2025

The 3,550 g Challenge: An Atypical Presentation of a 3.5 kg Seminoma Manifesting as Dry Skin (2025)

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Type of publication:

Journal article

Author(s):

Omorphos, Nicolas; Mohsin, Mohamed Shamil; *Mok, Spencer; Kitchen, Mark; Ho, Kuo J.

Citation:

Cureus. 17(7):e87174, 2025 Jul.

Abstract:

A 43-year-old male presented to the emergency department with a seven-year history of progressive left-sided scrotal swelling. On examination, a large mass was palpable in the left hemiscrotum, accompanied by eczema-like skin changes and a decubitus ulcer. Tumor markers were significantly elevated, particularly lactate dehydrogenase, and an urgent ultrasound confirmed the presence of a testicular tumor. CT revealed a scrotal mass originating from the left testis, along with bilateral inguinal lymphadenopathy. The patient underwent a left inguinal orchidectomy, and histopathological analysis confirmed a 3,550 g classical seminoma. He was subsequently referred to oncology for adjuvant chemotherapy.

DOI: 10.7759/cureus.87174

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Barriers to the safe discussion of the experience and management of menopausal symptoms: A systematic literature review (2025)

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Type of publication:

Journal article

Author(s):

Thavabalan, Karish; *Ovenell, Alistair; Pierce, Poppy; Sutaria, Aman; Parkhouse, Annabelle; Baydemir, Numan; Lally, Theodore.

Citation:

Maturitas. 201:108683, 2025 Aug 05.

Abstract:

As the number of women experiencing menopause continues to rise each year, the need for open and supportive discussions around the experience and management of menopausal symptoms becomes more imperative. Although research has identified numerous challenges women face during this life stage, many studies examine these barriers in isolated settings. Furthermore, how these challenges impact women's ability to safely discuss menopause remains poorly understood. This systematic literature review
sought to identify and synthesise the barriers that hinder safe discussions about the experience and management of menopausal symptoms. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, 21 qualitative studies were included. Six themes were identified regarding symptom experience: lack of support from friends and family, lack of workplace support, fear of menopause onset, variation in symptom experience, poor-quality information, and societal judgement. Two themes were identified regarding symptom management: perceived onus to endure symptoms and poor experiences with healthcare professionals. Notably, the themes revealed widespread shortcomings that collectively hinder safe discussions about menopause. Future work should prioritise intersectional approaches that tackle barriers across home, social, work, and healthcare settings. Proactive measures, such as placing a greater emphasis on menopause in medical education and developing culturally relevant resources, are crucial for fostering safe, informed discussions and improving care for all women.

DOI: 10.1016/j.maturitas.2025.108683

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Colorectal Cancer Mortality Rates in UK Shropshire County (2025)

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Type of publication:

Conference abstract

Author(s):

*Shah J.; *Shittu S.; *Goh Y.L.; *Ball W.;

Citation:

British Journal of Surgery. Conference: 49th ASiT Annual Surgical Conference. Belfast United Kingdom. 112(Supplement 10) (pp x64), 2025. Date of Publication: 01 Jun 2025.

Abstract:

Aim: Evaluate outcomes of patients dying within 12 months from diagnosis of colorectal cancer in Shropshire County. Method(s): Single-centre retrospective review of patients who died within 12 months of diagnosis between 2020-2024.Each patient's hospital records were reviewed, and data were collected on patient demographics, performance status, time from referral to imaging, diagnosis, MDT, death and treatment intent. Result(s): A total of 103(44 male: 59 female) patients,with a mean age at referral of 74 (range 32 – 96) years old. Most patients had a performance status of 1 and lived in their own home (92%). 60% of patients lived in Shrewsbury, 34% in Telford and 9% in Wolverhampton. Referral sources were mainly from GP (55%), emergency admission to SAU (20%) and AMU (16%).74% of GP referrals were seen within two weeks. All patients underwent CT imaging. Endoscopic procedures were performed in 57% of patients. The average age of death is 75 (range 34 – 97) years old, most commonly from distant metastatic sigmoid cancer. The average time between diagnosis and death was 4.4 months.Treatment intent was palliative in 90% (BSC in 44% and oncology in 56%).59% who were referred to oncology received palliative treatment. Eight patients were treated with curative intent but died due to sepsis and multiorgan failure(2), died prior to commencing treatment (1), complications from treatment (3) or declined treatment (2). Conclusion(s): This snapshot audit demonstrates that patients in Shropshire County newly diagnosed with colorectal cancer were elderly, aged over 70 years old with significant cardiovascular co-morbidities and performance status of at least 1.

