Spinal Infections Among Patients With Long-Term Central Venous Catheters for Home Parenteral Nutrition.

Spinal infections are a rare yet serious metastatic complication of bacteremia among patients with long-term central venous catheters (CVCs) for which clinicians must remain vigilant. We performed a retrospective review of all cases of spinal infection occurring in the context of a CVC for long-term parenteral nutrition (PN) managed in our department between January 2010 and October 2013, a cohort of 310 patients over this time period. Six patients were identified (mean age, 65 years; 5 male). One hundred percent of patients presented with spinal pain (5/6 cervical, 1/6 thoracic). Organisms were cultured from the CVC in 5 of 6 patients. In all cases, the white blood cell count was normal, and in 5 of 6, C-reactive protein was normal. All diagnoses were confirmed on magnetic resonance imaging (MRI), and in 3 of 6 cases, an MRI was repeated (on the advice of neurosurgical colleagues) to confirm resolution of changes after a period of antimicrobial therapy. There was no clear correlation between duration of PN or number of days following CVC insertion and onset of infection. The CVC was replaced in 4 of 6 patients at the time of diagnosis, delayed removal in 1 of 6, and salvaged in the remaining case. Although rare, a high index of suspicion is needed in patients receiving long-term PN who present with spinal pain. Peripheral inflammatory markers may not be elevated. MRI should be performed and patients should be treated with antibiotics alongside involvement of local microbiology and neurosurgical teams. Multidisciplinary discussion on CVC salvage in these cases is important, especially in cases of challenging vascular anatomy.

Spinal Infections Among Patients With Long-Term Central Venous Catheters for Home Parenteral Nutrition: A Descriptive Case Series.

Spinal infections are a rare yet serious metastatic complication of bacteremia among patients with long-term central venous catheters (CVCs) for which clinicians must remain vigilant. We performed a retrospective review of all cases of spinal infection occurring in the context of a CVC for long-term parenteral nutrition (PN) managed in our department between January 2010 and October 2013, a cohort of 310 patients over this time period. Six patients were identified (mean age, 65 years; 5 male). One hundred percent of patients presented with spinal pain (5/6 cervical, 1/6 thoracic). Organisms were cultured from the CVC in 5 of 6 patients. In all cases, the white blood cell count was normal, and in 5 of 6, C-reactive protein was normal. All diagnoses were confirmed on magnetic resonance imaging (MRI), and in 3 of 6 cases, an MRI was repeated (on the advice of neurosurgical colleagues) to confirm resolution of changes after a period of antimicrobial therapy. There was no clear correlation between duration of PN or number of days following CVC insertion and onset of infection. The CVC was replaced in 4 of 6 patients at the time of diagnosis, delayed removal in 1 of 6, and salvaged in the remaining case. Although rare, a high index of suspicion is needed in patients receiving long-term PN who present with spinal pain. Peripheral inflammatory markers may not be elevated. MRI should be performed and patients should be treated with antibiotics alongside involvement of local microbiology and neurosurgical teams. Multidisciplinary discussion on CVC salvage in these cases is important, especially in cases of challenging vascular anatomy.

A prolonged assistantship for final-year students.

BACKGROUND: The transition from medical student to junior doctor is challenging, therefore adequate preparation during medical school is crucial for a smooth transition. Tomorrow's Doctors expects students to undertake a student assistantship, separate from the local shadowing period prior to commencing employment. Sheffield Medical School initiated a 6-week assistantship within the Yorkshire and Humber deanery. This mixed-methodology study explores this experience from the perspective of final-year medical students. METHODS: Final-year medical students responded to a questionnaire about anxieties surrounding their forthcoming foundation year 1 (FY1). Students were purposefully sampled and semi-structured interviews (SSIs) were conducted, with 20 participants exploring their experience of the assistantship. Interviews were transcribed verbatim and thematic analysis was carried out. RESULTS: The questionnaire results highlighted that most students felt anxious about becoming a FY1 doctor, and subsequent interviews demonstrate that the assistantship mostly met with students' expectations. Major themes regarding their anxieties included the value of building professional relationships, familiarisation with the work environment, level of supervision and the value of targeted teaching. DISCUSSION: Student assistantships clearly improve preparedness and confidence in the transition to FY1 by enabling supervised, stepwise responsibility. In the future a nationally cohesive programme should be created for shadowing and assistantships matched with students' prospective jobs.

Is it intelligent to intercalate? A two centre cross-sectional study exploring the value of intercalated degrees, and the possible effects of the recent tuition fee rise in England.

AIMS AND OBJECTIVES: To explore the value of intercalated degrees, including student perceptions and academic sequelae. To gauge the likely effect of the recent tuition fee rise and to identify any differences in intercalated degrees between Bristol and Sheffield universities. DESIGN: Cross-sectional study using questionnaires. SETTING: Bristol and Sheffield Medical Schools, UK. PARTICIPANTS: 1484 medical students in their clinical years were e-mailed the questionnaire. 578 students responded: 291 from Bristol and 287 from Sheffield (n=578; mean age=22.41; SD 1.944; 38.9% male; 61.1% female). The response rate from previous intercalators was 52.5% from Bristol and 58.7% from Sheffield, while for non-intercalators it was 27.7% and 34.6%, respectively. MAIN OUTCOME MEASURES: (1) Student preconceptions, opinions, results and academic sequelae from intercalated degrees at both centres. (2) Students' attitudes concerning the effect of the increase in tuition fees. RESULTS: Those with clinical academic supervisors gained significantly more posters (p=0.0002) and publications (p<0.0001), and also showed a trend to gain more first class honours (p=0.055). Students at Sheffield had a significantly greater proportion of clinical academic supervisors than students at Bristol (p<0.0001). 89.2% said that an intercalated degree was the right decision for them; however, only 27.4% stated they would have intercalated if fees had been £9000 per annum. CONCLUSIONS: Students clearly value intercalated degrees, feel they gained a substantial advantage over their peers as well as skills helpful for their future careers. The rise in tuition fees is likely to reduce the number of medical students opting to undertake an intercalated degree, and could result in a further reduction in numbers following an academic path. Sheffield University have more intercalating students supervised by clinical academics. Clinical academics appear more effective as supervisors for medical students undertaking an intercalated degree in terms of results and additional academic sequelae.

Opposing actions of histone deacetylase 1 and Notch signalling restrict expression of erm and fgf20a to hindbrain rhombomere centres during zebrafish neurogenesis.

The rate and pattern of neurogenesis in the developing vertebrate nervous system is controlled by a complex interplay of intercellular signalling pathways and transcriptional control mechanisms. In the zebrafish hindbrain, Fgf20a promotes transcription of the gene encoding the ETS-domain transcription factor Erm in the non-neurogenic centres of rhombomeres. Here, we demonstrate that the epigenetic regulator, Histone Deacetylase 1 (Hdac1) and the Notch signalling pathway have opposing functions in regulating expression of both erm and fgf20a in the zebrafish hindbrain. Our results show that Hdac1 is required for expression of erm and fgf20a in rhombomeres, and that the Hdac1-dependent expression of these two genes is attenuated in rhombomere boundary regions by Notch signalling activity, thereby restricting erm and fgf20a transcripts to narrow stripes of cells at rhombomere centres.