The junior doctors’ contract dispute has shown the need for major and sustained changes in education, training, and policy, say Steven Alderson and colleagues
Primary pyomyositis is a rare bacterial infection of the skeletal muscle. Traditionally a tropical disease, it is increasingly described in westernised urban populations. The aetiology is due to transient bacteraemia in the presence of risk factors such as traumatised muscle, or immunocompromise. The condition presents in one of three stages, representing progression of disease severity. Intravenous antibiotic therapy is often sufficient for this disease at its early stage, but surgical drainage is necessary for advanced presentations. We report a severe case of stage 3 pyomyositis of the gluteus minimus, which led to Staphylococcus aureus sepsis, deranged liver function, acute kidney injury, autoanticoagulation and proximal femoral osteomyelitis in a healthy 64-year-old Caucasian man. This illustrates the potential severity of the disease, the life-threatening sequelae when diagnosis is delayed and the role of surgical drainage in averting the progression of systemic sepsis to end-organ dysfunction, disseminated intravascular coagulation and potentially death.
Intra-articular anterior cruciate ligament (ACL) cysts are rare, the pathogenesis remains unknown, with trauma often implicated. Often asymptomatic, incidental MRI findings, 11% produce symptoms such as pain, locking or instability. Treatment of intra-articular ganglia differs from the traditional 'bash it with a bible' mantra for ganglia elsewhere with surgical debridement generally indicated for symptomatic cases. This case report describes a 43-year-old male car mechanic who presented with a symptomatic ACL cyst diagnosed on MRI. While waiting for surgery the patient fell up his stairs at home, causing forced hyperflexion of his knee. After an initial sharp pain, within 24 h the patient experienced complete resolution of symptoms. Postfall MRI showed no evidence of the initial lesion, leading to our conclusion that for this patient, a fall up the stairs was the equivalent of 'bashing it with a bible' for an ACL ganglion cyst of the knee.
A recent survey of UK core medical training (CMT) training conducted jointly by the Royal College of Physicians (RCP) and Joint Royal College of Physicians Training Board (JRCPTB) identified that trainees perceived major problems with their training. Service work dominated and compromised training opportunities, and of great concern, almost half the respondents felt that they had not been adequately prepared to take on the role of medical registrar. Importantly, the survey not only gathered CMT trainees' views of their current training, it also asked them for their 'innovative and feasible ways to improve CMT'. This article draws together some of these excellent ideas on how the quality of training and the experience of trainees could be improved. It presents a vision for how CMT trainees, consultant supervisors, training programme directors, clinical directors and managers can work together to implement relevant, feasible and affordable ways to improve training for doctors and deliver the best possible care for patients.
BackgroundNew surgical procedures can expose patients to harm and should be carefully evaluated before widespread use. The InSpace balloon (Stryker, USA) is an innovative surgical device used to treat people with rotator cuff tears that cannot be repaired. We aimed to determine the effectiveness of the InSpace balloon for people with irreparable rotator cuff tears.MethodsWe conducted a double-blind, group-sequential, adaptive randomised controlled trial in 24 hospitals in the UK, comparing arthroscopic debridement of the subacromial space with biceps tenotomy (debridement only group) with the same procedure but including insertion of the InSpace balloon (debridement with device group). Participants had an irreparable rotator cuff tear, which had not resolved with conservative treatment, and they had symptoms warranting surgery. Eligibility was confirmed intraoperatively before randomly assigning (1:1) participants to a treatment group using a remote computer system. Participants and assessors were masked to group assignment. Masking was achieved by using identical incisions for both procedures, blinding the operation note, and a consistent rehabilitation programme was offered regardless of group allocation. The primary outcome was the Oxford Shoulder Score at 12 months. Pre-trial simulations using data from early and late timepoints informed stopping boundaries for two interim analyses. The primary analysis was on a modified intention-to-treat basis, adjusted for the planned interim analysis. The trial was registered with ISRCTN, ISRCTN17825590.FindingsBetween June 1, 2018, and July 30, 2020, we assessed 385 people for eligibility, of which 317 were eligible. 249 (79%) people consented for inclusion in the study. 117 participants were randomly allocated to a treatment group, 61 participants to the debridement only group and 56 to the debridement with device group. A predefined stopping boundary was met at the first interim analysis and recruitment stopped with 117 participants randomised. 43% of participants were female, 57% were male. We obtained primary outcome data for 114 (97%) participants. The mean Oxford Shoulder Score at 12 months was 34·3 (SD 11·1) in the debridement only group and 30·3 (10·9) in the debridement with device group (mean difference adjusted for adaptive design –4·2 [95% CI –8·2 to –0·26];p=0·037) favouring control. There was no difference in adverse events between the two groups.InterpretationIn an efficient, adaptive trial design, our results favoured the debridement only group. We do not recommend the InSpace balloon for the treatment of irreparable rotator cuff tears.FundingEfficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health and Care Research partnership
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