Clinical medicine (London, England)
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Acute myocarditis is a serious, likely underdiagnosed condition affecting people of all ages and for which the number of UK hospital admissions is rising. A primary diagnosis of myocarditis accounted for 0.04% (36.5 per 100,000) of all hospital admissions in England between 1998 and 2017, although this is likely to be an underestimate of the true burden of myocarditis. The aetiology is broad, including infective and inflammatory conditions as well as exposure to toxic agents. ⋯ There is emerging evidence for immunosuppressive therapy in certain cases. Prognosis is generally good with recovery in most; however, up to 30% with biopsy-proven myocarditis progress to develop a dilated cardiomyopathy and its potential associated complications. All-cause mortality in the UK for patients presenting to hospital with acute myocarditis is approximately 4%.
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Venous thromboembolism (VTE) is increasingly recognised in primary and secondary care practice. The arrival of direct oral anticoagulants (DOACs) has made the management of VTE easier and more convenient. Some patients established on DOACs may need screening for underlying thrombophilias as certain thrombophilic conditions are known to confer a higher thrombosis risk, although the guidelines for when and how to test for a thrombophilia, especially in a patient taking a DOAC, are unclear. This literature review aims to examine when thrombophilia screening should take place in a patient already taking a DOAC, the effect of DOACs on thrombophilia tests, and analyse whether DOACs are safe and effective in both inherited and acquired thrombophilias.
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Cancer patients are a highly vulnerable group in the COVID-19 pandemic and it has been necessary for oncology units to adapt to this unexpected situation. We present our management of outpatients with cancer during the pandemic. We applied two major adaptations: extending the intervals between injections for maintenance therapy and protocol adaptation for patients with comorbidities. ⋯ Among them, 49% had an extended interval between treatment administrations, 22.3% had modified protocols to reduce toxicity, 20.2% had therapeutic interruptions and 5.3% did not receive their treatment because of a COVID-19 infection. Overall, protocol adaptations concerned more than 20% of the patients. This pandemic was an opportunity for oncologists to re-examine the risk versus benefit balance of administering immunosuppressive treatment and highlighted that oncology daily routine should not be applied automatically.
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Case Reports
Resistant type 2 amiodarone-induced thyrotoxicosis responsive to cholestyramine as an adjunctive therapy.
Amiodarone is a class 3 antiarrhythmic drug which may be associated with thyroid dysfunction. Amiodarone-induced thyrotoxicosis (AIT) is classified as type 1 (AIT 1; which may develop in the presence of latent autoimmune hyperthyroid condition) or type 2 (AIT 2; which develops in an apparently normal thyroid resulting from destructive thyroiditis). AIT 1 routinely requires treatment with thionamides, whereas AIT 2 is treated with steroids. ⋯ Despite being on high doses of carbimazole and steroids (prednisolone), the patient remained thyrotoxic. Cholestyramine, a bile salt sequestrant, was used as an adjunctive therapy resulting in significant clinical and biochemical improvement. The patient subsequently became euthyroid and is being followed up in endocrine clinic.
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Case Reports
Lessons of the month 1: Longitudinal extensive transverse myelitis following AstraZeneca COVID-19 vaccination.
Longitudinal extensive transverse myelitis (LETM) is a rare but recognised complication of vaccination. We report the case of a 58-year-old man admitted to hospital 10 days after his first AstraZeneca COVID-19 vaccination with progressive neurological symptoms and signs, and investigations and imaging consistent with LETM. This case reviews the literature and the investigative process behind excluding other diagnoses given the patient's background of pulmonary sarcoidosis. It is unique in being the first UK report of a case of LETM with a strong temporal link to COVID-19 vaccination.