Cystic fibrosis (CF) is the most common autosomal recessive disorder in Caucasian populations. Individuals with CF have seen significant increases in life expectancy in the last 60 years. As a result, previously rare complications are now coming to light. The most common of these is cystic fibrosis-related diabetes (CFRD), which affects 40–50% of CF adults. CFRD significantly impacts the pulmonary function and longevity of CF patients, yet a lack of consensus on the best methods to diagnose and treat CFRD remains. We begin by reviewing our understanding of the pathogenesis of CFRD, as emerging evidence shows the cystic fibrosis transmembrane conductance regulator (CFTR) also has important roles in the release of insulin and glucagon and in the protection of β cells from oxidative stress. We then discuss how current recommended methods of CFRD diagnosis are not appropriate, as continuous glucose monitoring becomes more effective, practical, and cost-effective. Finally, we evaluate emerging treatments which have narrowed the mortality gap within the CF patient group. In the future, pharmacological potentiators and correctors directly targeting CFTR show huge promise for both CFRD and the wider CF patient groups.

Percutaneous coronary intervention (PCI) with a drug coated balloon (DCB) is a novel treatment which seeks to acutely dilate a coronary stenosis and deliver an anti-proliferative drug to the vessel wall (reducing the risk of re-stenosis), without implanting a drug eluting stent (DES). In this study, we performed a systematic review of stentless DCB-only angioplasty in de novo coronary artery disease. We identified 41 studies examining the effects of DCB-only PCI in a variety of clinical scenarios including small vessels, bifurcations, calcified lesions, and primary PCI. DCB-only PCI appears to be associated with comparable clinical outcomes to DESs and superior angiographic outcomes to plain-old balloon angioplasty. Although current data are promising, there is still a need for further long-term randomized control trial data comparing a DCB-only approach specifically against a second- or third-generation DES. A 4-week period of dual antiplatelet therapy provides a real advantage for the DCB-only PCI approach, which is not possible with most DESs. Since rates of adverse clinical outcomes are very low for all PCI procedures attention should be turned to the development of robust endpoints with which to compare DCB-only PCI approaches to the standard treatment with a DES.Electronic supplementary materialThe online version of this article (10.1007/s40119-018-0121-2) contains supplementary material, which is available to authorized users.

BackgroundClinical communication teaching for medical undergraduates may involve real patient contact alongside simulated patient (SP) contact. However, there is still comparatively little known about the experience of learning with real patients and how that may impact on the SP encounter.AimTo explore the impact of real patient contact on the experience of communication skills training and SP contact for first-year medical undergraduate students.MethodsAs part of the 6-year MBBS undergraduate medical degree at Imperial College London, students are obliged to undertake communication skills training, which involves teaching with simulated and real patients. In 2017 (toward the end of formal teaching), a small sample of Year 1 medical students, who had taken part in extra-curricular teaching with real patients were recruited for the study to compare their performance with a control group in a SP encounter. The performance of both groups was analyzed alongside follow-up focus group data from a sample of the study group.ResultsQuantitative analysis revealed there was no significant difference in communication skills during a scored SP interview between students with real patient contact and those without. Focus group data, however, revealed valuable insights into the experience of learning with real patients. Students reported a marked increase in their confidence and ability to naturalize their communication skills as a result of real patient contact. Students also reported that skills gained through real patient contact may not always transfer easily to the SP setting.ConclusionReal patient contact is an invaluable component of communication training for undergraduate medical students. For successful implementation, there needs to be a clear curricular purpose at pedagogical, practical and organizational levels. Students’ experience of real patient contact can provide an informed foundation upon which to implement other modes of teaching.

