Paul Howard

Pneumocystis pneumonia in older non-HIV-infected patients: a French, multicentre, retrospective, cohort study - Pneumonia Pneumonia - Pneumocystis pneumonia (PCP) is well-described in younger and HIV-infected populations, but limited data are available for older non-HIV-infected patients. The aim was to describe the...

This case series describes PCP pneumonia in older people immunocompromised by steroids, anti-cancer treatment etc.
Great summary of their clinical presentation (74% dyspnoea, 55% cough, 63% febrile, most tachypnoeic, whereas oxygen sats and neutrophil count mostly normal)

doi.org/10.1186/s414...

A study on 1.7 million people in Hong Kong shows superior hybrid immunity to Covid in people who got vaccinated before infection vs. people who got infected first. "Our findings are a direct rebuttal to arguments for natural immunity," the authors write. doi.org/10.1016/j.va...

Delighted to have been invited to speak at @careforthedying.bsky.social webinar.

Can we discuss progressive illness & dying without extinguishing hope?
I think we can. I think we do.
Join us to ponder on Dec 11th, noon -1pm GMT.

It's online, & free to attend.

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Sign up to hear about our latest research on improving end-of-life care and future projects and collaboration opportunities. Our research team is part of PELiCam in the Primary Care Unit, University of Cambridge.

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Introduction of oral methadone to high-risk patients with prolonged QT interval: A retrospective study - PubMed Even in patients with heart disease or prolonged QTc at baseline, methadone may be safely administered by initiating low-dose methadone when the dose of other opioids is low and by adjusting the concomitant medications that can interact with methadone.

Here, Dr Takemura and colleagues examined the impact of low dose ("adjuvant") methadone on QT internal. Even in those with cardiac risk factors, there was no increase in QT with these dose regimens.

pubmed.ncbi.nlm.nih.gov/40071699/

Really useful summary; thanks

What I'd add is: consider SC B12 replacement. I don't have easy access to MMA, so offer a trial of treatment if fatigued with a B12<350.

Nothing works every time. But can be spectacular: eg
From housebound to going on a holiday
From bedbound to going out for lunch

The overwhelming weight of scientific evidence says that vaccines do NOT cause autism. The link has been studied many many times. Here is just a taste of the mountains of peer-reviewed evidence:

Thread [1/9]

I’ve been circling around this idea for awhile but didn’t have the skill to summarize what others have now done extremely eloquently:

Proposing the concept of misinformation exposure as a social determinant of health.

Read on if you’re interested.

Subcutaneous Antibiotic Therapy: The Why, How, Which Drugs and When - PubMed SC administration of antibiotics may be useful in various settings such as in hospitalized patients and among those in long-term care facilities or being cared for at home. However, further clinical studies are needed to assess the pharmacokinetic/pharmacodynamic properties, as well as the risks and …

Other SC ABx with ph/kin data include: ceftriaxone, ertepenan, meropenam and teicoplanin

SC metronidazole, ceftazidime, pip-taz are all well tolerated

If you're new to SC ABx, this is an excellent review article

pubmed.ncbi.nlm.nih.gov/32674952/

Subcutaneous antibiotics in palliative medicine: Retrospective chart review Objectives To investigate the use and safety of subcutaneous (SC) antibiotics for infection and symptom control in the palliative setting. Methods We conducted a retrospective chart review of the use...

It also makes parenteral antibiotics more feasible outside of hospitals, ideal for those wanting active treatment, but at risk of harm from hospitalisation (eg those with frailty)

spcare.bmj.com/content/earl...

Here, subcutaneous co-amoxiclav becomes the latest ABx with pharmacokinetic information confirming absorption comparable to IV and sufficient to get above MIC

SC administration can avoid missed doses if delay cannulating, eg fragile veins
doi.org/10.1093/jac/...

I think "the need to recognise dying" is over-emphasised

For me, it's "needing to hear patients and families when they recognise deterioration and are asking for symptom focused care"
(As well as hearing the opposite, when frail people want active escalation; palliation should never be imposed)

For refractory symptoms, the specialist paramedics take out parecoxib, ketamine, clonidine, lacosamide, phenobarbital etc with our support/advice.

So there really is no excuse for people to die badly for want of access to medicines.

It's partly an equity issue: the paramedics are spotting "unplanned" dying as a result of frailty, advanced dementia and other diagnoses whose unpredictable prognoses hampers access to traditional palliative models based on planning ahead. Latter needs supplementing with rapid access approaches

Specialist paramedics from
@iownhs.bsky.social ambulance service identify people in their last days of life wanting symptom focused care, supplement their sch17 ability to give morphine with a PGD for midaz, hyoscine butylbr and levomepromazine, and then call our 24/7 community team to follow-up

Examples of solutions have existed for several years (eg @iownhs.bsky.social ambulance service, @nhswalesexecutive.bsky.social Wales ambulance service) so why are these not being taken up by other areas?