DOI: 10.1093/bjs/znaf128.248

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Evaluating the Referral Pathway for Colonoscopy in a District General Hospital (2025)

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Type of publication:

Conference abstract

Author(s):

*Lakshmipathy G.R.; *Zaman H.; *Ball W.; *Smith M.

Citation:

British Journal of Surgery. Conference: 49th ASiT Annual Surgical Conference. Belfast United Kingdom. 112(Supplement 10) (pp x109-x110), 2025. Date of Publication: 01 Jun 2025.

Abstract:

Objectives: We aim to evaluate: Method, urgency and appropriateness of colonoscopy referrals. Colonoscopies repeated within two years. Reasoning behind procedure modification or cancellation on the day Method: Data was collected between 5/1/24 and 28/2/24 using questionnaires completed by endoscopists. 112 colonoscopies in 51% (57) males and 49% (55) females were included. Result(s): The most common to least common referral sources are: Colorectal CNS telephone clinic 29(26%), consultant surgeon face-to-face Clinic 28(25%), triage system 14(12.5%), consultant surgeon telephone clinic 13(11.6%), others 13(11.6%), gastroenterology consultant face-to-face clinic 11(9.8%) and gastroenterologist telephone clinic 1(0.8%). Majority of referrals were two-week wait or urgent 97 (86.5%). Endoscopists were 18-week team 70(62.5%) followed by trust-employed consultant surgeons 26(23%). Four patients had repeat colonoscopies in last two years. 9(8%) scopes were modified or cancelled. Conclusion(s): Except for one scope, repeat scopes within two years had valid indications. Majority of the modified or cancelled scopes originated from telephone consultation referrals. Reasons for cancellation on the day included lack of fitness for scopy, ineffective bowel preparation, patient factor like uncontrolled atrial fibrillation on the day and no indication for colonoscopy. Modifications included switching from requests for flexible sigmoidoscopy to colonoscopy; colonoscopy to CTVC and vice versa. In light of this study, we aim to provide face-to-face appointments for patients referred through the urgent suspected cancer pathway. We plan to expand this study to evaluate the popularity of CTVC use as an alternative modality when colonoscopy is not possible.

DOI: 10.1093/bjs/znaf128.znaf128.438

Complications After Hydrocele Repair: Solving a Persistent Challenge (2025)

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Type of publication:

Conference abstract

Author(s):

*Lu Y.; *Abdellatif M.; *Desai C.; *Ali-Naja N.; *Han L.A.; *Kells L.; *Kachrilas S.;

Citation:

British Journal of Surgery. Conference: 49th ASiT Annual Surgical Conference. Belfast United Kingdom. 112(Supplement 10) (pp x179-x180), 2025. Date of Publication: 01 Jun 2025.

