How many patients can community matrons successfully case manage?

AIM: To describe actual patient caseload sizes among case managers for long term conditions and explore issues of caseload manageability. BACKGROUND: Department of Health guidance advises that community matron case managers for long term conditions should manage caseloads of 50-80 patients. However, there is currently no evidence to justify these caseload targets. METHOD: In-depth interviews were conducted with 46 case managers for long term conditions, five clinical leads and six programme leads across six Primary Care Trusts. FINDINGS: Case managers had caseloads of 10-55 patients each, although numbers fluctuated from week to week. The current caseload target was regarded as difficult to manage. Heavy caseloads were perceived to result in a shift from proactive care towards reactive care, decreased quality of care and increased hospital admissions. CONCLUSION: Case managers for long term conditions are struggling to achieve and maintain caseload targets. Further research is necessary to identify the most appropriate caseload size and provide an evidence base for policy. IMPLICATIONS FOR NURSING MANAGEMENT: Programme leads and managers need to carefully assess the local situation, the characteristics of the target population and the practicalities of delivering the model of care before identifying appropriate caseload targets.     

Does lenticulostriate vasculopathy predipose to ischemic brain infarct? A case report

Lenticulostriate vasculopathy (LSV) is a sonographic finding in infancy with obscure etiology and variable diagnostic and prognostic significance. Ischemic infarct in the territory of the lenticulostriate vessels after mild head trauma is a rare pathology. There are no publications on LSV followed by ischemic infarct. We present the case of an 8‐month‐old boy who suffered mild head trauma and developed an ischemic brain infarct in the territory of preexisting LSV. It is speculated that LSV might be a predisposing factor for ischemic brain infarct after mild head trauma in infants. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2012     

Gerstmann-Str?ussler-Scheinker disease: A case report

BACKGROUND Gerstmann-Str?ussler-Scheinker(GSS) disease is an inherited prion disease that is clinically characterized by the early onset of progressive cerebellar ataxia. The incidence of GSS is extremely low and it is particularly rare in China. Therefore,clinicians may easily confuse this disease with other diseases that also cause ataxia, resulting in its under-diagnosis or misdiagnosis.CASE SUMMARY Here, we report the first case of genetically diagnosed GSS disease in Northeast China. The patient exhibited typical ataxia and dysarthria 2.5 years after symptom onset. However, magnetic resonance imaging of the brain and spinal cord revealed a normal anatomy. Screening results for the spinocerebellar ataxia gene were also negative. We thus proposed to expand the scope of genetic screening to include over 200 mutations that can cause ataxia. A final diagnosis of GSS was presented and the patient was followed for more than 3.5 years, during which we noted imaging abnormalities. The patient gradually exhibited decorticate posturing and convulsions. We recommended administration of oral sodium valproate, which resolved the convulsions.CONCLUSION Patients with inherited ataxia should be considered for a diagnosis of GSS via genetic testing at an early disease stage.     

Obstructive jaundice secondary to multiple myeloma—A case report

Reported is a patient who presented with clinical obstructive jaundice caused by multiple myeloma involving the pancreatic head. This is a rare complication and a review of the literature showed only three similar reported cases.     

How do paramedics manage the airway during out of hospital cardiac arrest?

Aim

The best method of initial airway management during resuscitation for out of hospital cardiac arrest (OHCA) is unknown. The airway management techniques used currently by UK paramedics during resuscitation for OHCA are not well documented. This study describes the airway management techniques used in the usual practice arm of the REVIVE-Airways feasibility study, and documents the pathway of interventions to secure and sustain ventilation during OHCA.

Method

Data were collected from OHCAs attended by paramedics participating in the REVIVE-Airways trial between March 2012 and February 2013. Patients were included if they were enrolled in the usual practice arm of the study, fulfilled the main study eligibility criteria and did not receive either of the intervention supraglottic airway devices during the resuscitation attempt.

Results

Data from 196 attempted resuscitations were included in the analysis. The initial approach to airway management was bag-mask for 108 (55%), a supraglottic airway device (SAD) for 39 (20%) and tracheal intubation for 49 (25%). Paramedics made further airway interventions in 64% of resuscitations. When intubation was the initial approach, there was no further intervention in 76% of cases; this compares to 16% and 44% with bag-mask and SAD respectively. The most common reason cited by paramedics for changing from bag-mask was to carry out advanced life support, followed by regurgitation and inadequate ventilation. Inadequate ventilation was the commonest reason cited for removing a SAD.

