Search

Introduction Surgical inpatients frequently require peripherally inserted central catheters (PICCs) for parenteral feeding and administration of medication. PICCs may cause upper limb deep venous thrombosis (ULDVT), which impacts patient morbidity. We investigated the risk and prevention of PICC-ULDVT in hospitalised surgical inpatients. Methods We conducted a retrospective analysis of 168 consecutive surgical inpatients who received a PICC over the same four-year period. Data from 136 additional consecutive general medical inpatients with PICCs over the same period were included for comparison. We observed and compared the incidence of ULDVT confirmed on dedicated upper limb venous imaging in the cohort of surgical patients compared to a time matched cohort of medical patients. We extracted data including patient demographics, details of admission, and insertion site of the PICC from the hospital electronic notes. Results The incidence of ULDVT in surgical patients was 4.7% compared to 1.5% in medical patients despite increased age (p=0.001) and comorbidity burden (p=0.001) in the latter group. Ninety percent of surgical patients had abdominal surgery within 30 days of PICC placement. Regression multivariate analysis identified concurrent cancer (p=0.048), median Charlson Comorbidity Index (CCI) (p=0.034), admission with malignant bowel obstruction (p=0.002), and catheter insertion into the brachial vein (p=0.033) as significant risk factors for PICC-ULDVT in hospitalised surgical patients. Standard pharmacological venous thromboembolic events (VTE) prophylaxis, as per national guidelines, did not reduce the risk of PICC-ULDVT. Conclusion Our study indicates that surgical inpatients are at greater risk of developing PICC-associated upper limb deep vein thrombosis (ULDVT) compared to medical inpatients, with limited evidence supporting the effectiveness of pharmacological thromboprophylaxis in reducing this risk. PICCs should be used with caution in patients with cancer, cancer-related bowel obstruction, and surgical patients with a higher comorbidity index. PICCs inserted via the basilic vein may reduce ULDVT risk, but further studies are needed on the preferential site of insertion in surgical patients., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Wexham Park Hospital, Frimley Research, Quality Improvement and Excellence Department issued approval FH581. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Li et al.)

Sarcoidosis is an inflammatory disease characterised by non-caseating granulomas of unclear aetiology. Isolated cardiac sarcoidosis (ICS) is rare and occurs when there is granulomatous infiltration of myocardial tissue without evidence of extracardiac sarcoidosis. The heterogeneity in clinical manifestations often presents a diagnostic challenge which leads to delays in treatment initiation. Our case highlights the often quiescent presentation of ICS, the importance of early treatment and the diagnostic challenges that contribute to its underdiagnosis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: QRS fragmentation (fQRS) is a depolarization disorder that can be detected on routine electrocardiography (ECG). Current evidence suggests that fQRS is a prognosticator of adverse cardiovascular events. This study aimed to assess the relationship between fQRS and all-cause mortality in critically unwell coronavirus disease 2019 (COVID-19) patients and to investigate the significance of associated abnormalities on echocardiography., Methods: A retrospective cohort study of COVID-19 patients in a critical care setting was performed. Electrocardiography was performed on presentation to hospital, admission to the critical care unit, and at subsequent points according to clinical need. Transthoracic echocardiography was performed at clinical discretion to assess for structural and functional cardiac abnormalities. Primary outcome was in-hospital mortality and secondary outcome was the need for mechanical invasive ventilation., Results: Totally, 212 consecutive patients were included of which 120 (57%) exhibited fQRS and inferior leads were involved in 88% of the patients. Overall, fQRS was a significant predictor of mortality [65% vs. 44% P =.003; multivariate odds ratio = 2.96, 95% confidence interval (CI): 1.42-6.40, P =.005] and inferior fQRS itself was a significant predictor of mortality (P =.03). There was no significant association between fQRS and the need for invasive mechanical ventilation. A total of 112 patients underwent echocardiography. There was a greater incidence of right ventricular (RV) dilatation in the fQRS group (16% vs. 2% respectively, P =.02) and pulmonary hypertension (33% vs. 14% respectively, P =.03) based on echocardiographic criteria., Conclusion: Our study demonstrates that fQRS is significantly associated with RV dilation, pulmonary hypertension, and mortality in critically unwell COVID-19 patients.

