Clinical medicine (London, England)
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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.
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The COVID-19 pandemic has led to adaptations being made to all aspects of the NHS, including general practice, acute medical specialties and oncology. This has presented unique challenges to acute oncology services (AOSs) in how to provide continuity of care while maintaining the safety of patients and staff. ⋯ The patient population reviewed in April 2020 (at the initial peak of the pandemic in the UK) was markedly different to one reviewed in April 2019, with 55% more patients presenting with a new diagnosis of cancer via an emergency route. Finally, we suggest changes to AOSs for future waves of the pandemic.
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A significant proportion of COVID-19 patients show evidence of hyperinflammation (HI), of which secondary haemophagocytic lymphohistiocytosis (sHLH) is the most severe manifestation and diagnosed with HScore. Using a COVID-relevant modification of the HScore (%HScore), we set out to determine the prevalence of sHLH in 567 COVID-19 inpatient cases. The overall incidence of individuals with an 80% probability of sHLH in our COVID-19 cohort was 1.59% on admission and only rose to 4.05% if calculated at any time during admission. ⋯ Overall, %HScores were lower in older patients (p<0.0001) and did not reliably predict outcome at any cut-off value (AUROC 0.533, p=0.211, odds ratio 0.99). Our study demonstrates that a modified version (%HScore) of the conventional sHLH scoring system (HScore) does not enable risk stratification in people hospitalised with COVID. We propose further work is needed to develop novel approaches to predict HI and improve trial stratification for HI directed therapy in people with COVID-19.
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Liver disease in pregnancy can be related to a pre-existing condition (such as autoimmune liver disease) or arise as a consequence of pregnancy. In women with pre-existing disease, pre-pregnancy counselling is important to discuss the potential complications that may occur during pregnancy and how best to manage these. ⋯ Women with liver dysfunction need appropriate investigations, including blood tests and imaging. They should be managed as part of a multidisciplinary team with obstetricians, obstetric anaesthetists, specialist midwives, gastroenterologists and obstetric physicians.
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In part due to a greater understanding of trauma and its manifestation as disease, the field of functional neurology has seen rapid development over the past decade with the inauguration of the Functional Neurological Disorder Society. Recent developments in our understanding of functional neurology are translatable to other functional disorders and have laid the groundwork for future research opportunities that foundation trainees can contribute towards. At the very least, trainees have a responsibility to be aware of the involuntary nature of these conditions and direct patients towards appropriate help. This guide to functional neurology aims to clear the fog on this collection of poorly recognised conditions so that empathy and understanding can shine through.