Conclusion

Paramedics use a range of techniques to manage the airway during OHCA, and as the resuscitation evolves. It is therefore desirable to ensure that a range of techniques and equipment, supported by effective training, are available to paramedics who attend OHCA.     

A simple appendicitis? An anatomical pitfall: A case report

Rationale: We present a case of appendicitis with an uncommon course due to rare anatomical location of the appendix in the right retroperitoneal space below the diaphragm and above the liver.Patient's concern: A 32-year-old, previously healthy male with a history of congenital diaphragmatic hernia repair in childhood, presented with 3 days of mild, colicky, central abdominal pain associated with fever, nausea and vomiting. At presentation, pain was localized to the right lower quadrant. Diagnosis: Even though diagnosis of appendicitis was clear, we decided to confirm it with computer tomography (CT). CT revealed elevation of the right dome of the diaphragm and perforated appendix located above the liver. Intervention: Appendectomy was performed via right subcostal approach instead of usual incision in the right lower quadrant. Outcome: Patient recovered well and was discharged on the 5th day after operation. Lessons: Previous congenital diaphragmatic hermia repair may change the location of the appendix. The appendix at rare locations could lead to an uncommon course of appendicitis. On this very note, surgeons should have a high index of suspicion, and CT may help avoid inadvertent complications.     

How significant is persistent chest pain in a young HIV-positive patient during acute inpatient rehabilitation? a case report

Chest pain in a patient with acquired immune deficiency syndrome (AIDS) has a broad differential diagnosis including, but not limited to, coronary artery disease, gastroesophageal reflux, fungal esophagitis, and musculoskeletal pain. However, spontaneous pneumothorax must also be added to the list of possibilities. Spontaneous pneumothorax occurs 450 times more frequently in patients with AIDS versus the general population and is now the leading cause of nontraumatic pneumothorax in the urban population, to include both those with and without AIDS. Because many patients with human immunodeficiency virus (HIV) are young and typically devoid of comorbidity, the presentation of this pulmonary complication may be subtle. HIV-positive patients are receiving rehabilitation services more frequently; therefore, the physiatrist must be aware of the potential for spontaneous pneumothorax to be an etiology of chest pain. We present a case exemplifying the need for rehabilitation professionals to maintain a broad-based approach when caring for patients with HIV and AIDS.     

How do I manage post-polypectomy bleeding?

Colonoscopic polypectomy is an effective method for prevention of colorectal cancer and has become one of the most common procedures worldwide. Most colorectal polyps can be removed safely by various polypectomy techniques; however, serious complications can occur. Postpolypectomy bleeding is the most common complication of colonoscopic polypectomy, accounting for 0.3% to 6.1% of polypectomy. This issue summarizes various endoscopic techniques to treat postpolypectomy bleeding.     

Leave the levofloxacin? A case report of levofloxacin-induced psychosis

Fluoroquinolones, including levofloxacin, exhibit desirable antimicrobial characteristics, including broad spectrum of activity and excellent bioavailability. This widely prescribed class of antibiotics has come under scrutiny due to a new black box warning of adverse reactions. Central nervous system effects have been sparsely described in previous literature. We present a case of levofloxacin-induced psychosis in a patient without underlying psychological history.     

How do I manage severe postpartum hemorrhage?

In the United States, postpartum hemorrhage (PPH) accounts for 4.6% of all maternal deaths and is responsible for major peripartum medical and surgical morbidity. Therefore, a national health priority is to ensure that women who experience severe PPH receive timely, appropriate, and effective treatment. In this article, we describe our system-wide approach for the planning and delivery of women with suspected placenta accreta spectrum disorder, a condition associated with life-threatening blood loss at the time of delivery. We also highlight current evidence related to transfusion decision making and hemostatic monitoring during active postpartum bleeding. Specifically, we describe how we activate and use the massive transfusion protocol to obtain sufficient volumes and types of blood products. We also describe how we use viscoelastic monitoring (thromboelastography) and standard laboratory tests to assess the maternal coagulation profile. Finally, we review the findings of recent studies examining the potential efficacy of tranexamic acid and fibrinogen concentrate as adjuncts for PPH prevention and treatment. We describe how we have incorporated these drugs into PPH treatment protocols at our institution.