Right heart thrombus in transit or "free-floating right heart thrombus" is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored., (© 2023. The Author(s).)

Purpose: To evaluate the prevalence and incidence of significant structural heart disease in targeted patients with cardiac symptoms referred by general practitioners (GPs) using open access echocardiography, without prior clinical evaluation by a cardiologist., Design: Data were derived from 488 subjects who underwent transthoracic echocardiography between January and April 2018. Patients were referred directly by GPs in East Berkshire, South England, through an online platform. Echocardiography was performed within 4-6 weeks of referral and all reports were assessed by a consultant cardiologist with expedited follow-up facilitated pro re nata. Results were analysed to determine the frequency of detection of structural abnormalities, particularly of the left ventricle and cardiac valves., Results: Echocardiography was prospectively performed in consecutive subjects (50% male, mean (±SD) age 68.5±22 years; 50% female; mean (±SD) 64.6 (±19.1)). At least one abnormality likely to change management was found in 133 (27.3%) of all open access echocardiograms. Clinical heart failure with left ventricular systolic dysfunction (LVSD) and diastolic dysfunction was confirmed in 46 (9%) and 69 (14%), respectively. Of the 46 patients with LVSD, 33 were new diagnoses. Significant cardiac valve disease was found in 42 (8.6%) patients. 12 of these had known valvular disease or previous valvular surgery, and 30 were new diagnoses., Conclusion: Major structural and functional cardiac abnormalities are common in late middle-aged patients who present to GPs with cardiac symptoms and signs. Reported, unrestricted open access echocardiography enables early detection of significant cardiac pathology and timely intervention may improve cardiovascular outcomes., (© The Author(s) 2022. Published by Oxford University Press on behalf of Postgraduate Medical Journal. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Polypharmacy is a growing phenomenon associated with adverse effects in older adults. We assessed the potential confounding effects of cumulative anticholinergic burden (ACB) in patients who were hospitalized with falls., Methods: A noninterventional, prospective cohort study of unselected, acute admissions aged ≥ 65 years. Data were derived from electronic patient health records. Results were analyzed to determine the frequency of polypharmacy and degree of ACB and their relationship to falls risk. Primary outcomes were polypharmacy, defined as prescription of 5 or more regular oral medications, and ACB score., Key Results: Four hundred eleven (411) consecutive subjects were included, mean age 83.8 ± 8.0 years: 40.6% men. There were 38.4% patients who were admitted with falls. Incidence of polypharmacy was 80.8%, (88.0% and 76.3% among those admitted with and without fall, respectively). Incidence of ACB score of 0, 1, 2, ≥ 3 was 38.7%, 20.9%, 14.6%, and 25.8%, respectively. On multivariate analysis, age [odds ratio (OR) = 1.030, 95% CI:1.000 ~ 1.050, P  = 0.049], ACB score (OR = 1.150, 95% CI:1.020 ~ 1.290, P  = 0.025), polypharmacy (OR = 2.140, 95% CI:1.190 ~ 3.870, P  = 0.012), but not Charlson Comorbidity Index (OR = 0.920, 95% CI:0.810 ~ 1.040, P  = 0.172) were significantly associated with higher falls rate. Of patients admitted with falls, 29.8% had drug-related orthostatic hypotension, 24.7% had drug-related bradycardia, 37.3% were prescribed centrally acting drugs, and 12.0% were taking inappropriate hypoglycemic agents., Conclusion: Polypharmacy results in cumulative ACB and both are significantly associated with falls risk in older adults. The presence of polypharmacy and each unit rise in ACB score have a stronger effect of increasing falls risk compared to age and comorbidities., Competing Interests: All authors understand the policy of declaration of interests. H.L.W., C.W., L.M., K.O.M., J.D., F.R.A., R.C., A.K.J.M., and C.G.M. all declare that that they have no competing interests., (© 2023 The Authors. Aging Medicine published by Beijing Hospital and John Wiley & Sons Australia, Ltd.)

