Brit J Hosp Med
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Angiotensin-converting enzyme (ACE) inhibitors inhibit the enzyme that cleaves angiotensin I to form angiotensin II. They are potent vasodilators as they decrease concentrations of angiotensin II and noradrenaline and increase concentrations of bradykinin and nitric oxide. They reduce secretion of aldosterone and antidiuretic hormone, thus reducing salt and water reabsorption by the kidney (Groban and Butterworth, 2006).
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A Vascath dialysis line was inserted under direct ultrasound guidance into the left internal jugular vein for plasmapharesis to treat a 60-year-old woman admitted with a myasthenic crisis secondary to sepsis. A chest X-ray was arranged to check the position of the line and look for any complications, which revealed the presence of a left superior vena cava. Because of the uncertainty of the drainage of this vein a right-sided catheter was then inserted. The repeat chest X-ray (Figure 1) shows both lines, and the two vena cava.
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The transparency of surgical outcomes data and the drive for quality has been highlighted since the public inquiry, led by Professor Ian Kennedy, into children's heart surgery at the Bristol Royal Infirmary. This was formalized in Lord Darzi's 2008 report High Quality Care for All, that proposed the NHS should: 'systematically measure and publish information about the quality of care'. Subsequently the NHS White paper, Equity and Excellence: Liberating the NHS (Department of Health, 2010), set out the ambitions and aims of the NHS and in particular that it should provide: '...a service that offers care that is safe and of the highest quality.'