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Godlee discusses the long road ahead after covid-19.1 Is this an opportunity to reimagine healthcare and forge a “new normal” for medicine? After the most extraordinary few weeks, WB Yeats’s memorable line comes to mind: “All changed, changed utterly.” Normally complex changes such as virtual care and major service reconfigurations have occurred at breathtaking pace.2 Traditional barriers, institutional inertia, …

A man in his 50s with resistant hypertension and history of Langerhans cell histiocytosis (LCH) was referred to rheumatology after suspicion of inflammatory arteritis was raised. This followed detection of bilateral renal artery stenosis during investigation for severe hypertension refractory to medical therapy. CT angiography revealed diffuse wall thickening of the abdominal aorta, in keeping with an aortitis. However, there was no serological or clinical evidence suggestive of a vasculitic process. Medical history included cranial diabetes insipidus, subclavian artery stenosis and spinal stenosis requiring surgery, over the course of 8 years. These findings led to consideration of Erdheim-Chester disease (ECD), a form of non-Langerhans cell histiocytosis, where there is abnormal proliferation of histiocytes which causes tissue fibrosis and sclerosis of the long bones. Subsequent plain radiographs of the long bones revealed appearances consistent with a diagnosis of ECD. Thus, a diagnosis of an LCH/ECD overlap syndrome was made.

BackgroundSince 2000, vitamin D requests have increased 2–6 fold with no evidence of a corresponding improvement in the health of the population. The ease of vitamin D requesting may contribue to the rapid rise in its demand and, hence, pragmatic interventions to reduce vitamin D test ordering are warranted.AimTo study the effect on vitamin D requests following a redesign of the electronic forms used in primary care. In addition, any potential harms were studied and the potential cost-savings associated with the intervention were evaluated.Design & settingAn interventional study took place within primary care across Leicestershire, England.MethodThe intervention was a redesign of the electronic laboratory request form for primary care practitioners across the county. Data were collected on vitamin D requests for a 6-month period prior to the change (October 2016 to March 2017) and the corresponding 6-month period post-intervention (October 2017 to March 2018), data were also collected on vitamin D, calcium, and phosphate levels.ResultsThe number of requests for vitamin D decreased by 14 918 (36.2%) following the intervention. Changes in the median calcium and phosphate were not clinically significant. Cost-modelling suggested that if such an intervention was implemented across primary care in the UK, there would be a potential annual saving to the NHS of £38 712 606.ConclusionA simple pragmatic redesign of the electronic request form for vitamin D test led to a significant reduction in vitamin D requests without any adverse effect on the quality of care.

The Paterson case is an outrage. As a member of the medical profession, I was shocked and angry that a doctor could commit such heinous acts. The long term distress experienced by patients is unimaginable, …

Cryoballoon ablation has been associated with a significant incidence of phrenic nerve injury (PNI).The purpose of this study was to evaluate whether recordings of diaphragmatic compound motor action potentials (CMAP) on a modified lead I during cryoballoon ablation can predict PNI.Cryoballoon ablation was performed in 109 patients with atrial fibrillation (AF). During ablation of the right-sided pulmonary veins, the phrenic nerve was paced from the superior vena cava. The right and left arm electrodes from a 12-lead ECG were positioned 5 cm above the xiphoid process and 16 cm along the right costal margin. The amplitude of CMAP was recorded on lead I during ablation.Cryoballoon was applied 424 times in 211 right-sided veins. PNI occurred in 7 (6.4%) patients. The average CMAP amplitude did not significantly change in patients without PNI from the initial average CMAP amplitude of 0.34 ± 0.18 mV to 0.32 ± 0.17 mV (P = .58). In patients who developed PNI, there was a significant decrease in the initial average CMAP amplitude during the ablation from 0.33 ± 0.14 mV to 0.09 ± 0.05 mV (P.001). The maximal percent change in the average CMAP amplitude in patients with PNI was higher (70% ± 10%) than in patients without PNI (7.6% ± 7%; P.001). In any patient without PNI, the CMAP amplitude did not decrease more than 35% from baseline.Recording of CMAP amplitude on a modified lead I is reliable and could be early and sensitive method for predicting PNI in patients undergoing cryoballoon ablation for AF.

