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Visual hallucinations are common in older people and are especially associated with ophthalmological and neurological disorders, including dementia and Parkinson’s disease. Uncertainties remain whether there is a single underlying mechanism for visual hallucinations or they have different disease-dependent causes. However, irrespective of mechanism, visual hallucinations are difficult to treat. The National Institute for Health Research (NIHR) funded a research programme to investigate visual hallucinations in the key and high burden areas of eye disease, dementia and Parkinson’s disease, culminating in a workshop to develop a unified framework for their clinical management. Here we summarise the evidence base, current practice and consensus guidelines that emerged from the workshop.Irrespective of clinical condition, case ascertainment strategies are required to overcome reporting stigma. Once hallucinations are identified, physical, cognitive and ophthalmological health should be reviewed, with education and self-help techniques provided. Not all hallucinations require intervention but for those that are clinically significant, current evidence supports pharmacological modification of cholinergic, GABAergic, serotonergic or dopaminergic systems, or reduction of cortical excitability. A broad treatment perspective is needed, including carer support. Despite their frequency and clinical significance, there is a paucity of randomised, placebo-controlled clinical trial evidence where the primary outcome is an improvement in visual hallucinations. Key areas for future research include the development of valid and reliable assessment tools for use in mechanistic studies and clinical trials, transdiagnostic studies of shared and distinct mechanisms and when and how to treat visual hallucinations.

OBJECTIVE: To explore how patients who are wait-listed for or who have received a kidney transplant understand the current UK kidney allocation system, and their views on ways to allocate kidneys in the future.DESIGN: Qualitative study using semistructured interviews and thematic analysis based on a pragmatic approach.PARTICIPANTS: 10 deceased-donor kidney transplant recipients, 10 live-donor kidney transplant recipients, 12 participants currently wait-listed for a kidney transplant and 4 participants whose kidney transplant failed.SETTING: Semistructured telephone interviews conducted with participants in their own homes across the UK.RESULTS: Three main themes were identified: uncertainty of knowledge of the allocation scheme; evaluation of the system and participant suggestions for future allocation schemes. Most participants identified human leucocyte anitgen matching as a factor in determining kidney allocation, but were often uncertain of the accuracy of their knowledge. In the absence of information that would allow a full assessment, the majority of participants consider that the current system is effective. A minority of participants were concerned about the perceived lack of transparency of the general decision-making processes within the scheme. Most participants felt that people who are younger and those better matched to the donor kidney should be prioritised for kidney allocation, but in contrast to the current scheme, less priority was considered appropriate for longer waiting patients. Some non-medical themes were also discussed, such as whether parents of dependent children should be prioritised for allocation, and whether patients with substance abuse problems be deprioritised.CONCLUSIONS: Our participants held differing views about the most important factors for kidney allocation, some of which were in contrast to the current scheme. Patient participation in reviewing future allocation policies will provide insight as to what is considered acceptable to patients and inform healthcare staff of the kinds of information patients would find most useful.

A 75-year-old man, with hereditary multiple exostoses, had a positron emission tomography (PET)-CT scan for follow-up of an excised chondrosarcoma. Incidentally, he was found to have widespread subpleural cystic change (figure 1A and B) and a cystic right lower lobe lesion (figure 2) adjacent to a rib exostosis. He was referred to the urgent respiratory clinic on the basis of these unusual subpleural cystic findings and concern that the cystic right …

