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education education ART OF MEDICINE PRACTICE UPDATES Can I have cheese on my ham sandwich? Whistleblowing in primary care NHS England has published new guidance on supporting whistleblowing in primary care. Each NHS primary care provider should name an individual as the “Freedom to Speak Up Guardian,” who can ensure that policies are in place and that staff know who to contact if they have a concern. All primary care providers should review and update their local policies and procedures by September 2017, so that they align with this new guidance. NHS England will provide easy access to learning resources and will support a network of Freedom to Speak Up Guardians in primary care. “Can I have cheese on my ham sandwich?” My patient asked me this question several times during the first few weeks of my employment at a state • http://bit.ly/gpwhistleblow hospital. Although dieticians provided HIV testing: increasing uptake recommendations, I was ultimately responsible NICE and Public Health England have published new guidance on for entering dietary orders. Like most patients on the ward, my patient was prescribed psychotropic HIV testing. In “high prevalence” settings, everyone admitted to drugs that resulted in metabolic complications. As hospital (including emergency departments) who is undergoing a result, she required dietary restrictions. Despite blood tests should be recommended an HIV test as well. In areas of several explanations about these restrictions, “extremely high prevalence,” everyone should be recommended she continued to request cheese on her ham HIV testing on admission to hospital. GP surgeries in areas of high sandwiches. After I had denied her request on or extremely high prevalence should recommend HIV testing to numerous occasions, she finally said to me and all new registrants and to all patients undergoing blood tests for asked: “Why can’t I have cheese? I am stuck in a another reason who have not been tested in the previous year. hospital. I know I’m too sick to go home. I have •http://bit.ly/HIVtestingNICE nothing to look forward to except what I can eat.” For many patients in an institutional setting, days are regimented from the time of “lights FAST FACT—DIAGNOSTIC CRITERIA FOR DIABETES on” to “lights off.” They are told what activities Diabetes UK supports the WHO diagnostic to attend, when meals and snacks are served, criteria for diabetes, which are: and what they can eat. These patients have little control over many aspects of their lives, but they Glucose concentration in venous plasma can choose what they put into their mouths. – ≥7.0 mmol/L after fasting for ≥8 hours Food is such a basic human need that we often – ≥11.1 mmol/L on oral glucose tolerance forget its psychological significance. In an test environment where most control is taken away, – ≥11.1 mmol/L on random testing. patients can exert an influence on food. Hence For more information visit BMJ Learning many patients insist on certain meals, purchase • http://bit.ly/T1DMDiagnosis “unhealthy” items from the canteen, and engage in an “underground” snack distribution system. Food serves as a mechanism to exert control in You can gain CPD points from your reading an environment where patients feel they have no by recording and reflecting on what you have influence. READING READING read in your appraisal folder. We suggest LEARNING allowing half an hour to read and reflect on Within reason, negotiating meals and snacks MODULE READING each BMJ education article.0.5 HOURS could provide patients with a sense of control and 0.5 HOURS could increase treatment compliance. I added If you see a Learning module logo cheese to the patient’s order for a ham sandwich. 0.5 HOURS LEARNING Kaustubh G Joshi, associate professor of clinical psychiatry, Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, SC 29203, USA [email protected] We welcome contributions to this column via our online editorial office: https://mc.manuscriptcentral.com/bmj. Cite this as: BMJ 2016;355:i6024 log onto http://learning.bmj.com to complete the online module. MODULE 0.5 on H OURS We print a statement financial interests and patient partnership with each education article. We have resolved to reduce the involvement LEARNING of authors withMODULE financial interests that The BMJ judge as relevant. We READING encourage and make clear how patients have been involved and shaped our content. More details can be found on thebmj.com. the bmj | 7 January 2017 29 GUIDELINES End of life care for children: summary of NICE guidance READING 0.5 HOURS Gemma Villanueva,1 M Stephen Murphy,1 David Vickers,2 3 Emily Harrop,4 5 Katharina Dworzynski1 Children and young people can have a wide range of life limiting conditions and may sometimes live with such conditions for many years. This guideline recommends that end of life care be managed as a long term process that begins at the time of diagnosis of a life limiting condition and entails planning for the future. Sometimes it may begin before the child’s birth. It is part of the overall care of the child or young person and runs in parallel with other active treatments for the underlying condition itself.1 Finally, it includes those aspects related to the care of the dying. 