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Objective To evaluate the association of the discharge medicines review (DMR) community pharmacy service with hospital readmissions through linking National Health Service data sets. Design Retrospective cohort study. Setting All hospitals and 703 community pharmacies across Wales. Participants Inpatients meeting the referral criteria for a community pharmacy DMR. Interventions Information related to the patient’s medication and hospital stay is provided to the community pharmacists on discharge from hospital, who undertake a two-part service involving medicines reconciliation and a medicine use review. To investigate the association of this DMR service with hospital readmission, a data linking process was undertaken across six national databases. Primary outcome Rate of hospital readmission within 90 days for patients with and without a DMR part 1 started. Secondary outcome Strength of association of age decile, sex, deprivation decile, diagnostic grouping and DMR type (started or not started) with reduction in readmission within 90 days. Results 1923 patients were referred for a DMR over a 13-month period (February 2017–April 2018). Provision of DMR was found to be the most significant attributing factor to reducing likelihood of 90-day readmission using χ² testing and classification methods. Cox regression survival analysis demonstrated that those receiving the intervention had a lower hospital readmission rate at 40 days (p<0.000, HR: 0.59739, CI 0.5043 to 0.7076). Conclusions DMR after a hospital discharge is associated with a reduction in risk of hospital readmission within 40 days. Linking data across disparate national data records is feasible but requires a complex processual architecture. There is a significant value for integrated informatics to improve continuity and coherency of care, and also to facilitate service optimisation, evaluation and evidenced-based practice. [ABSTRACT FROM AUTHOR]

As technological advancements continue to transform the practice of pathology, new adopters of these technologies will look to guidelines on how best to incorporate them with an eye to preserving and enhancing patient safety and diagnostic quality. Telepathology, using a variety of digital pathology modalities, has tremendous potential to achieve that goal. Pathology departments are increasingly looking to implement different digital pathology platforms, whole slide imaging (WSI) systems in particular, for a broad range of applications in patient care. WSI allows for the acquisition, management and review of completely digitised slides as would be done with a light microscope. WSI also facilitates image analysis that cannot be carried out by a pathologist using traditional microscopy. Over the last few years, the Digital Pathology Association, The Royal College of Pathologists, College of American Pathologists, Canadian Association of Pathologists, the American Telemedicine Association and the Society of Toxicologic Pathology have published guidelines for validating and implementing digital pathology systems. This review summarises, compares and contrasts these published guidelines and discusses pertinent issues that need to be addressed as the guidelines are revised in the future. [ABSTRACT FROM AUTHOR]

Aims To assess the frequency and possible causes of downgrading from a Gleason score (GS) 7 at biopsy to a GS ⩽6 at radical prostatectomy (RP) in a Canadian referral centre. Methods Data were extracted from diagnostic reports of inhouse biopsies and matching prostatectomy specimens from 2008 to 2011 with a GS 7 at biopsy. Biopsies and corresponding prostatectomy specimens of downgraded cases were reviewed. Pathological features were assessed and possible predictors for downgrading were identified. Results Based on pathology reports, 29 (8.9%, 95% CI 5.8% to 11.9%) of the 327 eligible cases were downgraded from biopsy GS 7 to RP GS 6, 72% of them representing a GS ⩽6 with tertiary grade 4 at RP. Agreement at review of downgraded RP specimens for Gleason grading was fair and of borderline significance (?=0.34, 95% CI -0.01 to 0.68, p=0.055) with 65% agreement for tertiary grade. The predominant Gleason grade 4 pattern found in the downgraded biopsies was ill-formed glands. The number of cores with Gleason grade 4 component was found to be the strongest negative predictor of downgrading (prereview OR=0.56 (95% CI 0.39 to 0.80, p=0.002), postreview OR=0.19 (95% CI 0.07 to 0.52, p=0.001)). Conclusions The frequency of GS 7 in biopsies subsequently downgraded in RP is low and is associated with International Society of Urological Pathology modified Gleason grade 4 patterns. Downgrading could be attributed in most cases to the presence of a tertiary Gleason grade 4 pattern in the RP specimen. Interobserver agreement for the presence of tertiary grade 4 in RP specimens is moderate. [ABSTRACT FROM AUTHOR]

