Clinical medicine (London, England)
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Case Reports
Lesson of the month 2: The limitations of steroid therapy in bradykinin-mediated angioedema attacks.
Acute angioedema attacks are conventionally treated with antihistamines and steroids, in line with a presumed mechanism of disease involving overwhelming mast-cell degranulation. This approach overlooks a small but important minority of cases in which attacks are bradykinin driven and exhibit poor responsiveness to steroid or anti-histamine therapy. ⋯ In the long-term, they require C1 esterase inhibitor sparing therapy and a treat-the-cause approach to reduce the risk of recurrent attacks. We present here a case of a middle-aged woman who presented with recurrent angioedema of initially uncertain aetiology.
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Failure to provide prescribed medicines to inpatients has the potential to cause significant patient harm, to delay the resolution of the pathology and to increase the length of hospital stay. We measured the frequency at which medications were omitted in the non-admitting medical wards of a district general hospital, using two point-prevalence studies spaced one month apart. The results showed that the omission of prescribed medications remains a problem throughout the hospital stay of the patient. ⋯ The most common cause of omission was patients' refusal (47.22%), followed by patients' inability to take the medicine (22.7%). Medication unavailability came third (17.04%). Increased communication between medical, nursing and pharmacy staff, along with regular review of the patients by the patient team, with a view of reducing medication omission will go a long way in reducing the incidence of this problem.
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Although chronic liver disease (CLD) constitutes a significant proportion of acute medical admissions, it is not known how CLD influences venous thromboembolism (VTE) prophylaxis decision making and low molecular weight heparin (LMWH) prescription. Furthermore, recent evidence suggests that VTE risk has been underestimated in CLD and that prophylactic LMWH is safe and may improve outcome in this patient group. We therefore evaluated VTE prophylaxis in patients with CLD and aimed to determine the factors contributing to decisions to prescribe LMWH. ⋯ Decision making appears to be affected by whether an admission is 'liver' or 'non-liver' related. Prophylactic LMWH was safe in this small cohort. Further studies are warranted to further inform LMWH prescription in CLD.
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Diarrhoea is probably the single most common medical complaint in returning travellers. The most common pathogens are entero-toxigenic Escherichia coli, Shigella, Salmonella and Campylobacter. ⋯ Blood in stools is a sign of invasive disease and should trigger exclusion of invasive amoebic disease. The use of empiric antibiotics may shorten illness but is complicated by the diversity of bacterial causes and emerging resistance.
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Research to identify whether dizziness is a geriatric syndrome has largely overlooked often treatable vestibular causes. To ascertain the degree to which vestibular and other causes of dizziness interact in older people, an eight-month retrospective case-note review was undertaken in patients aged ≥: 65 years referred with dizziness or imbalance to an audiovestibular medicine clinic. Of 41 patients aged 65-93 years old, 15 (37%) had multiple symptom triggers, 23 (56%) had recent dizziness-related falls, 24 (59%) and 10 (24%) had peripheral and central vestibular causes for dizziness respectively, whereas 6 (15%) had both. ⋯ Polypharmacy, orthostatic hypotension, psychotropic drug use and anxiety were common contributory factors. Vestibular causes of dizziness contribute to a multifactorial geriatric syndrome. All patients with dizziness and falls should have a vestibular assessment (especially peripheral) to improve quality of life and reduce falls.