1 National Guideline Alliance, Royal College of Gynaecologists and Obstetricians, London Cambridgeshire Community Services NHS Trust, St Ives 3 East Anglia’s Children's Hospices, Milton 4 Helen & Douglas House, Oxford 5 Oxford University Hospitals, Oxford 2 Correspondence to: K Dworzynski [email protected] Further information about the guidance, a list of members of the guideline development group, and the supporting evidence statements are in the full version on bmj.com. SPENCER GRANT/SPL How to plan care • Recognise that children and young people with life limiting conditions and their parents or carers have a central role in decision making and care planning. • Explain to children and young people and to their parents or carers that their contribution to decisions about their care is important, but they do not have to make decisions alone and the multidisciplinary team will be involved as well. P HOW PATIENTS WERE INVOLVED IN THE CREATION OF THIS ARTICLE Patients were not directly involved in this article. Committee members involved in this guideline included two patient representatives, who contributed to the formulation of the recommendations summarised here. Children and young people with life limiting conditions also contributed to this guideline by having their voices heard by focus groups. WHAT YOU NEED TO KNOW • Involve children and young people with life limiting conditions and their parents or carers in decision making and care planning • An advance care plan is a core element of a child’s or young person’s end of life care • Be aware that other family members such as siblings and grandparents, and others (such as friends, boyfriends or girlfriends) may need support • Name a medical specialist who leads on and coordinates the child or young person’s care • Decisions about care should always consider what is in the best interest of the child 30 Advanced care planning • Develop and record an advance care plan at an appropriate time for the current and future care of each child or young person with a life limiting condition (see box, p 32). – In some cases planning may begin antenatally. • Share the advance care plan with the child or young person and their parents or carers (as appropriate), and think about which professionals and services involved in the individual child or young person’s care should also share it, for example: – General practitioners – Hospital consultants – Hospices – Respite centres – Nursing services (community or specialist) – School and other education services – Ambulance services. Multidisciplinary team working • Depending on the needs of the child or young person, the multidisciplinary team may include: – Healthcare professionals – Social care practitioners – Education professionals 7 January 2017 | the bmj Diagnosis of life limiting condition Bereavement Carry out wishes expressed in ACP Death Organ/tissue donation Care of body Advance ACP care plan Child / young person Rituals Recording memories End of life Plans for social media Working together, the young person, their carers and support team record important information and decisions. Multidisciplinary support team Update treatments Consider ending treatments Condition specialists Consider new invasive treatments Other family and important people Consider nonpharmacological treatments Record wishes + ambitions Palliative care team Siblings Social care practitioners Social activities Education professionals Religious/spiritual Chaplains Education Allied health professionals Family Team provides ongoing care and support Friends Spiritual/ religious Social Emotional/ psychological Practical Hospice professionals Grandparents Boy/girlfriends Bereavement support Assemble multidisciplinary support team Assign named medical specialist to lead and coordinate care Parents/ carers Funeral Help family to prepare Early stages Establish how a young person and carers want to be involved in decision making A living document Agree preferred places for care and death Care planning ACP is updated as needs change and decisions are made Delivery – Chaplains – Allied health professionals (such as physiotherapists, occupational therapists, and psychological therapists). E very child or young person with a life limiting • condition should have a named medical specialist who leads on and coordinates their care. Emotional and psychological support • Regularly discuss emotional and psychological wellbeing with children and young people and their parents or carers, particularly at times of change such as: – When the life limiting condition is diagnosed – If their clinical condition deteriorates – If their personal circumstances change – If there are changes to their nursery care, school, or college arrangements, or their employment – If there are changes to their clinical care (for example, if their