This bumper issue of London Journal of Primary Care (LJPC) provides a fitting end to its ten years of activity. It signals a PAUSE to prepare for a new stage of translating into practice the ideas ...

RCGP presidential portrait of Lotte Newman. With the kind permission of Sharon Messenger, College Archivist. On the 26th of April this year, our College said a final goodbye to one of our profession’s giants. Lotte Newman played a fundamental role in developing general practice, improving standards of care, and growing the RCGP. She was active in the North East Thames Faculty and became a College examiner in 1972, Secretary of the Board of Censors in 1981, and Vice-Chair of Council in 1988. In 1994, she became only the second ever female President of the …

Editor – Bradley and colleagues make an important contribution to understanding the cultural issues that underpin patient safety in the NHS by describing the problem of rude, dismissive and aggressive (RDA) communication between doctors.[1][1] I would like to emphasise that this problem is not

Simpson writes about the vital role that South Asian doctors have played in UK general practice and the ongoing recognition that overseas doctors who choose to come to work in the NHS deserve, as …

[Graphic][1] On 20 December 1952, the British Medical Journal announced the foundation of a college of GPs, now the Royal College of General Practitioners (RCGP).1 The College had a strong vision for general practice. A singular achievement was vocational training.2 Sir James Mackenzie would have been proud of this, as he had himself advocated special training for GPs. There has been immense progress since then. We now have one of the finest systems of general practice in the world: There are also examples of the professionalism of individual GPs up and down the country: the GP who has made that early diagnosis of meningitis in a baby and the GP who deals with the frail older patient with heart failure. ### Concerns about the future There is much to celebrate but we have more work to do. As a practising doctor, I want to do more for my patients. There is much more that we can, and need to do. Take some examples: Mrs Patel is 66, she is distressed, she is crying because she is dying from advanced bladder cancer; her GP failed to diagnose the cancer early enough. Mrs Jones is 86 and has complex multiple medical conditions; her health is declining. She has repeated hospital admissions and multiple referrals without any obvious medical benefit. Actually, she is dying and approaching the end of her life but this goes unrecognised in the health system. People are … [1]: /embed/inline-graphic-1.gif

Clinical governance is the core component of the new quality programme for the NHS (see box on next page) announced in the consultation document A First Class Service .1 It is described as “a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” It will be the central focus for assuring the quality of care and addressing the issue of providing accountability through the Commission for Health Improvement.2 The activities of the commission will reflect national and local priorities as identified by the National Institute of Clinical Excellence and health improvement programmes respectively. Although A First Class Service included details about the structure and functioning of clinical governance in health service trusts, arrangements for primary care groups were not specified. In this paper, we suggest a possible model for clinical governance in primary care groups. Clinical governance is central to the NHS quality programme, but how it will operate in primary care groups remains unclear Although many activities included in the new concept of clinical governance are already being undertaken, these need to be coordinated A model of governance that addresses the core tasks of defining, accounting for, and improving quality and incorporates evidence on effective methods of changing performance is suggested This model can improve professional, practice, and primary care group performance It shows how groups can introduce and develop clinical governance and how health authorities and the Commission for Health Improvement can monitor progress The model is based on three underlying precepts

BACKGROUND GPs are now playing a greater role in the care of patients with diabetes. The challenges described in the Saint Vincent Joint Task Force Report include achievement of a reduction in long-term complications by collecting key clinical information and systematically organizing care of patients with diabetes. The number of practices conducting audit and the number of primary care audit groups conducting multi-practice audits of diabetes have increased since the introduction of audit in 1991. OBJECTIVES We aimed to determine the feasibility of collating data from multi-practice audits of diabetes in primary care and to describe the pattern of care for diabetes patients in primary care. METHODS A confidential postal questionnaire was sent to all medical audit advisory groups that had completed a multi-practice audit of diabetic care. The main outcome measures studied were prevalence and treatment of known diabetes and annual compliance with key process measures. RESULTS Data could be collated for 17 of the 25 audit groups that supplied data representing information from 495 practices with 38 288 diabetic patients. Seven audit groups supplied data from a population denominator comprising 1475512 patients giving a prevalence of 1.46% (range 1.1-1.7%), 50.7% (range 32.5-69.0%) were managed by general practice only, 19.1% (7.6-39.7%) by hospital care only and 30.2% (11.0-49.5%) by shared care. Annual mean compliance for process measures showed wide variations: glycated haemoglobin or fructosamine checked for 72.5% (range 25.3-89.3%), fundi checked for 67.5% (57.8-86.6%), urine checked for 65.8% (27.5-80.0%), blood pressure checked for 87.6% (76.9-96.5%), smoking checked for 71.45 (21.9-86.0%), feet checked for 67.7% (40.0-90.8%) and BMI checked for 52.5% (26.4-68.2%). CONCLUSION This study shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies. Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity. Comparison of the health needs of local populations with national data could be used to inform commissioning services. However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.