Abstract:

Aim: Surgical intervention remains the gold-standard treatment for large or symptomatic hydroceles. Although hydrocele repair is a relatively minor procedure, complications such as haematoma and infection can have significant consequences. This study aims to evaluate the rates and severity of complications and explore strategies to minimise them following hydrocele repair Method: Aretrospective analysis was conducted of all hydrocele surgery performed in January 2021 to December 2022. Complication outcomes were classified using Clavien-Dindo grading. Result(s): A total of 85 hydrocele operations were included in the study, with an average patient age of 54.5. Post-operative complications occurred in 22 (25.88%) patients, including infection, haematoma and recurrence. Amount these, 7 complications (8.24%) were classified as Clavien-Dindo grade II, and 13 (15.29%) as grade III. No grade IV or V were recorded. Of the 22 patients with complications, 11 (12.94%) of them experienced recurrent hydroceles. Conclusion(s): Complications following hydrocele repair are relatively common, warranting further investigation. Comprehensive pre-operative counselling is essential to set realistic expectations and address potential risks with patients. Our centre implemented prophylactic antibiotics in high-risk group and the use of intra-operative betadine wash as potential solutions.

DOI: 10.1093/bjs/znaf128.718

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Survey of the current experience of colonoscopy training for colorectal surgical trainees in the UK (2025)

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Type of publication:

Journal article

Author(s):

Siggens K.; Williams S.; Yiu A.; El Sayed C.; Fletcher J.; Mills S.; Yeadon K.; Reza L.; Rabie M.; Drami I.; Green S.; Tamanna R.; Couderq D.; Javanmard-Emamghissi H.; Argyriou O.; Okocha M.; Khasawneh F.; Kat-Zsummercorn A.; Shakir T.; Anya L.; Bramwell C.; Haji A.; Johnston R.; Joshi H.; Oliphant R.; Piramanayagam B.

Citation:

Frontline Gastroenterology. (no pagination), 2025. Date of Publication: 2025.[epub ahead of print]

Abstract:

Introduction: The primary aim was to understand the current experience of colonoscopy training among general surgical trainees with a subspeciality interest in colorectal surgery. Method(s): An electronic survey was developed and disseminated by members of the Dukes' Club (colorectal trainees network) and Association of Coloproctologists of Great Britain and Ireland colonoscopy subcommittee between February and April 2024 to assess key themes identified through formal and informal feedback from colorectal trainees of endoscopy training experience. Result(s): The survey was completed by 196 participants. This included 13.3% from core trainee (CT) 2-speciality trainee (ST) 4, 28.6% from ST5-ST6, 36.5% from ST7-ST8, 13.3% from post-certificate for completion of training fellows, senior clinical fellows and speciality and specialist (SAS) doctors and 8.7% from early years consultants. The median number of colonoscopies performed by respondents was 121.6 (range 0-8000). Only 33.7% (66/196) reported having one dedicated training list per week, and 56.6% (111/196) were not allocated to any regular training list. The barriers to training were service provision (71.9%), lack of dedicated training lists (69.9%) and access to training lists due to other trainees or healthcare professionals (42.3%). Only 25% of respondents had experience of immersion training, but they consistently reported high numbers of colonoscopy during these periods, with 40% achieving more than 30 colonoscopies. Conclusion(s): There is an urgent need to improve access to colonoscopy training. Regular endoscopy training lists and funding of academies and immersion training centrally are likely to greatly improve the experience of colonoscopy training. Senior colorectal trainees should be prioritised to avoid delay in the completion of training.

DOI: 10.1136/flgastro-2025-103106

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Standardising the administration of joint injections across the Wolverhampton NHS Trust: a service improvement project in rheumatology through the lens of medical education (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.; Agunbiade T.; Chalam S.V.

Citation:

Future Healthcare Journal. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 12(2 Supplement) (no pagination), 2025. Article Number: 100432. Date of Publication: 01 Jun 2025.