care changes focus from treating the condition to end of life care). Social and practical support • Be aware that other family members and people important to the child or young person may need support, including social, practical, emotional, psychological, and spiritual support. the bmj | 7 January 2017 31 • Be aware that children and young people with life limiting conditions and their parents or carers have varied social and practical support needs, and that those needs may change during the course of their condition. This may include: – Material support, such as housing or adaptations to the home and equipment for home drug infusions – Practical support, such as access to respite care – Technical support, such as training and help with administering drug infusions at home – Education support, such as from hospital school services – Financial support. EDUCATION INTO PRACTICE •Has an advance care plan been developed and recorded, when appropriate, for the children and young people with a life limiting condition in your care? •Are there services in place that can provide round the clock care for a child or young person with a life limiting condition who is approaching the end of life? •Can patients and their families be cared for in their preferred place of care? •Are children or young people with life limiting conditions receiving symptom management that is adequate to maximise their quality of life? Approaching the end of life • When a child or young person is approaching the end of life, discuss with their parents or carers what would help them, for example: – Important rituals – Recording or preserving memories (for example, photographs, hair locks, or hand prints) – Plans for social media content. • Agree the preferred place of care and place of death with children and young people and their parents or carers, taking into account: – Their wishes, which are personal and individual – Their religious, spiritual, and cultural values – The views of relevant and experienced healthcare professionals – Safety and practicality. • Explain that the place of care or place of death may change, for example: Components of an advance care plan for a child or young person with a life limiting condition •Demographic information about the child or young person and their family •Up to date contact information for: – The child or young person’s parents or carers – The key professionals involved in care •A statement about who has responsibility for giving consent •A summary of the life limiting condition •An agreed approach to communicating with and providing information to the child or young person and their parents or carers •An outline of the child or young person's life ambitions and wishes, such as on: – Family and other relationships – Social activities and participation – Education – How to incorporate their religious, spiritual, and cultural beliefs and values into their care •A record of significant discussions with the child or young person and their parents or carers •Agreed treatment plans and objectives •Education plans, if relevant •A record of any discussions and decisions that have taken place on: – Preferred place of care and place of death – Organ and tissue donation (see recommendation 1.1.19 in the full NICE guideline2) – Management of life threatening events, including plans for resuscitation or life support – Specific wishes, such as on funeral arrangements and care of the body •A distribution list for the advance care plan 32 – If the child or young person and their parents or carers change their minds or – For clinical reasons or – Due to problems with service provision. • For children and young people with life limiting conditions who are approaching the end of life and are being cared for at home, services should provide (when needed): – Advice from a consultant in paediatric palliative care (such as by telephone) at any time (day and night) – Paediatric nursing care at any time – Home visits by a healthcare professional from the specialist paediatric palliative care team (see recommendation 1.5.4 in the full NICE guideline2), for example, for symptom management – Practical support and equipment for interventions including oxygen, enteral nutrition, and subcutaneous and intravenous therapies – Anticipatory prescribing for children and young people who are likely to develop symptoms. • Involve the specialist paediatric palliative care team if a child or young person has unresolved distressing symptoms as they approach the end of life. • Think about non-pharmacological interventions for pain management, such as: – Changes that may help them to relax, for example, environmental adjustments (for example reducing noise), music or physical contact (such as touch, holding or massage) – Local hot or cold applications to the site of pain – Comfort measures, such as sucrose for neonates. • In addition to background analgesia, consider giving anticipatory doses of analgesia for children and young people who have pain at predictable times (for example, when changing dressings or moving and