Clinical medicine (London, England)
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To review advance care planning (ACP) practice during the COVID-19 pandemic, evaluating the number of plans created, patient participation, cardiopulmonary resuscitation recommendations and variation between different population groups. ⋯ Increased ACP during a crisis can be achieved alongside increased patient participation in decision making. A tool such as ReSPECT that supports recommendations for, as well as limitations on, treatment may have enabled the expansion of ACP observed.
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A 54-year-old woman presented to the emergency department with fluctuating consciousness without localising signs and non-specific neurology. Urgent computed tomography (CT) was unremarkable and differentials of opioid overdose or post-ictal state were considered. Magnetic resonance imaging of the brain demonstrated an artery of Percheron (AOP) infarct; resulting from occlusion of an uncommon anatomical variant in the thalamic and midbrain circulation. This should be considered in patients presenting with fluctuating consciousness and normal CT.
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An 84-year-old man was admitted with urinary tract infection and chest discomfort. He initially responded to conservative acute coronary syndrome management and antibiotics. On day 6 of admission, he developed acute severe abdominal pain; 12-lead electrocardiography showed widespread ST-segment depression in the anterior chest leads with ST-elevation in the posterior leads (V7-9) suggestive of an acute posterior myocardial infarction. ⋯ The case was discussed with the on-call surgical team, who advised that, due to severe frailty, he was not fit for surgical intervention and should be managed conservatively. He was managed with intravenous heparin infusion and supportive measures, but sadly continued to deteriorate and was palliated. He died shortly afterwards.
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Increasing numbers of doctors in training are taking career breaks, with burnout cited as a potential cause. This study analysed General Medical Council (GMC) national training survey data (renal medicine) to understand the impacts of changing workforce demographics on trainee outcomes and wellbeing. Increasing proportions of female, Black, Asian and minority ethnic (BAME), and international medical graduates are entering the workforce. ⋯ Self-reported burnout rates for renal trainees were higher than other medical specialties and highest for male BAME trainees. Burnout was only partially mitigated by less-than-full-time working, but had no impact on progression, sick-leave or time out of training. It is important to recognise changes to the workforce and proactively plan to effectively support a more diverse group of trainees, to enable them to succeed and reduce differential attainment.
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Cardiac tamponade is a medical emergency, caused by rapid accumulation of fluid in the pericardium resulting in reduced ventricular filling which may result in pulmonary oedema, shock and death. The common causes of cardiac tamponade include malignancy, uraemia, infectious/idiopathic pericarditis, connective tissue diseases, post-cardiac surgery etc. Early recognition and treatment of the underlying cause of the tamponade along with pericardiocentesis improves the prognosis, otherwise untreated cardiac tamponade universally results in death. We report a rare case of 32-year-old man, who presented with cardiac tamponade due to a pancreatico-pericardial fistula secondary to pancreatitis and was successfully treated by endoscopic therapy.