Background: The public are increasingly reliant on the internet and media to access healthcare related information during the Covid-19 pandemic. Vitamin D is essential for musculoskeletal and immune health, with daily supplementation advised by public health bodies. Several studies assessing a possible link between vitamin D and Covid-19 severity have arrived at conflicting results and news articles have been rapidly disseminating such research to the public. There has been little focus on studying the quality of information available. Aim: To identify if online search interest in vitamin D increased with pandemic burden and analyse the accuracy of public health messaging relating to vitamin D in online news articles. Methods: Online search interest data for vitamin D was correlated with pandemic burden, defined as the number of Covid-19 deaths. Online news articles discussing vitamin D and Covid-19 were analysed using qualitative coding. Results: Online search interest for vitamin D increased as pandemic burden increased ( p  < 0.0001, Spearman's rank). Of the 72 articles identified, most (50%) offered a mixed opinion on the benefit of vitamin D in Covid-19. From articles making a recommendation for vitamin D supplementation, 23% of articles gave mixed messaging or advised against supplementation. 16% of articles recommended a dose which exceeded the safe limit of 4000 IU/day, risking toxicity. Conclusion: A significant number of articles provided mixed messaging or incorrectly advised supratherapeutic doses. This study highlights an opportunity for public health bodies to utilise the increased interest in vitamin D during the pandemic to raise awareness with accurate information.

Background: Drug-related bradycardia (DRB) is a common clinical conundrum and can result in multiple hospital admissions as a result of the increased prescription of rate-limiting medications that can predispose to presyncopal or syncopal episodes., Aim: To evaluate the incidence of DRB in elderly hospital inpatients., Methods: We conducted a retrospective analysis of all patients admitted to our acute medical unit between November 2018 and February 2019 and identified patients over the age of 70 with more than one diurnal bradycardic episode during their admission. We extracted patient demographics, presenting complaint, admission 12-lead ECG and medications from the hospital electronic database., Results: We screened 2312 adults and identified 100 patients over the age of 70 years with two or more episodes of diurnal bradycardia during their hospital admission. This constituted 4.32% of total admissions. Beta blockers were the most commonly prescribed rate-limiting medication (n=54, 87.1%), of which bisoprolol was the most frequently prescribed (n=41) and sinus bradycardia was the most commonly identified rhythm disturbance in our cohort of patients (n=41, 41%). Syncope was the most common presenting symptom and occurred in 23 patients, 14 (60.9%) of which were diagnosed with a DRB. Atrial fibrillation was more common in those with DRB compared with those with bradycardia not caused by medications (35.5% vs 10.5%, p=0.006), and atrial fibrillation was a significant predictor of DRB (OR=10.2, 95% CI 3.3 to 31.6, p&lt;0.001)., Conclusion: Bradycardia is a significant cause of hospital admissions in older adults and can be avoided with pharmacovigilance. Caution should be exercised when initiating or changing the dose of rate-limiting agents in these patients; while those with atrial fibrillation should undergo regular review of their heart rate followed by appropriate medication dose adjustments., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To evaluate the prevalence and incidence of significant structural heart disease in targeted patients with cardiac symptoms referred by general practitioners (GPs) using open access echocardiography, without prior clinical evaluation by a cardiologist., Design: Data were derived from 488 subjects who underwent transthoracic echocardiography between January and April 2018. Patients were referred directly by GPs in East Berkshire, South England, through an online platform. Echocardiography was performed within 4-6 weeks of referral and all reports were assessed by a consultant cardiologist with expedited follow-up facilitated pro re nata. Results