promotion. Quantitative data were analysed employing descriptive statistics, chi-square tests for categorical variables, and Kruskal-Wallis tests for Likert-scale data to explore differences by care setting and profession. A total of 409 HCPs responded, including a broad range of professions. Primary care professionals reported higher perceived knowledge in PA promotion and personal confidence in meeting PA guidelines than their secondary care colleagues. Physiotherapists and doctors reported the greatest perceived adequacy of training in, and subsequent confidence to deliver PA promotion, while nurses reported the lowest. Across all professions, most participants recognized PA as important for disease prevention (98.8%) and treatment (93.3%), but only 68% felt confident advising patients. The findings identify a disconnect between perceived value of PA and HCPs' preparedness to promote it and highlight the need for standardized, interdisciplinary PA education and the integration of consistent PA messaging across healthcare settings. Targeted educational resources and system-level initiatives could enhance practitioner competence and ensure cohesive delivery of PA promotion within Scottish healthcare.

Abstract Introduction Spontaneous perforation of the bile duct (BD) is a rare cause of acute abdomen in adults. Pre-operative diagnosis is challenging due to its non-specific presentation and the rarity of the condition. Method We present a case of a 66-year-old female who presented with right iliac fossa (RIF) pain and clinical signs suggestive of acute appendicitis. Laboratory investigations revealed raised inflammatory markers and mildly deranged liver function tests. CT imaging suggested perforated appendicitis with a possible free fecalith in the RIF. Results No evidence of appendicitis, small bowel, duodenal or gastric perforation could be identified during laparoscopy. Laparotomy and further exploration, revealed a 3 mm perforation was on the anterior surface of the mid-BD. A T-tube was utilized for biliary drainage and repair, and right paracolic drain; no cholecystectomy was performed. Patient had an uneventful recovery, however, serial T Tube cholangiograms up to 4 months later showed subclinical leak. Therefore, the T-tube was removed during ERCP, and a self-expanding-metal-stent was deployed. The patient developed mild post-ERCP pancreatitis and is awaiting elective cholecystectomy. Conclusions This case highlights the diagnostic difficulties of spontaneous BD perforation in adults. Total laparoscopic management is feasible if BD perforation is suspected. The slow healing observed may suggest an underlying ischemic component. Optimal drainage is essential if slow healing is potentially expected post operatively. Should the gallbladder be routinely removed during initial intervention? Is the use of silicone T-tubes optimal, or would latex T-tubes—due to their greater inflammatory response—facilitate more rapid healing through fibrotic tract formation?

[This retracts the article DOI: 10.7759/cureus.92264.].