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Giant cell arteritis (GCA) is an important condition to suspect and treat early, as failure to do so can result in anterior ischaemic optic neuropathy and subsequent permanent visual loss. A 71-year-old woman presented to her local emergency department with a 1-week history of constant, moderate–severe global headache associated with intermittent periorbital pain. Two weeks later she developed sudden horizontal diplopia. Examination demonstrated right oculomotor nerve palsy. Her erythrocyte sedimentation rate (ESR) was 9 mm/hr. Repeat blood tests 1 month later showed an ESR of 67 mm/hr. Temporal artery biopsy was positive. A review from a cohort of 764 patients with suspected GCA who underwent biopsy found the sensitivity of an elevated ESR and c-reactive protein was 84% and 86%, respectively, but the specificity was only 30%. Therefore, inflammatory markers should only act as a guide, and caution should be taken in their interpretation especially with respect to the time of sampling in the disease evolution. Isolated oculomotor nerve palsy in association with GCA is rare. The first case series was described by miller fisher in 1959 who observed two patients presenting with diplopia, ptosis and ocular palsies. In anyone over the age of 50 who develops a new, refractory headache and cranial neuropathy, GCA should be the first consideration.

To evaluate the impact of a dedicated, free-floating, pediatric-targeted care delivery model on emergency department (ED) waiting times, parent satisfaction, and transition of care.A prospective, observational study was conducted between July 16 and August 12, 2007. It incorporated a before-and-after design with a 2-week preintervention and a 2-week intervention group. In the intervention period, the pediatric ED initiative (PEDI) team was introduced, which consisted of a free-floating doctor and nurse equipped to see pediatric patients. Consenting patients/parents were followed up by telephone 7 to 14 days after discharge regarding satisfaction and waiting times.Four hundred fifty-three pediatric presentations (216 in the preintervention group and 237 in the intervention group) were analyzed, of which the PEDI team treated 81 pediatric patients during the intervention period. The intervention group had a significantly shorter length of stay in the ED (158 vs 194 minutes; P = 0.01). However, there was no difference in time to be seen by a doctor (80 vs 78 minutes; P = 0.54). Satisfaction of the total study group was significantly related to staff attitude and understanding of the wait.A dedicated pediatric team that specifically sees and treats pediatric populations during times of peak ED workload can reduce total ED length of stay for pediatric presentations, but has no effect on waiting time to see a doctor. There was only a marginal impact of the PEDI team on both transition of care and satisfaction indicators. Waiting times, staff attitude, and patient education proved to be important determinants of overall satisfaction for the total study group.

THE EXACT nature of essential hypertension has not been clearly established, and, as a result, many drugs, diets, and operative procedures have been used in the treatment of this disease. In most instances therapy has either proved more annoying to the patient than the disease itself or produced variable results. The numerous theories regarding the etiological basis of essential hypertension have been summarized repeatedly by many authors,1but at present most observers agree that there are probably both neurogenic and humoral factors that produce and maintain blood pressure in certain persons at a hypertensive level. A great deal of the treatment has been aimed at controlling or eliminating the neurogenic factor, for the exact humoral mechanism that operates in hypertension has still not been clarified. Other drugs have been used because of their direct action upon the vascular system. Therapy with thiocyanate derivatives has been employed for years, and