Clinical medicine (London, England)
-
Head injury is a common cause for hospital admission and additionally 250,000 UK inpatients fall during hospital admissions annually. Head injury most commonly occurs as a result of falls from standing height in older adults. Older adults are frequently frail and multi-morbid; many have indications for anticoagulation and antiplatelet agents. ⋯ Determining the role of surgery and interrupted anticoagulation requires careful personalised risk assessment. Appreciation of the opposing risks can be challenging; it requires an understanding of the evidence base in both surgery and medicine to rationalise decision making and inform communication. This article aims to provide an overview for the physician with clinical responsibility for patients who have sustained head injury.
-
Neuromyelitis optica spectrum disorder (NMOSD) is an uncommon antibody-mediated disease of the central nervous system. Long segments of spinal cord inflammation (myelitis), severe optic neuritis, and/or bouts of intractable vomiting and hiccoughs (area postrema syndrome) are classic presentations of the disease and may alert the clinician to the diagnosis. Untreated, approximately 50% of NMOSD patients will be wheelchair users and blind, and a third will have died within 5 years of their first attack. ⋯ Relapses are treated aggressively to prevent residual disability with high-dose steroids and often plasma exchange. Relapse prevention is crucial and achieved with long-term immunosuppression. In this article we review the pathogenesis, clinical features, diagnosis and management of NMOSD.
-
Implementation science uses methods to promote the scaling up and use of evidence-based practices by health systems to improve quality and outcomes. Its use is vital to maximise the efficiency of limited resources for health care in tropical settings. ⋯ We explore HIV and TB diagnostics that can be used at point-of-care in any settings, and outline some important principles and applications of implementation science to aid their application and use. Despite robust evidence of diagnostic accuracy and efficacy in improving patient-centred outcomes, such interventions cannot be fully utilised without addressing operational barriers and knowledge gaps.
-
An 18-year-old female patient presented to the emergency department with non-specific neurological and gastrointestinal symptoms and was found to be pancytopenic. Her vitamin B12 level was low with a normal mean corpuscular volume and her full blood count 2 months previously had been within normal range. ⋯ Her pancytopenia resolved with discontinuation of nitrous oxide and vitamin B12 treatment. Heavy use of nitrous oxide should be considered as a cause of pancytopenia.
-
Management of primary spontaneous pneumothorax (PSP) depends on the symptoms and size of lung collapse. The British Thoracic Society recommends needle aspiration (NA) for all PSP requiring intervention, followed by intercostal drain (ICD) if NA fails. We compared the role of NA versus ICD as the first step in PSP with 'complete lung collapse'. ⋯ The ICD group had a significantly better immediate success compared with the NA group (62% versus 11%, odds ratio (OR) = 12.5, p<0.0001; after adjustment for potential confounders, OR increased to 26.4, p=0.0001) although long-term outcomes were comparable. There should be clear consensus on definition and management of complete lung collapse. PSP with complete lung collapse could be managed as a separate subgroup where ICD placement is considered to be the first intervention.