Direct Admission from the Emergency Department to a Subacute Care Ward: An Alternative to Acute Hospitalization.

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.

Phaeochromocytoma presenting as Takotsubo cardiomyopathy.

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.

Breathlessness in liver disease: A case of hepatopulmonary syndrome .

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.

Rivaroxaban withdrawal and rebound hypercoagulability leading to upper extremity deep vein thrombosis: a case report.

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.

A stroke of bad luck.

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.