handling). Do not include anticipatory doses when calculating the required daily background dose of analgesia. • When a child or young person is approaching the end of life, discuss with them and their parents or carers and with relevant healthcare professionals: – Any available invasive treatments that might be in their best interest – Any interventions they are currently receiving that may no longer be in their best interest. • Attempt resuscitation for children and young people with life limiting conditions unless there is a “Do not attempt resuscitation” order in place. Competing interests: See bmj.com. Cite this as: BMJ 2016;355:i6385 Find this at: http://dx.doi.org/10.1136/bmj.i6385 7 January 2017 | the bmj CLINICAL UPDATES LEARNING READING READING Ischaemic colitis MODULE 0.5 HOURS 0.5 HOURS J M Trotter,1 L Hunt,2 M B Peter1 0.5 HOURS 1 Department of Surgery, Scarborough General Hospital, Scarborough, UK Department of Diabetes, Endocrinology and Metabolism, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, UK Correspondence to: [email protected] 2 Marginal artery of Drummond LEARNING READING MODULE Vasa recta This is an edited version; the full version is on bmj.com The incidence of ischaemic colitis1 has risen from 6.1 cases/100 000 person-years in 1976-80 to 22.9/100 000 in 2005-09.2 Acute gastrointestinal medical and surgical teams will see a few patients with ischaemic colitis each month. Prevalence increases with age and comorbidity,2 which might lead to an increase in the incidence of ischaemic colitis as the population ages.3 A small proportion of patients will present with a more chronic form of ischaemic colitis. Superior mesenteric arteryREADING Middle colic artery LEARNING MODULE 0.5 HOURS Ileocolic artery Left colic artery This article provides practical advice to non-specialists regarding the diagnosis, management, and guideline recommendations for ischaemic colitis in the acute setting. What is ischaemic colitis and what causes it? Ischaemic colitis and mesenteric ischaemia are different disorders but are often confused: the table (p 36) highlights their differences. Ischaemic colitis occurs when there is an acute, transient compromise in blood flow, below that required for the metabolic needs of the colon. This leads to mucosal ulceration, inflammation, and haemorrhage. The duration and severity of hypoperfusion determines whether the colonic injury is predominantly ischaemic or as a consequence of reperfusion.4 Figure 1 shows the arterial supply of the colon and the most common sites for ischaemic colitis. Ischaemic colitis often has a multifactorial origin, and patients with extensive comorbidities are at particular risk. The box lists common causes of ischaemic colitis. What are the symptoms and signs? Acute presenting symptoms are commonly diarrhoea, rectal bleeding, and colicky abdominal pain.12 Examination typically reveals a soft abdomen with tenderness and voluntary guarding over the affected segment of colon. The presence of peritonitis suggests full thickness ischaemia, perforation, or alternative diagnosis. The acute onset of the symptoms is a useful distinguishing factor between ischaemic colitis and inflammatory or infective colitis, where abdominal pain often has a more insidious onset.13 Symptoms of ischaemic colitis manifest in a matter of hours and, unlike infective or inflammatory colitis, continue to worsen with systemic instability. Inferior mesenteric artery Marginal artery of Drummond Fig 1 | Arterial supply of the colon and the most common sites for ischaemic colitis. The colon receives blood from both the superior and inferior mesenteric arteries. However, there are weak points, or “watershed” areas, at the borders of the territory supplied by each of these arteries,5 such as the splenic flexure and the transverse portion of the colon. These watershed areas are most vulnerable to ischaemia when blood flow decreases, as they have the fewest vascular collaterals WHAT YOU NEED TO KNOW • Ischaemic colitis is different from mesenteric ischaemia or “ischaemic bowel” • Ischaemic colitis is typically acute in onset and has a high mortality rate • Patients with suspected ischaemic colitis need urgent admission to a gastroenterological unit with specialist surgical services • Some patients with ischaemic colitis can be managed conservatively • Computed tomography is the investigation of choice for initial diagnosis of ischaemic colitis, using colonoscopy within 48 hours to give further prognostic information and to confirm diagnosis the bmj | 7 January 2017 33 Ischaemic colitis may result in systemic inflammatory response syndrome (SIRS) with associated observations of tachycardia, hypotension, tachypnoea, and occasionally raised temperature without an infective focus. Patients can present in a state of shock, leading on to multiorgan failure if not treated correctly. Clinically, it is difficult to differentiate between patients with possible infective, inflammatory, or ischaemic colitis, and even with diagnostic tests it is not always clear. Generalists