The forthcoming white paper is certain to result in changes in primary care, but the nature and effect of the reforms is unclear. We asked some people with an interest in general practice to predict the future What will English primary care look like in 2015? The proposed new white paper on health and community services in England1 will affect all of our futures—public, patients, and health professionals. The future is uncertain, but we can be sure that people will still get sick, or think they may be sick, and then they will value care from a doctor they know and who knows them. We present a vision of a values based, patient centred primary healthcare system that is consistently of high quality, safe, accessible, and accountable. We recognise that our aspiration will require considerable investment, system reform, and support for implementation but believe that it is a much needed yet achievable model to improve patient care. Primary care has been defined as: “The first level contact with people taking action to improve health in a community. In a system with a gatekeeper, all initial (non-emergency) consultations with doctors, nurses or other health staff are termed primary care as opposed to secondary health care or referral services.”2 International comparisons of healthcare systems have shown that the United Kingdom ranks highly on scores of primary care orientation, and countries with good primary care systems show improvement in the health of individuals and populations, together with greater satisfaction with care.3 Within the NHS general practice is a central component of primary care. General practice is defined as: “An academic and scientific discipline, with its own educational content, research base and clinical activity, orientated to primary care and built on fundamental principles.”4 Values …

This chapter discusses common coronary complications encountered during percutaneous coronary interventions.

Ostial lesions pose distinctive technical challenges. This chapter provides an overview of equipment and interventional techniques for ostial lesions.

Revalidation is a summative assessment and must be seen as separate fromappraisal and clinical governance The General Medical Council's proposals for recertifying doctors in the United Kingdom every five years have been thrown into confusion. A recent judicial inquiry into the case of Harold Shipman, who murdered at least 215 patients, found that the method for revalidating doctors based on regular appraisal would not detect poorly performing doctors.1 The government suspended plans for revalidation and ordered an urgent review led by the chief medical officer.2 This article gives a proposal for a way forward. Although the article is from general practice, the framework described is applicable to other specialties. The GMC's proposal for revalidation requires doctors to keep a portfolioshowing participation in appraisals and completion of an agreed personal development plan. They also have to provide a statement of “no concerns” fromtheir primary care organisation and evidence of probity and health. To understand the problems with the current model, we have to be clear about the definitions of appraisal, clinical governance, and revalidation (box 1). The three methods of assessing performance overlap.5 This overlap has advantages and disadvantages. On the one hand, data collected for appraisal can be used for revalidation, thus reducing the burden of assessment. On the other hand, a summative process such as revalidation could hijack a formative process such as appraisal. A fundamental observation of the Shipman report was that although appraisal and clinical governance inform revalidation, they are not sufficient to evaluate a doctor's practice. The current proposals therefore give an “illusion of protection,” particularly as patient safety and reassurance of the publicare important functions of revalidation. What can be done to overcome this fundamental shortcoming? My proposal for successful revalidation is based on 10 guiding principles (box 2). Below, I describe …

> ‘ ... the doctor has the map and the patient does not. In fact the doctor not only has the map but drives the vehicle and the patient may not know that they have reached a crucial crossroads, or that they have reached the end, until they get there and it is too late.’ 1 Care of the dying is inadequate in many developed countries, and its improvement is an important national and international challenge. Around 500 000 people die in England every year, of whom 53% die in hospital even though 63% indicate a preference to die at home.2 Although palliative care services have been available for many years for people with cancer, most people do not die of cancer. Other conditions, including multimorbidity and extreme old age, tend to have a less predictable course and such patients are less likely to be found on a GP’s palliative care register. Do older patients really have a voice when it comes to planning their future care? In the first ever systematic review of attitudes of the public and healthcare professionals to advance care planning, Sharp et al find there are some critical barriers to be overcome if we are to translate the concept of ‘advance care planning’ from its origins in palliative care for cancer to frail older people who are dying.3 We know what we ‘should be doing’. Why aren’t we doing it? In this editorial we examine the opportunities and challenges of advance care planning in the context of a much needed national conversation about death and dying.4 Advance care planning is defined as the ‘voluntary process of discussion and review to help an individual who has the capacity to anticipate how their condition may affect them in the future and if they …

