Clinical medicine (London, England)
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Anaphylaxis can induce life-threatening coagulopathy by releasing various mediators from activated mast cells. These mediators directly affect coagulation and fibrinolytic pathways, increasing the bleeding risk. Diagnosis and management of anaphylaxis-induced coagulopathy remain challenging. ⋯ Bone marrow examination subsequently confirmed isolated mastocytosis. This case highlights the potential of VEM for rapid diagnosis and management of coagulopathy in patients with anaphylaxis, potentially aiding in the identification of mast cell degranulation in undifferentiated shock. We suggest that VEM should be considered in the investigation of patients with suspected anaphylaxis-induced coagulopathy.
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Unidentified obstructive sleep apnoea (OSA) can lead to unexpected perioperative complications, unplanned postoperative admissions and increased length of hospital stay. NICE (National Institute for Health and Care Excellence) recommends a rapid preoperative assessment for patients undergoing elective surgery. ⋯ Prevalence of OSA is high in presurgical patients identified through preoperative screening. A diagnosis of moderate to severe OSA impacts surgical decision and planned anaesthetic route. Prior awareness of the diagnosis may help clinicians to identify the at-risk group. Timely CPAP initiation to facilitate surgery remains a challenge and, despite low compliance, CPAP may reduce postoperative complications. A multidisciplinary team (MDT) approach and a dedicated CPAP pathway post-diagnosis may help the clinicians and patients.
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The prevalence of smoking remains stubbornly high in the UK despite comprehensive tobacco control measures. A national quality improvement (QI) approach to enhance the treatment of an estimated 1,000,000 annual hospital admissions of tobacco smokers could provide a new opportunity to improve population health and reduce healthcare demand. Barriers to QI include knowledge, costs and competing demands. This study aimed to evaluate the feasibility and effectiveness of a national QI programme hosted by the British Thoracic Society, focused on improving NHS tobacco dependency treatment in acute hospitals. ⋯ This novel, national, online QI programme supported participating multidisciplinary teams in acute trusts across the UK to deliver tobacco dependency treatment pathway improvements using QI tools and methodology. This programme demonstrated the feasibility and effectiveness of delivering a national QI programme, at low cost using a microsystems approach applied to an important area of clinical medicine.
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Case Reports
Lessons of the month: Cerebrospinal Fluid Leak-associated Ventriculitis - a case report.
We present a case of a 74-year-old woman with headaches, pyrexia and intermittent right-sided otorrhoea and rhinorrhoea. Her nasal discharge tested positive for beta-2-transferrin, confirming a cerebrospinal fluid (CSF) leak. High-resolution CT (HRCT) mastoids showed a defect in the right tegmen, and CSF within the middle ear and mastoid air cells. ⋯ The patient had surgical repair of bony defects to prevent recurrence. This highlights a rare case of ventriculitis associated with a spontaneous CSF leak, with no existing set diagnostic criteria, and high mortality. High clinical suspicion aided by appropriate imaging, and a multidisciplinary approach to management are imperative.
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Pulmonary embolism (PE) is a significant cause of morbidity and mortality in pregnancy and the puerperium. In severe cases, it causes haemodynamic instability and can lead to cardiac arrest due to obstructive shock. Patients with acute PE can be risk stratified to guide their monitoring and treatment; this article focuses on intermediate- and high-risk PE. ⋯ Diagnostic imaging should not be delayed due to pregnancy. Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) can be used during pregnancy and breastfeeding, and systemic thrombolysis can be used in obstetric patients, but there are significant bleeding risks and it should be reserved for high-risk PE with hypotension and shock. Although pregnancy and the puerperium are risk factors for PE, it is important to avoid early diagnostic closure, and to consider other causes for the patient's presentation.