North Middlesex University Hospital NHS Trust

Abstract Aims To highlight the multidisciplinary coordination required for managing perforation peritonitis in a young patient with atypical mycobacteria, HIV, and haemophagocytic lymphohistiocytosis (HLH). Methods A patient in their 20s presented in septic shock at midnight requiring inotropic support, with a one-year history of weight loss. Examination revealed a cachectic individual with a grossly distended, tender abdomen. CT images revealed free fluid, locules of free air and clustered small bowel loops concentrated around the mid abdomen. Resuscitation followed the sepsis protocol, and an emergency laparotomy was performed. Intraoperatively, densely adherent matted, dusky small bowel loops with purulent fluid and multiple white nodules (images) were observed throughout visceral and parietal peritoneal surfaces. A damage control approach included extensive peritoneal washout, biopsies and abdominal drains, avoiding bowel disturbance to prevent further damage. Results Cultures identified atypical mycobacteria and polymicrobial flora. Histology (images) showed granulomas (caseation with atypical mycobacteria) and testing revealed first-presentation HIV with a very low CD4 count and a high viral load. Postoperatively, the patient developed migrating enterocutaneous fistulas, managed through an intestinal failure protocol and anti-TB therapy. HLH delayed antiretroviral therapy, requiring sequential treatment for HLH, HIV, and tuberculosis. Despite the complexity, the patient recovered, transitioned to oral feeding, gained weight and resumed normal activities within a year. Conclusions This case highlights the value of damage control surgery, early biopsy and microbiology sampling in managing matted bowel. Multidisciplinary input and the sequential treatment were pivotal role in recovery. Insights can guide management of similar cases in resource-constrained, time-critical settings.

This paper provides an overview of key concepts in evolutionary psychiatry, summarising major evolutionary explanations for mental illness and highlighting the potential of these perspectives to enhance assessment, diagnosis, explanation to the patient, treatment and prevention strategies. Expanding beyond conventional evolutionary approaches, we explore environmental influences on mental health and illness, emphasising the significant areas of convergence between evolutionary and environmental viewpoints. We then propose an integrated framework that combines insights from both perspectives, offering general principles for improving mental health outcomes at both individual and population levels. The discussion includes implications for general practice, public health and broader societal considerations, with particular reference to concepts such as biophilia and the emerging role of 'green care' in psychiatric practice.

This paper reviews survey studies to assess the global impact of the coronavirus disease 2019 (COVID-19) pandemic on obstetrics and gynaecology (O&G) training from the perspectives of trainees and programme directors (PDs). An electronic literature review of the PubMed database was conducted from March 2020 to December 2024 for topics pertaining to the COVID-19 pandemic and trainee education to identify pertinent validated and non-validated survey studies. Ten studies were identified that analysed the impact of the COVID-19 pandemic on postgraduate training in O&G. All 10 studies utilised non-validated questionnaires. Two studies (total respondents: N=182) assessed the viewpoint of O&G PDs, and eight studies (total respondents: N=1416) solicited the perspectives of postgraduate trainees (PGTs) in O&G. Countries represented include Brazil, the European Union (EU) (encompassing 25 different countries), Germany, India, Italy, Sweden, Turkey, the United Kingdom, and the United States. The themes identified were as follows: (1) trainee reassignment, (2) restructuring of didactic and research activities, and (3) loss of clinical training opportunities within the specialty and its impact on trainees' mental health. Understanding this impact is key to enable better planning in similar pandemics in the future. The review suggests that there were both positive and negative impacts of the pandemic that may forever shape trainee education.

Opt-out screening for blood-borne viruses (BBVs) in emergency departments (EDs) has been established in areas with a high prevalence of HIV diagnoses in England. This multi-site study explored the attitudes of healthcare workers (HCWs) towards BBV screening in EDs post-implementation. This was a cross-sectional electronic survey of HCWs. Between November 2023 and February 2024, HCWs across 33 EDs in England participating in opt-out BBV screening were invited to complete a survey about the feasibility and acceptability of screening, including the opt-out consent process. Factors independently associated with acceptability of opt-out screening were identified using multivariable logistic regression. Free-text responses were analysed thematically. Responses from 610 HCWs in 19 EDs were provided: 50.4% were nurses, 43.1% doctors, and 6.5% other healthcare professionals. Acceptability of the screening programme and opt-out consent was high (90.3% and 77.7%, respectively), with some variation between EDs. Acceptability of opt-out consent was greater among doctors than among other HCWs, and among HCWs who proactively discussed screening further with patients who opted out. However, 50.8% of HCWs felt that patients should be verbally reminded at blood draw, and 44.3% of HCWs wanted more training in discussing opt-out screening with patients. Free-text answers suggested changes to test-ordering systems, including simple integration of tick boxes to document whether patients opted out and to block repeated testing. There was substantial support from ED HCWs for routine opt-out ED BBV screening, including opt-out consent. Key areas suggested for improvement included changes to test-ordering systems and additional training for HCWs. Frequent preference for verbal reminders at the point of blood draw suggests continued HIV testing exceptionalism.

Over the last decade, the incidence of postpartum haemorrhage has risen because of increasing maternal age at time of delivery, multiple births, obesity and increased obstetric interventions, resulting in most of these women requiring blood transfusions. While lifesaving, blood transfusion is not without risk. Recipients may rarely develop transfusion-transmitted infections or suffer immunological sequelae. Intraoperative cell salvage is recommended by several national policy making organisations as a safe cost-effective alternative to autologous blood transfusion in both emergency and elective settings. Moreover, emerging data has also revealed that autotransfusion of vaginally shed blood is both feasible and safe. These techniques are useful in patients who decline blood transfusions for both personal and religious reasons and should therefore be taken into consideration when planning place of birth.

The author has no financial or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.op-rs.com). Address correspondence and reprint requests to Miles Kiernan, F.R.C.Ophth., North Middlesex University Hospital NHS Trust, London, United Kingdom. E-mail: [email protected]

Background Total hip arthroplasty (THA) is considered a successful treatment option for patients with degenerative hip arthritis. However, in the setting of neuromuscular diseases, patients with cerebral palsy (CP) are considered high-risk due to instability, contractures, and altered muscle tone. The purpose of this systematic review is to analyse the data in the setting of THA in CP patients including indications, types of implants, revision rates, and patient-reported outcomes and compare these with those of a cohort requiring THA due to degenerative arthritis unrelated to neuromuscular disorders. Methods PubMed, Embase, and Cochrane Library were searched from inception until June 10, 2023, to identify the relevant studies for THA on CP patients. The methodological quality of the studies was evaluated using the Newcastle–Ottawa Quality Assessment Scale (NOS). Results The initial search generated 190 studies out of which 21 met the inclusion criteria. The most frequently reported indication was painful hip dislocation or subluxation due to failure of prior nonoperative treatment. The most frequently reported complication was dislocation affecting overall 7.5% (0–28%) of all patients, while other complications included periprosthetic fractures and heterotrophic ossification. The survival rates of primary THAs ranged from 85% to 100% at 5 years and from 73% to 86% at 10 years. Patients with CP who undergo total hip arthroplasty experience a greater overall rate of complications compared to patients with rheumatoid arthritis (RA) that undergo the same procedure. Conclusion The current literature suggests that THA is a beneficial procedure for patients with CP through pain reduction and functional improvement. However, the increased rates of potential complications compared to the general population require careful consideration. We suggest that further investigations on the most appropriate time of procedure, implant type, and procedure are needed.