The National Health Service (NHS) relies on junior doctors in training to help deliver inpatient medical care. Through this service, trainees are able to gain experience and competence. The massive disruption to normal clinical practice brought about by the COVID-19 pandemic has exacerbated existing challenges in balancing health service provision and junior doctor training. The majority of trainees reported negative effects on their training during the first wave of infections, with those based in areas of higher COVID burden worst affected. [1][2][3] Here we explore the challenges for postgraduate diabetes and endocrinology (D&E) training in North East London faced during the pandemic, examine some of the solutions hastily put in place to mitigate those effects, and discuss how the response to the COVID-19 crisis could represent an opportunity for innovation. ChallengesWith rising COVID cases, significant changes to hospital staffing were required in order to provide safe patient care. Alteration of rota patterns, restructuring of clinical areas and staff redeployment were all introduced seemingly overnight. Rota changes frequently involved an increase in 'out of hours' work, as well as a move away from specialty team structures. This reduced trainee exposure to specialty-specific learning opportunities, including clinic attendance and taking referrals; such changes were not unique to D&E trainees, but were also reported by trainees in other specialties. 4,5 COVID-19 admissions predominated, while patients with other acute medical problems avoided
Disseminated adenovirus infection is recognised in transplant patients, often occurring early and associated with a high mortality rate. Treatment options are poorly understood and potentially toxic. Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper-inflammatory response. A 75-year-old ex-banker presented following a fall, with a 2-week history of fevers, cough and high stoma output after a recent cruise. Past medical history included heart-lung transplant (25 years previously), diverticular disease and diabetes mellitus. Initially, he was febrile and tachycardic and blood tests showed an acute kidney injury (AKI), transaminitis and pancytopenia. Chest radiograph and urinalysis were unremarkable. Initial treatment was with co-amoxiclav and intravenous fluids for neutropenic sepsis. Computerised tomography of thorax and abdomen showed moderate splenomegaly with no lymphadenopathy or pneumonitis. After 48 hours, he remained febrile with worsening renal and hepatic function. Nasopharyngeal swabs returned positive for adenovirus. Blood cultures were negative with undetectable serum cytomegalovirus (CMV) and Epstein-Barr virus (EBV) DNA. On day 4 he developed fulminant multi-organ failure. Further investigations were suggestive of HLH. Cidofovir/Brincidofovir were discussed as potential treatments but were difficult to obtain with concern regarding toxicity. On day 6, intravenous immunoglobulins for HLH was commenced. On day 8 he died. Adenovirus was later isolated from urine, stool and serum samples. Early diagnosis and treatment for infection in immunosuppressed patients is crucial. The 25-year interval between transplant and disseminated adenovirus infection in this case is unprecedented. Difficulty in obtaining adenovirus treatment combined with their toxicity and uncertainty of effectiveness prevented their immediate use in this patient.
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