Northampton General Hospital NHS Trust

Autoimmune glandular syndrome type 2 is a complex genetic condition where a triad of endocrinopathies is involved, namely, Addison’s disease, type 1 diabetes, and/or autoimmune thyroid disorder. The disease predisposes one to a variety of other autoimmune associations. Here, we report a rare presentation of a patient with autoimmune polyglandular syndrome type 2 (APS‐2) presenting with a 7‐year history of progressive splenic atrophy causing functional hyposplenism that ultimately progressed to anatomical asplenia (autosplenectomy) as demonstrated in the serial imaging. We postulate that the underlying cause of this presentation is also of autoimmune nature. Unlike APS‐1, which has been linked to hyposplenism, this is the first reported case of APS‐2 with similar splenic involvement. Splenic hypofunction can increase susceptibility to encapsulated bacterial infection, with overwhelming postsplenectomy infection (OPSI) being a significant threat. It is crucial that clinicians recognize the importance of providing guidance on vaccinations, antibiotic chemoprophylaxis, and patient education for individuals with asplenia or hyposplenism. If patients with APS can experience progressive splenic atrophy, we suggest long‐term follow‐up with splenic function assessment. It is yet unclear whether preemptive screening with pitted red cell count has any clinical impact in this group of patients.

Anti-synthetase syndrome (ASyS) is a rare autoimmune connective tissue disorder (CTD) characterized by the presence of autoantibodies targeting tRNA synthetase, most notably the anti-Jo1 antibody. Clinically, it typically manifests with interstitial lung disease (ILD), inflammatory myopathy, arthritis, Raynaud’s phenomenon, and the so-called mechanic’s hands. Diagnosis can be challenging due to clinical overlap with other pulmonary and rheumatological disorders.We report a case of a young woman in her early 20s who presented at our same day emergency care (SDEC) with a four-week history of exertional dyspnea, low-grade fever, and productive cough, initially managed as a lower respiratory tract infection in the community. Persistent symptoms prompted further evaluation, and CT imaging of the chest, abdomen, and pelvis revealed bilateral ground-glass opacities suggestive of ILD. Five days later, she re-presented with hemoptysis, worsening breathlessness, new-onset myalgia, arthralgia, facial erythema, and hyperkeratosis of the fingertips. Autoimmune screening revealed strongly positive anti-Jo-1 and anti-Ro52 antibodies, confirming the diagnosis of anti-synthetase syndrome. She was treated with intravenous (IV) pulse methylprednisolone, mycophenolate mofetil, and rituximab, with partial clinical improvement and ongoing follow-up for advanced ILD management in a tertiary center. This case highlights how an initial diagnosis of lower respiratory tract infection (LRTI) may mask an underlying autoimmune syndrome (anti-synthetase syndrome), which later manifests as progressive respiratory failure requiring lung transplant.Therefore, as acute medicine physicians, it is imperative to maintain a broad differential diagnosis, particularly in young females newly diagnosed with possible ILD. There may be underlying conditions that require careful examination by acute care physicians, especially in the presence of systemic symptoms, notably rheumatological symptoms. This vigilance is crucial to avoid delayed diagnosis of anti-synthetase syndrome, which necessitates early multidisciplinary involvement to achieve better outcomes.

A female in her 50s was referred by her General Practitioner (GP) to our Same Day Emergency Care (SDEC) unit due to an unresponsive migraine attack. Associated features included nausea, photophobia, phonophobia, intermittent visual aura, and unintentional weight loss over the last two weeks. Arteriovenous malformations (AVMs) are rare vascular anomalies, with a prevalence of approximately 18 per 100,000 individuals. Although often asymptomatic, they may present atypically with migraine-like headaches, posing a diagnostic challenge.Her full neurological assessment, including cranial nerves, cerebellar function, and motor and sensory systems, was unremarkable. However, neuroimaging revealed a large, unruptured, complex AVM in the left parieto-occipital region, associated with cerebral oedema and midline shift. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) confirmed a Spetzler-Martin Grade III AVM.Her imaging was urgently discussed with the Neurosurgery Department at Oxford University Hospitals for further intervention, as our institution does not have a neurosurgery department being a district general hospital. The multidisciplinary team (MDT) recommended radiosurgery, and her symptoms resolved after the intervention.This case illustrates the importance of neuroimaging in patients with refractory or unresponsive migraine, enabling early detection of serious intracranial pathology such as AVMs. It also highlights the value of timely specialist referral, inter-hospital collaboration, and patient-centred care in optimising outcomes.

Advanced Clinical Practitioners (ACPs) have emerged as essential healthcare professionals within the NHS, equipped with advanced medical knowledge, and decision-making and clinical skills that enable them to work with significant autonomy in patient care. This article explores the evolution and impact of ACPs, particularly in acute medicine, where their roles encompass responsibilities traditionally performed by doctors, such as admission clerking, generating differential diagnoses, prescribing medications and overall patient management. The article also examines the implementation and effectiveness of ACPs, supported by frameworks, such as the multi-professional framework for advanced clinical practice in England and the acute medicine ACP framework, highlighting their contributions to service delivery, patient satisfaction and the healthcare workforce. The author also reflects on his personal experiences across the four pillars of advanced clinical practice. Furthermore, it offers recommendations to standardise ACP training and supervision, ensuring consistent competencies and enhancing the recognition and development of ACP roles within acute medicine.

