Clinical medicine (London, England)
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Abdominal aorta aneurysm rupture is a potential lethal complication and is surgical emergency. In addition, formation of a portal vein and abdominal aorta fistula is a possible, very rare complication that enforces complicated surgical management. Multidetector computed tomography with bolus injection tracking and multiplanar reconstruction is the modality of choice in revealing an aortic rupture and its potential complications.
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The differential diagnosis of an acute liver injury is extremely broad and can often change following initial investigations. We describe the case of a 54-year-old woman whose liver function derangement was initially attributed to alcohol excess, but in fact turned out to be cardiac in origin. We describe the underlying mechanisms and features of cardiac-related liver injury, and how the pattern of liver tests alongside appropriate imaging can help obtain the diagnosis.
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Loperamide is an over-the-counter medication which is commonly used to treat diarrhoea. In excessive doses, loperamide acts as an opioid on the central nervous system, which contributes to its increasing popularity as an alternative substance for opiate addictions. High doses for prolonged periods can cause prolonged QTc and provoke life-threatening arrhythmias, such as ventricular fibrillation. ⋯ Following syncopal episodes at rest, she was admitted for a period of monitored observation and later discharged with a plan to taper her loperamide in the community. Upon second presentation, her loperamide was replaced with buprenorphine patches, which were then weaned successfully in the community. Despite this, she passed away several months later, most likely from an underlying congenital cardiac arrhythmia which was unmasked by excessive use of loperamide.
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The National Institute for Health and Care Excellence (NICE) 2016 guidelines (CG95) recommend patients with new stable chest pain be investigated with computed tomography coronary angiography (CTCA). An updated guideline (MTG32) recommended using CT fractional flow reserve (CTFFR) as a gatekeeper to invasive coronary angiography (ICA) for patients with coronary stenosis on CTCA. Subsequently, NHS England negotiated a UK-wide contract with HeartFlow, the provider of CTFFR. We describe our experience with CTFFR and consider the impact of the recent ISCHEMIA trial on these guidelines. ⋯ Our revascularisation rates suggest that CTFFR can potentially be a gatekeeper to ICA but does not necessarily yield cost savings.
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Following hyperacute management after traumatic brain injury (TBI), most patients receive treatment which is inadequate or inappropriate, and delayed. This results in suboptimal rehabilitation outcome and avoidable detrimental chronic effects on patients' recovery. This worsens long-term disability, and magnifies costs to the individual and society. ⋯ This approach would also encourage more efficient collaboration between research and the clinic. We propose that the current major trauma network is leveraged to introduce and evaluate this proposal. Improvements to patient outcomes through this approach would lead to reduced personal, societal and economic impact of TBI.