were analysed to determine the frequency of detection of structural abnormalities, particularly of the left ventricle and cardiac valves., Results: Echocardiography was prospectively performed in consecutive subjects (50% male, mean (±SD) age 68.5±22 years; 50% female; mean (±SD) 64.6 (±19.1)). At least one abnormality likely to change management was found in 133 (27.3%) of all open access echocardiograms. Clinical heart failure with left ventricular systolic dysfunction (LVSD) and diastolic dysfunction was confirmed in 46 (9%) and 69 (14%), respectively. Of the 46 patients with LVSD, 33 were new diagnoses. Significant cardiac valve disease was found in 42 (8.6%) patients. 12 of these had known valvular disease or previous valvular surgery, and 30 were new diagnoses., Conclusion: Major structural and functional cardiac abnormalities are common in late middle-aged patients who present to GPs with cardiac symptoms and signs. Reported, unrestricted open access echocardiography enables early detection of significant cardiac pathology and timely intervention may improve cardiovascular outcomes., (© The Author(s) 2022. Published by Oxford University Press on behalf of Postgraduate Medical Journal. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: We have previously demonstrated that vitamin D deficiency might be associated with worse outcomes in hospitalized Covid-19 patients. The aim of our study was to explore this relationship with dexamethasone therapy., Methods: We prospectively studied two cohorts of hospitalized Covid-19 patients between March and April and between September and December 2020 (n = 192). Patients were tested for serum 25-hydroxyvitamin D (25-OH-D) levels during admission. The first cohort not treated with dexamethasone (n = 107) was divided into vitamin D deficient (25-OH-D ≤ 30 nmol/L) (n = 47) and replete subgroups (25-OH-D > 30 nmol/L) (n = 60). The second cohort treated with dexamethasone (n = 85) was similarly divided into deficient (25-OH-D ≤ 30 nmol/L) (n = 27) and replete subgroups (25-OH-D > 30 nmol/L) (n = 58). Primary outcome was in-hospital mortality and secondary outcomes were elevation in markers of cytokine storm and ventilatory requirement., Results: No mortality difference was identified between cohorts and subgroups. The "no dexamethasone" cohort 25-OH-D deplete subgroup recorded significantly higher peak D-Dimer levels (1874 vs. 1233 µgFEU/L) (p = 0.0309), CRP (177 vs. 107.5) (p = 0.0055), and ventilatory support requirement (25.5% vs. 6.67%) (p = 0.007) compared to the replete subgroup. Among the 25-OH-D deplete subgroup higher peak neutrophil counts, peak CRP, peak LDH, peak ferritin, and lower trough lymphocyte counts were observed, without statistical significance. In the "dexamethasone" cohort, there was no apparent association between 25-OH-D deficiency and markers of cytokine storm or ventilatory requirement., Conclusion: Vitamin D deficiency is associated with elevated markers of cytokine storm and higher ventilatory requirements in hospitalized Covid-19 patients. Dexamethasone treatment appears to mitigate adverse effects of vitamin D deficiency., (© 2021 Wiley Periodicals LLC.)

Background: Diagnostic methods for Covid-19 have improved, both in speed and availability. Because of atypical and asymptomatic carriage of the virus and nosocomial spread within institutions, timely diagnosis remains a challenge. Machine learning models trained on blood test results have shown promise in identifying cases of Covid-19., Aims: To train and validate a machine learning model capable of differentiating Covid-19 positive from negative patients using routine blood tests and assess the model's accuracy against atypical and asymptomatic presentations., Design and Methods: We conducted a retrospective analysis of medical admissions to our institution during March and April 2020. Participants were categorized into Covid-19 positive or negative groups based on clinical, radiological features or nasopharyngeal swab. A machine learning model was trained on laboratory parameters and validated for accuracy, sensitivity and specificity and externally validated at an unconnected establishment., Results: An Ensemble Bagged Tree model was trained on data collected from 405 patients (212 Covid-19 positive) producing an accuracy of 