need to be equipped to recognise patients with symptoms of colitis who are deteriorating and refer them for specialist opinion. How do you diagnose ischaemic colitis? Investigate patients with possible ischaemic colitis urgently. Computed tomography is the diagnostic investigation of choice. Guidance from the American College of Gastroenterology4 recommends that computed tomography is performed within the first few hours of admission, with care led by a senior clinician from this point. Colonoscopic evaluation is recommended within 48 hours to visualise mucosa and confirm diagnosis. There is no role for abdominal plain radiographs or ultrasonography in diagnosing ischaemic colitis, though these investigations often used in practice in the assessment of abdominal pain. They can give some information about ischaemic colitis, such as “thumbprinting” on x ray or mural thickening and blood flow on ultrasonography and Doppler ultrasound.14‑17 However, the same, and more, information is provided in greater detail on computed tomography that is not user dependent and is usually more readily available out of hours than ultrasonography. Common causes of ischaemic colitis Physiological Systemic—Heart failure, systemic inflammatory response syndrome (SIRS), atherosclerosis Embolic—Atrial fibrillation Thrombotic—Concurrent malignancy and haematological disorders6 Iatrogenic Pharmacological—Chemotherapy, sex hormones, interferon therapy, pseudoephedrine, cardiac glycosides, diuretics, statins, non-steroidal antiinflammatory drugs (NSAIDS), immunosuppressive drugs, vasopressors6 7 Surgical—Abdominal aortic aneurysm repair8 Endoscopic—Colonoscopy and bowel preparation media for colonoscopy4‑11 HOW PATIENTS WERE INVOLVED IN THE CREATION OF THIS ARTICLE No patients were involved in the creation of this article. P Laboratory tests In the presence of rectal bleeding, perform clotting studies and a haemoglobin level. Inflammatory makers such as C reactive protein and neutrophil count are likely to be raised. Check renal function as patients are at risk of acute kidney injury because of the inflammatory response in ischaemic colitis. Serum lactate levels may be raised as a result of systemic dysfunction and hypoperfusion. The role of lactate in this scenario is in monitoring progress during resuscitation. Raised serum lactate does not indicate gastrointestinal ischaemia, and a normal lactate level does not exclude full thickness ischaemia of the colon.18 Contrast enhanced computed tomography Computed tomography gives prompt information, with positive findings in ischaemic colitis in up to 98% of cases.19 These include wall thickening, 34 Fig 2 | Computed tomographs of the abdomen (in axial and coronal views) showing fat stranding (increased density of fat, a sign of inflammatory process) and thickening (arrows) around the splenic flexure secondary to ischaemic colitis 7 January 2017 | the bmj abnormal or absent wall enhancement, dilatation, mesenteric stranding, venous engorgement, ascites, pneumatosis (gas within the bowel wall), and portal venous gas (fig 2).19 20 The CT findings suggest a diagnosis of ischaemic colitis, but they can be present regardless of severity,19 limiting the prognostic value. The presence of such features (particularly in the watershed between the superior and inferior mesenteric artery) will suggest a diagnosis of ischaemic colitis but cannot absolutely distinguish it from other types of colitis. CT can rule out other diagnoses and complications such as perforation that will change management. Endoscopic evaluation Early endoscopy can confirm the diagnosis by direct visualisation4 and provides prognostic information to help distinguish between cases that may settle with conservative management and those that may require emergency resection. Transient non-gangrenous features of ischaemic colitis observed at colonoscopy include: • Petechial haemorrhages • Oedematous and fragile mucosa • Segmental erythema • Scattered erosions • Longitudinal ulcerations (colon single stripe sign) (fig 3) • A sharply defined segment of involvement.21 Cyanosis and pseudo-polyps suggest a transmural ischaemia. Colonoscopy is advocated by most studies, and there is no evidence that its use in assessment of ischaemic colitis is unsafe when performed by experienced practitioners.4 22 Retrospective studies of a total of 659 cases reported no cases of perforation secondary to colonoscopy,23 24 in data published in recent guidance.4 What treatment is available? Initial resuscitation There is no specific guidance for the resuscitation of patients with ischaemic colitis. General resuscitation principles apply, including • Intravenous fluid resuscitation • Fluid balance monitoring with bladder catheterisation • Assessment of acid-base status with arterial blood gas sampling • Blood glucose control and monitoring in diabetic patients. While there is no specific evidence regarding fluid resuscitation in ischaemic colitis, aggressive and prompt resuscitation of a patient with SIRS has profound effects on