Nasogastric tube placement perforating the nasopharynx causing mediastinal passage and feeding into the pleural space.

A mid-60s female with known primary progressive multiple sclerosis was admitted to our hospital with aspiration pneumonia. Due to reduced consciousness, a nasogastric (NG) tube was inserted for feeding. A chest x-ray (CXR) report from a thoracic radiologist confirmed an atypical tip position due to a hiatus hernia but concluded it was almost certainly within the stomach. However, after deteriorating on feed commencement, a CT scan of the chest confirmed the tube had perforated the nasopharynx and run parallel to the oesophagus through the mediastinum into the right pleural space. The patient subsequently developed an empyema and pneumothorax, requiring multiple therapeutic interventions and a prolonged hospital stay. This case demonstrates how the routine insertion of an NG tube can lead to serious complications. Additionally, position check CXRs can be difficult to interpret, so the decision to use the tube must be made cautiously by the clinical team.

Primary central nervous system lymphoma: a practical guide for neurologists.

Primary central nervous system lymphoma is rare, comprising 4% of intracranial neoplasms. Although haematologists or oncologists subsequently manage the condition, it is often neurologists who first make, or at least suspect, the diagnosis. This article reviews the disease, its clinical and radiological features and details the work-up needed to achieve a diagnosis (namely histological or cytological confirmation) and to prepare the patient for treatment. We note the importance of brain biopsy, the role of corticosteroids and the varied treatment options.

'Face time' for the first time: Video communication between relatives and junior doctors in the COVID-19 pandemic.

Working on a COVID-19 ward presents a number of challenges to staff, with communication between families, patients and staff being highlighted as a key challenge. Novel methods are needed to overcome the barriers presented by COVID-19, with many turning to technology to offer solutions. Recognising these challenges as an area for improvement on our own ward, we sought to introduce new methods of communication to improve patient, relative and staff understanding and wellbeing. Through our own experiences and a discussion of the literature on this topic, we have identified some key themes which we believe can assist in the development of communication strategies in the developing pandemic.

To scan or not to scan - D-dimers and computed tomography pulmonary angiography in the era of COVID-19.

The COVID-19 pandemic has had many ramifications on healthcare delivery and practice. As part of this, utilising biomarkers to risk stratify patients has become increasingly popular. During the COVID-19 pandemic the use of D-dimer has increased due to the evidence of COVID-19 induced thrombo-embolic disease. We evaluated the use of D-dimer on all hospital admissions during the peak of the pandemic and evaluated its sensitivity in diagnosing pulmonary embolic disease (PE). Patients without COVID-19 infection were as likely to have evidence of PE as their COVID-positive counterparts. However, the sensitivity of a D-dimer was higher in COVID-positive patients at a lower D-dimer level (>1,500 µg/L, sensitivity 81%, specificity 70%) than in those without clinical, immunological or radiological evidence of COVID-19 infection (D-dimer >2,000 µg/L, sensitivity 80%, specificity 76%). These data suggest higher D-dimer thresholds should be considered for the exclusion of pulmonary emboli.

Investigating strategies to improve clinical trial opportunities for patients with cancer in New Zealand-INSIGHT.

AIMS: Fewer than 5% of adult cancer patients participate in clinical trials, with multiple patient, clinician and institutional barriers identified. This study aimed to explore patient factors that impact access to cancer trials in New Zealand. METHODS: A questionnaire that included demographics and factors that might impact trial participation was circulated via nine district health boards (DHBs) and four cancer foundations to patients with a cancer diagnosis. RESULTS: Between July 2016 and August 2017, 691 patients responded, 62% female and 77% aged >50 years. Most patients (86%) would consider trial participation, which differed by income (p=0.0001) but not by age, tumour type or gender. Patients would consider attending another hospital (44%) or relocating (11%); 10% considered trials a last resort. Advantageous factors to participation included: benefiting others (92%), better treatment (82%), more scans and longer follow-up (47% and 51%). Disincentives included fear of randomisation (78%), treatment toxicities (71%), time and cost of more visits (40%) and unspecified future research (32%). CONCLUSION: Identified barriers to trial participation were similar in New Zealand to other developed countries. In this motivated cohort, patients are very interested in trial participation at any stage of their treatment and did not mind extra travel or tests.

Evaluation of Clinical Prognostic Factors and Further Delineation of the Effect of Mesenteric Fibrosis on Survival in Advanced Midgut Neuroendocrine Tumours.

BACKGROUND: Small intestinal neuroendocrine tumours (SI NETs) represent 30-50% of small bowel neoplasms and often present at an advanced stage. To date, there is relatively limited literature regarding prognostic factors affecting overall survival (OS) in stage IV disease. In addition, the prevalence of mesenteric fibrosis (MF) in SI NETs and its effect on OS have not been sufficiently explored in the literature. AIM: The primary aim of this study was to perform a large-scale survival analysis in an institutional cohort of 387 patients with metastatic (stage IV) SI NETs. The secondary aim was to provide epidemiological information regarding the prevalence of MF and to evaluate its effect on OS. RESULTS: The median OS was 101 months (95% CI 84, 118). Age > 65 years, mesenteric metastases with and without desmoplasia, liver metastases, carcinoid heart disease (CHD) and bone metastases were associated with a significantly shorter OS, while primary tumour resection was predictive of a longer OS. The benefit of surgical resection was limited to symptomatic patients. MF was present in approximately 50% of patients with mesenteric lymphadenopathy. Elevated urinary 5-HIAA levels correlated strongly with the presence of CHD (p < 0.001) and to a lesser extent (p = 0.02) with MF. MF and CHD did not usually co-exist, suggesting that different mechanisms are likely to be involved in the development of these fibrotic complications. CONCLUSIONS: This study has identified specific prognostic factors in a large cohort of 387 patients with advanced SI NETs and has provided useful epidemiological data regarding carcinoid-related fibrotic complications.