Clinical medicine (London, England)
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Hypertensive encephalopathy (HE) is a subset of posterior reversible encephalopathy syndrome. It typically involves the posterior supratentorial structures, but variations do occur. However, isolated brainstem involvement in HE is rare, with a few cases reported in the literature. ⋯ Marked clinical-radiologic dissociation in this particular case was highly suggestive of hypertensive brainstem encephalopathy. Prompt recognition of the condition and aggressive treatment of hypertension in such patients is crucial to relieve oedema and to prevent life-threatening progression. Nevertheless, there is still a lack of awareness among physicians and radiologists regarding this rare clinical entity.
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Many perioperative clinical pathways, and therefore patient journeys, are focused around provider, rather than patient, convenience. Business process re-engineering (BPRE) offers a framework for transformative process-change with the aim of improving 'consumer experience' and efficiency and may be an effective driver for improving patient experience and value within healthcare. ⋯ Additional opportunities include improved management of transitions of care and effective medicines management to minimise polypharmacy. Pathway mapping, deconstruction and reconstruction enables such changes and is a method of service transformation that may have relevance for a spectrum of other elective/scheduled pathways.
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Case Reports
Lessons of the month 3: Gone but not forgotten - Osler - a reminder of the syndrome not bearing his name.
Streptococcus pneumoniae is the most frequently implicated microbial agent in community acquired bacterial pneumonia and meningitis. It is also responsible for between 1 and 3% of cases of native valve infective endocarditis, with mortality rates up to 60%. Osler first described the association between pneumococcal pneumonia, endocarditis, and meningitis secondary to bacteria that he described as 'micrococci', subsequently elucidated to be S pneumoniae by Robert Austrian, and the syndrome bears his name. We report a case of fulminant pneumococcal native aortic valve endocarditis and perforation in a young male patient with chronic alcoholism and splenectomy who exhibited poor compliance to pneumococcal prophylaxis.
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Historical Article
Lessons of the month 1: Learning from Harvey; improving blood-taking by pointing the needle in the right direction.
The taking of blood for diagnostic purposes is a frequent cause of difficulty for physicians. In patients with intact visible or palpable large veins, such as those often seen in the antecubital fossa, a needle or cannula entering from any direction will usually be rewarded with any quantity of blood. ⋯ Failure to take blood is very commonly because of failure to appreciate the direction of flow of venous blood up the arm, and the ubiquitous presence of valves in the veins, both aspects of the circulation clearly described by William Harvey nearly 4 centuries ago. This paper encourages more frequent success with phlebotomy by remembering Harvey's work and pointing the needle in the right direction; this is not always towards the heart.