Clinical medicine (London, England)
-
Immunoglobulin is an expensive blood product of potentially limited supply used in a wide variety of medical conditions, across a number of specialties. Historically, immunoglobulin has been associated with transmission of blood borne infection (eg hepatitis C). Immunoglobulin use needs to be carefully considered, appropriately prescribed and recorded. The Department of Health, in conjunction with relevant stakeholders, has established a demand management programme to secure immunoglobulin supplies for patients most in need of treatment and to limit use for indications where evidence is lacking.
-
Understanding and learning from hospital deaths is an important component of good clinical practice but current approaches and measures are complex, controversial and difficult to understand. Patients who die are not a homogeneous group but fall into three distinct categories; most learning will be achieved by recognising this and investigating categories of deaths in different ways, relying heavily on qualitative approaches. Numerical measures of overall hospital mortality, such as hospital standardised mortality ratio (HSMR) or measures of 'preventable' deaths, are most unlikely to be helpful at a hospital level and may even give false reassurance, as accuracy of measurement is strongly influenced by factors apart from quality of care.
-
Headaches are a common complaint in HIV positive patients attending emergency services. A thorough understanding of the differential diagnoses, initial investigations and empirical management of this presentation is essential for the assessing physician. We discuss a case of a patient with known advanced HIV infection presenting with headache to the emergency department. ⋯ This was stopped when magnetic resonance imaging confirmed a diagnosis of venous sinus thrombosis. Anticoagulation therapy was started in accordance with current clinical guidelines after discussing the rationale and options for treatment with the patient. Here, we review the guidelines and supporting evidence for management of venous sinus thrombosis, and consider the challenges and strategies for engaging a patient with previous poor attendance in their ongoing care.
-
Delirium describes a sudden onset change in mental status of fluctuating course. This is a state of altered consciousness characterised chiefly by inattention or lack of arousal, but can also include new impairment of language, perception and behaviour. ⋯ Stressors include direct insults to the brain, insults peripheral to the brain or external changes in the environment of an individual. Delirium is varied in its presentation, and can be categorised by the psychomotor profile as: hyperactive type (overly vigilant, agitated, often wandersome), hypoactive type (sedate or withdrawn) or mixed types.
-
A 19-year-old male with a history of idiopathic panuveitis, currently taking methotrexate and infliximab, presented to our institution with 6 weeks of cough, dyspnoea and fevers. He had failed outpatient antimicrobial therapy. ⋯ Bronchoalveolar lavage was performed with a transbronchial lung biopsy because of the diagnostic uncertainty of the patient's presentation. Pathology revealed non-budding yeasts, consistent with Pneumocystis Serological and urine studies were positive for both Histoplasma and Blastomyces The diagnosis of Histoplasma pneumonia was made because of the presentation being inconsistent with Pneumocystis pneumonia, and serology, urine and pathology testing being more consistent with Histoplasma The patient was treated with oral itraconazole and was doing well at follow-up 12 weeks after hospitalisation.