The 2025 Resuscitation Guidelines emphasise the importance of correct defibrillator pad placement - a simple step that gives someone in cardiac arrest the best chance of survival.

🎥 Watch the video to learn more
🔗 Read the full Guidelines at resus.org.uk/2025-guidelines

For cancer-related VTE, unless specific reason for a LMWH (eg drug interactions), apixaban is safer (n=12 011; less major bleeding [RR 0.67; P= 0.0003], more effective (reduced recurrence of PE), kinder (some find LMWH v painful), cheaper, and saves nursing time.

journals.lww.com/annals-of-me...

Apixaban is often the DOAC of choice for cancer-related VTE because its safer than rivaroxaban (quoted thread)
Its also cheaper in UK.
Further, this systematic review found reducing apixaban to 2.5mg BD after 6 months reduced bleeding risk without increasing VTE recurrence
doi.org/10.1016/j.th...

If you're invested in high quality palliative care and haven't heard @drkathrynmannix.bsky.social speak, you are missing out!

If you have, you'll know what a fantastic opportunity this is to come and listen and engage with Kathryn on "Talking about Dying".

📣 Join us 13th November 6pm GMT

I've decided to stop trusting experts.

Really looking forward to my forthcoming surgery being carried out by my mate Dave.
He's not an expert surgeon, but he is quite good with a chainsaw and has watched several series of House.

Who needs experts?

Just in case someone's never asked for mycoplasma serology, but isn't sure whether they're missing out, what would you tell them? Esp if they work with immunocompromised people who often have "inflammatory symptoms" (fatigue, sweats, wt loss, anorexia etc)
Asking for a friend.....

Exclusive: ex-CDC director talks about why she was fired “I would never do that, as a scientist,” Susan Monarez says of being asked to approve changes to vaccine recommendations without knowing the details.

Read our exclusive interview by @maxkozlov.bsky.social with the ex-CDC director - Susan Monarez -
In which she talks about the importance of the job and the reasons why she was fired

🧪 #CDC #MedSky
@nature.com

www.nature.com/articles/d41...

Ethnic disparities in opioid prescribing for cancer pain and associated emergency department visits and hospital admissions in the last three months of life: a retrospective cohort study - British Journal of Cancer British Journal of Cancer - Ethnic disparities in opioid prescribing for cancer pain and associated emergency department visits and hospital admissions in the last three months of life: a...

Important study examining effect of ethnicity on UK ED attendance outcomes in last 3 months of life.
Found white patients received more analgesia and were admitted less often.

www.nature.com/articles/s41...

@drkathrynmannix.bsky.social Edinburgh is famously accessible from the NE of England, & we are always delighted to welcome palliative care people across the border to our conferences. We have a great line up this year, closer & cheaper than London. www.palliativecarescotland.org.uk/content/annu...

Database studies are prone to streaming; i.e. since apixaban is known to carry a lower bleeding risk, more likely to select it if higher bleed risk - can only control for coded risk factors, so some risk factors missed
So it's interesting that they still found apixaban's non-major bleed risk lower

Comparative safety and effectiveness of apixaban and rivaroxaban for treatment of cancer-associated venous thromboembolism: A retrospective cohort study Jingjing Sun and colleagues compare the risk of recurrent venous thromboembolism, major bleeding, and clinically relevant non-major bleeding among individuals with cancer-associated venous thromboembo...

"In cancer-associated VTE, apixaban was associated with similar risks of recurrent VTE and major bleeding, and a lower risk of clinically relevant non-major bleeding compared with rivaroxaban"

journals.plos.org/plosmedicine...

a picture of a mosquito killer hanging from the ceiling with the caption i can 't help it it 's so beautiful Alt: a picture of a mosquito killer hanging from the ceiling with the caption i can 't help it it 's so beautiful

The idiom "like a moth to the flame" dates to at least the 12th century, to Persian love poem "Layla and Majnun". Shakespeare references it in "Merchant of Venice."

But here's the thing. Moths DON'T fly to flames. And we're just now understanding that.

Let's talk about dorsal light response.

I agree; in UK hospitals I see administration of fluids and drugs delayed for hours in those with difficult veins.
SC would often be a far faster option: fluids, many antibiotics, PPIs, TXA, metoprolol, corticosteroids; the list of drugs given SC grows yearly yet remains little used in UK hospitals

🙋‍♂️