81.79% (95% confidence interval (CI) 77.53-85.55%), the sensitivity of 85.85% (CI 80.42-90.24%) and specificity of 76.65% (CI 69.49-82.84%). Accuracy was preserved for atypical and asymptomatic subgroups. Using an external data set for 226 patients (141 Covid-19 positive) accuracy of 76.82% (CI 70.87-82.08%), sensitivity of 78.38% (CI 70.87-84.72%) and specificity of 74.12% (CI 63.48-83.01%) was achieved., Conclusion: A machine learning model using routine laboratory parameters can detect atypical and asymptomatic presentations of Covid-19 and might be an adjunct to existing screening measures., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Older adults are more likely to be vitamin D deficient. The aim of the study was to determine whether these patients have worse outcomes with COVID-19., Methods: We conducted a prospective cohort study between 1 March and 30 April 2020 to assess the importance of vitamin D deficiency in older patients with COVID-19. The cohort consisted of patients aged ≥65 years presenting with symptoms consistent with COVID-19 (n=105). All patients were tested for serum 25-hydroxyvitamin D (25(OH)D) levels during acute illness. Diagnosis of COVID-19 was confirmed via viral reverse transcriptase PCR swab or supporting radiological evidence. COVID-19-positive arm (n=70) was sub-divided into vitamin D-deficient (≤30 nmol/L) (n=39) and -replete groups (n=35). Subgroups were assessed for disease severity using biochemical, radiological and clinical markers. Primary outcome was in-hospital mortality. Secondary outcomes were laboratory features of cytokine storm, thoracic imaging changes and requirement of non-invasive ventilation (NIV)., Results: COVID-19-positive arm demonstrated lower median serum 25(OH)D level of 27 nmol/L (IQR=20-47 nmol/L) compared with COVID-19-negative arm, with median level of 52 nmol/L (IQR=31.5-71.5 nmol/L) (p value=0.0008). Among patients with vitamin D deficiency, there was higher peak D-dimer level (1914.00 μgFEU/L vs 1268.00 μgFEU/L) (p=0.034) and higher incidence of NIV support and high dependency unit admission (30.77% vs 9.68%) (p=0.042). No increased mortality was observed between groups., Conclusion: Older adults with vitamin D deficiency and COVID-19 may demonstrate worse morbidity outcomes. Vitamin D status may be a useful prognosticator., Competing Interests: Competing interests: All authors understand the policy of declaration of interests. CGM is a former member of the Fellowship of Postgraduate Medicine (FPM) council and is currently an FPM Fellow. VB, TH, NP, SS, PK, KVdA, AKJM all declare that they have no competing interests., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: No financial or personal conflicts of interest for any author.

Background: It is increasingly recognised that older patients may not present with typical symptoms of COVID-19., Aims: This study aims to evaluate the incidence, characteristics and clinical outcome of older adults with atypical presentations of COVID-19., Methods: A retrospective analysis of adults ≥ 65 years with confirmed COVID-19 admitted to our institution between 1 March and 24 April 2020 was performed. Patients were categorised into typical or atypical groups based on primary presenting complaint in the community., Results: One hundred twenty-two patients (mean age 81 ± 8 years; 62 male) were included. Seventy-three (60%) were categorised into the typical group and 49 (40%) into the atypical group. In the atypical group, common presenting complaints were fall in 18 (36%), reduced mobility or generalised weakness in 18 (36%) and delirium in 11 (22%). Further assessment by paramedics and on admission found 32 (65%) to have typical features of COVID-19, fever being the most common, and 22 (44%) were hypoxic. This subset had worse outcomes than those in the typical group with a mortality rate of 50% versus 38%, respectively, although this was not statistically significant (P = 0.27). No significant difference in mortality or length of hospital stay between the groups was demonstrated., Conclusion: Older patients with atypical presentation of COVID-19 in the community are equally susceptible to poor outcomes. Early detection may improve outcomes and limit community transmission. Primary care practitioners should be vigilant and consider prompt onward referral.

