Clinical medicine (London, England)
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Graves' disease (GD) and toxic nodular (TN) goitre account for most cases of thyrotoxicosis associated with hyperthyroidism. Hyperthyroidism is confirmed with measurement of a suppressed serum thyrotropin concentration (TSH) and elevated free thyroid hormones. ⋯ Many centres administer fixed doses of iodine-131; larger doses result in improved rates of cure at the cost of hypothyroidism. Surgery is usually considered for patients who have a large goitre, compressive symptoms or significant ophthalmopathy.
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The National Institute for Health and Care Excellence (NICE) published an update on its guideline on chest pain of recent onset in 2016. The new guideline makes three key changes to the 2010 version. ⋯ However, the most radical change is that NICE now recommend that all patients with new onset chest pain should be investigated with a computerised tomography coronary angiogram as a first-ine investigation. We discuss the recent trial evidence that has informed the NICE update and consider the impact of the new guidelines.
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A 59-year-old lady presented with a 1-week history of orthopnoea, paroxysmal nocturnal dyspnoea, night sweats and a productive cough. She had no recent history of travel. Transthoracic echocardiogram revealed preserved left ventricular systolic function with abnormal pericardial thickening and restrictive left ventricular filling consistent with pericardial constriction. ⋯ She did not respond to diuresis, pulsed intravenous steroids or broad spectrum antibiotics and multiple investigations were negative, including autoimmune screen and tuberculosis cultures. Eventually a serum sample was found to be positive for Strongyloides stercoralis and it emerged that this lady had travelled to Egypt 8 years previously, where it is thought that she contracted S stercoralis leading to her developing constrictive pericarditis. This case report summarises the presentation and progression of this case and rare diagnosis.
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Four non-vitamin K oral anticoagulants (NOACs) are now licensed and available in the UK, offering unprecedented choices in anticoagulant therapy for clinicians and patients. NOACs have many clear benefits over warfarin, the most striking being the reduction in intracranial haemorrhage. However, a number of uncertainties remain: their efficacy in certain situations, utility of drug assays, significance of drug interactions and management of bleeding. ⋯ The differential activities, pharmacokinetics, metabolism, excretion and side effects of the agents should be considered when selecting the most appropriate anticoagulant. In this article, we discuss how, with careful selection for the relevant indication, NOACs can simplify therapy while improving outcomes. We aim to provide clinicians with the information needed to select the most suitable anticoagulant drug for an individual patient in a given situation.