outcomes, and specific algorithms now exist for conditions such as sepsis and pancreatitis.25 26 Fig 3 | Endoscopic findings of inflamed mucosa and single stripe sign (a single longitudinal strip of ulcerated or inflamed colon (arrow)) in segment of ischaemic colitis (reproduced with permission of www.natural-health-news.com) With appropriate resuscitation measures, colonic inflammation and associated symptoms settle in some patients without the need for surgery. Data on the proportion of patients who may be expected to settle without surgical intervention vary widely, reflecting the differences in clinical practice with regards to ischaemic colitis and the current lack of robust guidance. Surgical intervention Consider surgical intervention if there is radiological evidence of perforation, generalised peritonitis, or continuing haemorrhage causing instability or repeated transfusion. For patients without these features, decisions whether to operate when conservative management fails are made on an individual basis. Factors associated with severe episodes that may not resolve with conservative treatment include4‑27 • Right sided distribution of colitis • Male sex • Lack of rectal bleeding • Renal dysfunction • Colonic strictures • Peritonitis. Where one or more of these features exist, provide senior review daily and be alert to signs of development of full thickness ischaemia such as worsening pain or peritonism. For patients whose clinical condition is not improving, consider further blood texts to review biochemical markers. In the case of any clinical or biochemical the bmj | 7 January 2017 35 QUESTIONS FOR ONGOING RESEARCH •Does anticoagulation provide protection for recurrence of ischemic colitis? •Should Doppler ultrasound be more readily available in centres dealing with ischaemic colitis? •Should formal angiography and endovascular treatment be performed in mesenteric stenoses found on computed tomography of patients with ischaemic colitis? Differences between mesenteric ischaemia and ischaemic colitis Characteristic Mesenteric ischaemia (ischaemic bowel) Ischaemic colitis Symptom onset Sudden Hours Cause Embolic Multifactorial Blood supply loss Total to affected segment Transient Presenting symptoms Abdominal pain out of Moderate abdominal pain and proportion with clinical tenderness over affected segment, findings bloody diarrhoea Management Urgent surgery Usually conservative, but surgery needed in some cases deterioration, consider the need for repeat imaging and surgical intervention. Patients who require surgical intervention for ischaemic colitis have higher mortality (37-48%4‑30) than those treated conservatively (6.2% in a large systematic review17 22). Operative intervention usually includes segmental resection and colostomy formation. In unstable patients, complex surgery can worsen outcome.31 Caring for patients with ischaemic colitis Anticoagulation Prophylactic anticoagulation is advocated, but therapeutic anticoagulation is not indicated. Current guidance from the National Institute for Health and Care Excellence (NICE) advocates mechanical and pharmacological prophylaxis for venous thromboembolism for most groups of patients who don’t have contraindications, including those with ischaemic colitis.32 NICE guidance recommends postoperative prophylaxis for venous thromboembolism continues “until mobility is no longer significantly restricted.” Cardiac emboli Cardiac emboli have been found in 43% of patients with ischaemic colitis compared with 23% of matched controls.33 These findings may be coincidental, but consider investigations in those with cardiac symptoms or signs.33 Nutritional support After admission for suspected ischaemic colitis, most patients will be fasted until a decision is made about surgery. There is a move away from 36 prolonged fasting in modern surgical practice in acute and elective settings.25‑35 Offer a dietetic-led enteral diet to help restore normal gut physiology and flora early. Parenteral nutrition may be necessary in severe cases when fasting is likely to exceed a week. Antimicrobial therapy The latest guidance on ischaemic colitis from the American College of Gastroenterology recommends antimicrobial therapy, although the evidence base for this is poor.4 Consider which specific agents to use with the help of microbiological guidance, taking account of local protocols and microbial resistance. What is the long term management of ischaemic colitis? Ischaemic colitis is multifactorial in origin and often occurs in a patient with multiple comorbidities. When treating ischaemic colitis, offer support in lifestyle modification to reduce recurrence or deterioration in other conditions, including advice on • Smoking cessation • Alcohol intake reduction • Increasing exercise. There is no guidance or evidence to suggest that antiplatelets are of benefit in treating ischaemic colitis. It is not a purely atherosclerotic condition, so, alone, it is not a reason to start antiplatelet therapy. Medication Patients who have had ischaemic colitis may take