Background: The neurocognitive benefits of donepezil are well recognised, but the potential side effects on cardiac conduction remain unclear., Objective: To investigate whether long-term donepezil therapy is associated with electrocardiographic (ECG) changes and in particular to assess its effects on the QT interval., Methods: We conducted a single centre retrospective analysis of patients admitted to our trust on donepezil therapy over a 12-month period. An admission resting 12-lead ECG was obtained and compared to their ECG prior to commencement of donepezil therapy to assess for any significant difference in ECG parameters., Results: We identified 59 patients suitable for analysis. PR (177.0 ± 29.0 ms vs. 186.1 ± 34.2 ms, p  = 0.04), QRS (101.7 ± 20.3 ms vs. 104.7 ± 22.3 ms, p  = 0.04) and QT (393.3 ± 35.6 ms vs. 411.9 ± 44.6 ms, p  = 0.002) interval prolongation were all associated with donepezil use. The increase in QT intervals remained significant on correction for heart rate; resulting in 8 (13.6%) patients developing high arrhythmogenic risk based on assessment using QT nomogram plots. Concomitant use of tricyclic antidepressants was associated with significant QT prolongation (QTcB: r pb = 0.344, p  = 0.008, QTcFred: r pb = 0.382, p  = 0.003, QTcFram: r pb = 0.379, p  = 0.003, QTcH: r pb = 0.352, p  = 0.006), while the use of rate-limiting calcium channel blockers was associated with significant PR prolongation ( r pb = 0.314, p  = 0.030), and beta-blockers with a reduction in heart rate ( r pb = 0.256, p  = 0.050)., Conclusion: Our results clearly demonstrate that long-term use of donepezil is associated with prolongation of the QT interval. We suggest ECG evaluation should take place before and after donepezil initiation, and clinicians should be even more vigilant in those prescribed tricyclic antidepressants.

Acetylcholinesterase inhibitors such as donepezil delay the progression of Alzheimer's dementia by increasing acetylcholine concentrations in the central nervous system. However, it is becoming apparent that cholinesterase inhibition by donepezil is not confined to the brain. This is supported by previous case reports of peripheral cholinergic side effects and adverse cardiac arrhythmias such as Torsades de Pointes which are reversible upon cessation of donepezil. The augmented acetylcholine concentrations and I Kr inhibition in cardiomyocytes caused by donepezil are believed to mediate this effect.

Purpose: Sacubitril/valsartan has been demonstrated to improve prognosis and outcomes in heart failure with reduced ejection fraction (HFrEF) patients. We sought to compare the improvement in cardiac function between non-ischaemic and ischaemic cardiomyopathy for patients receiving sacubitril/valsartan., Methods: We conducted a single centre prospective cohort survey of patients reviewed in the Heart Function Clinic between February 2017 and January 2018. Functional evaluation and measurement of biochemical and echocardiographic parameters occurred before the initiation of sacubitril/valsartan, and after 3 months of treatment., Results: We identified 52 patients (26 non-ischaemic and 26 ischaemic cardiomyopathy) suitable for treatment with sacubitril/valsartan. Treatment was followed by a significant decrease in a New York Heart Association (NYHA) class in both patients with non-ischaemic (2.3 ± 0.6 vs. 1.6 ± 0.7, P < 0.001) and ischaemic cardiomyopathy (2.3 ± 0.5 vs. 1.5 ± 0.6, P < 0.001), along with an increase in ejection fraction in both patients with non-ischaemic (26.2% ± 6.5% vs. 37.2% ± 13.8%, P < 0.001) and ischaemic cardiomyopathy (28.1% ± 5.7% vs. 31.5% ± 8.4%, P = 0.007). The improvement in ejection fraction was significantly greater in the patients with non-ischaemic cardiomyopathy compared to those with ischaemic cardiomyopathy (10.7% ± 13.0% vs. 3.9% ± 6.0%, P = 0.023)., Conclusion: Our study suggests that treatment with sacubitril/valsartan in patients with non-ischaemic cardiomyopathy is followed by a greater improvement in ejection fraction than in patients with ischaemic cardiomyopathy.