PurposeTo evaluate the prevalence and incidence of significant structural heart disease in targeted patients with cardiac symptoms referred by general practitioners (GPs) using open access echocardiography, without prior clinical evaluation by a cardiologist.DesignData were derived from 488 subjects who underwent transthoracic echocardiography between January and April 2018. Patients were referred directly by GPs in East Berkshire, South England, through an online platform. Echocardiography was performed within 4–6 weeks of referral and all reports were assessed by a consultant cardiologist with expedited follow-up facilitated pro re nata. Results were analysed to determine the frequency of detection of structural abnormalities, particularly of the left ventricle and cardiac valves.ResultsEchocardiography was prospectively performed in consecutive subjects (50% male, mean (±SD) age 68.5±22 years; 50% female; mean (±SD) 64.6 (±19.1)). At least one abnormality likely to change management was found in 133 (27.3%) of all open access echocardiograms. Clinical heart failure with left ventricular systolic dysfunction (LVSD) and diastolic dysfunction was confirmed in 46 (9%) and 69 (14%), respectively. Of the 46 patients with LVSD, 33 were new diagnoses. Significant cardiac valve disease was found in 42 (8.6%) patients. 12 of these had known valvular disease or previous valvular surgery, and 30 were new diagnoses.ConclusionMajor structural and functional cardiac abnormalities are common in late middle-aged patients who present to GPs with cardiac symptoms and signs. Reported, unrestricted open access echocardiography enables early detection of significant cardiac pathology and timely intervention may improve cardiovascular outcomes.

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BackgroundGout is well known old disease, with still increasing prevalence. We are not in short of well-established clear guidelines for its management. However, it is still not well managed even in developed countries.ObjectivesWe share our experience of auditing the gout management in our out-patient clinic with the completion of our audit cycle. The aim is to improve gout service in line with 2006 EULAR guidelines, using the ethos of treat-to-target approach.MethodsWe audited randomly selected 101 patients seen in our well established gout clinic. All patients should be in that clinic for a minimum of 6 months, ensuring sufficient time for prophylactic therapy to take effect. Records from patients attending the gout clinic between 07/07/2014 and 29/06/2015 were accessed & information was collected on serum urate and the treating medications, gouty attacks & presence of tophi. Patients' comorbidities were recorded. Recent serum uric acid levels were specifically scrutinized against both BSR and EULAR targets of ≤300 and ≤360 mmol/L respectivelyResultsFemale (27%), males (73%). Average age: 64. Acute attack management: NSAID (42%), Colchicine: (82%), Oral Steroid (10%), IA Steroid (27%).42% and 69% of patients acieved the BSR & EULAR s. uric acid target as compared with 9.3% for BSR target in 2010 and 29% & 60% for 2012 audit respectively. 64% of patients were under the BSR target reported no acute gout episodes since their last appointment, which is almost the same (66%) of patients achieving EULAR target.70%, 20% & 10% of patients in the sample were on allopurinol, Febuxostat and Benzbromarone respectively. For Allopurinol treated patients 36.6% & 67.6% were under BSR and EULAR targets respectively. For Febuxostat these figures were much better at: 61.9% and 85.7% and for Benzbromarone 54.5% achieved EULAR & BSR target. Patients on Febuxostat had a significantly lower average urate (290) than allopurinol (351) (P=0.015). Patients prescribed Febuxostat if they had experienced side-effects to allopurinol (in concordance with NICE guidelines) or if allopurinol found it to be ineffective (31%).However, for patient with tophi s. uric acid target of <300 (BSR) was achieved in 33.3% and of <360 (EULAR) in 59.3%.100% of patients received lifestyle advice on diet, exercise & alcohol (NICE recommendation) as compared to only 9% in 2010. In CHD patients, 71% reduced their Cholesterol/HDL ratio to <5.0. In hypertensive patients, 60% reduced systolic blood pressure to <160 & in obese patients 7.84% were able to significantly reduce their weight (>5 kg).ConclusionsThe proportion of patients achieving BSR & EULAR targets, in comparison to 2010 and 2012 were increased significantly on adapting gout speciality clinic. A greater proportion of patients on Febuxostat reached their targets compared to other urate lowering agents. No significant benefit (in terms of stopping further acute attacks with the meeting of the BSR target of <300 over the EULAR target of <360 were seen. Tophaceous gout has not been treated well when compare...