Clinical medicine (London, England)
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The COVID-19 pandemic represents one of the greatest ever challenges for healthcare. In the UK and beyond, acute medical units (AMUs) are the first point of assessment and care for the majority of medical inpatients. By their design and systems, they inevitably played an important role in the COVID-19 response but to date little has been published on how the COVID-19 pandemic has affected how AMUs have reorganised their resources, processes and structure. ⋯ The AMUs were able to adapt to meet the demands of acute care delivery during the first wave of the COVID-19 pandemic. Operational planning and prioritisation of resources must be optimised to ensure sustainability of these services for future waves.
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Case Reports
Lessons of the month 2: Meningococcal epiglottitis and connective tissue disease associated with C2 deficiency.
A 68-year-old woman was referred for immunological investigation following an episode of meningococcal epiglottitis with associated septicaemia. Several years previously, she had been diagnosed with undifferentiated connective tissue disease. On investigation, alternative pathway complement function was normal; however, classical pathway complement activation was reduced. C1q, C3 and C4 levels were all measured and found to be within their respective normal ranges, but C2 levels were low. Sequencing of the C2 gene was subsequently performed, confirming a diagnosis of type 1 C2 deficiency (C2D). ⋯ C2D is usually hereditary and inherited in an autosomal recessive manner. C2D is often asymptomatic, however, some patients suffer from infections with encapsulated bacteria and/or autoimmune diseases, particularly systemic lupus erythematosus. Recognition of complement pathway deficiency is important due to the predisposition to severe and/or recurrent infections by encapsulated bacteria. Immunisations have the potential to reduce both mortality and morbidity not only for the patient but also for any affected relatives.
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Despite distinct diagnostic criteria, several gastrointestinal pathologies can masquerade haemophagocytic lymphohistiocytosis (HLH) during the peripartum period. Acute fatty liver of pregnancy, HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome, miliary tuberculosis, visceral leishmaniasis, abdominal surgical emergencies, haemolytic anaemias and haematological malignancies may have clinical and laboratory presentation similar to that of HLH. ⋯ A thorough investigation suggested HLH and the patient was successfully treated with corticosteroids. This patient demonstrates the importance of a focused investigation strategy and timely management to prevent mortality and morbidity to both the mother and fetus in this rare and fatal disease.
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Severe hypertension in pregnancy is defined as a sustained systolic blood pressure of 160 mmHg or over or diastolic blood pressure of 110 mmHg or over and should be assessed in hospital. Severe hypertension before 20 weeks' gestation is rare and usually due to chronic hypertension; assessment for target organ damage and exclusion of secondary hypertension are warranted. The most common cause of severe hypertension in pregnancy is pre-eclampsia, which presents after 20 weeks' gestation. ⋯ Labetalol is the agent most commonly used, both orally and intravenously, in pregnancy in the UK. Severe hypertension is a risk factor for sustained hypertension after pregnancy. Hypertension in pregnancy is associated with increased cardiovascular risk.
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While all patients with chronic disease have undoubtedly been affected by the ongoing SARS-CoV-2 (COVID-19) pandemic, individuals with end-stage renal failure have suffered significant excess morbidity and mortality. Patients on haemodialysis have received extensive research and media attention into their vulnerability to the disease; however, those receiving peritoneal dialysis (PD) have been much less visible. We surveyed a selection of patients from a cohort receiving PD at a tertiary renal unit in Birmingham, UK. ⋯ Worryingly, 58% of respondents indicated that they feel negatively, or feel ambivalent, about the future. Patients receiving PD have suffered significantly during the COVID-19 pandemic and face ongoing difficulties and risks while accessing medical care. It is vital that this cohort is not forgotten in the planning of renal services during the pandemic, and that special attention is paid to both their physical and mental health.