Background: The thrombogenic potential of Covid-19 is increasingly recognised. We aim to assess the characteristics of COVID-19 patients diagnosed with pulmonary embolism (PE)., Methods: We conducted a single centre, retrospective observational cohort study of COVID-19 patients admitted between 1st March and 30th April 2020 subsequently diagnosed with PE following computed tomography pulmonary angiogram (CTPA). Patient demographics, comorbidities, presenting complaints and inpatient investigations were recorded., Results: We identified 15 COVID-19 patients diagnosed with PE (median age = 58 years [IQR = 23], 87% male). 2 died (13%), both male patients >70 years. Most common symptoms were dyspnoea (N = 10, 67%) and fever (N = 7, 47%). 12 (80%) reported 7 days or more of non-resolving symptoms prior to admission. 7 (47%) required continuous positive airway pressure (CPAP), 2 (13%) of which were subsequently intubated. All patients had significantly raised D-dimer levels, lactate dehydrogenase (LDH), C-reactive protein (CRP), ferritin and prothrombin times. The distribution of PEs correlated with the pattern of consolidation observed on CTPA in 9 (60%) patients; the majority being peripheral or subsegmental (N = 14, 93%) and only 1 central PE. 10 (67%) had an abnormal resting electrocardiogram (ECG), the commonest finding being sinus tachycardia. 6 (40%) who underwent transthoracic echocardiography (TTE) had structurally and functionally normal right hearts., Conclusion: Our study suggests that patients who demonstrate acute deterioration, a protracted course of illness with non-resolving symptoms, worsening dyspnoea, persistent oxygen requirements or significantly raised D-dimer levels should be investigated for PE, particularly in the context of COVID-19 infection. TTE and to a lesser degree the ECG are unreliable predictors of PE within this context., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Fahr's disease is a sporadic or familial neurodegenerative disorder characterized by symmetrical calcification of cerebral structures, particularly the basal ganglia, cerebellar dentate nuclei and surrounding white matter, in the absence of metabolic causes of calcification. We report the case of a previously fit, high functioning 58-year-old man who developed catastrophic irreversible neuropsychiatric collapse after sepsis despite appropriate antimicrobial treatment. Cranial computed tomography revealed extensive diffuse calcifications located in unusual areas. Laboratory studies excluded the presence of other pathologic processes leading to secondary intracranial calcification and a multigene panel failed to confirm mutations in the genes currently known to be associated with the disorder, supporting a diagnosis of sporadic Fahr's disease or idiopathic brain calcification. Important diagnostic considerations in the septic patient who develops neurological complications, namely sepsis-associated encephalopathy and antibiotic-associated encephalopathy, are discussed. The patient remains severely handicapped 6 months after the acute event. Patients with clinically silent neurodegenerative/neuropsychiatric conditions, such as Fahr's disease, may present with florid and unpredicted neurological features in the context of systemic illness., (Copyright © 2020 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Heart failure is a prevalent condition associated with frequent and costly hospital admissions. Hospitalizations are primarily related to worsening fluid retention and often require admission for decongestion with intravenous diuretics., Objective: To assess the safety of an outpatient intravenous diuresis service for heart failure patients, and its impact on emergency admissions and the cost of treatment., Methods: We conducted a prospective observational cohort registry study on patients referred to the diuretic lounge at our acute hospital between May 2017 and April 2018., Results: We analysed 245 patients treated in the diuretic lounge, of which 190 (77.6%) avoided hospitalization or any adverse events during the 60 days of follow up (77.6% vs. 22.4%; P < 0.001). The diuretic lounge service resulted in a significant decrease in emergency heart failure admissions compared to the previous 12 months (823 vs. 715 per annum; 68.6 ± 10.1 vs. 59.6 ± 14 per month; P = 0.04), and a numerical reduction in readmission rates (17.3% vs. 16.2%). The 13.1% decrease in admissions lead to financial savings of £315 497 per annum and £2921 per admission avoided. During the same time period, at the other acute hospital site in our trust, where no diuretic lounge service is available, the number of admissions did not significantly change (457 vs. 450 per annum; 37.5 ± 7.0 vs. 38.1 ± 7.6 per month; P = 0.81)., Conclusion: Ambulatory administration of intravenous diuretics reduces emergency admissions and is a safe and cost-effective alternative to treat acute decomposition in heart failure patients., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Pseudo-azotemia is the syndrome of hypercreatininemia and hyperkaliemia without a change in glomerular filtration rate or structure of the kidney. A 57-year-old vulnerable woman with learning difficulties experienced an intraperitoneal bladder rupture in the absence of a pelvic fracture after a fall. It is suspected that the blunt force compression of a distended bladder situated above the bony protection of the pelvis resulted in delayed intraperitoneal bladder rupture. Urinary ascites resulted in pseudo-azotemia because of urinary creatinine reabsorption across the peritoneum. This "apparent" renal failure is fully reversible when diagnosis and treatment are prompt, with normalization of abnormal laboratory-investigation results often within 24 hours., (Copyright © 2020 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)