The anti-platelet effect of aspirin (ASA) is widely proven to be effective in the prevention of fatal and non-fatal cardiovascular events in high risk patients. However, despite being on aspirin th...

Use of Intracardiac Echocardiography for Early Detection of Phrenic Nerve Injury. Cryoballoon catheter ablation has recently emerged as an effective tool to achieve pulmonary vein isolation (PVI). Right-sided PVI with cryoballoon ablation has been associated with a significant incidence of phrenic nerve palsy. Multiple modalities are currently utilized to monitor phrenic nerve function during ablation. We describe a novel approach toward monitoring and diagnosing phrenic nerve palsy using intracardiac echocardiography (ICE) during cryoballoon ablation of the right pulmonary veins. This technique of monitoring has the advantage of continuous direct diaphragmatic visualization without the use of fluoroscopy, hence significantly minimizing radiation to both the patient and the operator. In addition, this technique does not require extra personnel to monitor the diaphragm using manual palpation. Further prospective studies of our and other methods for prevention of phrenic nerve palsy are required. (J Cardiovasc Electrophysiol, Vol. 23, pp. 874-876, August 2012)

Delayed lead perforation (DLP) is an uncommon complication of permanent pacemaker and defibrillator implantation, especially that of the right atrium (RA).1 Lead perforation is considered delayed when it occurs >30 days after implantation. The incidence of DLP has been reported to be ≈0.8% and is more common in elderly individuals.1,2 With the yearly increase in implanted devices, and the advance in imaging modalities, this complication is more likely to be encountered. To our knowledge, delayed right atrial perforation involving a passive fixation lead remains extremely rare and has never been reported. We describe a case of an asymptomatic right atrial DLP resulting in a pseudoaneurysm and right coronary artery (RCA) fistula, diagnosed incidentally 53 months after the implantation of a passive atrial lead. Our patient is a 67-year-old man with a medical history of hypertension, diabetes mellitus, end-stage renal disease on hemodialysis, coronary artery bypass grafting, and ischemic cardiomyopathy. The patient had a dual-chamber implantable cardioverter-defibrillator implanted for primary prevention of sudden cardiac death. A passive fixation lead (5594 CapSureR SP Novus, Medtronic; Indianapolis, IN) was implanted in the RA appendage, and the right ventricular lead (6949 Sprint Fidelis, Medtronic) was implanted in the apical septum without difficulty. The initial atrial pacing threshold was 0.5 V at 0.4 ms and 1.5 V at 0.4 ms for the ventricular lead. The initial …

Case Report A 75-yr-old gentleman, with a past medical history of diabetes mellitus and Acute Myeloid Leukemia presented to our emergency department with a chief complaint of exertional dyspnea and chest pain. A week prior to this visit, he had recieved a cycle of decitabine chemotherapy at 20 mg/metered square for ten days. This was his second cycle of decitabine. His out patient medications included megesterol, omeprazole, morphine sulfate and insulin glargine. The patient was admitted to the Coronary Care Unit for Acute Coronary Syndrome. His cardiac enzymes were elevated (peak troponin 30 ng/mL, CKMB 67.4 ng/mL). His 12 lead EKG revealed sinus tachycardia with a ventricular rate of 113, but without acute ST–T wave changes. The BNP was 259 pg/mL. A 2D echo revealed moderate diffuse hypokinesis with an EF of 35%. He subsequently underwent a left heart catheterization, which showed non-obstructive CAD. In our patient, the elevated troponins (peak troponin 30 ng/mL) and BNP were seen concomitant with the onset of cardiogenic shock. Two months ago, his 2 D echocardiogram revealed an ejection fraction of about 55%–65% with slightly increased left ventricular (LV) wall thickness. Discussion The most common adverse effects of decitabine include cytopenia, nausea, pain and erythema/nodules at the injection site. To date, there has been only one reported case of a hypomethylating agent inducing acute myocarditis. We a present a case of reversible, non-ischemic cardiomyopathy secondary to decitabine chemotherapy, which resolved after the drug was discontinued. Trials involving decitabine for the treatment of MDS reported no myocarditis. In our case, the diagnosis of transient cardiomyopathy was highly probable since the patient's troponins and echocardiogram returned to baseline after discontinuation of treatment. Also, the patient never had any further chest pain at his 6 month follow up. In this case, we believe that the elevated Troponin I levels, along with a cardiac catheterization revealing patent coronary vessels, favor our hypothesis that our patient suffered from acute myocarditis as a result of direct toxicity from decitabine chemotherapy. We doubt that there was an underlying infectious etiology, since the patient had three negative blood cultures, two negative urine cultures and a negative viral serology. Our case demonstrates that chest pains in a patient treated with hypomethylating agents should be further explored in order to rule out acute myocarditis.

