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In recent years, subacute care units (SCUs) have emerged as alternatives to acute hospitalization for selected emergency department (ED) patients who might benefit from a short period of inpatient stay within a less acute setting. We developed a new protocol to directly admit selected older patients from our acute hospital's (AH) ED to the SCU of a partner community hospital, making use of our ED's short-stay ward as a transit area to overcome administrative, financial, and clinical barriers. The new protocol has removed the need for intervening stays of longer than 24 hours at our AH, reduced overall length of stay across both institutions, decreased hospital admissions, and reduced the number of patient hand-offs.

We report a case of a 72-year-old woman who presented with ST-elevation myocardial infarction (STEMI). However, coronary angiography showed unobstructed arteries while echocardiography (ECHO) showed severe left ventricular (LV) apical hypokinesia with ejection fraction (EF) of 25–30%. Seven months later she presented with a transient ischaemic attack and a repeat ECHO showed a normal EF. A few months later, she was diagnosed with breast cancer and as part of staging procedure, an incidental left adrenal mass was identified. This was biochemically confirmed as phaeochromocytoma (PY) and she underwent laparoscopic adrenalectomy. PY is a rare catecholamine secreting tumour arising from adrenomedullary chromaffin cells. Excessive catecholamine-induced stimulation can present as transient, reversible cardiomyopathy similar to Takotsubo cardiomyopathy and cerebrovascular events. The diagnosis of PY is often delayed but it is important to recognize PY as a cause of reversible cardiomyopathy. Early intervention is essential to improve mortality from cardiovascular and cerebrovascular complications.

Hepatopulmonary syndrome (HPS) is often not considered as a cause of breathlessness in patients with liver cirrhosis. It consists of a triad of liver disease, intrapulmonary shunting and hypoxaemia. Here we discuss HPS in a patient presenting with acute on chronic breathlessness and typical features of orthodeoxia and platypnoea. Evidence of intrapulmonary shunting on imaging was essential to making the diagnosis, which carries a poor prognosis and was an urgent indication for liver transplantation.

As the newer oral anticoagulants (NOACs) are increasingly used in older patients, clinical scenarios when they may need to be discontinued temporarily or indefinitely, may be encountered. Similarly with increasing use of permanent pacemakers and other intra-cardiac devices, there is an increased risk of upper limb venous thrombosis even few years after their insertion. We report a case of a patient with a permanent pacemaker, on rivaroxaban (NOAC) for atrial fibrillation, who developed an upper extremity deep vein thrombosis after its temporary withdrawal following a traumatic acute subdural haematoma. Physicians should be aware of the possibility of rebound hypercoagulability and venous thrombosis soon after the withdrawal of NOACs.

Giant cell arteritis is a common cause of headache in patients aged more than 50 years. It is an easy diagnosis to make if classical features, ie temporal headache, jaw claudication, visual symptoms, systemic symptoms of fever or weight loss with high erythrocyte sedimentation rate and anemia, are present. However, it may present atypically and stroke can be the presenting feature. A high index of suspicion is needed in atypical presentations such as stroke. Once a diagnosis is suspected it is imperative to start high dose steroids to prevent visual and neurological complications.

A 94 year old woman with mild dementia, peripheral vascular disease, and type 2 diabetes mellitus was discharged from hospital after completing antiviral treatment for a lower respiratory tract infection (influenza A3). She was readmitted four days later with secondary pneumonia and bacteraemia (meticillin sensitive Staphylococcus aureus , isolated from blood but not from lung or sputum samples). She was started on intravenous cloxacillin (2 g, every six hours) according to local guidelines. She had no episodes of diarrhoea, vomiting, respiratory muscle weakness, or paralytic ileus. On admission, her temperature was 38°C, blood pressure 141/70 mm Hg, respiratory rate 24 breaths/min, heart rate 114 beats/min, and peripheral capillary oxygen saturation 94%. Chest examination found normal heart sounds and right basal crepitations. Her abdomen was soft and non-tender; and her weight was 43 kg (body mass index 16 kg/m2). By day five, her respiratory parameters had improved, but she had developed extreme fatigue with refractory hypokalaemia, despite oral and parenteral replacements (table 1⇓). View this table: Table 1 Serum levels and intravenous potassium replacement She continued on regular 100 mg aspirin and 20 mg omeprazole once daily and 250 mg tolbutamide twice daily. She was started on 600 mg slow release potassium chloride twice daily in addition to intravenous replacement. Her haemoglobin level was 134 …