Abstract:

Introduction: The Rheumatology Resident Doctors' Forum identified a pressing need to standardise steroid injection training due to varying experience and confidence levels among resident doctors. Many expressed a strong interest in learning injection techniques but faced barriers in accessing training and achieving formal competency. Addressing this gap had the potential to enhance service delivery, support professional development and reduce patient wait times. General practice trainees also highlighted the value of joint injection skills in primary care, helping to alleviate pressure on rheumatology services. The Dreyfus model of skill acquisition describes five levels of competency in skill development, ranging from 'novice' to 'competent' and eventually 'expert'.1 The model shows how individuals progress from rule-based, analytical thinking to experience-driven mastery of a skill.1 A recent study demonstrates that structured training can enhance competency in procedural skills, such as joint injections.2 Methods: A SMART aim was used to design learning outcomes. Fourteen applicants were selected at random. Pre-course surveys collected quantitative and qualitative data on performance challenges, confidence, and baseline knowledge. Process mapping (Fig 1) and radar diagrams (Fig 2) highlighted gaps for intervention. Four trained rheumatology doctors, supervised by a consultant, led a teaching program. Virtual meetings guided plan-do-study-act (PDSA) cycles and driver diagrams to ensure constructive alignment. The goal was to advance learners from the Dreyfus level of 'Novice 1' to 'Competent 1'. The course, conducted in the clinical suite, used training mannikins of knees and shoulder joints, providing real-time feedback. Teaching combined interactive lectures, small-group sessions and individualised feedback. Formative assessments maximised educational impact. Post-course data were compared to baseline, with quality improvement (QI) sustainability tools used to draw portal diagrams, highlight improvement gains and discuss long-term impacts of the project. Results and discussion: Initially, 50% of participants were novices, with none having ever injected a shoulder joint. Confidence in consenting patients increased from 14% to 100% post-course. 64% of participants were unfamiliar with medications used for injections, while 28.6% were unsure of the evidence base. Post-course, both categories improved to 100%. Additionally, 43% initially lacked confidence in clinical decision-making regarding safe joint injection. There was a 100% increase in overall confidence surrounding decision-making (43% 'strongly confident' and 57% 'confident'). All doctors passed the criterion-referenced standard assessment, acquiring formal recognition of skills in their portfolios. The course was oversubscribed and received excellent feedback. QI tools, including radar diagrams, process mapping, and PDSA cycles, had a crucial role in refining training and driving measurable improvements. The structured application of QI methodology successfully upskilled doctors, advancing them from 'Novice' to 'Competent'. Simulation-based learning, combined with real-time feedback, proved to be a highly effective strategy for accelerating skill development while enhancing clinical decision-making and confidence. By integrating this training into departmental inductions, the initiative ensured sustainability and continuous professional development, benefiting both individual practitioners and the wider healthcare service. Conclusion(s): The project led to significant improvements in confidence and competency. It demonstrated sustainability through reproducibility and was incorporated into the rheumatology departmental induction. Positive feedback highlights the course's broader applicability in QI-driven medical training.

DOI: 10.1016/j.fhj.2025.100432

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Normal creatinine-kinase levels in post-COVID myositis: insights into localised muscle involvement (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.S.; *Elshehawy M.; *Olarewaju J.; Askari A.

Citation:

Clinical Medicine, Journal of the Royal College of Physicians of London. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 25(4 Supplement) (no pagination), 2025. Article Number: 100437. Date of Publication: 01 Jul 2025.

Abstract:

Introduction: Severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2; coronavirus 2019; COVID-19) has been increasingly implicated in post-infectious inflammatory complications, including varied presentations of inflammatory myopathies.1,2 Most literature highlights severe, systemic muscle involvement requiring immunosuppression, whereas localised myositis with normal creatine kinase (CK) levels remains underrecognised.3 This case presents a rare instance of localised paraspinal and proximal thigh myositis post-COVID-19, where CK levels remained normal, despite significant muscle involvement. Method(s): A 41-year-old previously healthy man presented with severe diffuse back and leg pain, muscle cramps, and low-grade fever for 2 weeks after confirmed COVID-19 infection. Examination revealed proximal thigh weakness (MRC Grade 3/5) and tenderness without neurological deficits. Investigations, including blood tests, magnetic resonance imaging (MRI), computed tomography (CT), autoimmune screening, echocardiography, blood cultures and electromyography (EMG) studies. were conducted.1 Management required evaluating the progression of symptoms in the light of test results to identify the aetiology of disease, considering differential diagnosis and early establishment of localised vs systemic inflammatory myopathy.2 The patient was diagnosed as post-viral myositis with a normal CK. Empirical intravenous piperacillin-tazobactam was discontinued after infection was excluded. Simple analgesia and vitamin D sufficed for symptom control. The patient showed resolution of fever, significant improvement in muscle pain and normalisation of inflammatory markers, preventing the need for immunosuppression. Results and Discussion: Laboratory findings showed elevated C-reactive protein (237 mg/L), white cell count (12.0 x 109/L), and neutrophilia (9.4 x 109/L). Alkaline phosphatase (192 U/L) and gamma glutamyl transferase (202 U/L) were mildly elevated, while CK levels were normal (22 U/L, peaking at 56 U/L). MRI revealed diffuse oedema in posterior paraspinal muscles without abscess or infection, and CT imaging confirmed intermuscular oedema in paraspinal and proximal thigh muscles without systemic involvement. Autoimmune screening (antinuclear antibodies, weakly positive; extractable nuclear antigen antibodies and anti-neutrophil cytoplasmic antibodies, negative) and echocardiogram were unremarkable. Blood cultures showed no growth and EMG displayed a myopathic pattern in the right shoulder. This case provides insight into an atypical presentation of post-COVID 19 myositis, where the CK level remains normal despite muscle weakness.3 It evaluates the diagnostic and management challenges in this scenario. Other differentials include amyopathic dermatomyositis (ADM). However, differentiating localised post-viral myositis from ADM is essential, because ADM presents with cutaneous manifestations, which are absent in this case. A detailed history of recent viral illness and advanced imaging (eg, MRI) are critical for identifying myositis and excluding systemic or infectious causes.1Conclusion(s): This case highlights that post-viral localised myositis can present with significant muscle involvement despite normal CK levels, necessitating MRI for diagnosis.1,3 Early rheumatology input can optimise management by differentiating self-limiting inflammatory myopathies from those requiring immunosuppression.

DOI: 10.1016/j.clinme.2025.100437

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Complex lupus management: when multiple organs demand precision (2025)

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Type of publication:

Conference abstract

Author(s):

*Jayasekera H.S.; Askari A.; *Chand S.

Citation:

Clinical Medicine, Journal of the Royal College of Physicians of London. Conference: Medicine 2025: The future of medicine. RCP annual conference. 11 St Andrews Pl, London United Kingdom. 25(4 Supplement) (no pagination), 2025. Article Number: 100376. Date of Publication: 01 Jul 2025.

Abstract:

Introduction: Systemic lupus erythematosus (SLE) is a complex autoimmune disease with a wide spectrum of severity, ranging from mild manifestations to life-threatening organ damage. Its multisystem involvement poses a significant treatment challenge, because interventions targeting one organ system may inadvertently impact another. The Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) is a widely used tool for assessing disease activity, with a score above 12 indicating severe disease. However, studies estimate that approximately 20% of patients present with severe manifestations at diagnosis. One of the most serious complications of SLE is lupus nephritis, which is classified into six classes by the International Society of Nephrology/Renal Pathology Society (ISN/RPS), ranging from Class I (minimal-mesangial lupus nephritis) to Class VI (advanced-sclerosing lupus nephritis). We present a case of a patient newly diagnosed with severe SLE and lupus nephritis, characterised by high disease activity and multisystemic involvement. This case highlights the complex treatment considerations necessary when managing severe lupus.