Aim: To investigate the experiences of people with macular disease within the British healthcare system. Method: The Macular Disease Society Questionnaire, a self completion questionnaire designed to survey the experiences of people with macular disease, was sent to 2000 randomly selected members of the Macular Disease Society. The questionnaire incorporated items about people's experiences with health professionals and the information and support provided by them at the time of diagnosis and thereafter. Results: Over 50% thought their consultant eye specialist was not interested in them as a person and 40% were dissatisfied with their diagnostic consultation. 185 people thought their general practitioner (GP) was well informed about macular disease but twice as many people thought their GP was not well informed. About an equal number of people thought their GP was supportive as those who thought their GP was not supportive. A total of 1247 people were told "nothing can be done to help with your macular disease." A number of negative emotional reactions were experienced by those people as a result, with 61% of them reporting feeling anxious or depressed. Of 282 people experiencing visual hallucinations after diagnosis with macular disease, only 20.9% were offered explanations for them. Conclusions: Many people with macular disease have unsatisfactory experiences of the healthcare system. Many of the reasons for dissatisfaction could be resolved by healthcare professionals if they were better informed about macular disease and had a better understanding of and empathy with patients' experiences.

Introduction and Objectives Tuberculosis notifications in the UK continue to rise and the diagnosis of both disease and drug resistance can be challenging. Endobronchial ultrasound (EBUS) and EBUS-guided transbronchial nodal aspirates (TBNA) have been shown recently to be a safe and effective tool in the diagnosis of intra-thoracic TB lymphadenopathy. New molecular techniques, notably the GeneXpert MTB.Rif system (Cepheid) have shown great promise in the diagnosis of pulmonary disease but have not been evaluated in intra-thoracic nodal disease. Methods As part of an ongoing study, consecutive patients with intra-thoracic lymphadenopathy were prospectively studied within our tertiary EBUS service between January 2010 and March 2011. In addition to standard cytological and microbiological investigations, a single GeneXpert MTB.Rif assay was performed on EBUS-TBNA samples. Using established methods, a final diagnosis was given of definite/highly probable TB, possible TB or not TB/alternative diagnosis. Performance of the GeneXpert MTB.Rif assay was then evaluated in the context of these final diagnoses. Results 74 patients (3 HIV-positive) underwent EBUS-TBNA sampling. Nineteen have been diagnosed with definite/highly probable TB to date. A single GeneXpert assay had a sensitivity of 67% (8/12) from culture-positive TBNA. 11/15 (73%) of patients with a positive culture from any tissue and 13/19 (68%) patients classed as definite/highly probable TB had positive GeneXpert results. One case of confirmed MDR-TB was correctly identified and treatment started promptly. Fifteen patients had positive GeneXpert MTB.Rif results from EBUS-TBNA: 13/15 were given immediate TB treatment. One of the remaining two cases without strong microbiological or cytological findings was subsequently diagnosed with active tuberculosis supported by evidence of PET-positive mediastinal lymph nodes. The other case appears not to have active disease and remains under follow-up. Conclusions A single GeneXpert MTB.Rif assay has good sensitivity in the context of culture-positive intra-thoracic tuberculous lymphadenopathy and can provide an immediate diagnosis of likely MDR-TB. Positive PCR results were seen in two patients where conventional techniques were inconclusive and in one provided the main support for the diagnosis. These results suggest the addition of the GeneXpert MTB.Rif assay to the investigation of intra-thoracic nodal disease improves diagnostic yield.

Objectives: To evaluate whether a course teaching flexible intensive insulin treatment combining dietary freedom and insulin adjustment can improve both glycaemic control and quality of life in type 1 diabetes. Design: Randomised design with participants either attending training immediately (immediate DAFNE) or acting as waiting list controls and attending “delayed DAFNE” training 6 months later. Setting: Secondary care diabetes clinics in three English health districts. Participants: 169 adults with type 1 diabetes and moderate or poor glycaemic control. Main outcome measures: Glycated haemoglobin (HbA 1c ), severe hypoglycaemia, impact of diabetes on quality of life (ADDQoL). Results: At 6 months, HbA 1c was significantly better in immediate DAFNE patients (mean 8.4%) than in delayed DAFNE patients (9.4%) ( t =6.1, Pt =−5.4, Pt =2.9, P Conclusion: Skills training promoting dietary freedom improved quality of life and glycaemic control in people with type 1 diabetes without worsening severe hypoglycaemia or cardiovascular risk. This approach has the potential to enable more people to adopt intensive insulin treatment and is worthy of further investigation.