Aims Pathological separation of poorly differentiated urothelial and prostate carcinoma is difficult, but imperative because of the impact on patient management. Tumour morphology, in conjunction with a panel of immunohistochemistry (IHC), such as prostate-specific antigen (PSA), prostatic acid phosphatase (PSAP), CK7, CK20, p63 and high molecular weight keratins (HMWKs) are usually employed to resolve this issue. Androgen receptor (AR) expression is maintained in high-grade, undifferentiated prostate carcinoma, and thus, could be considered as a potentially useful adjunct to the conventional panel of markers. Methods We performed an institutional review of all cases from 2006 to 2012 in which AR IHC had been performed to determine its diagnostic utility in discriminating between poorly differentiated urothelial and prostate carcinoma. Of the eligible cases (n=40), there were 9 high-grade urothelial carcinomas, 27 prostate carcinomas and 4 with both prostate and bladder tumours. All diagnoses were made by integrating the clinical, radiological, morphological and IHC results. Results In all the prostate carcinomas, there was diffuse, intense nuclear staining for AR. The urothelial tumours were either negative, had cytoplasmic staining or showed occasionally weak nuclear staining. The difference was highly significant with p<0.0001 (Mann-Whitney U test). Conclusions We conclude that AR is an important marker as it is best able to distinguish between poorly differentiated urothelial and prostate carcinoma. AR appears superior to PSA and PSAP, which are not consistently expressed in high-grade prostate carcinoma. Also, high-grade urothelial carcinoma may be negative for CK20, p63/HMWK and occasionally CK7. We advocate the inclusion of AR in the panel of markers to differentiate these tumours [ABSTRACT FROM AUTHOR]

Aims High intensity focused ultrasound (HIFU) is currently offered as primary treatment for patients with clinically localised prostate cancer. Data on histopathological features of post-treatment biopsies are limited. Methods Pretreatment biopsies were identified in 45 men (age range 41e85) who received primary HIFU therapy. Post-HIFU biopsies were performed in 30 of these patients (67%) at mean 14.1 months (95% CI 11.7 to 16.5) follow-up, 22 due to rising PSA and eight as part of routine follow-up. Biopsies were examined for presence, distribution and extent of adenocarcinoma, Gleason scores, use of standard immunohistochemistry and ablative tissue changes were attributable to HIFU. Results In post-HIFU biopsies performed for biochemical failure, 17/22 (77%) contained adenocarcinoma; 4/22 (18%) had higher post-HIFU Gleason score; 3/22 (14%) had newly recognised bilateral involvement; and 4/22 (18%) had higher percentage tissue involvement compared with pre-HIFU biopsies. Of cases without rising post-HIFU PSA, 2/8 (25%) routine follow-up biopsies contained adenocarcinoma. Stromal fibrosis was the commonest finding in non-tumour post-HIFU biopsy tissue (17/30, 57%) with coagulative necrosis occurring in fewer cases (4/30, 13%) and over a shorter follow-up interval than cases showing fibrosis (8.5 (0.2e16.8) vs 15.3 (11.5e19.1) months). Treatment effects in tumour cells precluding the assignment of Gleason scores or use of immunohistochemistry in post- HIFU biopsies were not identified. Conclusion Post-HIFU biopsies are positive in more than 75% of patients with elevated or rising PSA. Stromal fibrosis is common but the tissue effects of this modality do not appear to impair pathologists' ability to detect and grade adenocarcinoma in follow-up biopsies. [ABSTRACT FROM AUTHOR]

Background Triple antibody cocktail immunohistochemical staining is routinely used as an ancillary method to establish a diagnosis of prostate cancer in biopsies with small foci of atypical glands. Crush artefact can distort surgical margins in radical prostatectomy specimens, occasionally making it difficult to diagnose a positive margin. Aim To investigate the ability of a cocktail stain to distinguish carcinoma from benign prostatic glands at the edge of crushed margins in prostatectomy specimens. Methods 10 radical prostatectomy specimens with crushed benign glands at the surgical margins, and 20 with crushed margins positive for carcinoma were retrieved from the pathology archives. The latter included 16 (80%) with positive apical margins, 2 (10%) incised intraprostatic margins, and 1 (5%) soft tissue margin. Two-colour triple antibody stain using a cocktail of antibodies against a-methylacyl coenzyme A racemase (AMACR), high molecular weight keratin and p63 was performed on all the selected cases. Results In 10/10 specimens with crushed benign glands, basal cell staining continued to be detectable, while AMACR staining was negative in all cases (0/10). In the positive margin cases, none of the crushed glands expressed basal cell marker staining (0/20), whereas 14/ 20 (70%) of the cases showed variable levels of AMACR positivity at the inked margin. Conclusion Two-colour triple antibody cocktail stain is useful in the assessment of most, but not all, surgical margins with crushed artefact in prostatectomy specimens by helping to establish whether glands are malignant or benign. INSETS: Take-home message;Interactive multiple choice questions. [ABSTRACT FROM AUTHOR]

The article presents an overview of the causes, symptoms, diagnosis and treatment of rhinosinusitis, one of the most common diagnoses seen in primary care medicine. The disease, which is generally triggered by a viral upper respiratory tract infection and can be complicated by bacterial sinusitis, causes substantial morbidity and often results in time off from work. It is one of the commonest reasons a physician will prescribe antibiotics. A discussion of the difficulties involved in diagnosing sinusitis, which is often.