Method(s): A 62-year-old woman presented with flu-like symptoms followed by a malar rash, mouth ulcers, fatigue, alopecia and pancytopenia. She was diagnosed with SLE with lupus nephritis confirmed by renal biopsy, and SLE on skin biopsy. Management required significant consideration because of high disease activity (SLEDAI 16) complicated by pancytopenia and liver dysfunction. Therapeutic options were systematically evaluated to balance efficacy and safety given the patient's pancytopenia, liver dysfunction and renal involvement. Mycophenolate mofetil (MMF), effective for lupus nephritis, was excluded because of its potential to worsen pancytopenia. Azathioprine, suitable for mild renal involvement, was ruled out because of liver dysfunction. Cyclophosphamide, typically used for severe SLE, was contraindicated because of its haematological and hepatic toxicity. Tacrolimus was considered for renal SLE, given the biopsy Class of I, but was unsuitable for non-renal lupus without MMF. Belimumab, an FDA-approved agent with steroid-sparing effects and a favourable safety profile, was considered but deemed challenging because of its slower onset of action and approval barriers. Hydroxychloroquine (300 mg daily) and corticosteroids (40 mg prednisolone) were ultimately chosen as the safest and most effective initial therapy. Close liaision with the renal team was essential to optimise management. Results and Discussion: Laboratory results revealed low complements (C3 0.38 g/L, C4 0.03 g/L), pancytopenia (WBC 1.2 x 109/L, platelets 126 x 109/L), elevated ferritin (5,490 mug/L), and positive dsDNA. Skin biopsy was consistent with SLE and renal biopsy confirmed lupus nephritis (ISN/RPS Class I). CT-TAP imaging showed axillary lymphadenopathy without malignancy. This case highlights the challenges of managing multisystemic lupus presenting with renal and non-renal SLE symptoms of varying degree, in a patient not already established on baseline treatment. Hydroxychloroquine and corticosteroids formed the cornerstone of treatment, while other options were systematically excluded based on contraindications. Multidisciplinary collaboration was pivotal in tailoring therapy.

Conclusion(s): There are two key learning points highlighted in this case. First, that treating multisystemic lupus requires understanding the degrees of individual organ involvement to determine immunosuppressive needs. Second, that management decisions should balance efficacy and toxicity, guided by interdisciplinary input6 and renal biopsy findings to inform immunosuppression.

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Therapeutic Duel of Rifaximin Versus Lactulose in Hepatic Encephalopathy: A Systematic Review (2025)

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Type of publication:

Systematic Review

Author(s):

Oriko, David O; Khawaj, Zainab; Cheema, Muhammad Usairam; Talreja, Anjali; Tayyab, Muhammad Abbas; Zamir, Muhammad Hamza; Iqbal, Maheen; Farooq, Umer; *Ekomwereren, Osatohanmwen; Tariq, Muhammad M; Hasan, Abdul Haseeb.

Citation:

Cureus. 17(6):e86193, 2025 Jun.

Abstract:

This systematic review aimed to compare the clinical efficacy of rifaximinversus lactulose in the management of hepatic encephalopathy (HE) by analyzing evidence from randomized controlled trials (RCTs). A comprehensive search across major databases identified seven eligible RCTs encompassing 693 adult patients diagnosed with overt or minimal HE. Findings demonstrated that rifaximin is at least as effective as lactulose in reversing HE symptoms, with some studies reporting significantly higher HE reversal rates when rifaximin was used in combination with lactulose (e.g., 76% vs. 50.8%, p<0.004), reduced mortality (23.8% vs. 49.1%, p<0.05), and shorter hospital stays (5.8 vs. 8.2 days, p=0.001). While other trials reported similar efficacy between the two agents (e.g., HE improvement: 84.4% vs. 95.4%, p=0.315), rifaximin was generally associated with better tolerability and fewer gastrointestinal side effects. These results support rifaximin as an effective and well-tolerated therapeutic option, either as monotherapy or in combination with lactulose. Further large-scale, multicenter trials are warranted to assess long-term outcomes, recurrence rates, and cost-effectiveness.

DOI: 10.7759/cureus.86193

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