Clinical medicine (London, England)
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The National Institute for Health and Care Excellence (NICE) updated its guidelines for chronic heart failure (HF) in 2010. This re-audit assessed interim improvement as compared with an audit in 2011. Patients with HF (preserved and reduced ejection fraction) attending a tertiary cardiac centre over a 2-year period (January 2013-December 2014) were audited. ⋯ Although 100% of patients were educated about exercise, only 21 (4%) enrolled in a supervised exercise programme. This audit demonstrated high rates of documentation, follow-up and compliance with guideline-based medical therapies. A consistent finding was poor access to cardiac rehabilitation.
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Case Reports
Lesson of the month 1: Autoinflammatory syndromes - an unusual cause of pyrexia of unknown origin.
Autoinflammatory diseases are disorders of innate immunity and are characterised by recurring and unprovoked episodes of inflammation. We present a case of episodic pyrexia, associated with a significant inflammatory response, in a young man in whom the cause had remained unexplained since infancy. He was eventually diagnosed with hyperimmunoglobulinaemia D syndrome (HIDS); one of the autoinflammatory syndromes.
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Ritonavir and cobicistat, used as pharmacokinetic enhancers in combination with some antiretrovirals (ARVs) for the treatment of HIV, are potent inhibitors of the CYP3A4 isoenzyme. Most glucocorticoids are metabolised via the CYP3A4 pathway and iatrogenic Cushing's syndrome (ICS), with possible secondary adrenal insufficiency (SAI), is a recognised complication following co-administration with ritonavir or cobicistat. ⋯ While this significant drug interaction and its complications are now well-recognised, it is apparent that there is no standardised approach to management or guidance for the general physician. Here we describe the management of ICS/SAI in our current practice, review the available evidence and suggest practice recommendations.
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We describe the case of an 85-year-old woman who developed acute confusion, acute kidney injury and temperature spikes while on extended courses of beta-lactams for osteomyelitis. The cause of her deterioration was felt to be due to sepsis when in fact it was as a result of toxicity from antibiotics. This was demonstrated by a rapid resolution in her condition following haemodialysis. We also performed a literature review to appraise the neuro and nephrotoxicity of various antibiotics and how best to manage toxicity when it occurs.