Clinical medicine (London, England)
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Case Reports
An unusual case of refractory status epilepticus in a young lady: anti-NMDA receptor encephalitis.
We describe a case of a young lady with anti-NMDA (N-methyl-D-aspartate) receptor encephalitis, who initially presented with status epilepticus. Her seizures and orofacial dyskinesia were refractory to four anticonvulsants. ⋯ However, her outcome was poor because of delayed treatment, autonomic dysfunction and complications of prolonged hospitalisation. This case highlights the importance of an early recognition of this rare but increasingly recognised disease.
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Case Reports
Lesson of the month 2: Autoimmune sequelae of anti-GAD antibodies - thinking outside the box.
A 52 year-old female with no significant medical problems presented with left-sided weakness, unsteady gait and speech disturbance. It was thought that she had neuro-inflammation and she remained clinically stable. Several years later, she was diagnosed with latent autoimmune diabetes of adulthood. ⋯ This led to the diagnosis of glutamic acid decarboxylase (GAD) positive cerebellar ataxia. She was treated with plasma exchange and intravenous immunoglobulins and over next 12 weeks her symptoms improved. Our case highlights the need for appropriate treatment of patients with GAD positive cerebellar ataxia to achieve good outcomes.
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Achieving competence in thoracic ultrasound is a mandatory requirement for the successful completion of respiratory specialty training in the UK. We evaluated trainee competencies, access to training and confidence in thoracic ultrasound by means of a nationally distributed survey with the participation of 202 (of approximately 600) respiratory trainees. 65.8% (131/199) of responders are RCR Level 1 accredited and 20.6% (22/107) of these trainees had performed fewer than 20 ultrasounds in the past year. 29.2% (50/171) of trainees reported that access to an ultrasonographer for advice was either 'not easy' or 'impossible'. 59% (107/171) of all respondents are 'never' or 'rarely' supervised, with 60% (102/169) of queries answered by real-time evaluation or review of stored media. ⋯ There is a case for reviewing current guidance and to consider tailoring training and expectations to align with the specific needs of respiratory registrars. We propose a revision of the current Royal College of Radiologists framework towards a respiratory specialist led accreditation in thoracic ultrasound.
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Cognitive screening is recommended for older patients with unplanned hospital admission. We determined rates of reassessment/specialist memory referral after routine inclusion of at risk of dementia status in discharge documentation to primary care. Questionnaires were sent to relevant GP practices on consecutive patients aged ≥75 years identified as at risk and discharged 6 months earlier. ⋯ The most common reasons for non-assessment/referral included clinical factors (eg terminal illness/comorbidities) (n=15) and patient/family wishes (n=5) and that confusion was expected in unwell older patients (n=5). Routine cognitive reassessment/specialist referral appears unjustified in patients identified as at risk of dementia during unplanned hospital admission. However, the prognostic value of delirium/confusion in acute illness is under-recognised and could be used to highlight those at risk.
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We sought to establish whether an expedited or 'fast-track' NHS service to diagnose obstructive sleep apnoea (OSA) and establish vocational drivers on continuous positive airway pressure (CPAP) within 4 weeks of referral was possible. This model is recommended by the OSA Partnership Group. ⋯ Of those commenced on CPAP, review was a mean of 15 days after initiation (range 3-62 days). Median time from referral (or first clinic visit) to review on CPAP was 32 days, showing a 'fast-track' pathway is deliverable.