Kartagener's syndrome is a condition that consists of situs inversus, bronchiectasis, and sinusitis. Some patients have respiratory symptoms that date from early infancy, and electron microscopical examination has shown that adults with this condition lack dynein arms in ciliary microtubules. It has been suggested that an inherited defect in ciliary ultrastructure, the immotile cilia, is the basis for the syndrome. We report 6 patients who presented within the first 24 hours of life with tachypnoea, retraction, rales, and dextrocardia. Five of them had situs inversus. They all responded to physiotherapy after antibiotics had failed to improve their condition. Electron microscopical examination of the cilia in 2 of the infants confirmed deficiency of dynein arms. All 6 infants had recurrent respiratory infections. Four went on to develop recurrent otitis media, 2 had sinusitis, and 1 now has bronchiectasis. The immotile cilia syndrome should be added to the list of causes of respiratory distress in newborn infants. The condition is worth diagnosing because of the good response to physiotherapy, and because of the likelihood of recurrent respiratory problems. [ABSTRACT FROM AUTHOR]

The article presents the case of a 42-year-old man with Parkinson's disease that demonstrates the phenomenon of punding, which is characterized by pointless repetitive behaviors that are performed for long periods of time. He developed a tendency of spending up to 10 hours doing housework. This tendency disrupted his sleep pattern.

The most common renal tumours are clear cell, papillary, chromophobe and collecting duct renal cell carcinomas (RCCs), and benign oncocytomas and angiomyolipomas. Tumours with hybrid features between some of these entities have been recognised; in particular, tumours with features of both chromophobe RCC and oncocytoma. Case reports describing one distinct type of primary renal tumour actually within another are very rare. The incidental finding of a papillary RCC located in an oncocytoma in a nephrectomy specimen from a 75-year-old man is described. Morphological criteria for each tumour type were completely satisfied and fluorescence in situ hybridisation detected the expected number of copies of chromosome 7 in the cells of each tumour type. The cells in the papillary tumour contained three copies, whereas the oncocytoma cells contained only two per nucleus. To our knowledge, this is the first report of a papillary RCC being identified within an oncocytoma. [ABSTRACT FROM AUTHOR]

Background Informal care givers support disabled stroke patients at home but receive little training for the caregiving role. Objective To evaluate the effectiveness of training care givers in reducing burden of stroke in patients and their care givers. Design A single, blind, randomized controlled trial. Setting Stroke rehabilitation unit. Subjects 300 stroke patients and their care givers. Interventions Training care givers in basic nursing and facilitation of personal care techniques. Main outcome measures Cost to health and social services, caregiving burden, patients' and care givers' functional status (Barthel index, Frenchay activities index), psychological state (hospital anxiety and depression score), quality of life (EuroQol visual analogue scale) and patients' institutionalization or mortality at one year. Results Patients were comparable for age (median 76 years; interquartile range 70-82 years), sex (53%men), and severity of stroke (median Barthel index 8; interquartile range 4-12). The costs of care over one year for patients whose care givers had received training were significantly lower (£10 133 v £13 794 ($18 087 v $24 619;€ 15 204 v € 20 697); P =0.001). Trained care givers experienced less caregiving burden (care giver burden score 32 v 41; P =0.0001), anxiety (anxiety score 3 v 4; P =0.0001)or depression (depression score 2 v 3; P =0.0001) and had a higher quality of life (EuroQol score 80 v 70; P =0.001). Patients' mortality, institutionalization, and disability were not influenced by caregiver training. However, patients reported less anxiety (3 v 4.5;P <0.0001) and depression (3 v 4;P <0.0001) and better quality of life (65 v 60; P =0.009) in the caregiver training group. Conclusion Training care givers during patients' rehabilitation reduced costs and caregiver burden while improving psychosocial outcomes in care givers and patients at one year. [ABSTRACT FROM AUTHOR]

