The "Cooing Pigeon": TAVI for Acute Aortic Regurgitation Secondary to Homograft Degeneration.

We present a case of acute aortic homograft regurgitation manifesting as a new-onset "cooing" murmur in a patient with congenital heart disease who did not have signs of clinical decompensation or evidence of infective endocarditis. He underwent successful transcatheter aortic valve implantation following a diagnosis of sterile acute valvular degeneration. (Level of Difficulty: Intermediate.).

Mother-and-Child Telescopic Guide-Catheter Extension to Identify Severe Left Main Stem Disease in a Patient With a Severely Dilated Aortic Root.

The importance of selective coronary angiography in patients with severely dilated aortas awaiting surgery is discussed.

Improving phlebotomy handover to doctors: a quality improvement project.

AIM: To design a hospital-standardised phlebotomy handover method to improve the communication between phlebotomists and doctors. To reduce delays in patient management and discharges which occur due to poor handover. METHOD: Qualitative data was collected to gauge junior doctors' experiences of the current handover process. Quantitative data was collected over a two-week period across two medical wards to measure the proportion of requested bloods that could not be taken by phlebotomists that were successfully handed over to doctors. Brainstorming sessions were held with junior doctors, phlebotomists and ward staff in order to design a, cheap, effective, sustainable, hospital-wide method of handover. The chosen intervention was a red ward-based phlebotomy handover folder for phlebotomists to place stickers of unbled patients in. The folder was trialled on two medical wards. Feedback obtained helped improve the intervention before implementing it hospital-wide. RESULTS: Seventeen of 23 junior doctors (74%) felt that a formalised handover process would be very useful. Baseline measurement over two weeks revealed that 24/129 blood tests ordered for phlebotomists to take were not taken. Only three (13%) of these were handed over to doctors. Post-intervention, 18/106 blood tests requested were not taken. All 18 (100%) were successfully handed over to doctors. CONCLUSIONS: Implementation of a hospital-standardised phlebotomy handover folder dramatically improved the communication and handover between phlebotomists and doctors allowing for medical teams to take prompt action on unbled patients. This intervention will help improve patient safety, reduce delays in management/discharge and reduce the number of jobs handed over to evening on-call teams.

Improving the accuracy of operation coding in surgical discharge summaries.

Procedural coding in surgical discharge summaries is extremely important; as well as communicating to healthcare staff which procedures have been performed, it also provides information that is used by the hospital's coding department. The OPCS code (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures) is used to generate the tariff that allows the hospital to be reimbursed for the procedure. We felt that the OPCS coding on discharge summaries was often incorrect within our breast and endocrine surgery department. A baseline measurement over two months demonstrated that 32% of operations had been incorrectly coded, resulting in an incorrect tariff being applied and an estimated loss to the Trust of £17,000. We developed a simple but specific OPCS coding table in collaboration with the clinical coding team and breast surgeons that summarised all operations performed within our department. This table was disseminated across the team, specifically to the junior doctors who most frequently complete the discharge summaries. Re-audit showed 100% of operations were accurately coded, demonstrating the effectiveness of the coding table. We suggest that specifically designed coding tables be introduced across each surgical department to ensure accurate OPCS codes are used to produce better quality surgical discharge summaries and to ensure correct reimbursement to the Trust.

A salty cause of severe hypertension.

A 51-year-old lady was referred to our clinic because of severe hypertension; blood pressure 214/119 mm Hg despite treatment with an angiotensin receptor antagonist and a calcium channel blocker. Her initial laboratory results showed hypokalaemic alkalosis with normal urea and creatinine levels. Her 24-h urinary sodium excretion was markedly elevated at 244 mmol (equivalent to a daily intake of approximately 16 g of salt). Hyperaldosteronism was suspected but her plasma aldosterone level was subsequently found to be normal. On further questioning, the patient admitted to eating considerable amounts of salted liquorice and a diagnosis of acquired apparent mineralocorticoid excess was made. Liquorice has a well-known mineralocorticoid activity as it inhibits the action of 11ß-hydroxysteroid dehydrogenase 2 and can induce mineralocorticoid hypertension. After stopping eating the salted liquorice, the patient's blood pressure quickly normalised and all her antihypertensive medications were stopped.