Positive remodelling of coronary arteries on computed tomography coronary angiogram: an observational study.

Background: Coronary artery disease (CAD) due to atherosclerosis is projected to be the leading cause of morbidity and mortality worldwide until 2040. CAD affects approximately 2.6 million people in the United Kingdom (UK), and 1 in 4 of them do not experience any symptoms. Aims: The aim of this study was to assess the characteristics and outcomes of patients with plaque features of positive remodelling (PR) on their computed tomography coronary angiogram (CTCA) images. Methods: Patients who were referred for CTCA from June 2018 to January 2020 were retrospectively identified. Patients underwent prospective, gated 128-slice dual-source CTCA. Patients with PR were compared to those without PR for demographics and outcomes. Results: A total of 861 patients were included in our study; 241 (28%) had PR, and 620 (72%) had no PR. Patients with PR were older (PR: 63.9±11.0 years vs no PR: 62.1±11.2 years; p=0.04), more likely to be male (PR: 65.6% vs no PR: 55.8%; p=0.01) and underwent coronary angiography more frequently (PR: 25.7% vs no PR: 14.4%; p<0.01). There were also significant increases in subsequent acute coronary syndrome (ACS) events (PR: 2.5% vs no PR: 0.0%; p<0.01) and the need for revascularisation therapy (PR: 15.4% vs no PR: 7.8%; p<0.01) in patients with PR despite being on statins (not a high dose). There was no difference in all-cause mortality. Conclusions: Detection of PR on CTCA is a reliable prognostic indicator of future cardiovascular events and presents a valuable opportunity for initiation of aggressive primary prevention therapy.

Fatal case of delayed-onset haemolytic anaemia after oral artemether-lumefantrine.

Artemisinin derivatives are used globally in the management of falciparum malaria. Postartemisinin delayed haemolysis (PADH) is a recognised adverse event contributing to severe anaemia. To the best of our knowledge, we report the first recorded fatal case of PADH. A 60-year-old woman presented with two episodes of collapse at home and feeling generally unwell. She had recently been treated for uncomplicated falciparum malaria 1 month prior with artemether 80 mg/lumefantrine 480 mg in Congo. Her results on admission revealed an anaemia (haemoglobin 43 g/L), raised lactate dehydrogenase and positive direct antiglobulin test that suggested an intravascular haemolytic process. She made a capacitous decision to refuse blood products in line with her personal beliefs. Despite best supportive treatment, she did not survive. This case highlights the importance of postartemisinin follow-up and should encourage discussion and careful consideration of its use in the context of lack of access to/patient refusal of blood products.

Surgical management of a giant abdominal wall desmoid tumour.

Desmoid tumours are clonal fibroblastic proliferations in soft tissues, characterised by infiltrative growth and local recurrence, but not metastasis. Various treatment strategies for desmoid tumours exist, varying from observation, medical and systemic therapy to radiotherapy and surgery. A 25-year-old woman with a background of familial adenomatous polyposis was referred with an enlarging abdominal desmoid tumour measuring 40×40×40 cm despite repeated radiofrequency ablation, surgical debulking and hormone therapy. The patient had a two-stage operation. The first stage involved excision of the desmoid tumour with full-thickness abdominal wall. The abdominal wall was not closed, and a topical negative pressure seal was applied. After 2 days, she underwent the second stage: reconstruction of the abdominal wall defect with a large porcine mesh which was covered with anterolateral thigh flaps. Postoperative complications included ileus and a fall which required further surgery. The patient was discharged 1 month after the first operation. Abdominal MRI scans were performed at 3 and 7 months postdischarge and showed no recurrence of diseaseBackground.

Brainstem stroke presenting as isolated bilateral ptosis.

Pure midbrain infarctions not involving surrounding structures are an uncommon clinical phenomenon. A midbrain infarction that results in isolated bilateral ptosis as the only neurological deficit is much rarer and an easy diagnosis to miss; therefore, potentially leading to further downstream complications. We describe the case of an elderly patient who presented with isolated bilateral ptosis, initially thought to be consequent to myasthenia gravis but subsequently identified to have a perforator infarct in the midbrain, resulting in his symptoms.

Cat scratch disease sepsis in an immunocompromised patient.

As a greater number of households have pets, the likelihood of zoonotic infections can rise too. Although in most healthy individuals these infections are self-limiting, they are more serious and can lead to adverse outcomes in the immunocompromised. There is minimal information available for the immunocompromised patient who are pet owners or on pet handling. We report a case of cat scratch disease-related sepsis in an immunocompromised patient. This case illustrates the need for a detailed history, including a pet history, in immunocompromised patients presenting with fever of unknown origin and the need for UK-based information for the immunocompromised on pet care and risks associated with having a pet.

Recurrent severe respiratory infections with low CRP secondary to autoimmune IL-6 deficiency.

C reactive protein (CRP) is an inflammatory protein that is often used in conjunction with the clinical presentation of a patient to help with quantifying infection severity and measuring treatment response. We report the case of a patient who presented with severe pneumonias but had a suboptimal CRP response, later diagnosed as having an underlying immunodeficiency. This case exemplifies the need to consider immunodeficiency as an underlying pathophysiological cause in patients presenting with complicated and severe infections.

Bilateral optic disc swelling resulting from lymphocytic meningitis and posterior uveitis secondary to syphilis.

Idiopathic intracranial hypertension (IIH) is being diagnosed more often in the UK due to the rise in obesity. In fact, patients who present with bilateral optic disc swelling are habitually put on the papilloedema pathway, often without consideration of other diagnoses. We report the case of a middle-aged woman diagnosed with papilloedema and managed as IIH, until, cerebrospinal fluid (CSF) analysis revealed evidence of lymphocytic meningitis secondary to syphilis. The patient was treated successfully with intravenous antibiotics. Syphilis is the great masquerader and should be a diagnosis to consider in patients who have CSF findings incongruent with their clinical presentation.

Constrictive pericarditis masquerading as hepatic sequestration crisis in a patient with sickle cell disease: a case report.

BACKGROUND: Constrictive pericarditis is a challenging diagnosis that is easily overlooked. Worldwide, tuberculosis (TB) is the leading cause; however, in the developed countries pericarditis and cardiac surgery are common aetiologies. Medical therapy can be sufficient in specific aetiologies preventing progression of constriction and thus surgery. CASE SUMMARY: A young student from Nigeria, with established sickle cell disease, presented with hepatomegaly and features of right heart failure. Following multiple investigations for hepatomegaly and pyrexia of unknown origin he was initially treated for hepatic sequestration crisis. After readmission with ongoing pyrexia, he was noted to have features of constrictive physiology on cardiac imaging. Constrictive pericarditis, secondary to TB, was suspected based on the patient's background and clinical features. He was empirically commenced on anti-TB therapy after a positive interferon-gamma release assay test; Mycobacterium tuberculosis was later isolated in sputum cultures. He made a successful recovery with full radiological resolution of constrictive features on follow-up cardiac imaging. DISCUSSION: Constrictive pericarditis remains an elusive diagnosis in the context of coexisting medical problems. Revisiting the presentation and imaging helped in establishing the diagnosis. It is a potentially curable cause of diastolic heart failure with good outcomes if diagnosed and managed early. We were able to successfully manage the patient for TB constrictive pericarditis on medical therapy alone without surgical intervention.

Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study.

Objectives: We postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management. Design: The study was based on 'theory of change' concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome. Setting: This study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country. Participants: All participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study. Interventions: Monthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study. Main outcome measures: Total DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists. Results: There was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration. Conclusion: Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.