regular medication that can impair colonic blood flow. These drugs are commonly prescribed for primary or secondary prevention of ischaemic heart disease such as angiotensin converting enzyme inhibitors or β adrenoreceptor blockers. If cardiac medications have been stopped temporarily during the acute illness, reintroduce them with caution to avoid periods of hypotension that might exacerbate ischaemic colitis. Follow-up care Uncomplicated ischaemic colitis is usually followed up once after admission by the surgical team, then the patient discharged back to community care. Chronic or recurrent ischaemic colitis occurs in 6.816% of patients.4 This can present as another acute episode similar to the index admission. At the site of previous ischaemic colitis stricturing can occur, causing bloating, constipation, and colicky pain as well as chronic ulceration prone to bleeding that may manifest itself only as anaemia. The chronic, more benign symptoms of ischaemic colitis, although rare, are non-specific; if encountered, they warrant prompt referral to specialist services to confirm the diagnosis. Competing interests: None declared. Cite this as: BMJ 2016;355:i6600 Find this at: http://dx.doi.org/10.1136/bmj.i6600 7 January 2017 | the bmj ENDGAMES For long answers go to the Education channel on thebmj.com CASE REVIEW A case of pulsatile tinnitus A 32 year old man presented to his primary care doctor with an eight month history of hearing loss and a pulsatile noise that sounded like a heartbeat in his left ear. In the previous four months he had experienced otalgia in the left ear and headaches. On examination, the doctor noticed a mass behind the left tympanic membrane, with pulsation of the membrane. Tuning fork tests identified a conductive hearing loss in the left ear. Other than headaches, there were no red flag symptoms such as weight loss, fever, or other signs of raised intracranial pressure. The patient was referred to an ear, nose, and throat specialist, who noted that the left tympanic membrane was intact and facial nerve function on both sides was normal. There was an obvious pulsating mass behind the left tympanic membrane (fig 1). Endoscopic examination of the larynx showed normal vocal cord movement, but there was evidence of a hypoglossal palsy on the left side, with unilateral tongue wasting. The patient had some difficulty articulating speech but reported no dysphagia. Audiometry confirmed a conductive hearing loss in the left ear. Contrast enhanced computed tomography (CT) and magnetic resonance imaging (MRI) (fig 2) of the base of the patient’s skull showed an enhanced jugular fossa mass on the left side. @bmj_latest SPOT DIAGNOSIS Abnormality on a skull radiograph 1. What are the differential diagnoses for pulsatile tinnitus? 2. What is the most likely diagnosis? 3. What are the management options? Submitted by Karan Jolly, Pawanjit Hare, Richard Irving, and Peter Monksfield Patient consent obtained. Cite this as: BMJ 2017;356:i6402 A 65 year old woman presented with a four week history of increased fatigue, intermittent chest pain, dyspnoea, and frequent constipation. Biochemistry showed haemoglobin of 95 g/L (baseline 130 g/L) and an estimated glomerular filtration rate of 5 ml/min/1.73m2 (baseline 50 ml/min/1.73m2). Initial chest radiography revealed multiple unexplained rib fractures, which prompted a further skeletal survey, including a radiograph of the skull (figure). What does the skull radiograph show? Submitted by Janice Ser Huey Tan and Timothy Shao Ern Tan Patient consent obtained. Cite this as: BMJ 2017;356:i6315 Fig 1 3 Three main treatment modalities exist: surveillance with repeat imaging after an interval, surgical resection, and radiotherapy. Treatment is guided by discussion between members of the skull base multidisciplinary team. 1 Differential diagnoses include vascular stenosis due to atherosclerotic plaques; arteriovenous fistula; vascular tumours (including paragangliomas), and intracranial hypertension. Alternatively, the tinnitus can result from increased sensitivity to normal bodily noises such as blood flow. This can be due to conductive hearing loss caused by wax obstruction or middle ear infection/effusion. CASE REVIEW A case of pulsatile tinnitus Lateral radiograph of the skull showing focal mandibular lucency (*) on a background of “pepper pot” lucencies in the skull vault (white arrow) caused by myeloma bone disease SPOT DIAGNOSIS Abnormality on a skull radiograph the bmj | 7 January 2017 answers 2 Paraganglioma of the head and neck, more specifically known as a glomus jugulare tumour. FigFig 2 2 If you would like to write a Case Review for Endgames, please see our author guidelines at http://bit.ly/29HCBAL and submit online at http://bit.ly/29yyGSx 41 MINERVA A wry look at the world of research Cutaneous sarcoid granulomas within a cosmetic tattoo A 40 year old man who had known multisystem sarcoidosis noticed the re-emergence of well defined, non-tender papules within the borders of his preexisting tattoo (figure). The papules arose after