Introduction: Bifurcation lesions have traditionally presented a unique problem for interventional cardiologists because of their inherent anatomy and risk of closure of the side branch, after a percutaneous intervention for the primary lesion of the main branch. Case Presentation: We report the case of a 57-year-old man who presented with acute STsegment elevation myocardial infarction secondary to a 100% occlusion at the ostium of first diagonal (D1) branch. Patient also had a 70% stenosis of the mid-segment of the left anterior descending (LAD) coronary artery at the D1 branching point (1,1,1 Medina classification). A bare metal stent (BMS) was deployed at the site of the culprit lesion in the D1, while a drug eluting stent (DES) was placed in the LAD. We believe that the BMS at the culprit thrombotic, inflamed site in D1 is more likely to re endothelialize than a DES and the DES in the LAD, is less likely to re-stenose than a BMS. Conclusion: This is the only reported case, where in the setting of an acute ST elevation myocardial infarction, a hybrid Culotte technique was successfully performed with excellent longterm results, thus achieving an acceptable balance of risks between restenosis (in the case of a BMS) and stent thrombosis (in the case of a DES).

Making Things Happen (MaTH) was devised as a six-module educational programme to support clinical governance leads (CGLs) in primary health care. The aim of the programme was to help develop practice CGLs' awareness, understanding and ability to initiate and manage change. The objectives of the training programme were: * to promote an increased and sophisticated understanding of clinical governance by building on knowledge gained already * to develop skills in delivering and sustaining improvements * to improve personal effectiveness in bringing about change. A pilot training programme was planned and delivered twice in 2003/2004 to two separate cohorts of clinical governance leads (n = 30 and n = 15) from two pilot primary care trusts (PCTs). The six training modules were delivered to the two groups by the same staff but at different times and in two separate locations. The effectiveness of the programme was evaluated in both PCTs at three levels. First the content of the programme was evaluated by the CGLs that attended the programme. Secondly, the value of the programme to the PCT was considered by the PCT co-ordinators. Thirdly, the effectiveness of the programme was considered by the presenting team. All three groups felt that the objectives were met, that the principles of MaTH training were sound and that it would be a valuable resource to offer nationally. It was also noted that training for PCT local co-ordinators in how to support clinical governance would be a useful training co-opportunity.

I want to consider the potential use of the Scottish Audit of Surgical Mortality (SASM)1 scheme for revalidation of surgeons. Revalidation is an important policy initiative in the United Kingdom from the medical profession's regulatory body, the General Medical Council.2 It is aimed at ensuring that doctors remain up to date and fit to practise, and is also a way of restoring and retaining the public's trust in doctors. The policy is in some difficulty, and the government has ordered a review of how revalidation can be made to work. The Royal College of Surgeons of England and the Senate of Surgery recommend that …

In a 2008 poll BMJ readers voted “palliative care in conditions other than cancer” as the intervention that would make the “greatest difference to healthcare.” If I ruled the NHS I would make this a reality. All people with advanced progressive incurable illnesses would receive palliative care regardless of diagnosis or postcode. By doing this, we would make good care for all at the end of life the norm. People in the last years of their life or with life limiting diagnoses would be encouraged to think ahead and make advance care plans. Quality and value would improve dramatically. Moreover, it could tackle the problem of …