A woman in her early 40s presented with pleuritic chest pain and shortness of breath, which had progressively worsened over 20 days following initiation of tirzepatide (Manjaro). Her D-dimer level was elevated at 1340 ng/mL, prompting a CT pulmonary angiogram that confirmed right main pulmonary artery pulmonary embolism (PE). The patient had no identifiable provoked or unprovoked risk factors for venous thromboembolisms (VTEs). To our knowledge, this is the first reported case of PE that might be associated with the use of tirzepatide worldwide. The relationship between tirzepatide and VTEs events remains unclear. This case highlights the need for further research to explore the incidence and underlying mechanisms of VTEs in patients receiving tirzepatide.

Trillions of microorganisms play a pivotal role in maintaining health and preventing disease in humans. Their presence influences daily life, habits, energy levels, and pathologies. The present narrative review synthesized recent studies of microbial diversity across organ systems. The composition of the microbiota regulates the intestinal barrier, modulates the immune response, influences metabolism, and produces essential compounds such as short-chain fatty acids and neurotransmitters. Dysbiosis is associated with numerous pathologies, including metabolic, autoimmune, neurodegenerative, and cardiovascular diseases. The microbiota is key to maintaining physiological balance and reducing disease risk. Therapeutic interventions, such as probiotics, prebiotics, postbiotics, and microbiome transplantation, offer promising perspectives in restoring microbial homeostasis and preventing chronic diseases.

Some current prostate cancer (PCa) treatment regimens are known to have adverse effects on bone, for example androgen deprivation therapy (ADT), and on cardiovascular health, for example ADT and antiandrogen therapy. Strengthened recommendations for the practical assessment and management of bone and cardiovascular health in men with PCa are needed. This review aims to provide practical guidance for healthcare providers along the continuum of patient care on the management of bone and cardiovascular health in men with PCa undergoing ADT and antiandrogen therapy based on real-world evidence. Evidence was identified by searching PubMed for publications that reported the effects of PCa treatment on bone or cardiovascular health in a real-world setting and were published between January 2017 and August 2023. Review articles were excluded. The evidence identified indicates that ADT decreases bone mineral density (BMD) and increases the risk of osteoporosis and fractures. Bone-protecting agents (BPAs) are effective at improving bone health in patients undergoing ADT and antiandrogen therapy at all stages of the PCa pathway. Despite this, the use and timing of initiation of BPAs are variable. Furthermore, real-world studies have confirmed an association between ADT and cardiovascular risk. As survival outcomes improve, maintenance of bone and cardiovascular health is increasingly important in men with PCa. Risk is a continuous variable that must be assessed throughout the continuum of PCa treatment. Therefore, all men starting ADT should be assessed for bone and cardiovascular risk. Lifestyle adjustments, dietary supplementation and pharmacological intervention may be advised.

We present the case of a male patient in his late 80s who presented with a fall with symptoms and signs of community-acquired pneumonia. Chest X-ray showed the suspicion of a left-sided pneumothorax. A CT of the chest subsequently ruled out the presence of a pneumothorax on the left side. The pseudo-pneumothorax on the chest X-ray was secondary to a skinfold. This case highlights how well a skinfold can mimic pneumothorax. Careful clinical and radiological examination with bedside lung ultrasound and/or CT of the chest can help differentiate true pneumothorax from pseudo-pneumothorax, provided the patient is hemodynamically stable. Our case highlights the importance of clinical examination, various imaging modalities, and confirmation of a diagnosis before proceeding to interventional procedures in the context of limited clinical suspicion of the differential.

Telerehabilitation (TR) shows promise as a method of remote service delivery, yet there is little guidance to inform implementation in the context of the National Health Service (NHS) in England. This paper presents the protocol for a realist synthesis study aiming to investigate how TR can be implemented to support the provision of high-quality, equitable community-based stroke rehabilitation, and under what conditions. Using a realist approach, we will synthesise information from (1) an evidence review, (2) qualitative interviews with clinicians (n ≤ 30), and patient-family carer dyads (n ≤ 60) from three purposively selected community stroke rehabilitation services in England. Working groups including rehabilitation professionals, service-users and policy-makers will co-develop actionable recommendations. Insights from the review and the interviews will be synthesised to test and refine programme theories that explain how TR works and for whom in clinical practice, and draw key messages for service implementation. This protocol highlights the need to improve our understanding of TR implementation in the context of multidisciplinary, community-based stroke service provision. We suggest the use of a realist methodology and co-production to inform evidence-based recommendations that consider the needs and priorities of clinicians and people affected by stroke.

This paper considers the common presentation of upper gastrointestinal (GI) signs and symptoms. It discusses their prevalence, aetiology, clinical presentation and the importance of comprehensive history taking and examination. In addition, the article explores investigations, management pathways and criteria for referral to a gastroenterologist, including the two-week referral pathway. While the paper focuses on UK practice, it draws upon evidence and guidance from around the world and therefore guidelines for managing upper GI presentations can vary between countries and continents.