his dose of prednisolone was reduced from 7 mg to 6 mg once daily, and were associated with an increase in serum angiotensin converting enzyme activity, which is a marker of sarcoid activity. Invasion of cosmetic tattoos and scars by sarcoid granulomas is a well recognised phenomenon of unknown pathophysiological cause, and cutaneous involvement occurs in up to one third of patients. Currently, patients with sarcoidosis are not advised against having cosmetic tattoos. Increasing the prednisolone dose back up to 7 mg resulted in almost complete resolution of the lesions within three months. Stephanie Laura Tanner ([email protected]); Sarah Menzies, Wexham Park Hospital, Slough Patient consent obtained. Cite this as: BMJ 2017;356:i6324 Don't blame the staff for staph Lung transplant window opens The idea that hospital staff might go around spreading infection arose in the 1780s and took about a hundred years to sink in. Whole genome bacterial sequencing can now track how many bacteria come to hospitals from outside and how many are spread by healthcare workers. Reassuringly, a study from the intensive care unit at the Royal Sussex Hospital, UK, found that in the presence of standard infection control measures, healthcare workers were infrequently sources of transmission of Staphylococcus aureus to patients (Lancet Infect Dis doi:10.1016/S14733099(16)30413-3). Instead, the epidemiology showed a continuous ingress of distinct subtypes rather than transmission of genetically related strains. Traditionally, the optimal time from lung explantation to transplantation is 12 hours, but this can be extended by splitting it into two periods of cold ischaemia, separated by a period of ex vivo lung perfusion. Looking retrospectively at 906 patients on the Toronto Lung Transplant Program database, investigators found that extending graft preservation time beyond 12 hours with ex vivo lung perfusion does not negatively affect early lung transplantation outcomes (Lancet Respir Med doi:10.1016/S22132600(16)30323-X). Bednets bomb in Haiti Bednets treated with insecticide are useful for preventing malaria when the disease is spread by Anopheles mosquitoes that bite in the night. Unfortunately, the chief malarial vector in Haiti, Anopheles albimanus, bites primarily outdoors and often when people are awake. A casecontrol study from 17 centres in Haiti concluded that, despite a campaign to encourage the use of bednets, the nets did not statistically significantly protect against clinical malaria (Lancet Glob Health doi:10.1016/S2214109X(16)30238-8). The mosquitoes all showed high susceptibility to the bednet insecticide but they just fed too early. 42 Know your genes, avoid diabetes? Personal genetic testing is sold throughout the world as a guide to preventing diseases such as type 2 diabetes by enabling better risk assessment and informing on lifestyle change. The Fenland study, based in Cambridge, UK, recruited 569 healthy middle aged adults and randomised them to receive either standard lifestyle advice alone (control group n=190) or in combination with a genetic (n=189) or a phenotypic (n=190) risk estimate for type 2 diabetes. After eight weeks, there was no difference in health related behaviours between the groups (PLOS Med doi:10.1371/journal.pmed.1002185). Stenting without a surgical safety net Percutaneous coronary intervention started cautiously in large hospitals that had cardiac surgery teams on site in case anything went wrong with the balloon or the stent in the coronary artery. But in the USA, the years 2003-12 saw a sevenfold increase in the use of percutaneous coronary intervention in smaller hospitals. A survey covering nearly seven million inpatient procedures shows that adjusted in-hospital mortality does not differ between hospitals with and without surgical “rescue” teams. (JAMA Cardiol doi:10.1001/jamacardio.2016.4188). Inspecting skin in Queensland White people living in sunny places get skin cancers, but not always at the sites on the body that are most exposed. A survey of the anatomical location of basal cell and squamous cell carcinomas in Queensland, Australia, found the expected predominance on the head and neck for both (JAMA Dermatol doi:10.1001/ jamadermatol.2016.4070). But squamous cell carcinomas were more common than basal cell carcinomas on the arms, and basal cell cancers were more common on the hands and the buttocks. Do benzos make nurses snore? Minerva’s owl assures her that she never snores. The Nurses' Health Study (USA, 2008), however, found that 10.6% of its all female cohort aged between 62 and 86 snored regularly, increasing to 11.4% if they took benzodiazepine receptor agonists (JAMA Otolaryngol Head Neck Surg.doi:10.1001/ jamaoto.2016.3174). But after adjustment for confounders, this small difference disappeared. Use of benzodiazepine receptor agonists is not associated with odds of snoring in middle aged and elderly women, and their bedfellows have a nearly nine out of 10 chance of sleeping soundly. Cite this as: BMJ 2017; 356:i6825 7 January 2017 | the bmj