Clinical medicine (London, England)
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Evidence-based audit tools were used to identify the antibiotic stewardship improvements necessary to meet the NHS England targets in a 750-bed teaching hospital. Antibiotic prescribing was reviewed against published evidence-based audit tools for 139 patients treated with antibiotics. Severe community-acquired pneumonia (CAP) median course length was 8.5 days. ⋯ Of these, 17% met the IV to oral switch criteria at 72 hours but were not switched. On average, antibiotic courses were 19% longer than recommended. Three key areas for improvement consist of: (a) implement the National Institute of Health and Care Excellence UTI Quality Standard - only 38% of patients treated for UTI met the UTI definition; (b) ensure antibiotic course lengths are in line with local prescribing guidelines - antibiotics were continued for 14% longer than recommended in local guidelines; (c) switch antibiotic therapy to oral when switch criteria met - 17% percent of patients initiated on IV antibiotics were eligible for oral switch by 72 hours and were not switched.
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Safe exclusion of pulmonary embolism (PE) is a common problem in acute medicine. Common care pathways usually involve the use of a pre-test probability score with a D-dimer test to aid clinical decision-making. Unfortunately, the specificity of many D-dimer assays decreases with age. ⋯ D-dimers in patients with low or moderate Wells score were analysed for both conventional and age-adjusted cut-offs. The use of an adjusted D-dimer showed a sensitivity of 0.97 (95% CI 0.9-1.0) while the specificity increased from 0.07 (95% CI 0.04-0.11) for the conventional cut-off to 0.32 (95% CI 0.27-0.38) for the age-adjusted cut-off. Using a 5 x patient's age-adjusted D-dimer cut-off is both safe and showed an increased specificity comparable to those published previously on other D-dimer assays.
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Case Reports
Lesson of the month 1: Case reports of arrhythmogenic cardiomyopathies in military personnel.
In military recruits, sudden cardiac death rates have been reported as varying from 2 to 13 per 100,000 per year which are mostly related to exercise. However, the development of structural heart changes that may be associated with ventricular arrhythmias have not been reported among this cohort, despite them undergoing endurance training similar to athletes. Here, we report two cases where military personnel were found to have life-threatening cardiac arrhythmias associated with structural heart disease, highlighting the importance of early recognition and treatment of these arrhythmias.