Background: Pressure ulcers are associated with significant morbidity and mortality as well as high cost to the health service. Although often linked with inadequate care, in some patients, they may be unavoidable. Aim: This systematic review aims to quantify the prevalence and incidence of pressure ulcers in patients receiving palliative care and identify the risk factors for pressure ulcer development in these patients as well as the temporal relationship between pressure ulcer development and death. Design: The systematic review is registered in the PROSPERO database (CRD42017078211) and conducted in accordance with the ‘PRISMA’ pro forma. Articles were reviewed by two independent authors. Data sources: MEDLINE (1946–22 September 2017), EMBASE (1996–22 September 2017), CINAHL (1937–22 September 2017) and Cochrane Library databases were searched. In all, 1037 articles were identified and 12 selected for analysis based on pre-defined inclusion and exclusion criteria. Results: Overall pressure ulcer prevalence and incidence were found to be 12.4% and 11.7%, respectively. The most frequently identified risk factors were decreased mobility, increased age, high Waterlow score and long duration of stay. Conclusion: The prevalence of pressure ulcers is higher in patients receiving palliative care than the general population. While this should not be an excuse for poor care, it does not necessarily mean that inadequate care has been provided. Skin failure, as with other organ failures, may be an inevitable part of the dying process for some patients.

Haemosiderin deposition in the legs of patients with venous leg ulcers is well established, and several theories suggest this stored iron has a role in disease pathophysiology. In this novel pilot study of patients with chronic venous leg ulcers, we aimed to establish the relationship between wound fluid iron levels, serum iron parameters and healing. Fifteen patients with venous ulcers were included in the study. Blood samples were taken for full blood count and iron studies, while simultaneously wound fluid was obtained from the wound surface using filter paper. Wound areas were measured at initial and 4 week (+/− 2 day) follow‐up visits. We found a positive correlation between wound fluid and serum iron (correlation co‐efficient 0.27) and those with the lowest wound fluid iron level were also anemic. No association was found between initial wound area and wound fluid iron level but the largest wound areas were found in patients with anemia. Only 38% of patients demonstrated a reduction in wound area during the 4 week study, and 80% of those were not anemic or iron deficient. Conversely in those patients whose wounds did not reduce in size 88% were anemic or iron deficient. These findings demonstrate a previously unrecognized phenomenon of systemic iron store depletion secondary to leaching out of the body in wound exudate. In addition, these results suggest a high prevalence of anemia in patients with chronic venous ulcers, though whether this is cause or effect requires further research. Our findings also suggest that patients with venous ulcers have a high prevalence of iron deficiency and anemia, which appears to be often undiagnosed, and that diagnostic criteria for iron deficiency in patients with chronic wounds need to be revised to reflect the effect of chronic inflammation on iron metabolism.

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The factors preventing healing in venous leg ulcers are still not fully understood. Iron‐mediated tissue damage has been hypothesised, yet anecdotally anaemia is also thought to have a negative effect on wound healing. This article summarises the current evidence for these theories and their likely effects in the context of venous ulceration. A comprehensive search of the literature was conducted. Studies suggest that a number of forms of iron including haemosiderin and ferritin are implicated in progression of venous disease, ulcer formation, and impaired healing, which is thought to be primarily free radical mediated. There is a paucity of evidence for the role of iron deficiency and anaemia on ulcer healing; however, there is likely to be a highly complex interplay between the damaging effects of iron on local tissues and the negative effects of anaemia‐mediated tissue hypoxia. Studies looking at options to increase local oxygen delivery such as topical haemoglobin suggest that this may have an impact on some aspects of healing, but findings are generally inconclusive. There is growing evidence that locally elevated iron levels may have a detrimental effect on ulcer healing and formation; however, more robust research is needed.

Anticholinergic agents are used in a number of conditions ranging from overactive bladder and bradycardia to travel sickness but side‐effects such as hallucinations, impaired memory and restlessness are increasingly recognised, though still under‐reported in clinical practice. In Parkinson's disease anticholinergics such as atropine are recommended by NICE for the management of excessive drooling. Dr Ferris et al. present such a case where commencing sublingual atropine drops caused a patient to develop hyperactive delirium and psychosis. They also discuss the subsequent clinical management steps.

Linked Article: Klonizakis et al. Br J Dermatol 2018; 178:1072–1082.

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BackgroundNeurology is widely considered one of the most challenging subjects in the undergraduate medical curriculum, so any improvement in training large numbers of medical students simultaneously in a standardised way would be welcomed. E-learning is currently a prominent area of research and is thought to hold potential for future education as it enables large groups of students to be taught at a time and place convenient to them.MethodsAn e-module on epilepsy was created to meet the specified learning outcomes for Neurology in one UK medical school, and evaluated subjectively by groups of medical students in years 3, 4 and 5. Knowledge test scores before and after using the module were also recorded.ResultsStudents perceived a significant improvement in their knowledge after using the module, and this was confirmed by a statistically significant improvement in knowledge test scores. The results of the study also supported findings in the literature of the main benefits of e-learning, and how this should be used.ConclusionThis study has shown that e-modules can be successfully used to increase both objective and subjective knowledge of epilepsy in students at one UK medical school. However there is still opportunity for further research to prove the usefulness of e-modules for long-term information retention, and teaching different subjects and training grades.