Background Training care givers reduces their burden and improves psychosocial outcomes in care givers and patients at one year. However, the cost effectiveness of this approach has not been investigated. Objective To evaluate the cost effectiveness of caregiver training by examining health and social care costs, informal care costs, and quality adjusted life years in care givers. Design A single, blind, randomized controlled trial. Setting Stroke rehabilitation unit. Subjects 300 stroke patients and their care givers. Interventions Caregiver training in basic nursing and facilitation of personal care techniques compared with no caregiver training. Main outcome measures Health and social care costs, informal care costs, and quality adjusted life years in care givers over one year after stroke. Results Total health and social care costs over one year for patients whose care givers received training were significantly lower (mean difference -£ 4043 ($7249;€ 6072), 95% confidence interval -£6544 to -£ 1595). Inclusion of informal care costs, which were similar between the two groups, did not alter this conclusion. The cost difference was largely due to differences in length of hospital stay. The EQ-5D did not detect changes in quality adjusted life years in care givers. Conclusion Compared with no training, caregiver training during rehabilitation of patients reduced costs of care while improving overall quality of life in care givers at one year. [ABSTRACT FROM AUTHOR]

The article presents an obituary for Robert William Nicholson, former consultant surgeon and former president of the Manchester Medical Society in England.

Population-level biomedical research offers new opportunities to improve population health, but also raises new challenges to traditional systems of research governance and ethical oversight. Partly in response to these challenges, various models of public involvement in research are being introduced. Yet, the ways in which public involvement should meet governance challenges are not well understood. We conducted a qualitative study with 36 experts and stakeholders using the World Café method to identify key governance challenges and explore how public involvement can meet these challenges. This brief report discusses four cross-cutting themes from the study: the need to move beyond individual consent; issues in benefit and data sharing; the challenge of delineating and understanding publics; and the goal of clarifying justifications for public involvement. The report aims to provide a starting point for making sense of the relationship between public involvement and the governance of population-level biomedical research, showing connections, potential solutions and issues arising at their intersection. We suggest that, in population-level biomedical research, there is a pressing need for a shift away from conventional governance frameworks focused on the individual and towards a focus on collectives, as well as to foreground ethical issues around social justice and develop ways to address cultural diversity, value pluralism and competing stakeholder interests. There are many unresolved questions around how this shift could be realised, but these unresolved questions should form the basis for developing justificatory accounts and frameworks for suitable collective models of public involvement in population-level biomedical research governance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objective: A National Health Service (NHS)-funded sore throat test and treat (STTT) service was introduced in selected pharmacies in two local health boards in Wales, as an extension to the national pharmacy common ailment scheme. The aim of this study was to evaluate the impact of STTT on provision and quality of patient care, namely antibiotic use, patient safety and general practitioner (GP) consultation rates., Methods: Secondary analyses of STTT consultation data to describe service outcomes, and routine data to explore changes in antibiotic prescribing and the prevalence of complications. Data were also collected from one GP practice to explore the feasibility of measuring changes in sore throat consultation rates in general practice., Results: Less than 20% of 1725 consultations resulted in antibiotic supply. The availability of STTT was associated with greater reductions in prescriptions for phenoxymethylpenicillin than in areas where STTT was not available (-3.8% and -3.4%, difference 0.4%). When pharmacy supplies were included, the reductions in the supply of the antibiotic were similar. No increase in the monthly number of incidents of quinsy was detected, and patients were appropriately referred to other healthcare professionals during pharmacy consultations. GP consultation rates since introduction of STTT were found to be lower than the equivalent monthly average since 2014., Conclusions: Data from the first 5 months of the STTT service suggest that it may have a role in safely rebalancing uncomplicated sore throat management from general practice to community pharmacies while continuing to promote antibiotic stewardship., Competing Interests: Competing interests: Three of the authors (EW, CW, EM) are pharmacists and were involved in the development of the service specification and all other aspects of the running of the STTT service pilot., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Impulsive-compulsive behaviours (ICBs) in Parkinson's disease (PD) have been anecdotally linked with impaired sleep. The authors investigate measures of sleep in PD patients with and without ICBs, and in healthy controls., Methods: The authors compare Parkinsonian features, measures of depression, anxiety and mania, and sleep disturbance in 30 PD patients with ICBs (PD+ICB), 62 PD patients without ICBs (PD-ICB) and 48 healthy controls., Results: PD+ICB patients had a younger age of PD onset, took more dopamine replacement therapy (DRT) and had worse sleep, and elevated anxiety, depression and mania scores. Using multiple linear regression analyses, the total anxiety and depression scores, and presence of ICBs were the only variables associated with poorer sleep in PD., Conclusions: PD+ICB patients may show enhanced psychomotor effects of DRT that may in turn contribute to poor sleep quality. Sleep disturbance should be specifically queried in PD+ICB patients.